Current through Register No. 40, October 3, 2024
(a) The licensee
shall comply with all relevant federal, state, and local laws, rules,
regulations, codes, and ordinances as applicable.
(b) The licensee shall admit only those
clients whose needs can be met by the RTRF.
(c) The licensee shall have a system to
regularly identify the daily census, including times any client is absent from
the RTRF.
(d) The licensee shall
define, in writing, the scope and type of services to be provided by the
RTRF.
(e) The licensee shall comply
with the Patients' Bill of Rights as set forth in
RSA
151:19-30.
(f) The licensee shall have a written
policies and procedures to include:
(1) The
rights and responsibilities of all clients in accordance with the Patients'
Bill of Rights under
RSA
151:21;
(2) The policies described in He-P 807.14,
He-P 807.16,
He-P 807.19, and
He-P 807.26; and
(3) A policy that
ensures the safety of all persons present on the licensed premises where
firearms are permitted.
(g) The licensee shall develop and implement
written policies and procedures governing the operation of the RTRF and all
services provided by the facility and for:
(1) Reviewing the policies and procedures
every 3 years; and
(2) Revising
them as needed.
(h) The
licensee shall assess and monitor the quality of care and service provided to
clients on an ongoing basis.
(i)
The licensee or personnel shall not falsify any documentation or provide false
or misleading information to the department.
(j) The licensee shall not:
(1) Advertise or otherwise represent itself
as operating a RTRF, unless it is licensed; or
(2) Advertise that it provides services that
it is not authorized to provide.
(k) The licensee shall comply with all
conditions of warnings and administrative remedies issued by the department,
and all court orders.
(l) Licensees
shall:
(1) Meet the needs of the clients
during those hours that the clients are in the care of the RTRF;
(2) Establish, in writing, a chain of command
that sets forth the line of authority for the operation of the RTRF;
(3) Appoint an administrator;
(4) Verify the qualifications of all
personnel;
(5) Provide sufficient
numbers of qualified personnel to meet the needs of clients during all hours of
operation;
(6) Provide sufficient
supplies, equipment, and lighting to meet the needs of the clients;
(7) Require all personnel to follow the
orders of the licensed practitioner for every client that has such orders and
encourage the client to follow the licensed practitioner's orders;
(8) Initiate action to maintain the RTRF in
full compliance at all times with all relevant health and safety requirements
contained in applicable federal, state, and local laws, rules, regulations, and
ordinances; and
(9) Implement any
POC that has been accepted by the department.
(m) The licensee shall consider all clients
competent and capable of making health care decisions unless the client:
(1) Has a guardian appointed by a
court;
(2) Has a durable power of
attorney for health care or surrogate decision making that has been activated;
or
(3) Is an un-emancipated minor.
(n) In accordance with
RSA
141-C:7,
He-P 301.02,
and
He-P
301.03 the licensee shall report all positive
tuberculosis test results for personnel to the office of infectious disease
control by:
(1) Telephone at 603-271-4496;
(2) Telephone at 603-271-5300
after business hours; or
(3) Fax
to 603-271-0545.
(o) If
the licensee registers and treats a client 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 and personnel
training for the care of the clients, 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.
(p) In addition to the posting requirements
specified in
RSA 151:29,
the licensee shall post the following documents in a public area:
(1) The license and current license
certificate issued in accordance with
RSA
151:2;
(2) All inspection reports issued in
accordance with,
He-P 807.09(d)
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) The licensee's evacuation floor plan
identifying the location of and access to all fire exits; and
(6) A copy of the licensee's complaint
procedure, including a statement that complaints may be submitted, in writing,
to the Department of Health and Human Services, Health Facilities
Administration, 129 Pleasant Street, Concord, NH 03301 or by calling
1-800-852-3345;
(q) 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 807
as authorized by
RSA
151:6 and
RSA
151:6-a.
(r) A licensee shall, upon request, provide a
client or the client's guardian, agent, or surrogate decision-maker if any,
with a copy of his or her client record pursuant to the provisions of
RSA
151:21, X.
(s) All records required for licensing 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.
(t) Any licensee that maintains electronic
records shall develop written policies and procedures designed to protect the
privacy of clients 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
clients and staff; and
(3) Systems
to prevent tampering with information pertaining to clients and
staff.
(u) The licensee
shall develop policies and procedures regarding the release of information
contained in client records.
(v)
The licensed premises shall comply with all state and local:
(1) Health requirements;
(2) Building ordinances;
(3) Fire ordinances; and
(4) Zoning ordinances.
(w) Smoking shall be prohibited in the RTRF
per
RSA 155:66, I(b)
, except as permitted by
RSA 155:67. If
allowed, smoking shall be restricted to designated smoking areas as per the
licensee's official smoking policy, but in no case shall smoking be permitted
in any room containing an oxygen cylinder or oxygen delivery system or in a
resident's bedroom.
(x) For
reportable incidents, allegations of abuse, neglect, mistreatment or
misappropriation of property, the licensee shall have responsibility for:
(1) Completing an investigation to determine
if abuse or neglect could have been a contributing factor to the incident;
and
(2) Faxing to 603 271-4968, or
if a fax machine is not available, submitting via regular mail, postmarked
within 24 hours of the incident together with a telephone call to the
department reporting the incident and notifying the department of the mailed
report, the following information to the department within 24 hours of the
reportable incident:
a. The RTRF name;
b. A description of the incident,
including identification of injuries, if applicable;
c. The name of the licensee(s) or personnel
involved in, witnessing, or responding to the reportable incident;
d. The name of client(s) involved in or
witnessing the incident;
e. The
date and time of the incident;
f.
