Current through Register No. 40, October 3, 2024
(a) The
department shall impose administrative remedies for violations of RSA 151, He-P
806, or other applicable licensing rules, including:
(1) Requiring a licensee to submit a POC in
accordance with He-P 806.12(c);
(2)
Imposing a directed POC upon a licensee in accordance with He-P
806.12(d);
(3) Imposing conditions
upon 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 area of noncompliance with RSA151 or a provision of these rules;
and
(2) Identifies the specific
remedy(s) that has been proposed.
(c) A POC shall be developed and enforced in
the following manner:
(1) Upon receipt of a
statement of findings or a notice to correct, the licensee shall submit its
written POC for each item, written in the appropriate place on the statement or
notice and containing:
a. How the licensee
intends to correct each area on non-compliance;
b. What measures will be put in place, or
what system changes will be made to ensure that the non-compliance does not
recur, to include how the measures will be evaluated for
effectiveness;
c. The date by which
each area of non-compliance shall be corrected; and
d. The position of the employee responsible
for the corrective action;
(2) The licensee shall submit a POC to the
department within 21 days of the date on the letter that transmitted the
statement of findings or notice to correct 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 he or she has made a good faith effort to develop
and submit the POC within the 21calendar day period but has been unable to do
so; and
b. The department
determines that the health, safety or well-being of a patient will not be
jeopardized as a result of granting the extension;
(3) The department shall review each POC and
accept each plan that:
a. Achieves compliance
with RSA 151 and He-P 806;
b.
Addresses all areas of non-compliances as cited in the statement of findings or
notice to correct;
c. Prevents a
new violation of RSA 151 or He-P 806 as a result of the implementation of the
POC; and
d. Specifies the date upon
which the areas of non-compliance 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 within 14 days 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 via telephone or in writing
and the department grants the extension based on the following criteria:
1. The licensee demonstrates that he or she
has 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 extension;
c. The revised POC shall comply with He-P
806.12(c) (1) and be reviewed in accordance with He-P 806.12(c) (3);
and
d. If the revised POC is not
acceptable to the department, or is not submitted within 14-days of the date of
the written notification from the department that states the original POC was
rejected, the licensee shall be subject to a directed POC in accordance with
He-P 806.12(d) and a fine in accordance with
He-P 806.13(c)
(12) ;
(6) The department shall verify the
implementation of any POC that has been submitted and accepted by:
a. Reviewing materials submitted by the
licensee;
b. Conducting an onsite
follow-up inspection; or
c.
Reviewing compliance during the next annual inspection;
(7) Verification of the implementation of any
POC shall only occur after the date of completion specified by the licensee in
the plan; and
(8) If the POC or
revised POC has not been implemented by the completion date, at the time of the
next inspection the licensee shall be:
a.
Notified by the department in accordance with He-P 806.12(b); and
b. Issued a directed POC in accordance with
He-P 806.12(d) and a fine in accordance with
He-P 806.13(c)
(3) .
(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, areas
on non-compliance were identified that require immediate corrective action to
protect the health and safety of the patients and personnel;
(2) A revised POC is not submitted within
14-days of the written notification from the department; or such other date as
applicable if an extension was granted by the department; and
(3) A revised POC submitted by the licensee
or administrator has not been accepted.
(e) If at the time of the next inspection the
directed POC referenced in He-P 806.12(d) has not been implemented by the
completion date stated in the directed POC, the department shall:
(1) Impose a fine according to He-P 806.12(f)
(10);
(2) Deny the application for
a renewal of a license in accordance with
He-P 806.13(b)
; or
(3) Revoke the license in accordance with
He-P 806.13(b)
.
(f) The department shall offer an opportunity
for informal dispute resolution to any applicant or licensee who disagrees with
an area or areas of non-compliance cited by the department on a statement of
findings provided that the applicant or licensee submits a written request for
an informal dispute resolution to the department.
(g) The informal dispute resolution shall be
requested in writing by the applicant, licensee, or administrator no later than
14 days from the date the statement of findings was issued by the
department.
(h) The department
shall change the statement of findings if, based on the evidence presented, the
statement of findings is determined to be incorrect. The department shall
provide a written notice to the applicant or licensee of the
determination.
(i) The deadline to
submit a POC in accordance with He-P 806.12(c) shall not apply until the notice
of the determination in He-P 806.12(h) has been provided to the applicant or
licensee.
(j) 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.
(k) An informal dispute
resolution shall not be available for any applicant or licensee against who the
department has imposed an administrative fine, or initiated action to suspend,
revoke, deny, or refuse to issue or renew a license.
(l) The department shall impose state
monitoring under the following conditions:
(1)
Repeated non-compliance on the part of the facility in areas that impact the
health, safety, or well-being of clients; or
(2) The presence of conditions in the NEWCC
that negatively impact the health, safety, or well-being of patients.
#2349, eff 4-28-83; ss by #3193, eff 1-28-86; ss by
#5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92
New. #5512, eff 11-25-92; ss by
#6895, INTERIM, eff 11-26-98, EXPIRED: 3-26-99
New. #9655, eff
2-13-10
