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 823 - HOME HOSPICE CARE PROVIDER
Section He-P 823.14 - Duties and Responsibilities of All Licensees

Universal Citation: NH Admin Rules He-P 823.14

Current through Register No. 40, October 3, 2024

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

(b) The licensee shall have a written policies and procedures to include:

(1) The rights and responsibilities of admitted patients in accordance with the "Home Care Clients' Bill of Rights" under RSA 151:21-b;

(2) The policies described in He-P 823; and

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

(c) The licensee shall define, in writing, the scope and type of services to be provided by the HHCP, which shall include at a minimum, the core services listed in He-P 823.15.

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

(1) Reviewing the policies and procedures every 2 years; and

(2) Revising them as needed.

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

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

(g) The licensee shall not advertise or otherwise represent the program as operating an HHCP, or providing services that it is not licensed to provide, pursuant to RSA 151:2, III.

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

(i) The licensee shall:

(1) Manage and operate the HHCP;

(2) Meet the needs of the patients during those hours that the patient is in the care of the HHCP;

(3) Initiate action to maintain the HHCP 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 HHCP;

(5) Appoint an administrator and a medical director;

(6) Verify the qualifications of all personnel;

(7) Provide sufficient numbers of qualified personnel who are available to meet the needs of patients during all hours that the HHCP has contracted with patients to provide service;

(8) Provide personnel with sufficient supplies and equipment to meet the needs of the patients;

(9) Require all personnel to follow the orders of the licensed practitioner for every patient and encourage the patient to follow the licensed practitioner's orders; and

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

(j) The licensee shall consider all patients to be competent and capable of making all decisions relative to their own health care unless the patient:

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

(2) Has a durable power of attorney for health care that has been activated in accordance with RSA 137-J or a surrogate decision-maker in accordance with RSA 137-J:35.

(k) The licensee shall only accept a patient whose needs can be met through the program and services offered under the current license.

(l) If the licensee accepts a patient 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 patient, 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.

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

(n) The licensee shall post the following documents in a public area:

(1) The license and current license certificate issued in accordance with RSA 151:2;

(2) All inspection reports for the last 12 months issued in accordance with He-P 823.09(d) and He-P 823.11(d) (4) ;

(3) A copy of the "Home Care Clients' Bill of Rights" specified by RSA 151:21-b;

(4) A copy of the licensee's policies and procedures relative to the implementation of patient rights and responsibilities;

(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; and

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

(o) For reportable incidents, the licensees shall:

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

(2) Fax to 271-5574 or, if a fax machine is not available, submit via regular mail, postmarked within 2 business days of the incident together with a telephone call to the department reporting the incident and notifying the department of the mailed report, the following information to the department within 2 business days of a reportable incident:

a. The HHCP 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 patientinvolved 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 patient's guardian, agent, or personal representative, if any, was notified;

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

j. The date and time the patient's licensed practitioner was notified;

(3) Immediately notify the guardian, agent, or personal representative, if any;

(4) If abuse or neglect is suspected, the licensee shall 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;

(5) Contact the department immediately by telephone, fax, or e-mail to report the information required by (2) above in the case of the death of any patient who dies within 10 days of a reportable incident;

(6) Provide the information required by (4) above in writing within 72 hours of the unexpected death of any patient or the death of any patient who dies within 10 days of a 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

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

(p) The licensee shall admit and allow any department representative to inspect the HHCP and all programs and services that are being provided at any time for the purpose of determining compliance with RSA 151 and He-P 823 as authorized by RSA 151:6 and RSA 151:6-a.

(q) A licensee shall, upon request, provide a patientor their legal guardian or agent, or surrogate decision-maker if applicable, with a copy of his or her patient record pursuant to the provisions of RSA 151:21, X.

(r) All records required for licensing shall be legible, current, 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.

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

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

(t) At the time of admission the licensee shall give a patient and their legal guardian agent, or surrogate decision-maker if applicable, a listing of all HHCP's charges and identify what care and services are included in the charge.

(u) At the time of admission the licensee shall give a patient and their guardian, agent, or surrogate decision-maker if applicable, a listing of all applicable HHCP charges and identify what care and services are included in the charge.

(v) The licensee shall provide all personnel with education in hospice philosophy and hospice care.

(w) No patient shall receive any direct patient care at the HHCP primary location, branch office, or drop site(s) .

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

#9292, eff 10-9-08

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