Current through Register No. 40, October 3, 2024
(a) The
department shall impose administrative remedies for violations of RSA 151, He-P
818, 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 licensee;
or
(4) Monitoring of a licensee in
accordance with (k) below.
(b) When administrative remedies are imposed,
the department shall provide a 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 its
written POC for each item, written in the appropriate place on the statement or
notice and containing:
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;
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 to develop
and submit the POC within the 21 calendar day period but has been unable to do
so; and
b. The department
determines that the health, safety, or well-being of a participant 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 818;
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 818 as a result of the implementation of the
POC;
d. Identifies the position of
the employee responsible for the corrective action; and
e. 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:
a. The department shall notify the licensee
in writing of the reason for rejecting the POC;
b. 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, via telephone or in writing, and
the department grants the extension, based on the following criteria:
1. The licensee demonstrates that he or she
has made a good faith effort to develop and submit the POC within the 14 day
period but has been unable to do so; and
2. The department determines that the health,
safety or wellbeing of a resident will not be jeopardized as a result of
granting the waiver;
c.
The revised POC shall comply with (c) (1) above and be reviewed in accordance
with (c) (3) above; and
d. 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, unless the department has granted an extension,
the licensee shall be subject to a directed POC in accordance with (d) below
and a fine in accordance with
He-P
818.13(c) (12) ;
(6) 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;
(7) Verification of the implementation of any
POC shall only occur after the date of completion specified by the licensee in
the plan; and
(8) 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 818.12(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
818.13(c) (13) .
(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
participants and personnel;
(2) A
revised POC is not submitted within 14 days of the written notification from
the department or such other 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 not been implemented by
the completion date stated in the directed POC the department shall, as
appropriate:
(1) Impose a fine;
(2) Deny the application for a renewal of a
license in accordance with
He-P
818.13(b) ; or
(3) Revoke the license in accordance with
He-P
818.13(b) .
(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 program director 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 the 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) above shall not apply until the notice of the determination
in (h) above has been provided to the applicant or licensee.
(j) An informal dispute resolution shall not
be available for any applicant or licensee against whom the department has
imposed an administrative fine or initiated action to revoke, deny, or refuse
to issue or renew a license.
(k)
The department shall impose state monitoring under the following conditions:
(1) The department determines that repeated
poor compliance on the part of the facility in areas that may impact the
health, safety, or well-being of participants; or
(2) Concern that the conditions in the ADP
have the potential to worsen.
#9106, eff 3-18-08; ss by #9565, eff
10-16-09
