N.H. Admin. Code § He-P 815.14

Current through Register No. 45, November 7, 2024

Section He-P 815.14 - Duties and Responsibilities of All Licensees

(a) The licensee shall comply with all federal, state, and local laws, rules, codes, and ordinances, as applicable, including RSA 161-F:49 and rules promulgated thereunder.

(b) In accordance with RSA 151:20, the licensee shall have a written policy setting forth the rights and responsibilities of residents receiving services at the ICF/IID, as well as written procedures to implement its policy to ensure that the rights set forth in RSA 151:21, "Patients' Bill of Rights" are upheld.

(c) The licensee shall define, in writing, the scope and type of services to be provided by the ICF/IID, which shall include at a minimum, the required services listed in He-P 815.15.

(d) The licensee shall develop and implement written policies and procedures governing the operation of all services provided by the ICF/IID and for:

(1) Reviewing the policies and procedures annually;

(2) Revising them as needed;

(3) Implementing a written policy that ensures the safety of all persons present on the licensed premises where firearms are permitted; and

(4) Managing the behavior of residents under the age of 18, including how and under what circumstances seclusion or restraint is used, pursuant to RSA 126-U:2.

(e) The licensee shall assess and monitor the quality of care and service provided to residents on an ongoing basis.

(f) The licensee or any personnel shall not falsify any documentation or provide false or misleading information to the department.

(g) The licensee shall not:

(1) Advertise or otherwise represent the program as operating an ICF/IID, without a valid license; and

(2) Advertise that it provides services that it is not authorized to provide.

(h) The licensee shall comply with all conditions of warnings and administrative remedies issued by the department, and all court orders.

(i) Licensees shall:

(1) Meet the needs of the resident;

(2) Initiate action to maintain the ICF/IID 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;

(3) Establish, in writing, a chain of command that sets forth the line of authority for the operation of the ICF/IID;

(4) Appoint a qualified administrator and medical director;

(5) Verify the qualifications of all personnel;

(6) Provide sufficient numbers of personnel who are present in the ICF/IID and are qualified to meet the needs of residents during all hours of operation;

(7) Provide the ICF/IID with sufficient supplies, equipment, and lighting to meet the needs of the residents;

(8) Implement any POC that has been accepted or issued by the department; and

(9) Require that all personnel follow the orders of the licensed practitioner for each resident and encourage the residents to follow the licensed practitioner's orders.

(j) The licensee shall consider all residents to be competent and capable of making health care decisions unless the resident:

(1) Has a guardian appointed by a court of competent jurisdiction;

(2) Has a durable power of attorney for health care that has been activated; or

(3) Is an un-emancipated minor.

(k) The licensee shall not exceed the maximum number of residents or beds licensed by the department, unless authorized by the department, such as during an emergency.

(l) The licensee shall not admit a resident whose needs exceed the program and services offered by the ICF/IID.

(m) If the licensee accepts a resident 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 and personnel training for the care of the residents, as specified by the United States Centers for Disease Control and Prevention (CDC) "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" (June 2007 edition), available as noted in Appendix A.

(n) The licensee shall report all positive tuberculosis test results for employees to the department's bureau of disease control in accordance with RSA 141-C:7, He-P 301.02, and He-P 301.03.

(o) The licensee shall implement measures to ensure the safety of residents who are assessed as an elopement risk or danger to self or others.

(p) If serving an adult population, the licensee shall ensure compliance with all dementia training requirements pursuant to RSA 151:47-49 including continuing education to include new information on best practices in the treatment and care of persons with dementia and be provided for:

(1) A minimum of 6 hours for initial continuing education to covered administrative staff members and covered direct service staff members; and

(2) A minimum of 4 hours of ongoing training each calendar year.

(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) All inspection reports issued in accordance with He-P 815.09, for the previous 12 months;

(3) A copy of the residents' bill of rights specified by RSA 151:21;

(4) A copy of the licensee's policies and procedures relative to the implementation of resident rights and responsibilities as required by RSA 151:20;

(5) A copy of the licensee's complaint procedure, including a statement that complaints may be submitted, in writing, to "Department of Health and Human Services, Office of Legal and Regulatory Services, Health Facilities Administration, 129 Pleasant Street, Concord, NH 03301" or by calling 1-800-852-3345, and information on how to contact the office of the long-term care ombudsman; and

(6) The licensee's plan for fire safety, evacuation, and emergencies, identifying the location of, and access to, all fire exits.

