Section He-P 811.14 - Duties and Responsibilities of All Licensees(a) The licensee shall comply with the patients' bill of rights as set forth in RSA 151:19-21.(b) The licensee shall define, in writing, the scope and type of services to be provided by the ESRDDC, which shall include, at a minimum, the core services listed in He-P 811.15.(c) The licensee shall develop and implement written polices and procedures governing the operation and all services provided by the ESRDDC.(d) All policies and procedures shall be reviewed per licensee policy and revised as needed.(e) The licensee shall educate personnel about the needs and services required by the clients under their care.(f) The licensee shall assess and monitor the quality of care and service provided to clients on an ongoing basis.(g) The licensee or any employee shall not falsify any documentation or provide false or misleading information to the department.(h) The licensee shall not advertise or otherwise represent the program as having health care programs or services that they are not licensed to provide.(i) The licensee shall comply with all conditions of warnings and administrative remedies issued by the department and all court orders.(j) The licensee shall not exceed the maximum number of stations authorized by the department.(k) The licensee shall establish and maintain by-laws that: (1) Define the operation and performance of the ESRDDC;(2) Establish a credentialing process; and(3) Maintain documentation of all medical staff privileges.(l) Licensees shall: (1) Ensure that the dialysis needs of the clients are met during those hours that the client is in the care of the ESRDDC;(2) Establish, in writing, a chain of command that sets forth the line of authority for the operational responsibilities of the ESRDDC;(3) Appoint an administrator who shall meet the requirements of He-P 811.15(a) ;(4) Appoint a medical director, who shall meet the requirements of He-P 811.15(e) ;(5) Initiate action to maintain the ESRDDC in full compliance at all times with all relevant health and safety requirements contained in applicable federal, state, and local laws, rules, regulations, and ordinances;(6) Provide sufficient numbers of personnel who are present in the ESRDDC and are qualified to meet the needs of clients during all hours of operation;(7) Provide the ESRDDC with sufficient supplies, equipment, and lighting to meet the needs of clients;(8) Implement any POC that has been accepted or issued by the department; (9) Initiate, implement, and continue action to correct any issue identified by the quality improvement committee; and(10) Comply with all conditions of warnings and administrative remedies issued by the department and all court orders.(m) The licensee shall provide housekeeping and maintenance adequate to protect clients, personnel, and the public.(n) The licensee shall consider all clients to be competent and capable of making health care decisions unless the client: (1) Has a guardian or conservator appointed by a court of competent jurisdiction;(2) Has durable power of attorney for health care that has been activated; or(3) Is an un-emancipated minor.(o) The licensee shall only accept a client whose needs can be met under the current licensing classification and through the programs and services offered.(p) The licensee shall have a written affiliation agreement with at least one acute care hospital for the provision of inpatient care and other acute care hospital services.(q) In addition to the posting requirements specified in RSA 151:29, the licensee shall post the following documents in a public area: (1) The current license certificate issued in accordance with RSA 151:2;(2) The most recent inspection report as specified in RSA 151:6-a;(3) A copy of the patient's bill of rights specified by RSA 151:21;(4) A copy of the licensee's policies and procedures relative to the implementation of client's rights and responsibilities as required by RSA 151:20; (5) A copy of the licensee's complaint procedure, including the address and phone number of the department to which complaints may also be made, which shall also be posted on the ESRDDC website if available; and(6) The licensee's floor plan for fire safety, evacuation, and emergencies identifying the location of, and access to all fire exits.(r) The licensee shall develop policies and procedures regarding the release of information contained in client records.(s) The licensee shall ensure that all personnel required to be licensed in the state of New Hampshire practice in accordance with the appropriate practice act and the rules adopted there under.(t) The licensee shall not exceed the number of occupants authorized by NFPA 101, as adopted by the commissioner of the department of safety under Saf-C 6000, as adopted by the commissioner of the department of safety under RSA 153, and as amended pursuant to RSA 153:5, I by the state fire marshal with the board of fire control, and identified on the licensing certificate.(u) If the licensee accepts a client who is known to have a disease reportable under He-P 301 or an infectious disease, which is any disease caused by the growth of microorganisms in the body which might or might not be contagious, the licensee shall follow the required procedures for the care of the client as specified by the United States Centers for Disease Control and Prevention "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" (June 2007), available as noted in Appendix A. (v) The licensee shall report all positive tuberculosis test results for personnel to the office of disease control in accordance with RSA 141-C:7, He-P 301.02, and He-P 301.03.(w) The licensee shall ensure that all records required for licensing: (1) Shall be available to the department during an inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a; and(2) Shall be legible, current, and accurate.(x) Smoking shall be prohibited in an ESRDDC per RSA 155:66, I(b) , except as permitted by RSA 155:67. If allowed, smoking shall be restricted to designated smoking areas as per the licensee's official smoking policy, but in no case shall smoking be permitted in any room containing an oxygen cylinder or oxygen delivery system or in a client's bedroom.(y) The water used in the ESRDDC shall be suitable for human consumption pursuant to Env-Dw 702.02 and Env-Dw 704.02.(z) For reportable incidents, allegations of abuse, neglect, mistreatment, or misappropriation of property the licensee shall: (1) Notify the department by fax to 603 271-5574, or if a fax machine is not available, submit via regular mail, postmarked within 24 hours of the incident together with a telephone call to the department reporting the incident and notifying the department of the mailed report, the following information: b. A description of the incident, including identification of injuries, if applicable;c. The name of the licensee(s) or personnel involved in, witnessing, or responding to the incident;d. The name of client(s) involved in or witnessing the incident;e. The date and time of the incident;f. The action taken in direct response to the incident, including any follow-up;g. If medical intervention was required, by whom and the date and time;h. Whether the client's guardian or agent, if any, or personal representative was notified;i. The signature of the person reporting the incident; andj. The date and time the client's licensed practitioner was notified; (2) Within 5 days a completed investigation report shall be submitted to the department and contain the following information:a. All items referenced in (1) above;b. The names and results of interview(s) with all personnel, client(s), or other individuals involved in the reportable incident, including all applicable statement signatures; andc. The action taken by the licensee in direct response to the incident(s), including any and all follow-up;(3) Immediately notify the local police department, the department, guardian, agent, or personal representative, if any, when a client, who has been assessed or is known as being a danger to self or others, has eloped after the licensee has searched the building and the grounds of the ESRDDC; and(4) Submit additional information if required by the department.N.H. Admin. Code § He-P 811.14
Amended by Volume XXXIX Number 32, Filed August 8, 2019, Proposed by #12827, Effective 7/20/2019, Expires 1/16/2020.Amended by Volume XL Number 7, Filed February 13, 2020, Proposed by # 12985, Effective 1/29/2020, Expires 1/29/2030.