The action taken in direct response to the incident, including any follow-up;
g. If medical intervention was
required, who provided the medical intervention and the date and time that the
medical intervention was provided;
h. When the client's guardian, agent,
surrogate decision-maker, or personal representative, if any, was notified;
i. The signature of the person
reporting the incident; and
j. The
date and time the client's licensed practitioner was notified, if applicable;
and
(3) Within 5 days,
submit a completed investigation report to the department containing the
following information:
a. All items
referenced in (1) above;
b. The
names and results of interview(s) with all personnel, resident(s) or other
individuals involved in the reportable incident, including all applicable
statement signatures; and
c. The
action taken by the licensee in direct response to the incident(s), including
any and all follow-up.
(4) Immediately notifying the local police
department, the department, and the guardian, agent, surrogate decision-maker,
or personal representative, if any, when a client who has been assessed or is
known as being a danger to self or others, has eloped after the licensee has
searched the building and the grounds of the RTRF; and
(5) Submit additional information, if
required to the department, to support the incident report referenced in (x)
(3) above.
(y) The
licensee shall provide the following core services:
(1) Health and safety services to minimize
the likelihood of accident or injury, with protective care and oversight
provided regarding:
a. The clients'
functioning, safety and whereabouts;
b. The clients' health status, including the
provision of intervention as necessary or required; and
c. Personnel safety.
(2) Emergency response and crisis
intervention;
(3) Medication
services in accordance with
He-P
807.17;
(4) Food services in accordance with
He-P 807.20;
(5) Housekeeping, laundry and
maintenance services;
(6) On-site
activities designed to sustain and promote physical, intellectual, social and
spiritual well-being of all clients;
(7) Assistance in arranging medical and
dental appointments, including arranging transportation to and from such
appointments and reminding the clients of the appointments; and
(8) Personal supervision of clients when
required to offset deficits that may pose a risk to self or others if the
client is not supervised.
(z) The licensee shall provide access, as
necessary, to the following services pursuant to
RSA 151:2,
IV and
RSA 151:9, VII(a) (4)
:
(1)
Nursing services, in accordance with RSA 326-B, including supervision and
instruction of direct care personnel, relative to the delivery of nursing care;
(2) Rehabilitation services,
including documentation of the licensed practitioner's order for the service,
such as physical therapy, occupational therapy, and speech therapy;
and
(3) Behavioral health care
services.
(aa) The
licensee shall:
(1) Provide basic supplies
necessary for clients to maintain grooming and personal hygiene, such as soap,
shampoo, toothpaste, toothbrush, and toilet paper; and
(2) Not be responsible for the cost of
purchasing a specific brand of product at a client's request.
(ab) The licensee shall educate
personnel about the needs and services required by the clients under their
care.
(ac) Physical or chemical
restraints shall only be used as allowed by
RSA
151:21, IX.
(ad) Immediately after the use of a physical
or chemical restraint, the client's guardian or agent, if any, and the
department shall be notified of the use of restraints.
(ae) The RTRF shall:
(1) Have policies and procedures on:
a. What type of emergency restraints may be
used;
b. When restraints may be
used; and
c. Who may authorize the
use of restraints; and
(2) Provide personnel with education and
training on the limitations and the correct use of restraints.
(af) The use of physical
restraints shall be allowed only as defined under
He-P 807.03(bf)
.
(ag) The RTRF shall document accidents,
injuries, and reportable incidents and include:
(1) The date and time of the
occurrence;
(2) A description of
the occurrence, including identification of injuries, if applicable;
(3) The actions taken;
(4) The signature of the person documenting
the unusual incident; and
(5) If
medical intervention was required, the date and time that the emergency contact
person and guardian or agent, if any, and the licensed practitioner were
notified.
(ah) The
licensee shall not exceed the maximum number of clients or beds licensed by the
department, unless authorized by the department, such as during an
emergency.
(ai) The licensee shall
give a client a written notice as follows:
(1) For an increase in the cost or fees for
any RTRF services 30 days advanced notice; or
(2) For an involuntary change in room or bed
location, 14 days advanced notice, unless the change is required to protect the
health, safety, and well-being of the client or other clients, in such case the
notice shall be as soon as practicable.
(aj) The licensee shall determine the smoking
status of the RTRF.
(ak) If smoking
is to be allowed, the licensee shall develop and implement smoking policies and
designate smoking areas in accordance with
RSA 155:66-69
and
He-P 807.24(f)
.
(al) The licensee may hold or manage a
client's funds or possessions only when the facility receives 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 clients or other
household members.
(am) The
licensee shall not falsify any documentation required by law or provide false
or misleading information to the department.
(an) The licensee shall respond to a notice
of areas of non-compliance by providing a POC in accordance with
He-P 807.12(c)
.
(ao) The licensee shall comply with all
conditions of warnings and administrative remedies issued by the department and
all court orders.
#9873-A, eff
2-24-11
