Section He-P 812.12 - Administrative Remedies(a) The department shall, after notice and an opportunity to be heard, impose administrative remedies for violations of RSA 151, He-P 812, or other applicable licensing rules, including:(1) Requiring a licensee to submit a POC in accordance with (c) below;(2) Imposing a directed POC upon a licensee in accordance with (d) below; (3) Imposing conditions upon a licensee; or(4) Monitoring of a license.(b) When administrative remedies are imposed, the department shall provide a written notice, as applicable, which: (1) Identifies each area in which the licensee is not in compliance with RSA 151 or a provision of these rules; and(2) Identifies the specific remedy(s) that has been proposed. (c) A POC shall be developed and enforced in the following manner:(1) Upon receipt of a statement of findings or a notice to correct the licensee shall submit its written POC for each item, written in the appropriate place on the state notice detailing:a. How the licensee intends to correct each area of non-compliance;b. What measures will be put in place, or what system changes will be made to ensure that the non-compliance does not recur, to include how the measures will be evaluated for effectiveness; c. The date by which each area of non-compliance shall be corrected; andd. The position of the employee responsible for the corrective action.(2) The licensee shall submit a POC to the department within 21 days of the date on the letter that transmitted the statement of findings or notice to correct unless the licensee requests, either verbally or in writing, and the department agrees, to extend that deadline, based on the following criteria: a. The licensee demonstrates that he or she has made a good faith effort to develop and submit the POC within the 21-day period but has been unable to do so; andb. The department determines that the health, safety, or well-being of a patient will not be jeopardized as a result of granting the extension;(3) The department shall review and accept each POC that: a. Achieves compliance with RSA 151 and He-P 812;b. Addresses all areas of non-compliance as cited in the statement of findings or notice to correct;c. Prevents a new violation of RSA 151 or He-P 812 as a result of the implementation of the POC; andd. Specifies the date upon which the areas of non-compliance will be corrected;(4) If the POC is acceptable, the department shall issue a license certificate or provide written notification of acceptance of the POC, whichever is applicable;(5) If the POC is not acceptable the department shall notify the licensee in writing, within 14 days, of the reason for rejecting the POC;(6) The licensee shall develop and submit a revised POC within 14 days of the date of the written notification from the department that states the original POC was rejected unless, within the 14-day period, the licensee requests an extension, either via telephone or in writing, and the department grants the extension, based on the following criteria:a. The licensee demonstrates that he or she has made a good faith effort to develop and submit the POC within the 14-day period but has been unable to do so; andb. The department determines that the health, safety, or well-being of a patient will not be jeopardized as a result of granting the waiver;(7) The revised POC shall comply with (c) (1) above and be reviewed in accordance with (c) (3) above;(8) If the revised POC is not acceptable to the department, or is not submitted within 14 days of the date of the written notification from the department that states the original POC was rejected, the licensee shall be subject to a directed POC in accordance with (d) below and a fine in accordance with He-P812.13(c) (12);(9) The department shall verify the implementation of any POC that has been submitted and accepted by: a. Reviewing materials submitted by the licensee; b. Conducting a follow-up inspection; orc. Reviewing compliance during the next annual inspection;(10) Verification of the implementation of any POC shall only occur after the date of completion specified by the licensee in the plan; and(11) If the POC or revised POC has not been implemented by the completion date at the time of the next inspection, the licensee shall be: a. Notified by the department in accordance with He-P 812.12(b); and b. Issued a directed POC in accordance with (d) below and shall be subject to a fine in accordance with He-P 812.13(c) (13) below. (d) The department shall develop and impose a directed POC that specifies corrective actions for the licensee to implement when: (1) As a result of an inspection, areas of non-compliance were identified that require immediate corrective action to protect the health and safety of the patients and personnel; (2) A revised POC is not submitted within 14 days of the written notification from the department or such other date as applicable if an extension was granted by the department; or(3) A revised POC submitted by the licensee or administrator has not been accepted.(e) If at the time of the next inspection the directed POC referenced in (d) above has not been implemented by the completion date stated in the directed POC, the department shall: (1) Issue a warning that enforcement action will be taken if the POC is not implemented;(3) Deny the application for a renewal of a license in accordance with He-P 812.13(b) ; or (4) Revoke the license in accordance with He-P 812.13(b) .(f) The department shall offer an opportunity for informal dispute resolution to any applicant or licensee who disagrees with an area or areas of non-compliance cited by the department on a statement of findings, provided that the applicant or licensee submits a written request for an informal dispute resolution.(g) The informal dispute resolution shall be requested in writing by the applicant, licensee or program director no later than 14 days from the date the statement of findings was issued by the department.(h) The department shall change the statement of findings if, based on the evidence presented, the statement of findings is determined to be incorrect. The department shall provide a written notice to the applicant or licensee of the determination.(i) The deadline to submit a POC in accordance with (c) above shall not apply until the notice of the determination in (h) above has been provided to the applicant or licensee.(j) Any violations cited for the state fire code may be appealed to the New Hampshire state fire marshal and shall not be the subject of informal dispute resolutions as described in this section.(k) An informal dispute resolution shall not be available for any applicant or licensee against whom the department has imposed an administrative fine or initiated action to suspend, revoke, deny or refuse to issue or renew a license.(l) The department shall impose state monitoring under the following conditions:(1) Repeated non-compliance on the part of the facility in areas that impact health, safety, or well-being of patients; or(2) The presence of conditions in the ASC that negatively impact the health, safety, or well-being of patients.N.H. Admin. Code § He-P 812.12
#5514, eff 11-25-92; ss by #6530, eff 6-27-97, EXPIRED: 6-27-05
New. #9727-A, eff 6-18-10
Amended by Volume XXXVIII Number 28, Filed July 12, 2018, Proposed by #12557, Effective 6/26/2018, Expires 12/24/2018.Amended by Volume XXXIX Number 50, Filed December 12, 2019, Proposed by #12926, Effective 11/26/2019, Expires 11/26/2029.