Current through Register No. 40, October 3, 2024
(a) The
department shall, after notice and an opportunity to be heard, impose
administrative remedies for violations of RSA 151, He-P 812, or other
applicable licensing rules, including:
(1)
Requiring a licensee to submit a POC in accordance with (c) below;
(2) Imposing a directed POC upon a licensee
in accordance with (d) below;
(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 in which the
licensee is not in compliance with RSA 151 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 state notice
detailing:
a. How the licensee intends to
correct each area of 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 21-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 and accept
each POC that:
a. Achieves compliance with
RSA 151 and He-P 812;
b. Addresses
all areas of non-compliance as cited in the statement of findings or notice to
correct;
c. Prevents a new
violation of RSA 151 or He-P 812 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 the
department shall notify the licensee in writing, within 14 days, of the reason
for rejecting the POC;
(6) 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:
a. 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
b. The department determines
that the health, safety, or well-being of a patient will not be jeopardized as
a result of granting the waiver;
(7) The revised POC shall comply with (c) (1)
above and be reviewed in accordance with (c) (3) above;
(8) 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 (d) below and a
fine in accordance with He-P812.13(c) (12);
(9) 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 a
follow-up inspection; or
c.
Reviewing compliance during the next annual inspection;
(10) Verification of the implementation of
any POC shall only occur after the date of completion specified by the licensee
in the plan; and
(11) 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 812.12(b); and
b. Issued a directed POC in accordance with
(d) below and shall be subject to a fine in accordance with
He-P 812.13(c)
(13) below.
(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
of 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; or
(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 (d) above has not been implemented by the completion
date stated in the directed POC, the department shall:
(1) Issue a warning that enforcement action
will be taken if the POC is not implemented;
(2) Impose a fine;
(3) Deny the application for a renewal of a
license in accordance with
He-P 812.13(b)
; or
(4) Revoke the license in accordance with
He-P 812.13(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.
(g)
The informal dispute resolution shall be requested in writing by the applicant,
licensee or program director 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 (c) above shall not apply until the notice of the determination
in (h) above 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 resolutions as described in this
section.
(k) An informal dispute
resolution shall not be available for any applicant or licensee against whom
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
health, safety, or well-being of patients; or
(2) The presence of conditions in the ASC
that negatively impact the health, safety, or well-being of patients.
#5514, eff 11-25-92; ss by #6530, eff 6-27-97, EXPIRED:
6-27-05
New. #9727-A, eff
6-18-10
