N.H. Admin. Code § He-P 826.14

Current through Register No. 50, December 12, 2024

Section He-P 826.14 - Duties and Responsibilities of the Licensee

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

(b) The licensee shall have written policies and procedures to include:

(1) The rights and responsibilities of clients in accordance with the patients' bill of rights under RSA 151:20, II;

(2) A policy that ensures the safety of all persons present on the licensed premises where firearms are permitted; and

(3) All other policies required by He-P 826.

(c) The licensee shall define, in writing, the scope and type of services to be provided at the SUD-RTF.

(d) The licensee shall have a system to regularly identify the SUD-RTF's daily census, including times client is absent from the SUD-RTF.

(e) The licensee shall comply with the patients' bill of rights as set forth in RSA 151:19-30.

(f) The licensee shall develop and implement written policies and procedures governing the operation of the SUD-RTF to include a clinical care manual covering the policies and procedures for all clinical services provided.

(g) All policies and procedures shall be reviewed annually and revised as needed.

(h) All clinical services provided by the licensee shall:

(1) Focus on the clients strengths;

(2) Be sensitive and relevant to the diversity of the clients;

(3) Be client and family centered;

(4) Be evidence-based by meeting one of the following:

a. The service shall be included as an evidence-based mental health and substance abuse intervention on the SAMHSA Evidence-Based Practices Resource Center (April 2018 edition) available at https://www.samhsa.gov/ebp-resource-center, or as listed in Appendix A;

b. The services are published in a peer reviewed journal and found to have positive effects; or

c. The treatment and support service provider shall be able to document the services effectiveness based on a theoretical model with validated research or a documented body of research generated from similar services that indicates effectiveness;

(5) Be designed to acknowledge the impact of violence and trauma on client's lives which shall be addressed in the services provided; and

(6) Be delivered in accordance with the following:

a. The American Society of Addiction Medicine (ASAM) Criteria, 2013 edition, available as listed in Appendix A; or

b. The Treatment Improvement Protocols and Technical Assistance Publications promulgated by SAMSHA: https://www.samhsa.gov/kap/resources, September 2017 edition, available as listed in Appendix A.

(i) The licensee shall assess and monitor the quality of care and services it provides to clients on an ongoing basis.

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

(k) The licensee shall not advertise or otherwise represent the SUD-RTF as having residential care or health care programs or services for which it is not licensed to provide.

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

(m) Licensees shall:

(1) Meet the needs of the clients during the hours that the clients are in the care of the SUD-RTF;

(2) Initiate action to maintain the SUD-RTF 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 SUD-RTF;

(4) Appoint a medical director who shall meet the requirements of He-P 826.18(k) ;

(5) Appoint an administrator who shall meet the requirements of He-P 826.18(i) ;

(6) Verify the qualifications of all personnel;

(7) Provide sufficient numbers of personnel who are present in the SUD-RTF and are qualified to meet the needs of clients during all hours of operation;

(8) All unlicensed clinical staff providing treatment, education, and/or recovery support services shall be under the direct supervision of a licensed clinical supervisor;

(9) Licensed clinical supervisors must provide at least one hour of supervision for all unlicensed clinical staff for every 40 hours of direct client contact which shall include:

a. Review of case records;

b. Observation of interactions with clients;

c. Skill development;

d. Review of case management activities; and

e. The maintenance of a log of the supervision date, duration, content, and the identity of the participants;

(10) Ensure that personnel, licensed or certified, by the NH board of licensing for alcohol and other drug use professionals or any other licensing or certification board, receive supervision in accordance with the requirements set forth for the licenses or certifications held by the individual;

(11) Ensure that no LADC or MLADC shall supervise more than 12 unlicensed staff;

(12) Provide the SUD-RTF with sufficient supplies, equipment, and lighting to ensure that the needs of clients are met;

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

(13) Require that all personnel follow the orders of the licensed practitioner for each client and encourage the clients to follow the licensed practitioner's orders.

(n) The licensee shall employ or contract with a nurse who is currently licensed in the state of New Hampshire pursuant to RSA 326-B, or licensed pursuant to the multi-state compact, and who is an RN or LPN with at least 2 year's relevant experience in substance use disorder treatment or behavioral health services.

(o) The licensee shall employ or contract with a clinical services director who is a LADC or MLADC licensed by the NH board of licensing for alcohol and other drug use professionals or an individual licensed by the board of mental health practice and who has at least 2 year's relevant experience in substance use disorder treatment or behavioral health services.

