New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Chapter He-P 800 - RESIDENTIAL CARE AND HEALTH FACILITY RULES
Part He-P 812 - RULES FOR AMBULATORY SURGICAL CENTERS
Section He-P 812.14 - Duties and Responsibilities of All Licensees

Universal Citation: NH Admin Rules He-P 812.14

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, including RSA 161-F:40 and rules promulgated thereunder.

(b) The licensee shall comply with the patients' bill of rights as set forth in RSA 151:19-21.

(c) The licensee shall define, in writing, the scope and type of services to be provided by the ASC, which shall include at a minimum, the required services listed in He-P 812.18.

(d) The licensee shall develop and implement written policies and procedures governing the operation and all services provided by the ASC.

(e) All policies and procedures shall be reviewed annually.

(f) The licensee shall assess and monitor the quality of care and service provided to patients on an ongoing basis.

(g) The licensee or any employee shall not falsify any documentation or provide false or misleading information to the department.

(h) The licensee shall not:

(1) Advertise or otherwise represent itself as operating a ASC, unless it is licensed; and

(2) Advertise that it provides services that it is not authorized to provide.

(i) The licensee shall comply with all conditions of warnings and administrative remedies issued by the department, and all court orders.

(j) Licensees shall:

(1) Meet the needs of the patients during those hours that the patients are in the care of the ASC;

(2) Establish, in writing, a chain of command that sets forth the line of authority for the operation of the ASC;

(3) Appoint an administrator and medical director;

(4) Verify the qualifications of all personnel;

(5) Provide sufficient numbers of qualified personnel to meet the needs of patients during all hours of operation;

(6) Provide sufficient supplies, equipment, and lighting to meet the needs of the patients; and

(7) Implement any POC that has been accepted by the department.

(k) The licensee shall consider all patients to be competent and capable of making health care decisions unless the patient:

(1) Has a guardian appointed by a court;

(2) Has a durable power of attorney for health care or surrogate that has been activated; or

(3) Is an un-emancipated minor.

(l) If the licensee accepts a patient 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 for the care of the patients, 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), available as noted in Appendix A.

(m) The licensee shall report all positive tuberculosis test results for personnel to the office of disease control in accordance with RSA 141-C:7, He-P 301.02, and He-P 301.03.

(n) In addition to the posting requirements specified in RSA 151:29, the licensee shall post the following documents in a public area:

(1) The current license and license certificate issued in accordance with RSA 151:2;

(2) All inspection reports issued in accordance with He-P 812.09(b) , 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 floor plan, identifying the location of, and access to all fire exits;

(6) A copy of the licensee's complaint procedure, including a statement that complaints may be submitted by calling 1-800-852-3345 or in writing to:

Department of Health and Human Services

Health Facilities Administration

129 Pleasant Street

Concord, NH 03301 or by calling 1-800-852-3345; and

(7) A list of physicians who have an ownership or financial interest in the ASC.

(o) 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 812 as authorized by RSA 151:6 and RSA 151:6-a.

(p) Licensees shall, in accordance with He-P 812.15:

(1) Report all adverse events to the department as required by He-P 812.15(a) -(c) ;

(2) Submit additional information if required by the department; and

(3) Report the event to other agencies as required by law.

(q) A licensee shall, upon request, provide a patient or the patient's guardian or agent, if any, with a copy of his or her patient record pursuant to the provisions of RSA 151:21, X.

(r) 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.

(s) Any licensee that maintains electronic records shall develop written policies and procedures designed to protect the privacy of patients 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 patients and personnel; and

(3) Systems to prevent tampering with information pertaining to patients and personnel.

(t) The licensee shall develop policies and procedures regarding the release of information contained in patient records.

(u) The licensee shall provide cleaning and maintenance services, as needed, to protect patients, personnel, and the public.

(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 ASC 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) If the licensee is not on a public water supply, the water used by the licensee shall be suitable for human consumption, pursuant to Env-Dw 702.02 and Env-Dw 704.02.

(y) Upon request, the licensee shall give a patient and the patient's guardian, agent, or personal representative, or surrogate decision-maker as applicable, a listing of all known applicable charges and identify what care and services are included in the charge.

(z) The licensee may perform the following Clinical Laboratory Improvement Amendments (CLIA) waived tests, as per 42 CFR Part 493.15, without obtaining a NH state laboratory license:

(1) Urine drug screening;

(2) Alcohol screening;

(3) Urine pregnancy; and

(4) Glucose testing.

(aa) If the licensee collects urine specimens for laboratory testing, the licensee shall follow the manufacturer's instructions and the reference laboratory's instructions for collection, transporting, and storage of urine specimens.

(ab) If the licensee collects other human specimens it shall be licensed as a collection station in accordance with He-P 817.

(ac) If the ASC performs any laboratory test other than those exempted by (z) above, the licensee shall be licensed as a laboratory in accordance with He-P 808.

(ad) The ASC shall hold the appropriate CLIA certificate to perform any laboratory tests.

(ae) The licensee shall maintain the manufacturer's test system instructions including package inserts and operator's manuals.

#9727-A, eff 6-18-10

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