Current through Register No. 40, October 3, 2024
(a) The
certificate holder shall comply with all federal, state, and local laws, rules,
codes, ordinances, licenses, permits, and approvals, and any rules promulgated
thereunder, as applicable.
(b) The
certificate holder shall define, in writing, the scope and type of services to
be provided by the OTP.
(c) The
certificate holder shall monitor, assess, and improve, as necessary, the
quality of care and services provided to clients on an ongoing basis.
(d) The certificate holder shall develop and
implement written policies and procedures governing its operation and all
services provided. Such policies shall be submitted to the bureau upon
request.
(e) If an existing policy
fails to support the health, safety, and well-being of clients, staff, and the
public, the OTP shall be required to submit a POC in accordance with
He-A
304.09.
(f) All policies and procedures shall be
reviewed annually and revised as needed.
(g) All staff shall receive a minimum of 8
hours annually of in-service training on OTP policies and procedures.
(h) The certificate holder shall:
(1) Employ an administrator responsible for
the day-to-day operation of the OTP; and
(2) Establish, in writing, a chain of command
that sets forth the line of authority for the operation of the OTP and the
staff position(s) to be delegated the authority and responsibility to act on
the administrator's behalf when the administrator is absent.
(i) The certificate holder shall
post the following documents in a public area:
(1) The current certification issued in
accordance with these rules;
(2) A
copy of the certificate holder's policies and procedures relative to the
implementation of client rights and responsibilities, including client
confidentiality per 42 CFR Part 2; and
(3) The certificate holder's plan for fire
safety, evacuation, and emergencies identifying the location of, and access to,
all fire exits.
(j) The
certificate holder or any employee shall not falsify any documentation or
provide false or misleading information to the department.
(k) The certificate holder shall comply with
all conditions of warnings, administrative remedies, and enforcement actions
issued by the department, and all court orders.
(l) The certificate holder shall admit and
allow any department representative to inspect the certified premises and all
programs and services that are being provided at any time during regular
business hours for the purpose of determining compliance with these
rules.
(m) Certificate holders
shall:
(1) Report all critical incidents to
the bureau in writing as soon as possible and no more than 24 hours following
the incident;
(2) Report all
contact with law enforcement to the bureau in writing as soon as possible and
no more than 24 hours following the incident;
(3) Report all media contacts to the bureau
in writing as soon as possible and no more than 24 hours following the
incident;
(4) Report all sentinel
events to the department as follows:
a.
Sentinel events shall be reported when they involve any individual who is
receiving services governed by this rule;
b. Upon discovering the event, the OTP shall
provide immediate verbal notification of the event to the bureau, which shall
include:
1. The reporting individual's name,
phone number, and agency/organization;
2. Name and date of birth (DOB) of the
individual(s) involved in the event;
3. Location, date, and time of the
event;
4. Description of the event,
including what, when, where, how the event happened, and other relevant
information, as well as the identification of any other individuals
involved;
5. Whether the police
were involved due to a crime or suspected crime; and
6. The identification of any media that had
reported the event;
c.
Within 72 hours of the sentinel event, the OTP shall submit a completed
"Sentinel Event Reporting Form" (February 2017), available at
https://www.dhhs.nh.gov/dcbcs/documents/reporting-form.pdf to the
bureau;
d. Additional information
on the event that is discovered after filing the form in c. above shall be
reported to the bureau, in writing, as it becomes available or upon request of
the bureau; and
e. Reporting in c.
and d. above shall be completed through the E-Studio web application, available
at https://nh.same-page.com [File Link Not Available];
(5) Submit additional information regarding
(1) - (4) above if required by the department; and
(6) Report the event in (1) - (4) above, as
applicable, to other agencies as required by law.
(n) The certificate holder shall implement
policies and procedures for reporting:
(1)
Suspected child abuse, neglect, or exploitation, in accordance with
RSA
169-C:29-30; and
(2) Suspected abuse, neglect, or exploitation
of adults, in accordance with RSA 149-F:49.
(o) The certificate holder shall report all
positive tuberculosis test results for personnel to the department's bureau of
disease control in accordance with
RSA
141-C:7,
He-P 301.02
and
He-P
301.03.
(p) Certificate holders shall develop
policies and procedures to implement state and federal regulations on client
confidentiality, including provisions outlined in 42 CFR, Part 2,
RSA
172:8-a, and
RSA
318-B:12.
