Current through Register No. 40, October 3, 2024
(a) The licensee
shall ensure that sufficient numbers of qualified personnel are present in the
ASC to meet the needs of the patients at all times.
(b) For all applicants for employment,
volunteers, or independent contractors who provide direct personal care
services to patients or who will be unaccompanied by an employee while
performing non-direct care or non-personal services within the facility, the
licensee shall:
(1) Obtain and review a
criminal records check from the New Hampshire department of safety in
accordance with
RSA
151:2-d;
(2) Review the results of the criminal
records check in accordance with (d) below;
(3) Verify the qualifications of all
applicants prior to employment;
(4) Verify that the applicant is not on the
List of Excluded Individuals/Entities, maintained by the U.S. Department of
Health and Human Services Office of Inspector General; and
(5) Verify that the applicant is not listed
on the BEAS registry maintained by the department's bureau of elderly and adult
services.
(c) Unless a
waiver is granted in accordance with (e) (2) below, the licensee shall not
offer employment, contract with, or engage a person in (b) above, if the
person:
(1) Has been convicted of any felony
in this or any other state;
(2) Has
been convicted for sexual assault, other violent crime, assault, fraud, theft,
abuse, neglect, or exploitation in this or any other state;
(3) 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
(4) Otherwise poses a threat to the health,
safety, or well-being of patients.
(d) If the information identified in (c)
above regarding any person subject to (b) above is learned after the person is
hired, contracted with, or engaged with, the licensee shall immediately notify
the department and either:
(1) Cease
employing, contracting with, or engaging with the person; or
(2) Request a waiver of (c) above.
(e) If a waiver of (c) above is
requested, the department shall review the information and the underlying
circumstances in (c) above and shall either:
(1) Notify the licensee that the person shall
not or no longer shall be employed, contracted with, or engaged by the
licensee, if, after investigation, it determines that the person poses a threat
to the health, safety, or well-being of a patient(s); or
(2) Grant a waiver of (c) above, if after the
investigation, it determines that the person does not pose a current threat to
the health, safety, or well-being of a patient(s) .
(f) The licensee shall:
(1) Not employ, contract with, or engage with
any person in (b) above who is listed on the BEAS state registry unless a
waiver is granted by BEAS; and
(2)
Only employ, contract with, or engage with board of nursing licensees who are
listed on the licensing site with the NH board of nursing registry or compact
site.
(g) In lieu of (c)
and (f) above, the licensee may accept from independent agencies contracted by
the licensee or by an individual patient to provide direct care or personal
care services a signed statement that the agency's employees have complied with
(c) and (f) above and do not meet the criteria in (c) and (g) above.
(h) All personnel shall:
(1) Meet the educational and physical
qualifications of the position as listed in their job description;
(2) Be licensed, registered, or certified as
required by state statute and as applicable;
(3) Receive an orientation within the first 3
days of work or prior to the assumption of duties that includes:
a. The ASC's policies on rights and
responsibilities and complaint procedures as required by
RSA
151:20;
b. The duties and responsibilities, policies,
procedures, and guidelines, of the position they were hired for;
c. The ASC's infection prevention
program;
d. The ASC's fire,
evacuation, and emergency plans which outline the responsibilities and
educational requirements of personnel in an emergency; and
e. Mandatory reporting requirements for abuse
or neglect such as those found in RSA 161-F and
RSA
169-C:29;
(4) Complete a mandatory annual in-service
education, which includes a review of the ASC's:
a. Policies and procedures on patient rights
and responsibilities and abuse or neglect;
b. Infection prevention; and
c. Education program on fire and emergency
procedures.
(i) Prior to having contact with patients,
personnel shall:
(1) Submit to the licensee
proof of a physical examination or a health screening conducted not more than
12 months prior to employment which shall include at a minimum the following:
a. The name of the examinee;
b. The date of the examination;
c. Whether or not the examinee has a
contagious illness or any other illness that would affect the examinee's
ability to perform their job duties;
d. Results of a 2-step tuberculosis (TB)
test, Mantoux method or other method approved by the Centers for Disease
Control (CDC); and
e. The dated
signature of the licensed health practitioner;
(2) Be allowed to work while waiting for the
results of the second step of the TB test when the results of the first step
are negative for TB; and
(3) Comply
with the requirements of the United States Centers for Disease Control
"Guidelines for Preventing the Transmission of 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.
(j)
Personnel who have direct contact with patients who have a history of TB or a
positive laboratory and antigen testing shall have a symptomology screen of a
TB test.
(k) The licensee shall
provide all personnel with an annual continuing education or in-service
education training, which at a minimum contains the following:
(1) The licensee's patient's rights and
complaint procedures required under RSA 151;
(2) The licensee's written emergency plan;
and
(3) The mandatory reporting
requirements including
RSA
161-F:46 and
RSA
169-C:29.
(l) Current, separate and complete personnel
files shall be maintained and stored in a secure and confidential manner.
(m) The licensee shall maintain a
separate employee file for each employee, which includes the following:
(1) A completed application for employment or
a resume;
(2) A signed statement
acknowledging the receipt of the ASC's policy setting forth the patient's
rights and responsibilities, and acknowledging training and implementation of
the policy as required by
RSA
151:20;
(3) A job description signed by the
individual that identifies the:
a. Position
title;
b. Qualifications and
experience; and
c. Duties required
by the position;
(4)
Record of satisfactory completion of the orientation program required by (h)
(3) above;
(5) A copy of each
current New Hampshire license, registration, or certification in health care
field and basic life support certification, if applicable;
(6) Documentation that the required physical
examination or health screening and TB test results or radiology reports of
chest x-rays, if required, have been completed by the appropriate health
professionals;
(7) Record of
satisfactory completion of all required education programs and demonstrated
competencies that are signed and dated by employee;
(8) Documentation of annual performance
review;
(9) A statement which shall
be signed at the time the initial offer of employment, contract, or engagement
is made and then annually thereafter, that he or she:
a. Does not have a felony conviction in this
or any other state;
b. Has 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(s) in this or any other state; and
c. Has 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 in this or any other
state;
(10)
Documentation of the criminal records check;
(11) Documentation that the individual is not
on the List of Excluded Individuals/Entities, maintained by the U.S. Department
of Health and Human Services Office of Inspector General; and
(12) The results of the registry checks in
(11) above.
(n) The
licensee shall maintain the records, but not necessarily a separate file, for
all volunteers and for all independent contractors who provide direct care or
personal care services to patients or who will be unaccompanied by an employee
while performing non-direct care or non-personal care services within the
facility, as follows:
(1) For volunteers, the
information in (m) (1), (3), (4), (6) and (8) through (12) above; and
(2) For independent contractors, the
information in (m) (3), (4), (6) and (8) through (12) above.
(o) An individual need not
re-disclose any of the matters in (9) and (10) above if the documentation is
available and the department has previously reviewed the material and granted a
waiver so that the individual can continue employment.
#9727-A, eff
6-18-10
