Current through Register No. 40, October 3, 2024
(a) The
department shall impose administrative remedies for violations of RSA 151, He-P
823, 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
license.
(b) When
administrative remedies are imposed, the department shall provide written
notice, as applicable, which:
(1) Identifies
each area of non-compliance; 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 ,
the licensee shall submit a written POC for each item, written in the
appropriate place on the statement 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, 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, 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-day period but has been unable to do so; and
b. The department determines that the health,
safety, or well-being of a patient will not be jeopardized as a result of
granting the extension;
(3) The department shall review each POC and
accept each plan that:
a. Achieves compliance
with RSA 151 and He-P 823;
b.
Addresses all areas of non-compliance as cited in the statement of
findings;
c. Prevents a new
violation of RSA 151 or He-P 823 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 applies;
(5)
If the POC is not acceptable:
a. The
department shall notify the licensee in writing within 14 days 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 patient 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 823.13(c)
(11) ;
(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 on-site
follow-up inspection; or
c.
Reviewing compliance during the next 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 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 823.12(b); and
b. Issued a directed POC in accordance with
(d) below and a fine in accordance with
He-P 823.13(c)
(12) .
(d) The department shall develop and impose a
directed POC that specifies corrective actions for the applicant or 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 patients or
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 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:
(1) Impose a fine;
(2) Deny the application for a renewal of a
license in accordance with
He-P 823.13(b)
; or
(3) Revoke the license in accordance with
He-P 823.13(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, provided that the applicant or licensee submits a written request for
an informal dispute resolution to the department.
(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 was issued by the
department.
(h) The department
shall change the statement of findings if, based on the evidence presented, the
statement of findings 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 He-P823.12(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) Repeated non-compliance on the part of
the facility in areas that impact the health, safety, or well-being of
patients; or
(2) The presence of
conditions in the facility that negatively impact the health, safety, or
well-being of patients.
#9292, eff
10-9-08