(q) A certificate holder shall, upon request,
provide a client or the client's guardian or agent, if any, with a copy of his
or her client record.
(r) All
records required for certification shall be legible, current, accurate, and
available to the department during an inspection or investigation conducted in
accordance with these rules.
(s)
Any certificate holder that maintains electronic records shall develop written
policies and procedures designed to protect the privacy of clients and
personnel that are consistent with all state and federal regulations and, 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.
(t) The certificate holder's service site(s)
shall:
(1) Be accessible to a person with a
disability using ADA accessibility and barrier free guidelines per
42
U.S.C. 12131 et seq;
(2) Have a reception area separate from
service areas;
(3) Have private
space for personal consultation, charting, service delivery, and social
activities, as applicable;
(4) Have
secure storage of active and closed confidential client records; and
(5) Have separate and secure storage of toxic
substances.
(u) The
certificate holder shall establish and monitor a code of ethics for the OTP and
its staff, as well as a mechanism for reporting unethical conduct to the
department, appropriate licensing boards, and any other oversight
entities.
(v) The certificate
holder shall maintain specific written policies on the following:
(1) Client rights and
responsibilities;
(2) Grievance
policies and procedures for staff and clients including:
a. Specific time frames for written responses
to the client's written request for consideration or reconsideration of a OTP
decision;
b. Process for escalating
unresolved grievances within the OTP; and
c. Information about making complaints to the
department;
(3)
Progressive discipline, leading to administrative discharge, including
behaviors that may lead to progressive discipline and/or administrative
discharge;
(4) Policies on client
alcohol and other drug use while receiving OTP services;
(5) Policies to create a tobacco-free
environment, which, at a minimum, shall:
a.
Include the smoking of any tobacco product, the use of oral tobacco products or
"spit" tobacco, and the use of electronic devices for smoking or
vaping;
b. Apply to employees,
clients, and visitors;
c. Prohibit
the use of tobacco products within the OTP's facilities at any time;
d. Include whether or not use of tobacco
products is prohibited outside of the facility on the grounds and if use of
tobacco products is allowed outside of the facility on the grounds:
1. There shall be a designated smoking
area(s) which is located at least 20 feet from the main entrance;
2. All materials used for smoking in this
area, including cigarette butts and matches, shall be extinguished and disposed
of in appropriate containers; and
3. OTPs shall ensure periodic cleanup of the
designated smoking area;
e. Prohibit the use of tobacco in any OTP
owned vehicle;
f. Prohibit tobacco
use in personal vehicles when transporting clients or staff on authorized
business;
h. Post the tobacco free
environment policy in the OTP's facilities and vehicles; and
i. Provide the policy to employees, clients,
and visitors at orientation, as applicable;
(6) Drug-free workplace policy and
procedures, including a requirement for the filing of written reports of
actions taken in the event of staff misuse of alcohol or other drugs;
(7) Client and staff exposure to synthetic
opioids, including but not limited to fentanyl and carfentanyl;
(8) Procedures for the prevention, detection,
and resolution of controlled substance misuse and diversion, which shall:
a. Apply to all personnel;
b. Be the responsibility of a designated
employee or interdisciplinary team; and
c. Include the following:
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;
(9) A client medication
policy;
(10) Urine specimen
collection, as applicable, that:
a. Ensures
that collection is conducted in a manner that preserves client privacy as much
as possible; and
b. Minimizes
falsification;
(11)
Safety and emergency procedures on the following:
a. Medical emergencies;
b. Infection control and universal
precautions, including the use of protective clothing and devices;
c. Reporting employee injuries;
d. Fire monitoring, warning, evacuation, and
safety drill policy and procedures;
e. Emergency closings; and
f. Posting of the above safety and emergency
procedures;
(12)
Procedures for protection of client records that govern use of records,
storage, removal, conditions for release of information, and compliance with
the 42 CFR, Part 2 and the Health Insurance Portability and Accountability Act
(HIPAA); and
(13) Procedures
related to quality assurance and quality improvement.
(w) The OTP shall ensure that all staff
having direct contact with clients have been trained in the administration of
naloxone and that naloxone kits are readily available for staff use at all
times.
(x) The OTP shall ensure
that all staff have annual in-service training in the content and
implementation of He-A 304.
#7496, eff 5-23-01; amd by #7599, eff 11-20-01; ss by
#9476, eff 5-22-09 (from
He-A
304.10)
