Current through Register No. 40, October 3, 2024
(a) All personnel
shall:
(1) Meet the educational and physical
qualifications of the position and in accordance with the requirements of 42
CFR § 493;
(2) Be licensed,
registered, or certified if required by state statute;
(3) Receive an orientation within the first 7
days of work that includes:
a. The duties and
responsibilities of the position;
b. The laboratory's infection control
program; and
c. The laboratory's
fire, evacuation, and emergency plans, which outline the responsibilities of
personnel in an emergency; and
(4) Prior to testing patient samples, the
employee shall have an orientation in the applicable policies, procedures, of
the laboratory.
(b) All
personnel shall complete annual in-service education in the laboratory:
(1) Policies and procedures on patients'
rights;
(2) Infection control
program; and
(3) Fire and emergency
procedures.
(c) All
licensees using the service of independent clinical contractors shall:
(1) Provide the clinical contractors with an
orientation as specified in (a)(3) above;
(2) Maintain a copy of the clinical
contractors' licenses as required by (a)(2) above, if applicable;
(3) Have a written agreement with each
clinical contractor that describes the services that will be provided and
agrees to comply with the requirements of (a)(1) through (3) above;
and
(4) Have documentation of the
criminal record check or employee waiver, as applicable.
(d) For all new hires, including volunteers
and independent contractors whose scope of employment will involve direct
contact with a patient, patient records, or patient tissue, body fluids, or
other biological material, the licensee shall:
(1) Obtain and review a criminal records
check, which shall include results of criminal history from the state of New
Hampshire;
(2) Review the results
of the criminal records check in accordance with (e) below and verify the
qualifications of all applicants prior to employment;
(3) Require the employee to submit the
results of a physical examination or pre-employment health screening performed
by a licensed nurse or a licensed practitioner and 2 step tuberculosis testing,
Mantoux method, or other method approved by the Centers for Disease Control,
conducted not more than 12 months prior to employment;
(4) Allow the employee to work while waiting
for the results of the second step of the TB test when the results of the first
test are negative for TB;
(5)
Comply with the requirements of the United States Centers for Disease Control
and Prevention, "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 M. tuberculosis through shared air space
with persons with infectious tuberculosis; and
(6) Report all positive tuberculosis (TB)
test results for personnel to the department's TB program in accordance with
RSA
141-C:7,
He-P
301.02, and 301.03.
(e) Unless a waiver is granted in accordance
with (f) below, the licensee shall not offer employment for any position if the
individual:
(1) Has been convicted for sexual
assault, other violent crime, assault, fraud, theft, abuse, neglect, or
exploitation;
(2) Has been found by
the department or any administrative agency in this or any other state for
assault, fraud, theft, abuse, neglect, or exploitation of any person;
or
(3) Otherwise poses a threat to
the health, safety, or well-being of the patients.
(f) The department shall grant a waiver of
(e) above if, after reviewing the underlying circumstances, it determines that
the person does not pose a threat to the health, safety, or well-being of
patients.
(g) The waiver in (f)
above shall be permanent for as long as the individual remains in the same job
unless additional convictions or findings under (e) above occur.
(h) If the information identified in (e)
above regarding any employee is learned after the person is hired, the licensee
shall immediately notify the department.
(i) An employee shall not be permitted to
maintain their employment if they have been convicted of a felony, sexual
assault, other violent crime, assault, fraud, theft, abuse, neglect, or
exploitation of any person in this or any other state by a court of law or had
a complaint investigation for abuse, neglect, or exploitation adjudicated and
founded by the department unless a waiver has been granted by the
department.
(j) All personnel shall
sign a statement at the time the initial offer of employment is made and then
annually thereafter stating that they:
(1) Do
not have a felony conviction in this or any other state;
(2) Have not been convicted of a sexual
assault, other violent crime, assault, fraud, theft, abuse, neglect, or
exploitation or pose a threat to the health, safety, or well-being of a
patient; and
(3) Have not had a
finding by the department or any administrative agency in this or any other
state for assault, fraud, theft, abuse, neglect, or exploitation of any
person.
(k) For
individuals with the waiver described in (f) above, the statement required by
(j) above shall cover the period of time since the waiver was
granted.
(l) An individual shall
not be required to re-disclose any of the matters in (f) above if the
documentation is available and the department has previously reviewed the
material and determined that the individual can continue employment.
(m) Current and complete personnel files
shall be maintained at the licensed premises, except as allowed by (p)
below.
(n) Personnel files shall
include:
(1) Identification data;
(2) Qualifications and work
experience;
(3) Record of
satisfactory completion of the orientation program required by (a)(3)
above;
(4) A copy of each current
New Hampshire license, registration, or certification in health care field, if
applicable;
(5) Documentation of
annual in-service education as required by (b) above; and
(6) The statement required by (j)
above.
(o) Personnel
files shall be:
(1) Maintained on an
individual basis, separate and distinct from other employees, and contain only
information relating to the specific personnel member;
(2) Stored in locked containers or cabinets
or in a locked room on the premises; and
(3) Maintained for at least 5 years following
termination of employment.
(p) Personnel files may be stored in a
central location provided that:
(1) The
personnel file is available to the department at the licensed premises within
30 minutes of being requested; and
(2) The files are in accordance with (n) and
(o) above.
(q) All
testing personnel shall have a competency review for each test procedure
performed prior to testing patient samples, as well as twice in the first year
and annually thereafter.
(r) The
competency review shall include:
(1)
Monitoring the pre-analytic, analytic, and post analytic phases of the testing
procedure;
(2) Direct observation
of the testing personnel in the performance of the test procedure;
and
(3) Documentation of test
results and awareness of test parameters and limitations as described in the
package insert.
#2192, eff 11-25-82; ss by #3193, eff 1-28-86; ss by
#5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92
New. #5758, eff 12-20-93,
EXPIRED: 12-20-99
New. #8409, eff 8-19-05; ss by
#8852, eff 3-24-07; ss by #10267, eff
2-2-13
