N.H. Admin. Code § He-P 812.17

Current through Register No. 50, December 12, 2024

Section He-P 812.17 - Personnel

(a) The licensee shall ensure that sufficient numbers of qualified personnel are present in the ASC to meet the needs of the patients at all times.

(b) For all applicants for employment, volunteers, or independent contractors who provide direct personal care services to patients or who will be unaccompanied by an employee while performing non-direct care or non-personal services within the facility, the licensee shall:

(1) Obtain and review a criminal records check from the New Hampshire department of safety in accordance with RSA 151:2-d;

(2) Review the results of the criminal records check in accordance with (d) below;

(3) Verify the qualifications of all applicants prior to employment;

(4) Verify that the applicant is not on the List of Excluded Individuals/Entities, maintained by the U.S. Department of Health and Human Services Office of Inspector General; and

(5) Verify that the applicant is not listed on the BEAS registry maintained by the department's bureau of elderly and adult services.

(c) Unless a waiver is granted in accordance with (e) (2) below, the licensee shall not offer employment, contract with, or engage a person in (b) above, if the person:

(1) Has been convicted of any felony in this or any other state;

(2) Has been convicted for sexual assault, other violent crime, assault, fraud, theft, abuse, neglect, or exploitation in this or any other state;

(3) Has been found by the department or any administrative agency in this or any other state for assault, fraud, theft, abuse, neglect, or exploitation of any person; or

(4) Otherwise poses a threat to the health, safety, or well-being of patients.

(d) If the information identified in (c) above regarding any person subject to (b) above is learned after the person is hired, contracted with, or engaged with, the licensee shall immediately notify the department and either:

(1) Cease employing, contracting with, or engaging with the person; or

(2) Request a waiver of (c) above.

(e) If a waiver of (c) above is requested, the department shall review the information and the underlying circumstances in (c) above and shall either:

(1) Notify the licensee that the person shall not or no longer shall be employed, contracted with, or engaged by the licensee, if, after investigation, it determines that the person poses a threat to the health, safety, or well-being of a patient(s); or

(2) Grant a waiver of (c) above, if after the investigation, it determines that the person does not pose a current threat to the health, safety, or well-being of a patient(s) .

(f) The licensee shall:

(1) Not employ, contract with, or engage with any person in (b) above who is listed on the BEAS state registry unless a waiver is granted by BEAS; and

(2) Only employ, contract with, or engage with board of nursing licensees who are listed on the licensing site with the NH board of nursing registry or compact site.

(g) In lieu of (c) and (f) above, the licensee may accept from independent agencies contracted by the licensee or by an individual patient to provide direct care or personal care services a signed statement that the agency's employees have complied with (c) and (f) above and do not meet the criteria in (c) and (g) above.

(h) All personnel shall:

(1) Meet the educational and physical qualifications of the position as listed in their job description;

(2) Be licensed, registered, or certified as required by state statute and as applicable;

(3) Receive an orientation within the first 3 days of work or prior to the assumption of duties that includes:

a. The ASC's policies on rights and responsibilities and complaint procedures as required by RSA 151:20;

b. The duties and responsibilities, policies, procedures, and guidelines, of the position they were hired for;

c. The ASC's infection prevention program;

d. The ASC's fire, evacuation, and emergency plans which outline the responsibilities and educational requirements of personnel in an emergency; and

e. Mandatory reporting requirements for abuse or neglect such as those found in RSA 161-F and RSA 169-C:29;

(4) Complete a mandatory annual in-service education, which includes a review of the ASC's:

a. Policies and procedures on patient rights and responsibilities and abuse or neglect;

b. Infection prevention; and

c. Education program on fire and emergency procedures.

(i) Prior to having contact with patients, personnel shall:

(1) Submit to the licensee proof of a physical examination or a health screening conducted not more than 12 months prior to employment which shall include at a minimum the following:

a. The name of the examinee;

b. The date of the examination;

c. Whether or not the examinee has a contagious illness or any other illness that would affect the examinee's ability to perform their job duties;

d. Results of a 2-step tuberculosis (TB) test, Mantoux method or other method approved by the Centers for Disease Control (CDC); and

e. The dated signature of the licensed health practitioner;

(2) Be allowed to work while waiting for the results of the second step of the TB test when the results of the first step are negative for TB; and

(3) Comply with the requirements of the United States Centers for Disease Control "Guidelines for Preventing the Transmission of in Health-Care Settings" (2005 edition), available as noted in Appendix A, if the person has either a positive TB test, or has had direct contact or potential for occupational exposure to M. tuberculosis through shared air space with persons with infectious tuberculosis.

(j) Personnel who have direct contact with patients who have a history of TB or a positive laboratory and antigen testing shall have a symptomology screen of a TB test.

(k) The licensee shall provide all personnel with an annual continuing education or in-service education training, which at a minimum contains the following:

(1) The licensee's patient's rights and complaint procedures required under RSA 151;

(2) The licensee's written emergency plan; and

(3) The mandatory reporting requirements including RSA 161-F:46 and RSA 169-C:29.

(l) Current, separate and complete personnel files shall be maintained and stored in a secure and confidential manner.

(m) The licensee shall maintain a separate employee file for each employee, which includes the following:

(1) A completed application for employment or a resume;

(2) A signed statement acknowledging the receipt of the ASC's policy setting forth the patient's rights and responsibilities, and acknowledging training and implementation of the policy as required by RSA 151:20;

(3) A job description signed by the individual that identifies the:

a. Position title;

b. Qualifications and experience; and

c. Duties required by the position;

(4) Record of satisfactory completion of the orientation program required by (h) (3) above;

(5) A copy of each current New Hampshire license, registration, or certification in health care field and basic life support certification, if applicable;

(6) Documentation that the required physical examination or health screening and TB test results or radiology reports of chest x-rays, if required, have been completed by the appropriate health professionals;

(7) Record of satisfactory completion of all required education programs and demonstrated competencies that are signed and dated by employee;

(8) Documentation of annual performance review;

(9) A statement which shall be signed at the time the initial offer of employment, contract, or engagement is made and then annually thereafter, that he or she:

a. Does not have a felony conviction in this or any other state;

b. Has not been convicted of a sexual assault, other violent crime, assault, fraud, theft, abuse, neglect or exploitation or pose a threat to the health, safety or well-being of a patient(s) in this or any other state; and

c. Has not had a finding by the department or any administrative agency in this or any other state for assault, fraud, theft, abuse, neglect or exploitation of any person in this or any other state;

(10) Documentation of the criminal records check;

(11) Documentation that the individual is not on the List of Excluded Individuals/Entities, maintained by the U.S. Department of Health and Human Services Office of Inspector General; and

(12) The results of the registry checks in (11) above.

(n) The licensee shall maintain the records, but not necessarily a separate file, for all volunteers and for all independent contractors who provide direct care or personal care services to patients or who will be unaccompanied by an employee while performing non-direct care or non-personal care services within the facility, as follows:

(1) For volunteers, the information in (m) (1), (3), (4), (6) and (8) through (12) above; and

(2) For independent contractors, the information in (m) (3), (4), (6) and (8) through (12) above.

(o) An individual need not re-disclose any of the matters in (9) and (10) above if the documentation is available and the department has previously reviewed the material and granted a waiver so that the individual can continue employment.

N.H. Admin. Code § He-P 812.17

#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.