New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Section He-P 814.15 - Duties and Responsibilities of All Licensees

Universal Citation: NH Admin Rules He-P 814.15

Current through Register No. 12, March 21, 2024

(a) The licensee shall comply with all federal, state, and local laws, rules, codes, and ordinances, as applicable, including RSA 161-F:49 and rules promulgated thereunder.

(b) In accordance with RSA 151:20, the licensee shall have a written policy setting forth the rights and responsibilities of individuals receiving services at the CR, as well as written procedures to implement its policy to ensure that the rights set forth in RSA 151:21, "Patients' Bill of Rights" are upheld.

(c) The licensee shall define, in writing, the scope and type of services to be provided by the CR, which shall include at a minimum, the required services listed in He-P 814.16.

(d) The licensee shall develop and implement written polices and procedures governing the operation and all services provided by the CR and for:

(1) Reviewing the policies and procedures annually;

(2) Revising them as needed; and

(3) Implementing a written policy that ensures the safety of all persons present on the licensed premises where firearms are permitted.

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

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

(g) The licensee shall not:

(1) Advertise or otherwise represent the program as operating a CR, unless it is licensed; and

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

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

(i) Licensees shall:

(1) Meet the needs of the individuals during those hours that the individuals are in the care of the CR;

(2) Initiate action to maintain the CR 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;

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

(4) Appoint a qualified administrator;

(5) Verify the qualifications of all personnel, in accordance with He-M 1001 or 1002;

(6) Provide sufficient numbers of personnel who are present in the CR and are qualified to meet the needs of individuals during all hours of operation;

(7) Provide the CR with sufficient supplies, equipment, and lighting to meet the needs of the individuals; and

(8) Implement any POC that has been accepted or issued by the department.

(j) The licensee shall consider all individuals to be competent and capable of making health care decisions unless the individual:

(1) Has a guardian appointed by a court of competent jurisdiction; or

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

(k) The licensee shall not exceed the number of occupants as authorized by NFPA 101 as adopted by the commissioner of the department of safety under RSA 153 as Saf-C 6000, and as amended pursuant to RSA 153:5, I, by the state fire marshal with the board of fire control, and identified on the license certificate issued by the department.

(l) The licensee shall not admit an individual whose needs exceed the program and services offered by the CR.

(m) If the licensee accepts an individual 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 individuals, 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.

(n) The licensee shall report all positive tuberculosis test results for employees to the department's bureau of disease control in accordance with RSA 141-C:7, He-P 301.02, and He-P 301.03.

(o) Any licensee who admits or who has an individual with a diagnosis of dementia, Alzheimer's disease, or a primary or secondary diagnosis of mental illness shall:

(1) Require all direct care personnel caring for the individual to be trained in the special care needs of individuals with dementia, Alzheimer's disease, or mental illness; and

(2) Provide a physical environment that has a safety and security system that prevents an individual from leaving the premises without the knowledge of personnel, if the individual:
a. Has eloped from the CR in the last 60 days; or

b. Is a danger to self or to others.

(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 current license certificate issued in accordance with RSA 151:2;

(2) All inspection reports issued in accordance with He-P 814.12(d), for the previous 12 months;

(3) A copy of the patients' bill of rights specified by RSA 151:21;

(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) A copy of the licensee's complaint procedure, including a statement that complaints may be submitted, in writing, to "Department of Health and Human Services, Office of Legal and Regulatory Services, Health Facilities Administration, 129 Pleasant Street, Concord, NH 03301" or by calling 1-800-852-3345, and information on how to contact the office of the long-term care ombudsman; and

(6) The licensee's plan for fire safety, evacuation, and emergencies, identifying the location of, and access to all fire exits.

(q) For reportable incidents, the licensee shall:

(1) Complete an investigation to determine if abuse or neglect could have been a contributing factor to the incident;

(2) Fax to 271-4968 or, if a fax machine is not available, convey by electronic or regular mail, the following information to the department within 48 hours of a reportable incident:
a. The CR name;

b. A description of the incident, including identification of injuries, if applicable;

c. The name of the licensee(s) or employees involved in, witnessing, or responding to the reportable incident;

d. The name of individual(s) involved in or witnessing the reportable incident;

e. The date and time of the reportable incident;

f. The action taken in direct response to the reportable incident, including any follow-up;

g. If medical intervention was required, by whom and the date and time;

h. When the individual's guardian or agent, if any, or personal representative was notified;

i. The signature of the person reporting the reportable incident;

j. The date and time the individual's licensed practitioner was notified, if applicable; and

k. The date the facility performed the investigation required by (1) above;

(3) As soon as practicable, notify the guardian, agent, or personal representative, if any;

(4) As soon as practicable, notify the local police department, the department, and the guardian, agent, or personal representative, if any, when an individual has an elopement or unexplained absence and the licensee has searched the building and the grounds of the CR without finding the individual; and

(5) Notify the department with a written report within 5 days describing the actions taken by personnel, the final outcome or continuation of the reportable incident, and actions taken to prevent a reoccurrence if it was not submitted in the initial report.

(r) The licensee shall admit and allow any department representative to inspect the CR and all programs and services that are being provided at any time for the purpose of determining compliance with RSA 151 and He-P 814 as authorized by RSA 151:6 and RSA 151:6-a.

(s) Applicants, licensees, and employees shall cooperate with the department during all departmental inspections and investigations authorized under RSA 151 and He-P 814, including allowing representatives of the department to:

(1) Enter and complete an inspection of the premises;

(2) Review and reproduce any records, forms, or reports which are required to be maintained or made available to the department; and

(3) Interview employees and individuals of the CR.

(t) A licensee shall, upon request, provide an individual or the individual's guardian or agent, if any, with a copy of his or her individual record pursuant to the provisions of RSA 151:21, X.

(u) 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.

(v) Any licensee that maintains electronic records shall develop written policies and procedures designed to protect the privacy of individuals and employees 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 individuals and employees; and

(3) Systems to prevent tampering with information pertaining to individuals and employees.

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

(x) The licensee shall provide cleaning and maintenance services, as needed, to protect individuals, employees, and the public.

(y) The CR shall comply with all federal, state, and local health, building, fire, and zoning laws, rules, and ordinances.

(z) If the CR is not on a municipal water system, the water used in the CR shall be potable and suitable for human consumption.

(aa) The licensee shall determine whether smoking will be allowed at the CR.

(ab) If smoking is to be allowed, the licensee shall develop and implement smoking policies and designate smoking-permitted areas in accordance with RSA 155:68 and RSA 155:69 and He-P 1900, as applicable.

(ac) If the licensee holds or manages an individual's funds or possessions, it shall first receive 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 individuals, or other household members.

(ad) At the time of admission the licensee shall give an individual and the individual's guardian, agent, or personal representative, if applicable, a listing of all CR charges and identify what care and services are included in the charge.

(ae) The licensee shall give an individual a 30-day written notice before any increase is imposed in the cost or fees for any CR services.

#9288, eff 10-3-08

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