Current through Register No. 40, October 3, 2024
(a) The
department shall impose administrative remedies for violations of RSA 151, He-P
802, or other applicable licensing rules, including:
(1) Requiring a licensee to submit a POC in
accordance with (c) below;
(2)
Imposing a directed POC upon a licensee in accordance with (d) below;
(3) Imposing conditions on a
licensee; or
(4) Monitoring of a
license.
(b) When
administrative remedies are imposed, the department shall provide a written
notice, as applicable, which:
(1) Identifies
each deficiency in which the licensee is not in compliance with RSA 151 or He-P
802; and
(2) Identifies the
specific remedy(s) that has been imposed.
(c) A POC shall be developed and enforced in
the following manner:
(1) Upon receipt of a
notice of deficiencies, the licensee shall submit a written POC detailing:
a. How the licensee intends to correct each
deficiency;
b. What measures will
be put in place, or what system changes will be made to ensure that the
deficiency does not recur, including how the measures are evaluated for
effectiveness;
c. The date by which
each deficiency shall be corrected; and
d. The position(s) of the employee(s)
responsible for the corrective action;
(2) The licensee shall submit the POC in (c)
above to the department within 21 days of the date on the letter that
transmitted the inspection report unless the licensee requests, either verbally
or in writing, and the department agrees, to extend that deadline based on the
following criteria:
a. The licensee
demonstrates that it has made a good faith effort to develop and submit the POC
within the 21-day period but has been unable to do so; and
b. The department determines that the health,
safety, or well-being of the patients, personnel, or visitors 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 802;
b. Addresses
all deficiencies and deficient practices as cited in the inspection
report;
c. Prevents a new violation
of RSA 151 or He-P 802 as a result of the implementation of the POC;
d. Identifies the position(s) of the
employee(s) responsible for the corrective action; and
e. Specifies the date upon which the
deficiencies will be corrected;
(4) If the POC is acceptable, the department
shall issue a license certificate or provide written notification of acceptance
of the POC, whichever is applicable;
(5) If the POC is not acceptable:
a. The department shall notify the licensee
in writing of the reason for rejecting the POC;
b. The licensee 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 licensee requests an extension, either verbally or in writing, and
the department grants the extension, based on the following criteria:
1. The licensee demonstrates that it made a
good faith effort to develop and submit the POC within the 14-day period but
has been unable to do so; and
2.
The department determines that the health, safety, or well-being of a patient
will not be jeopardized as a result of granting the waiver;
c. The revised POC shall comply
with (c) (1) above and be reviewed in accordance with (c) (3) above;
and
d. If the revised POC is not
acceptable to the department, or is not submitted in accordance with this
section, the licensee shall be subject to a directed POC in accordance with (d)
below and a fine in accordance with
He-P 802.13(c)
(12) ;
(6) Following the date of completion
specified by the licensee in the POC, the department shall verify the
implementation of any POC by:
a. Reviewing
materials submitted by the licensee;
b. Conducting an onsite follow-up inspection;
or
c. Reviewing compliance during
the next annual inspection; and
(7) If the POC or revised POC has not been
implemented as verified by (6) above, the licensee shall be:
a. Notified by the department in accordance
with (b) above;
b. Issued a
directed POC in accordance with (d) below; and
c. Subject to a fine in accordance with He-P
802(c) (13) .
(d) The department shall develop and impose a
directed POC that specifies corrective actions for the licensee to implement
when:
(1) As a result of an inspection,
deficiencies were identified that require immediate corrective action to
protect the health and safety of the patients and personnel; and
(2) A POC or revised POC is not submitted or
accepted in accordance with (c) (1) and (5) respectively.
(e) The department shall offer an opportunity
for informal dispute resolution to any licensee 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 licensee submits a written
request for an informal dispute resolution to the department.
(f) The informal dispute resolution shall be
requested in writing by the licensee or administrator no later than 14 days
from the date the statement of findings or notice to correct was issued by the
department.
(g) The department
shall change the statement of findings or notice to correct if, based on the
evidence presented, the statement of findings is determined to be incorrect.
The department shall provide a written notice to the licensee of the
determination.
(h) The deadline to
submit a POC in accordance with (c) (2) above shall not apply until the notice
of the determination in (g) above has been provided to the licensee.
(i) Any violations cited for the state fire
code may be appealed to the New Hampshire state fire marshal and shall not be
the subject of informal dispute resolution as describe in this
section.
(j) An informal dispute
resolution shall not be available for any licensee against whom the department
has imposed an administrative fine, or initiated action to suspend, revoke,
deny, or refuse to issue or renew a license.
(k) The department shall impose state
monitoring if it determines that repeated poor compliance or the conditions of
the facility might negatively impact the health, safety, or well-bring of
patients.
#2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED:
1-28-92; ss by #5317, EMERGENCY, eff 1-29-92, EXPIRED 5-28-92
New. #5846, eff 6-22-94,
EXPIRED: 6-22-00
New. #9580, eff
10-24-09
