N.H. Admin. Code § He-P 830.14

Current through Register No. 50, December 12, 2024

Section He-P 830.14 - 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 setting forth:

(1) The rights and responsibilities of clients in accordance with the patients' bill of rights;

(2) The policies described in He-P 830.14, He-P 830.16, He-P 830.19, and He-P 830.26; and

(3) A policy that ensures the safety of all persons present on the licensed premises where firearms are permitted.

(c) The licensee shall admit only those clients whose needs can be met by the PRTP.

(d) The licensee shall define, in writing, the scope and type of services to be provided by the PRTP.

(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 PRTP and all services provided by the facility and for:

(1) Reviewing the policies and procedures every 3 years; and

(2) Revising them as needed.

(g) The licensee shall assess and monitor the quality of care and service provided to clients on an ongoing basis.

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

(i) The licensee shall not:

(1) Advertise or otherwise represent itself as operating a PRTF, unless it is licensed; or

(2) Advertise that it provides services that it is not authorized to provide.

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

(k) The licensee shall provide the following core services:

(1) Health and safety services to minimize the likelihood of accident or injury, with protective care and oversight provided regarding:

a. The clients' functioning, safety, and whereabouts;

b. The clients' health status, including the provision of intervention as necessary or required; and

c. Personnel safety;

(2) Emergency response and crisis intervention;

(3) Medication services in accordance with He-P 830.17;

(4) Food services in accordance with He-P 830.20;

(5) Housekeeping, laundry, and maintenance services;

(6) On-site activities designed to sustain and promote physical, intellectual, social, and spiritual well-being of all clients;

(7) Assistance in arranging medical and dental appointments, including assistance in arranging transportation to and from such appointments and reminding the clients of the appointments; and

(8) Personal supervision of clients when necessary to prevent unreasonable risks to the safety of self or others if the client is not supervised.

(l) The licensee shall provide access, as necessary, to the following services pursuant to RSA 151:2, IV and RSA 151:9, VII(a)(4):

(1) Nursing services, in accordance with RSA 326-B, including supervision and instruction of direct care personnel, relative to the delivery of nursing care;

(2) Rehabilitation services, including documentation of the licensed practitioner's order for the service, such as physical therapy, occupational therapy, and speech therapy; and

(3) Behavioral health care services.

(m) Licensees shall:

(1) Appoint an administrator;

(2) Establish, in writing, a chain of command that sets forth the line of authority for the operation of the PRTP;

(3) Verify the qualifications of all personnel;

(4) Provide sufficient numbers of qualified personnel to meet the needs of adult clients;

(5) Maintain a minimum staff-to-client ratio of one staff person to 6 clients during awake hours and one staff person to 12 clients during sleeping hours, for children or youth clients;

(6) Provide additional staff when a client's treatment plan requires a more stringent staff to client ratio than required above;

(7) Provide sufficient supplies, equipment, and lighting to meet the needs of the clients;

(8) Require all personnel to follow the orders of the licensed practitioner for every client that has such orders and encourage the client to follow the licensed practitioner's orders;

(9) Initiate action to maintain the PRTP in full compliance at all times with all relevant health and safety requirements contained in applicable federal, state, and local laws, rules, regulations, accreditations, and ordinances; and

(10) Implement any POC that has been accepted by the department.

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

(o) Physical or chemical restraints shall only be used as allowed by RSA 151:21, IX.

(p) The licensee shall consider all clients competent and capable of making health care decisions unless the client:

(1) Has a guardian appointed by a court;

(2) Has a durable power of attorney for health care or surrogate decision making that has been activated; or

(3) Is an un-emancipated minor.

(q) In accordance with RSA 141-C:7, He-P 301.02, and He-P 301.03 the licensee shall report all positive tuberculosis test results for personnel to the office of infectious disease control by:

(1) Telephone at 603-271-4496;

(2) Telephone at 603-271-5300 after business hours; or

(3) Fax to 603-271-0545.

(r) If the licensee registers and treats a client 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:

(1) Follow the required procedures and personnel training for the care of the clients, 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; and

(2) Have an Airborne Infection Isolation (AII) Room, compliant with the Facility Guidelines Institute's (FGI) "Guidelines for Design and Construction of Hospitals" (2018 edition), available as noted in Appendix A.

