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 816 - EDUCATIONAL HEALTH CENTERS
Section He-P 816.14 - Duties and Responsibilities of All Licensees

Universal Citation: NH Admin Rules He-P 816.14

Current through Register No. 40, October 3, 2024

(a) The licensee shall comply with all relevant federal, state, and local laws, rules, codes, and ordinances, as applicable.

(b) In accordance with RSA 151:20, the licensee shall have a written policy setting forth the rights and responsibilities of students receiving services at the EHC, 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.

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

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

(f) The licensee shall assess and monitor the quality of care and services it provides to students on an ongoing basis.

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

(h) The licensee shall not advertise or otherwise represent the EHC as having residential care or health care programs or services for which it is not licensed 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) Manage and operate the EHC;

(2) Meet the needs of the students during the hours that the students are in the care of the EHC;

(3) Initiate action to maintain the EHC 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;

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

(5) Appoint an onsite administrator;

(6) Appoint a director of nursing;

(7) Appoint a medical director;

(8) Verify the qualifications of all personnel;

(9) Provide sufficient numbers of personnel who are present in the EHC and are qualified to meet the needs of students during all hours of operation;

(10) Provide the EHC with sufficient supplies, equipment, and lighting to ensure that the needs of students are met;

(11) Implement any POC that has been accepted or issued by the department; and

(12) Require that all personnel follow the orders of the licensed practitioner for each student and encourage the students to follow the licensed practitioner's orders.

(k) The licensee shall consider all students to be competent and capable of making health care decisions unless the student is under 18 years of age.

(l) The licensee shall only admit or treat a student whose needs can be met by the EHC.

(m) If the licensee has a student whose needs cannot be met by the programs and services offered at the EHC, the licensee shall transfer the student to a hospital or other appropriately licensed facility.

(n) The licensee shall not occupy more beds or exceed the maximum number of students to be cared for each day as authorized by NFPA 101 as adopted by the commissioner of the department of safety as Saf-C 6000 under RSA 153, 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.

(o) If the licensee accepts a student 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 students, 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.

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

(q) 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 issued in accordance with RSA 151:2;

(2) All clinical inspection reports for the last 12 months in accordance with He-P 816.09(d) and He-P 816.11(d) (1) ;

(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 students' 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 the 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;

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

(7) The EHC's hours of operation.

(r) Licensees shall:

(1) Fax to 271-5574 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 EHC name;

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

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

d. The name of the student(s) or person(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. Whether the emergency contact or guardian, if any, was notified;

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

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

(2) 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;

(3) Contact the department immediately by telephone, fax, or e-mail to report the information required by (1) above to report the death of any student or the death of any student who dies within 10 days of a reportable incident;

(4) Provide the information required by (3) above in writing within 72 hours of the death of any student or the death of any student who dies within 10 days of an reportable incident if the initial contact was made by telephone or if additional information becomes available subsequent to the time the initial contact was made; and

(5) Submit any further information requested by the department.

(s) The licensee shall admit and allow any department representative to inspect the EHC and all programs and services that are being provided at any time for the purpose of determining compliance with RSA 151 and He-P 816, as authorized by RSA 151:6 and RSA 151:6-a.

(t) Applicants, licensees, and personnel shall cooperate with the department during all departmental inspections and investigations authorized under RSA 151 and He-P 816, 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 personnel and students of the EHC.

(u) The licensee shall, upon request, provide a student or their guardian, if applicable, with a copy of his or her student record pursuant to the provisions of RSA 151:21, X.

(v) All records required for licensing shall be legible, current, and accurate and be made available to the department during an inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a.

(w) Any licensee that maintains electronic records shall develop a system with written policies and procedures to protect the privacy of students 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 students and personnel; and

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

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

(y) The licensee shall provide housekeeping and maintenance services, as needed to protect students, personnel, and the public.

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

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

#9193, eff 6-26-09

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