Section He-P 818.14 - 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, including RSA 161-F:49 and He-E 720.(b) The licensee shall comply with the patients' bill of rights as set forth in RSA 151:20, II.(c) The licensee shall define, in writing, the scope and type of services to be provided by the ADP, which shall include, at a minimum, the core services listed in He-P 818.15.(d) The licensee shall develop and implement written polices and procedures governing the operation and all services provided by the ADP.(e) All policies and procedures shall be reviewed annually and revised as needed.(f) The licensee shall assess and monitor the quality of care and service provided to participants on an ongoing basis.(g) The licensee or any personnel shall not falsify any documentation or provide false or misleading information to the department.(h) The licensee shall not: (1) Advertise or otherwise represent the program as operating an ADP, unless it is licensed; and(2) Advertise that it provides services that it is not authorized to provide.(i) The licensee shall comply with all conditions of warnings and administrative remedies issued by the department, and all court orders.(j) Licensees shall: (1) Meet the needs of the participants during those hours that the participants are in the care of the ADP;(2) Initiate action to maintain the ADP 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 ADP;(4) Appoint an administrator;(5) Verify the qualifications of all personnel;(6) Provide sufficient numbers of personnel who are present in the ADP and are qualified to meet the needs of participants during all hours of operation;(7) Provide the ADP with sufficient supplies, equipment, and lighting to meet the needs of the participants; and(8) Implement any POC that has been accepted or issued by the department.(k) The licensee shall consider all participants to be competent and capable of making health care decisions unless the participant: (1) Has a guardian appointed by a court of competent jurisdiction; or(2) Has a durable power of attorney for health care that has been activated.(l) 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, 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.(m) The licensee shall not admit a participant whose needs exceed the program and services offered by the ADP.(n) If the licensee accepts a participant 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 participants, 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 edition), available as noted in Appendix A.(o) 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.(p) Any licensee who admits or who has a participant with a diagnosis of dementia, Alzheimer's disease, or a primary or secondary diagnosis of mental illness shall: (1) Require all direct care personnel caring for the participant to be trained in the special care needs of participants with dementia, Alzheimer's disease, or mental illness; and(2) Provide a physical environment that has a safety and security system that prevents a participant from leaving the premises without the knowledge of staff, if the participant: a. Has wandered from the ADP in the last 60 days;b. Has had a change in their wandering behavior as determined by the nursing assessment completed in accordance with He-P 818.16(a) (4) ; orc. Is a danger to self or to others.(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 clinical inspection reports issued in accordance with He-P 818.09(d) and He-P 818.11(d) (1) , for the previous 12 months;(3) A copy of the patients' bill of rights specified by RSA 151:21;(4) A copy of the licensee's complaint procedure, including a statement that complaints may be submitted, in writing, to the Department of Health and Human Services, Health Facilities Administration, 129 Pleasant Street, Concord, NH 03301 or by calling 1-800-852-3345; and(5) The licensee's evacuation floor plan identifying the location of and access to all fire exits.(r) The licensee shall admit and allow any department representative to inspect the ADP and all programs and services that are being provided at any time for the purpose of determining compliance with RSA 151 and He-P 818 as authorized by RSA 151:6 and RSA 151:6-a.(s) Licensees shall: (1) Fax to 271-5574 or, if a fax machine is not available, convey by electronic or regular mail, the following information to the department within 48 hours of a reportable incident: 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 participant(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. Whether the participant's guardian or agent, if any, or personal representative was notified; andi. The signature of the person reporting the reportable incident;(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 it was not submitted in the initial report;(3) Contact the department immediately by telephone, fax, or e-mail to report the death of any participant or the death of any participant who dies within 10 days of a reportable incident;(4) Provide the information required by (3) above in writing within 72 hours of the death of any participant if the initial contact was made by telephone or if additional information becomes available subsequent to the time the initial contact was made;(5) Immediately notify the local police department, the department, guardian, agent, or personal representative if any, when a participant has an unexplained absence after the licensee has searched the building and the grounds of the ADP; and(6) Submit additional information if required by the department.(t) A licensee shall, upon request, provide a participant or the participant's guardian or agent, if any, with a copy of his or her participant record pursuant to the provisions of RSA 151:21, X.(u) 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.(v) Any licensee that maintains electronic records shall develop written policies and procedures designed to protect the privacy of participants and personnel 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 participants and staff; and(3) Systems to prevent tampering with information pertaining to participants and staff.(w) The licensee shall develop policies and procedures regarding the release of information contained in participant records.(x) The licensee shall provide cleaning and maintenance services, as needed to protect participants, personnel, and the public.(y) The building housing the ADP shall comply with all state and local: (z) If the ADP is not on a public water supply, the water used in the ADP shall be suitable for human consumption, pursuant to Env-Dw 702.02 and Env-Dw 704.02. (aa) The licensee shall determine whether smoking will be allowed at the ADP.(ab) If smoking is to be allowed, the licensee shall develop and implement smoking policies and designate smoking areas in accordance with RSA 155:68 and RSA 155:69.(ac) If the licensee holds or manages a participant'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 participants, or other household members.(ad) At the time of admission the licensee shall give a participant and the participant's guardian, agent, or personal representative, if applicable, a listing of all ADP's charges and identify what care and services are included in the charge.(ae) The charge for core services described in He-P 818.15 shall be included in the basic rate and shall not be charged separately.(af) The licensee shall give a participant and the participant's guardian, agent, or personal representative, if applicable, a 30-day written notice before any increase is imposed in the cost or fees for any ADP services.N.H. Admin. Code § He-P 818.14
Amended by Volume XXXVI Number 45, Filed November 10, 2016, Proposed by #12006, Effective 10/15/2016, Expires 4/13/2017.Amended by Volume XXXVII Number 23, Filed June 8, 2017, Proposed by #12198, Effective 6/2/2017, Expires 6/2/2027.