(s) Immediately after the use of a physical or chemical restraint, the client's guardian or agent, if any, and the department shall be notified of the use of restraints.

(t) The PRTP shall:

(1) Have policies and procedures on:

a. What type of emergency restraints may be used;

b. When restraints may 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 chemical, mechanical, or physical restraints, as defined by He-P 830.03(q), (aq), and (bb), respectively, shall only be permitted as allowed by RSA 151:21.

(v) For reportable incidents, allegations of abuse, neglect, mistreatment, or misappropriation of property, the licensee 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 603 271-4968, or if a fax machine is not available, submitting via regular mail, postmarked within 24 hours of 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 24 hours of the reportable incident:

a. The PRTP 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 incident;

d. The name or identifying code for client(s) involved in or witnessing the incident;

e. The date and time of the incident;

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

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

h. Whether the client's guardian or agent, surrogate decision-maker, or personal representative, or emergency contact person was notified;

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

j. The date and time the client's licensed practitioner was notified, if applicable;

(3) Within 5 days, submitting a completed investigation report to the department containing the following information:

a. All items referenced in (1) above;

b. The names and results of interview(s) with all personnel, resident(s) or other individuals involved in the reportable incident, including all applicable statement signatures; and

c. The action taken by the licensee in direct response to the incident(s), including any and all follow-ups;

(4) Immediately notifying the local police department, the department, and the guardian, agent, surrogate decision-maker, or personal representative, if any, when a client who has been assessed or is known as being a danger to self or others, has eloped after the licensee has searched the building and the grounds of the PRTP; and

(5) Submit additional information, if required to the department, to support the incident report referenced in (w)(3) above;

(w) The licensee shall:

(1) Provide basic supplies necessary for clients to maintain grooming and personal hygiene, such as soap, shampoo, toothpaste, toothbrush, and toilet paper; and

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

(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) 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) The most recent inspection report as specified in RSA 151:6-a; 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 policies and procedures relative to the implementation of clients' rights and responsibilities as required by RSA 151:20;

(5) 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

(6) The licensee's evacuation floor plan identifying the location of, and access to all fire exits.

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

(1) For an increase in the cost or fees for any PRTP services 30 days advanced notice; or

(2) For an involuntary change in room or bed location, 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.

(aa) The licensee shall admit and allow any department representative to inspect the premises and all programs and services that are being provided by the licensee at any time for the purpose of determining compliance with RSA 151 and He-P 830 as authorized by RSA 151:6 and RSA 151:6-a.

(ab) A licensee shall, upon request, provide a client or the client's guardian, agent, or surrogate decision-maker if any, with a copy of his or her client record pursuant to the provisions of RSA 151:21, X.

(ac) 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.

(ad) Any licensee that maintains electronic records shall develop written policies and procedures designed to protect the privacy of clients 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 clients and staff; and

(3) Systems to prevent tampering with information pertaining to clients and staff.

(ae) The licensee shall develop policies and procedures regarding the release of information contained in client records.

(af) The licensed premises shall comply with all state and local:

(1) Health requirements;

(2) Building ordinances;

(3) Fire ordinances; and

(4) Zoning ordinances.

(ag) The licensee shall determine the smoking status of the PRTP.

(ah) If smoking is to be allowed, the licensee shall develop and implement smoking policies and designate smoking areas in accordance with RSA 155:66-69 and He-P 830.24(f).

(ai) 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 or other clients.

(aj) The licensee shall not falsify any documentation required by law or provide false or misleading information to the department.

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

N.H. Admin. Code § He-P 830.14

#6154, eff 12-29-95, EXPIRED: 12-29-03

New. #10059, eff 12-23-11

Amended by Volume XL Number 2, Filed January 9, 2020, Proposed by #12952, Effective 12/21/2019, Expires 6/18/2020.

Amended by Volume XLI Number 19, Filed May 13, 2021, Proposed by #13195, Effective 4/24/2021, Expires 4/24/2031.