N.H. Admin. Code § He-P 817.14

Current through Register No. 45, November 7, 2024

Section He-P 817.14 - Duties and Responsibilities of All Licensees

(a) The licensee shall comply with all relevant federal, state, and local laws, rules, codes, and ordinances as applicable.

(b) The licensee shall have a written policy and procedure setting forth the rights and responsibilities of clients receiving services at the facility in accordance with RSA 151:20.

(c) The licensee shall define, in writing, the scope and type of services to be provided at the collection station or mobile collection station van.

(d) The licensee shall not falsify or omit any information contained in:

(1) The "Application for Residential or Health Care License," or any other documents required for the licensing of a collection station; or

(2) The records maintained for the clients and personnel of the collection station.

(e) The licensee shall have responsibility and authority for:

(1) Managing, controlling and operating the collection station;

(2) Developing and implementing written policies and procedures governing all of the operations and services provided, and for reviewing said policies and procedures annually and revising them as needed;

(3) Initiating action to maintain the collection station 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;

(4) Establishing, in writing, a chain of command that sets forth the line of authority for the operational responsibilities of the collection station;

(5) Appointing an administrator who shall be responsible for the day-to day operations of the collection station;

(6) Providing sufficient numbers of personnel who are present in the collection station and are qualified to perform the services stated in the collection station's scope of services;

(7) Providing sufficient supplies, equipment, and lighting to ensure all services are provided in a safe and timely manner;

(8) Reporting all positive tuberculosis test (TB) results for personnel to the department's TB program in accordance with RSA 141-C:7, He-P 301.02 and 301.03; and

(9) Implementing any POC that has been accepted or issued by the department.

(f) The licensee shall ensure that all specimen collection and storage requirements are met and only provide phlebotomy collection services:

(1) At their licensed premises, including in a licensed mobile collection station van under the oversight of the collection station;

(2) At a client's place of residence; and

(3) At a senior center, adult day care center, or an outpatient mental health facility provided that collection occurs no more than one day per week at this location.

(g) The licensee shall post the following documents in an area of the licensed premises that is conspicuous and open to clients and the general public:

(1) The current license issued in accordance with RSA 151:2;

(2) All inspection and investigation reports issued in accordance with He-P 817.09(c) and He-P 817.11(d) (2) a. for the previous 12 months;

(3) Any notice of pending hearing or order as required by RSA 151:29, II, pertaining to the licensee issued by the department, or a court during the previous 24 months;

(4) A copy of the patients' bill of rights specified by RSA 151:21 or RSA 151:21-b;

(5) A notice as required by RSA 151:29 stating complaints may be submitted to:

Department of Health and Human Services

Health Facilities Administration

129 Pleasant Street

Concord, NH 03301

(6) The licensee's evacuation floor plan identifying the location of, and access to, all fire exits, except that mobile collection station vans shall be exempt from this requirement.

(h) The licensee shall ensure that all personnel read and comply with the patients' bill of rights as set forth in RSA 151:21.

(i) The licensee shall admit and allow any department representative to inspect the licensed premises and all programs and services of any licensee that is providing collection station services at any time for the purpose of determining compliance with RSA 151 and He-P 817 as authorized by RSA 151:6 and RSA 151:6-a.

(j) All records required for licensing shall be:

(1) Available to the department during any inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a; and

(2) Legible, current, and accurate.

(k) For reportable incidents, the licensee shall:

(1) Convey by electronic or regular mail the following information to the department within 48 hours of a reportable incident as defined in He-P 817.03(z) :

a. The collection station name;

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 reportable incident;

d. The name of client(s) involved in the reportable incident;

e. The date and time of the reportable incident;

f. The action taken in direct response to the reportable incident; and

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

(2) 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 these were not submitted in the initial report.

(l) Any licensee maintaining electronic records shall develop a system with written policies and procedures to protect the privacy of clients and staff that, at a minimum, include:

(1) Procedures for backing up files to prevent deletion;

(2) Safeguards to ensure the confidentiality of the information on clients and staff; and

(3) Systems to prevent the tampering of information on clients and staff.

(m) The licensee shall provide a client or their legal representative with a copy of his or her client record, pursuant to the provisions of RSA 151:21, X, upon request.

(n) The licensee shall develop written policies and procedures that will ensure that only the client and the ordering licensed practitioner are allowed to receive a copy of the laboratory tests results unless the collection station has written consent from the client to release the test results to others.

(o) Mobile collection station vans shall maintain a log on-site documenting that all on-board water used for drinking and washing was obtained from a verifiable potable source.

N.H. Admin. Code § He-P 817.14

#5775, eff 1-24-94, EXPIRED: 1-24-00

New. #8410 eff 8-19-05; ss by #8853, eff 3-24-07

Amended by Volume XXXV Number 49, Filed December 10, 2015, Proposed by #10979, Effective 11/20/2015, Expires11/20/2025.