N.H. Admin. Code § He-P 826.18

Current through Register No. 45, November 7, 2024

Section He-P 826.18 - Personnel

(a) The licensee shall ensure that sufficient numbers of qualified personnel are present in the SUD-RTF to meet the needs of clients at all times.

(b) There shall be at least one awake personnel member on duty at all times while clients are in the facility.

(c) For all applicants for employment, for all volunteers, for all independent contractors who will provide direct care or personal care services to clients or who will be unaccompanied by an employee while performing non-direct care or non-personal care services within the facility, the licensee shall:

(1) Obtain and review a criminal records check from the New Hampshire department of safety, except, pursuant to RSA 151:2-d, VI, for those licensed by the New Hampshire board of nursing;

(2) Review the results of the criminal records check in accordance with (d) below;

(3) Verify the qualifications of all applicants prior to employment; and

(4) Verify that the applicant is not listed on the BEAS registry maintained by the department's bureau of elderly and adult services.

(d) Unless a waiver is granted in accordance with (f) (2) below, the licensee shall not offer employment, contract with, or engage a person in (c) above, if the person:

(1) Has been convicted of a felony in this or any other state;

(2) Has been convicted for sexual assault, other violent crime, assault, fraud, theft, abuse, neglect, or exploitation in this or any other state;

(3) Has been found by the department or any administrative agency in this or any other state for assault, fraud, theft, abuse, neglect, or exploitation of any person; or

(4) Otherwise poses a threat to the health, safety, or well-being of the clients.

(e) If the information identified in (d) above regarding any person in (c) above is learned after the person is hired, contracted with, or engaged, or after the person becomes a household member, the licensee shall immediately notify the department and either:

(1) Cease employing, contracting with, or engaging the person, or not permit the household member to continue to reside in the residence; or

(2) Request a waiver of (d) above.

(f) If a waiver of (d) above is requested, the department shall review the information and the underlying circumstances in (d) above and shall either:

(1) Notify the licensee that the person cannot or can no longer be employed, contracted with, or engaged by the licensee, or the person cannot or can no longer reside in the facility if, after investigation, it determines that the person poses a threat to the health, safety, or well-being of a client; or

(2) Grant a waiver of (d) above if, after investigation, it determines that the person does not pose a current threat to the health, safety, or well-being of a client(s) .

(g) The licensee shall:

(1) Not employ, contract with, or engage, any person in (c) above who is listed on the BEAS state registry unless a waiver is granted by BEAS; and

(2) Only employ, contract with, or engage persons in (c) above who are listed on the NH board of nursing unless a waiver is granted by the NH board of nursing.

(h) In lieu of (c) and (g) above, the licensee may accept from independent agencies contracted by the licensee or by an individual client to provide direct care or personal care services a signed statement that the agency's employees have complied with (c) and (g) above and do not meet the criteria in (d) and (g) above.

(i) Administrators shall be at least 21 years of age and have a minimum of one of the following combinations of education and experience:

(1) A bachelor's degree from an accredited institution and one year of relevant experience working in a health related field;

(2) A New Hampshire license as an RN, with at least one year relevant experience working in a health related field;

(3) An associate's degree from an accredited institution plus 3 years relevant experience in a health related field;

(4) A MLADC or LADC license issued by the State of New Hampshire; or

(5) Licensed by the board of mental health practice with at least one year of relevant experience working in substance use disorder treatment.

(j) All administrators shall obtain and document in accordance with (q) (7) and (q) (8) below, 12 hours of continuing education related substance use disorder services each annual licensing period.

(k) The licensee shall employ or contract with a medical director who is:

(1) A licensed practitioner who is licensed in the state of New Hampshire; and

(2) Has experience providing medical services to clients with behavioral health or substance use disorder needs.

(l) All direct care personnel shall be at least 18 years of age unless they are:

(1) A licensed nursing assistant working under the supervision of a nurse in accordance with Nur 700; or

(2) Involved in an established educational program working under the supervision of licensed staff.

(n) The licensee shall inform personnel of the line of authority at the SUD-RTF.

(n) The licensee shall educate personnel about the needs and services required by the clients under their care.

(o) Prior to having contact with clients or food, personnel shall:

(1) Submit to the licensee the results of a physical examination or a health screening performed by a licensed nurse or a licensed practitioner and the results of a 2-step tuberculosis (TB) test, Mantoux method, or other method approved by the Centers for Disease Control, both conducted not more than 12 months prior to employment, contract, or engagement;

(2) Be allowed to work while waiting for the results of the second step of the TB test when the results of the first step are negative for TB; and

(3) Comply with the requirements of the Centers for Disease Control and Prevention "Guidelines for Preventing the Transmission of M. tuberculosis in Health-Care Settings" (2005 edition), available as noted in Appendix A, if the person has either a positive TB test, or has had direct contact or potential for occupational exposure to M. tuberculosis through shared air space with persons with infectious tuberculosis.

