Current through Register No. 40, October 3, 2024
(a) The
department shall impose administrative remedies for violations of RSA 151, He-P
824, 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 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 proposed.
(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 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 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 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 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 824;
b.
Addresses all areas of non-compliance as cited in the statement of findings or
notice to correct;
c. Prevents a
new violation of RSA 151 or He-P 824 as a result of this 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 patient 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
824.12(d) and a fine in accordance
with He-P
824.13(c)(12);
(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 a follow-up
inspection; or
c. Reviewing
compliance during the next 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
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
824.12(b); and
b. Issued a directed POC in accordance with
He-P
824.12(d) and a fine in accordance
with He-P
824.13(f)(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 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) Issue a
warning that enforcement action will be taken if the POC is not
implemented;
(2) Impose a
fine;
(3) Deny the application for
a renewal of a license in accordance with He-P 824,13(b); or
(4) Revoke the license in accordance with
He-P
824.13(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.
(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 (c) 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 or initiated action to
suspend, revoke, deny, or refuse to issue or renew 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
health, safety, or well-being of patients;
(2) The presence of conditions in the HH that
negatively impact the health, safety, or well-being of patients;
(3) Concern that the facility is not ending
the pattern of citations for violations of licensing rules and coming into
compliance with those rules; or
(4)
Conditions exist for implementation of temporary management as described in (i)
below but no temporary manager can be found.
(m) The department shall appoint a temporary
manager to assume operation of a HH when, following an inspection, the
department determines that:
(1) The licensee
has repeatedly failed to manage and operate the HH in compliance with RSA 151
and He-P 824 and such HH practices have failed to meet the needs of the
patients;
(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
patients; or
(3) The health, safety
and well-being of the patients are at risk and emergency action is
required.
#5648, eff 6-25-93; ss by #7020, INTERIM, eff 6-23-99,
EXPIRED: 10-21-99
New. #9317, eff
11-8-08
