New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Chapter He-P 800 - RESIDENTIAL CARE AND HEALTH FACILITY RULES
Part He-P 802 - RULES FOR HOSPITALS
Section He-P 802.14 - Duties and Responsibilities of All Licensees

Universal Citation: NH Admin Rules He-P 802.14

Current through Register No. 40, October 3, 2024

(a) The licensee shall comply with all relevant federal, state, and local laws, rules, codes, and ordinances, including RSA 161-F:49 and rules promulgated thereunder, and:

(1) For Medicare Certified Hospitals (Acute), CMS federal regulation at 42 CFR Part 482 ;

(2) For Medicare Certified Critical Access Hospitals (CAH), CMS federal regulations at 42 CFR Part 485 ;

(3) For Medicare Certified Psychiatric Hospitals, CMS federal regulations at 42 CFR Part 482 ;

(4) For Medicare Certified Rehabilitation Hospitals, CMS federal regulations at 42 CFR Part 482 ;

(5) For Medicare Certified Hospitals with Prospective Payment System Units for Psych or Rehab, CMS federal regulations at 42 CFR Part 412 ; and

(6) For any newly licensed and certified hospital not specified as an acute, rehab, psych, or CAH hospital, all applicable CMS federal regulations for that hospital's particular designation.

(b) The licensee shall comply with the patients' bill of rights as set forth in RSA 151:19-21.

(c) The licensee shall define, in writing, the scope and type of services to be provided by the hospital, which shall include, at a minimum, the required services listed in He-P 802.18.

(d) The licensee shall develop and implement written policies and procedures governing the operation and all services provided by the licensee.

(e) By January 1, 2023, the licensee shall complete and implement an operational plan for the recognition and management of patients with dementia or delirium in accordance with RSA 151:2-I. The licensee shall keep the plan on file and make the plan available to the department of health and human services, bureau of licensing and certification upon request.

(f) All policies and procedures shall be reviewed per licensee policy.

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

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

(i) Except for the requirements of RSA 151:4, III(a)(5), the licensee shall not:

(1) Advertise or otherwise represent itself as operating a hospital or providing a special health care service, unless it is licensed; and

(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) Licensees shall:

(1) Meet the needs of the patients during those hours that the patients are in the care of the licensee;

(2) Establish, in writing, a chain of command that sets forth the line of authority for the operation of the hospital or special health care service;

(3) Appoint an administrator;

(4) Verify the qualifications of all personnel;

(5) Provide sufficient numbers of qualified personnel to meet the needs of patients during all hours of operation;

(6) Provide sufficient supplies, equipment, and lighting to meet the needs of the patients; and

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

(l) The licensee shall consider all patients to be competent and capable of making health care decisions unless the patient:

(1) Has a guardian appointed by a court;

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

(3) Is an un-emancipated minor.

(m) The licensee shall not exceed the number of occupants authorized by NFPA 101 as adopted pursuant to RSA 153:1, VI-a and amended in Saf-FMO 300 by the fire marshal with the board of fire control, pursuant to RSA 153:5.

(n) If the licensee accepts a patient 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 follow the required procedures for the care of the patients, 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.

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

(p) The licensee shall implement measures to ensure the safety and stabilizing treatment of patients who are assessed as an elopement risk or danger to self or others.

(q) 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) All inspection reports issued in accordance with He-P 802.09(b), for the previous 12 months;

(3) A copy of the patients' bill of rights;

(4) A copy of the licensee's policies and procedures relative to the implementation of patient 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 by calling 1-800-852-3345 x 9499 or in writing, to the:

Department of Health and Human Services

Office of Legal and Regulatory Services

Health Facilities Administration

129 Pleasant Street, Concord, NH 03301; and

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

(r) 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 802 as authorized by RSA 151:6 and RSA 151:6-a.

(s) Licensees shall, in accordance with He-P 802.15:

(1) Report all adverse events to the department;

(2) Submit additional information if required by the department; and

(3) Report the event to other agencies as required by law.

(t) The licensee shall immediately notify the local police department, the guardian and agent if any, when a patient, who has been assessed or is known as being a danger to self or others, has an unexplained absence after the licensee has searched the building and the grounds of the hospital.

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

(v) All records required by law or this rule 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.

(w) Any licensee that maintains electronic records shall develop written policies and procedures designed to protect the privacy of patients 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 patients and personnel; and

(3) Systems to prevent tampering with information pertaining to patients and personnel.

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

(y) The licensee shall provide cleaning and maintenance services, as needed to protect patients, personnel, and the public.

(z) The building housing the licensed facility shall comply with all state and local:

(1) Health requirements;

(2) Building ordinances;

(3) Fire ordinances; and

(4) Zoning ordinances.

(aa) Smoking shall be prohibited in the licensed facility as required by RSA 155:66, I(b).

(ab) If the licensee is not on a public water supply, the water used by the licensee shall be suitable for human consumption, pursuant to Env-Dw 702.02 and Env-Dw 704.02.

(ac) If the licensee holds or manages a patient's funds or possessions, it shall first receive 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 patients, or other household members.

(ad) The licensee shall have written policies on the proper completion of an involuntary emergency admission certificate for those in need of mental health treatment that:

(1) Are in compliance with RSA 135-C:27-33 and He-M 613; and

(2) Detail the medical screening examination and stabilizing treatment provided to patients with mental health needs.

#2144, eff 9-28-82; 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

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