(r) For reportable incidents, the licensee shall:

(1) Complete an investigation to determine if abuse or neglect could have been a contributing factor to the incident;

(2) Fax to 603-271-4968 or, if a fax machine is not available, convey by electronic mail to hfa-licensing@dhhs.nh.gov or regular mail to 129 Pleasant Street, Concord, NH 03301, the following information to the department within 48 hours of a reportable incident:

a. The ICF/IID name;

b. A description of the incident, including identification of injuries, if applicable;

c. The name of the licensee(s) or employees involved in, witnessing, or responding to the reportable incident;

d. The name of resident(s) involved in or witnessing the reportable incident;

e. The date and time of the reportable incident;

f. The action taken in direct response to the reportable incident, including any follow-up;

g. If medical intervention was required, by whom and the date and time;

h. When the resident's guardian or agent, if any, or personal representative was notified;

i. The signature of the person reporting the reportable incident;

j. The date and time the resident's licensed practitioner was notified, if applicable; and

k. The date the facility performed the investigation required by (1) above;

(3) As soon as practicable, notify the local police department, the department, and the guardian, agent, surrogate decision-maker, or personal representative, if any, when a resident has an elopement or unexplained absence and the licensee has searched the building and the grounds of the ICF/IID without finding the resident; and

(4) Notify the department with a written report within 5 days describing the actions taken by personnel, the final outcome or continuation of the reportable incident, and actions taken to prevent a reoccurrence if it was not submitted in the initial report.

(s) For uses of restraint with a resident under the age of 18, the license shall notify the resident's parents or guardians in accordance with RSA 126-U:7 including verbal and written documentation.

(t) The licensee shall admit and allow any department representative to inspect the ICF/IID and all programs and services that are being provided at any time for the purpose of determining compliance with RSA 151 and He-P 815 as authorized by RSA 151:6 and RSA 151:6-a.

(u) Applicants, licensees, and employees shall cooperate with the department during all departmental inspections and investigations authorized under RSA 151 and He-P 815, including allowing representatives of the department to:

(1) Enter and complete an inspection of the premises;

(2) Review and reproduce any records, forms, or reports which are required to be maintained or made available to the department; and

(3) Interview employees and residents of the ICF/IID.

(v) A licensee shall, upon request, provide a resident or the resident's guardian or agent, if any, with a copy of his or her resident record pursuant to the provisions of RSA 151:21, X.

(w) All records required for licensing shall be legible, current, accurate, and available to the department during an inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a.

(x) Any licensee that maintains electronic records shall develop written policies and procedures designed to protect the privacy of residents and employees that, at a minimum, include:

(1) Procedures for backing up files to prevent loss of data;

(2) Safeguards for maintaining the confidentiality of information pertaining to residents and employees; and

(3) Systems to prevent tampering with information pertaining to residents and employees.

(y) The licensee shall develop policies and procedures regarding the release of information contained in resident records.

(z) The licensee shall provide cleaning and maintenance services, as needed, to protect residents, employees, and the public.

(aa) The ICF/IID shall comply with all federal, state, and local health, building, fire, and zoning laws, rules, and ordinances.

(ab) If the ICF/IID is not on a municipal water system, the water used in the ICF/IID shall be potable and suitable for human consumption.

(ac) If the licensee holds or manages a resident's funds or possessions, it shall first receive written authorization in accordance with RSA 151:24 and RSA 151:21, VII, and such funds shall not be used for the benefit of the licensee, other residents, or other household members.

(ad) The licensee shall develop and follow policies and procedures regarding resident room or bed location changes.

(ae) Following the death of a roommate, the licensee shall facilitate the provision of social services for the resident as needed.

(af) If the residents are minors, any licensee, employee, personnel, or other person associated with the facility who suspects that a child is being abused or neglected is a mandated reporter in accordance with RSA 169-C:29 and shall report the suspected abuse to the division for children, youth, and families at 1-800-894-5533.

N.H. Admin. Code § He-P 815.14

Derived from Number 10, Filed March 9, 2023, Proposed by #13568, Effective 2/25/2023, Expires 2/25/2033.