Current through Register No. 40, October 3, 2024
(a) The licensee
shall ensure that sufficient numbers of qualified staff are present in the
facility to meet the needs of patients at all times.
(b) For all applicants for employment, for
all volunteers, or for all independent contractors who will provide direct care
or personal care services to patients, the licensee shall:
(1) Obtain and review a criminal records
check from the New Hampshire department of safety, except those exempted
pursuant to
RSA 151:2-d,
VI;
(2) Review the results of the criminal
records check in accordance with (c) below;
(3) Verify the qualifications of all
applicants prior to employment; and
(4) Verify that the applicant is not on the
List of Excluded Individuals/Entities, maintained by the U.S. Department of
Health and Human Services Office of Inspector General.
(c) Unless a waiver is granted in accordance
with He-P 802.10 and(e) below, the licensee shall not employ, contract, or
engage an individual if that individual:
(1)
Has been convicted of any felony in this or any other state;
(2) Has been convicted of sexual assault,
other violent crime, assault, fraud, theft, abuse, neglect, or exploitation in
this or any other state;
(3) Has
had a finding by the department or any administrative agency in this or any
other state for assault, fraud, theft, abuse, neglect, or exploitation or any
person; or
(4) Otherwise poses a
threat to the health, safety or well-being of patients.
(d) If the licensee discovers that an
individual meets one of the criteria in (c) above and that individual is
already employed, contracted with, or engaged, the licensee shall immediately
notify the department and either:
(1) Cease
employing, contracting with, or engaging the individual; or
(2) Request a waiver of (c) above.
(e) If a waiver of (c) above is
requested, the department shall review the information and the underlying
circumstances and shall either:
(1) Notify
the licensee that the person cannot or can no longer be employed, contracted
with, or engaged by the licensee if the department determines that the person
poses a threat to the health, safety, or well-being of a patient; or
(2) Grant a waiver pursuant to
He-P 802.10 if the
department determines that the person does not pose a current threat to the
health, safety, or well-being of a resident(s) .
(f) The licensee shall check the names of the
persons in (c) above against the bureau of elderly and adult services (BEAS)
state registry, maintained pursuant to
RSA 161-F:49 and He-E
720, the NH board of nursing, nursing assistant registry, maintained pursuant
to
RSA
326-B:26 and
42 CFR
483.156, and the medical technician registry,
maintained pursuant to RSA 328-I prior to employing, contracting with, or
engaging them.
(g) The licensee
shall:
(1) Not employ, contract with, or
engage, any person in (b) above who is listed on the BEAS state registry unless
a waiver is granted by BEAS;
(2)
Only employ, contract with, or engage board of nursing licensees who are listed
on the nursing assistant registry; and
(3) Only employ, contract with, or engage
medical technicians who are listed on the medical technician
registry.
(h) In lieu of
(e) and (g) above, the licensee may accept from independent agencies contracted
by the licensee or by an individual patient to provide direct care or personal
care services a signed statement that the agency's employees have complied with
(c) and (f) above and are allowable under (e) and (g) above.
(i) Prior to having contact with patients or
food, all personnel shall:
(1) Receive a tour
of the employee's work environment relative to their position;
(2) Receive a copy of the job description for
his or her position containing:
a. Duties and
responsibilities of the position;
b. Physical requirements of the position;
and
c. Education and experience
requirements of the position;
(3) Meet the educational and physical
qualifications of the position as listed in their job description;
(4) Be licensed, registered, or certified as
required by state statute and as applicable;
(5) Receive an orientation within the first 3
days of work or prior to the assumption of duties that includes:
a. The licensee's policies on rights and
responsibilities and complaint procedures as required by
RSA
151:20;
b. The procedures for food safety for
personnel involved in preparation, serving, and storing of food;
c. The licensee's infection control
program;
d. The licensee's fire,
evacuation and emergency plans which outline the responsibilities of personnel
in an emergency;
e. Mandatory
reporting requirements for abuse or neglect such as those found in RSA 161-F
and
RSA
169-C:29; and
f. Beginning no later than January 1, 2023,
the recognition and management of patients with dementia or delirium, in
accordance with the licensee's operational plan developed pursuant to
He-P
802.14(e) ;
(6) 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;
(7) 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;
(8) Comply with the requirements of the
United States Centers for Disease Control "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
Mycobacterium tuberculosis through shared air space with persons with
infectious tuberculosis; and
(9)
Comply with all public health guidelines with requirements for infectious
disease reporting and management.
(j) All personnel shall complete a mandatory
annual in-service education, which includes a review of the licensee's:
(1) Policies and procedures required under
He-P 802;
(2) Infection control
program;
(3) Education program on
fire and emergency procedures;
(4)
Mandatory reporting requirements including
RSA
161-F:46 and
RSA
169-C:29; and
(5) Beginning no later than January 1, 2023,
plan regarding the recognition and management of patients with dementia or
delirium, in accordance with the licensee's operational plan developed pursuant
to
He-P
802.14(e) .
(k) Personnel who have direct contact with
patients who have a history of TB or a positive laboratory and antigen testing
shall have a symptomatology screen of a TB test.
(l) Current and complete personnel files
shall be maintained and stored in a secure and confidential manner at the
hospital.
(m) The licensee shall
maintain a separate employee file which shall include, at a minimum, the
following:
(1) A completed application for
employment or a resume;
(2) A
signed statement acknowledging the receipt of the licensee's policy setting
forth the patient's rights and responsibilities, and acknowledging training and
implementation of the policy as required by
RSA
151:20;
(3) A signed and dated job description;
(4) A record of satisfactory
completion of the orientation program required by (i) (5) above;
(5) A copy of each current New Hampshire
license, registration, or certification in health care field and CPR
certification, if applicable;
(6)
Documentation that the required physical examination, or health screening, and
TB test results or radiology reports of chest x-rays, if required, have been
completed by the appropriate health professionals;
(7) A record of satisfactory completion of
all required education programs and demonstrated competencies that are signed
and dated by the employee as required by (j) above;
(8) Documentation of any performance reviews
conducted;
(9) Information as to
the general content and length of all continuing education or educational
programs attended;
(10) A
statement, which shall be signed at the time the initial offer of employment,
contract, or engagement is made and then annually thereafter, stating that he
or she:
a. Does not have a felony conviction
in this or any other state;
b. Has
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 patient in this or any other state; and
c. Has 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 in this or any other state;
(11) A copy of the results of a
criminal records check;
(12)
Documentation that the individual or entity is not on the List of Excluded
Individuals/Entities, maintained by the U.S. Department of Health and Human
Services Office of Inspector General; and
(13) The results of the registry check in (f)
above.
(n) The licensee
shall maintain the records, but not necessarily a separate rile, for all
volunteers and for all independent contractors who provide direct care or
personal care services to patients, as follows:
(1) For volunteers, the information in (m)
(1), (3), (4), (6), and (8) -(12) above; and
(2) For independent contractors, the
information in (m) (3), (4), (6), and (8) -(12), except that the letter in (h)
above may be substituted for (m) (11) and (13) .
#5846, eff 6-22-94, EXPIRED: 6-22-00
New. #9580, eff
10-24-09