(p) In lieu of (o) (1) above, independent agencies contracted by the facility or by an individual client to provide direct care or personal care services may provide the licensee with a signed statement that its employees have complied with (o) (1) and (3) above before working at the SUD-RTF.

(q) Prior to having contact with clients or food, personnel shall receive a tour of and orientation to the SUD-RTF that includes the following:

(1) The clients' rights in accordance with RSA 151:20;

(2) The SUD-RTF's complaint procedures;

(3) The duties and responsibilities of the position;

(4) The medical emergency procedures;

(5) The emergency and evacuation procedures;

(6) The infection control procedures as required by He-P 826.21;

(7) The facility confidentiality requirements;

(8) Grievance procedures for both staff and clients;

(9) The procedures for food safety for personnel involved in preparation, serving, and storing of food; and

(10) The mandatory reporting requirements including RSA 161-F:46 and RSA 169-C:29.

(r) The licensee shall provide all personnel with an annual continuing education or in-service education training, which at a minimum contains the following:

(1) The licensee's client's rights and complaint procedures required under RSA 151;

(2) The licensee's infection control program;

(3) The licensee's written emergency plan;

(4) The provisions of 42 CFR Part 2;

(5) The licensee's policies and procedures; and

(6) The mandatory reporting requirements including RSA 161-F:46 and RSA 169-C:29.

(s) The SUD-RTF shall maintain a separate employee file for each employee, which shall include the following:

(1) A completed application for employment or a resume;

(2) Proof that the individual meets the minimum age requirements;

(3) A statement signed by each individual that he or she has received a copy of and received training on the implementation of the licensee's policy setting forth the clients rights and responsibilities as required by RSA 151:21;

(4) A copy of the results of the criminal record check as described in (c) above;

(5) A job description signed by the individual that identifies the:

a. Position title;

b. Qualifications and experience; and

c. Duties required by the position;

(6) Record of satisfactory completion of the orientation program required by (r) above;

(7) Information as to the general content and length of all in-service or educational programs attended;

(8) Record of satisfactory completion of all required education programs required by (s) above;

(9) A copy of each current driver's license, including proof of insurance, if the employee transports clients using their own vehicle;

(10) Documentation that the required physical examinations, health screenings, TB test results, and radiology reports of chest x-rays, if required, have been completed by the appropriate health professionals;

(11) The statement required by (v) below; and

(12) The results of the registry checks in (g) above.

(t) The SUD-RTF shall maintain the records, but not necessarily a separate file, for all volunteers and for all independent contractors who provide direct care or personal care services to clients or who will be unaccompanied by an employee while performing non-direct care or non-personal care services within the facility, as follows:

(1) For volunteers, the information in (s) (1), (3), (4), (6), and (8) -(12) above; and

(2) For independent contractors, the information in (s) (3), (4), (6), and (8) -(12) above, except that the letter in (h) and (o) above may be substituted for (s) (4), (10), and (12) above, if applicable.

(u) All personnel shall sign a statement at the time the initial offer of employment is made and then annually thereafter stating that they:

(1) Do not have a felony conviction in this or any other state;

(2) Have not been convicted of a sexual assault, other violent crime, assault, fraud, abuse, neglect, or exploitation or pose a threat to the health, safety, or well-being of a client; or

(3) Have not had a finding by the department or any administrative agency in this or any other state for assault, fraud, abuse, neglect, or exploitation of any person.

(v) An individual shall not have to re-disclose any of the matters in (u) above if the documentation is available and the department has previously reviewed the material and determined that the individual can continue employment, contract, or engagement.

(w) The licensee shall protect and store in a secure and confidential manner all records described in (s) and (t) above.

(x) The licensee shall document evidence of immunization against influenza and pneumococcal disease for all consenting employees and shall provide to its consenting employees annual immunizations against influenza, to include:

(1) That immunizations shall be provided and reported in accordance with RSA 151:9-b, I-V; and

(2) The facility shall have a plan that identifies and documents, with dates, employees that have received or declined to receive immunizations.

(y) Personnel shall not be impaired while on the job by any substances including, but not limited to, legally prescribed medication, therapeutic cannabis, or alcohol.

(z) The SUD-RTF shall have a written policy, as described in RSA 151:41, establishing procedures for the prevention, detection, and resolution of controlled substance misuse, and diversion, which shall apply to all personnel, and which shall be the responsibility of a designated employee or interdisciplinary team.

(aa) The policy in (z) above shall include:

(1) Education;

(2) Procedures for monitoring the distribution and storage of controlled substances;

(3) Voluntary self-referral by employees who are misusing substances;

(4) Co-worker reporting procedures;

(5) Drug testing procedures to include at a minimum, testing where reasonable suspicion exists;

(6) Employee assistance procedures;

(7) Confidentiality;

(8) Investigation, reporting, and resolution of controlled drug misuse or diversion; and

(9) The consequences for violation of the controlled substance misuse, and diversion prevention policy.

N.H. Admin. Code § He-P 826.18

(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.