(p) The licensee shall:

(1) Make available basic supplies necessary for clients to maintain grooming and personal hygiene, such as soap, shampoo, toothpaste, toothbrush, and toilet paper. Such basic supplies shall be included in the basic rate, except that there may be an additional charge for specific brands or items required to meet individual clients' needs or requests;

(2) Not be responsible for the cost of purchasing a specific brand of product at a client's request;

(3) Identify in the admission agreement the cost, if any, of basic supplies or other services for which there will be a charge;

(5) Ensure that all personnel have received the training necessary to be qualified personnel to include demonstrated competency in the training given with documentation maintained in the employee personnel file;

(6) Require any paid provider providing direct care, other than an employee, to provide a brief written, signed, and dated note describing the reason for the service(s), and the next planned visit, if known;

(7) Have a clearly identified policy for CPR that includes the following:

a. If CPR is not performed, the policy shall include a statement that 911 shall be called in an emergency;

b. If CPR is performed, the policy shall include a statement that 911 shall be called and there shall be either at least one person on duty per shift who is certified to perform CPR or an AED available for use; and

c. This policy shall be signed by each client and their guardian, agent, surrogate decision-maker or personal representative, if any, and be located in the client's file with their admission agreement; and

(8) There shall be at least one personnel on the premises during all hours the facility is open.

(q) The licensee shall educate personnel about the needs and services required by the clients under their care and document such education to include demonstrated competencies.

(r) Physical or chemical restraints shall only be used in the case of an emergency, pursuant to RSA 151:21, IX.

(s) As soon as is practicable but no longer than 24 hours after the use of a physical or chemical restraint, the client's licensed practitioner, the department, and the client's guardian, agent, surrogate decision-maker or personal representative, if any, shall be notified of the use of such restraints.

(t) The SUD-RTF shall:

(1) Have policies and procedures on:

a. What type of emergency restraints can be used;

b. When restraints can be used; and

c. Who may authorize the use of restraints; and

(2) Provide personnel with education and training on the limitations and the correct use of restraints.

(u) The use of physical restraints shall be allowed only as defined under He-P 826.03(bl) .

(v) Separation from a situation may be used as an alternative to physical restraint and shall not be considered a form of restraint.

(w) For reportable incidents, licensees shall have responsibility for:

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

(2) Faxing to 271-4968 or, if a fax machine is not available, submit via regular mail, postmarked within 48 hours off the incident together with a telephone call to the department reporting the incident and notifying the department of the mailed report, the following information to the department within 48 hours of a reportable incident:

a. The SUD-RTF 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 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 client's guardian, agent, surrogate decision-maker or personal representative, if any, was notified;

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

j. The date and time the client'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, notifying the local police department, the department, and the guardian, agent, surrogate decision-maker, or personal representative, if any, when a client has an unexplained absence and the licensee has searched the building and the grounds of the SUD-RTF without finding the client and it has been determined by the facility that the client is a danger to themselves or others; and

(4) If abuse or neglect is suspected, the licensee shall 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.

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

(y) The licensee shall give a client a written notice as follows:

(1) For an increase in the cost or fees for any SUD-RTF services, 30 days advanced notice shall be required except for clients receiving Medicaid whose financial liability is determined by the state's standard of need; or

(2) For an involuntary change in room or bed location, the facility shall make reasonable accommodation of individual needs and preferences and give 14 days advanced notice, unless the change is required to protect the health, safety, and well-being of the client or other clients, in such case the notice shall be as soon as practicable.

(z) In addition to the posting requirements specified in RSA 151:29, the licensee shall post the following documents in a conspicuous area accessible to clients, employees, and visitors:

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

(2) All statement of findings for the last 12 months in accordance with He-P 826.09(d) and He-P 826.11(d) ;

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

(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, Office of Legal and Regulatory services, Health Facilities Administration, 129 Pleasant Street, Concord, N.H. 03301 or by calling 1-800-852-3345, and information on how to contact the office of the long-term care ombudsman.

(aa) The licensee shall not allow smoking in the facility at any time.

(ab) If smoking is allowed on the grounds of the SUD-RTF, the licensee shall develop and implement smoking policies and designate smoking areas in accordance with RSA 155:66-69 and He-P 826.26.

(ac) The licensee may hold or manage a client's funds or possessions only when the facility receives 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 clients, or other household members.

(ad) The SUD-RTF may perform the following Clinical Laboratory Improvement Amendments (CLIA) waived tests, as per 42 CFR Part 493.15, without obtaining a NH state laboratory license:

(1) Urine drug screen;

(2) Alcohol screen; and

(3) Urine pregnancy.

(ae) If the licensee collects urine specimens for laboratory testing, the licensee shall follow the manufacturer's instructions and the reference laboratory's instructions for collection, transporting, and storage of urine specimens.

(af) If the licensee collects other human specimens it shall be licensed as a collection station in accordance with He-P 817.

(ag) If the SUD-RTF performs any laboratory test other than those exempted by (ad) above, the licensee shall be licensed as a laboratory in accordance with He-P 808.

(ah) The SUD-RTF shall hold the appropriate CLIA certificate to perform any laboratory tests.

(ai) The licensee shall maintain the manufacturer's test system instructions including package inserts and operator's manuals.

N.H. Admin. Code § He-P 826.14

(See Revision Note at Part Heading for He-P 826) #12658, eff 11-1-18

Derived From Volume XXXVIII Number 45, Filed November 8, 2018, Proposed by #12658, Effective 11/1/2018, Expires 11/1/2028.

Amended by Volume XXXIX Number 50, Filed December 12, 2019, Proposed by #12928, Effective 11/26/2019, Expires 11/26/2029.