N.H. Admin. Code § He-P 820.10

Current through Register No. 45, November 7, 2024

Section He-P 820.10 - Administrative Remedies

(a) The department shall impose administrative remedies for violations of RSA 151, He-P 820, or other applicable rules, including:

(1) Requiring a registrant to submit a plan of correction (POC) in accordance with (c) below;

(2) Imposing a directed POC upon a registrant in accordance with (d) below;

(3) Imposing a fine upon an unregistered individual, applicant, or a registrant;

(4) Monitoring of a registrant; or

(5) Revocation of a registration.

(b) When administrative remedies are imposed, the department shall provide a written notice, as applicable, which:

(1) Identifies each area in which the registrant is not in compliance with RSA 151 or a provision of these rules; and

(2) Identifies the specific remedy(s) that have been proposed.

(c) A POC shall be developed and enforced in the following manner:

(1) Upon receipt of a statement of findings, the registrant shall submit its written POC for each item, written in the appropriate place on the statement or notice and containing:

a. How the registrant 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; and

d. The position of the employee responsible for the corrective action;

(2) The registrant shall submit a POC to the department within 21 calendar days of the date on the letter that transmitted the statement of findings or notice to correct unless the registrant requests, either verbally or in writing, and the department agrees, to extend that deadline, based on the following criteria:

a. The registrant demonstrates that he or she has made a good faith effort to develop and submit the POC within the 21-calendar day period but has been unable to do so; and

b. The department determines that the health, safety, or well-being of a client 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 820;

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 820 as a result of the implementation of the POC; and

d. Specifies the date upon which the deficiencies will be corrected;

(4) If the POC is acceptable, the department shall issue a registration 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 registrant in writing within 14 days of the reason for rejecting the POC;

(6) The registrant 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 registrant requests an extension, either via telephone or in writing, and the department grants the extension, based on the following criteria:

a. The registrant demonstrates that the registrant has made a good faith effort to develop and submit the POC within the 14-day period but has been unable to do so; and

b. The department determines that the health, safety, or well-being of a client will not be jeopardized as a result of granting the waiver;

(7) The revised POC shall comply with (1) above and be reviewed in accordance with (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 registrant shall be subject to a directed POC in accordance with (d) below and a fine in accordance with He-P 820.11(c)(7);

(9) The department shall verify the implementation of any POC that has been submitted and accepted by:

a. Reviewing materials submitted by the registrant;

b. Conducting a follow-up inspection; or

c. 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 registrant 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 registrant shall be:

a. Notified by the department in accordance with (b) above; and

b. Issued a directed POC in accordance with (d) below and shall be subject to a fine in accordance with He-P 820.11(c)(7).

(d) The department shall develop and impose a directed POC that specifies corrective actions for the registrant 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 clients and personnel;

(2) A revised POC is not submitted within 14 days of the written notification from the department; or

(3) A revised POC submitted by the registrant 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;

(2) Impose a fine according to He-P 820.11(c)(7);

(3) Deny the application for a renewal of a registration in accordance with He-P 820.11(b)(6); or

(4) Revoke or suspend the registration in accordance with He-P 820.11(b).

(f) The department shall offer an opportunity for informal dispute resolution to any applicant or registrant who disagrees with an area or areas of non-compliance cited by the department on a statement of findings or a notice to correct, provided that the applicant or registrant submits a written request for an informal dispute resolution to the department.

(g) The informal dispute resolution shall be requested in writing by the applicant, registrant, or administrator no later than 14 days from the date the statement of findings or notice to correct 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 registrant of the determination.

(i) An informal dispute resolution shall not be available for any applicant or registrant against who the department has imposed an administrative fine, or initiated action to suspend, revoke, deny, or refuse to issue or renew a registration.

(j) The department shall impose state monitoring under the following conditions:

(1) Repeated non-compliance on the part of the IHCSP in areas that impact the health, safety, or well-being of clients; or

(2) The presence of conditions in the IHCSP that negatively impact the health, safety, or well-being of clients.

N.H. Admin. Code § He-P 820.10

#10013, eff 10-22-11; ss by #10206, eff 10-20-12

Amended by Number 6, Filed February 9, 2023, Proposed by #13531, Effective 1/25/2023, Expires 1/25/2033.