Current through Register No. 40, October 3, 2024
(a) The department
shall impose administrative remedies for violations of RSA 151, He-P 815, 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 license;
or
(4) Monitoring of a
licensee.
(b) When
administrative remedies are imposed, the department shall provide 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 imposed.
(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 a
written POC for each item, written in the appropriate space 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 area of 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 written 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, as
verified by documentation or other means, 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 resident 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 815;
b. Addresses all
areas of non-compliance cited in the statement of findings or notice to
correct;
c. Prevents a new
violation of RSA 151 or He-P 815 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, as verified
by documentation or other means, 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 resident will not be jeopardized as a result of
granting the extension;
(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
He-P
815.12(d) and a fine in accordance
with He-P
815.13(c)(11);
(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 an onsite
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
815.12(b); and
b. Issued a directed POC in accordance with
(d) below and shall be subject to a fine, as appropriate, in accordance with
He-P
815.13(c)(12) 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 residents
and employees;
(2) A revised POC is
not submitted within 14 days of the written notification from the department or
such later 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 been found not to have been
implemented by the completion date stated in the directed POC, the department
shall:
(1) Impose a fine;
(2) Deny the application for a renewal of a
license in accordance with
He-P
815.13(b)(6); or
(3) Revoke the license in accordance with
He-P
815.13(b)(6).
(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 or a notice to correct, 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 administrator no later than
14 days from the date the statement of findings or notice to correct was issued
by the department.
(h) The
department shall change the statement of findings or notice to correct if,
based on the evidence presented, the statement of findings or notice to correct
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)(2) 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, initiated action to
suspend or revoke a license, or denied an application for 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 the
health, safety, or well-being of residents; or
(2) The presence of conditions in the
facility that negatively impact the health, safety, or well-being of
residents.
(m) The
department shall appoint a temporary manager to assume operation of an ICF/IID
when, following an inspection, the department determines that:
(1) The licensee has repeatedly failed to
manage and operate the ICF/IID in compliance with RSA 151 and He-P 815 and such
ICF/IID practices have failed to meet the needs of the residents;
(2) The licensee has failed to develop or
implement policies and procedures for infection control, sanitation, or life
safety codes, imposing harm or the potential for harm to the residents;
or
(3) The health, safety, and
well-being of the residents are at risk and emergency action is
required.
