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 824 - HOSPICE HOUSE
Section He-P 824.14 - Duties and Responsibilities of All Licensees

Universal Citation: NH Admin Rules He-P 824.14

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) Each HH shall be owned and operated by a home hospice care provider licensed in New Hampshire in accordance with RSA 151:2.

(c) The licensee shall have written policies and procedures setting forth:

(1) The rights and responsibilities of patients in accordance with the patients' bill of rights; and

(2) The policies described in (d), (e), and (w) below.

(d) The HH shall define, in writing, the scope and type of services to be provided by the HH, which shall include at a minimum, the core services listed in He-P 824.15.

(e) The HH shall develop and implement written policies and procedures governing the operation and all services and shall assess and monitor the quality of care and service provided to patients on an ongoing basis.

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

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

(h) The HH shall not advertise or provide services that it is not licensed to provide, pursuant to RSA 151:2, III.

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

(j) The HH shall have responsibility and authority for:

(1) Managing, controlling, and operating the HH;

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

(3) Initiating action to maintain the HH 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) The continuity of inpatient care;

(5) Establishing, in writing, a chain of command that sets forth the line of authority for the operation of the HH;

(6) Appointing an administrator;

(7) Verifying the qualifications of all personnel;

(8) Providing sufficient numbers of qualified personnel who are available to meet the needs of patients during all hours that the HH has told the patient that they will provide service;

(9) Providing personnel with sufficient supplies and equipment to meet the needs of the patients;

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

(11) Implementing any POC that has been accepted or issued by the department.

(k) 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;

(2) Has a durable power of attorney for health care that has been activated in accordance with RSA 137-J; or

(3) Has a surrogate designated in accordance with RSA 137-J.

(l) The licensee shall only admit an individual or retain a patient whose needs are compatible with the facility and the services and programs offered, and whose needs can be met by the HH.

(m) If an individual is admitted who requires lift equipment for transfers, all direct care personnel shall have been trained in the correct operation of such equipment.

(n) A licensee shall not deny admission to any person because that person does not have a guardian or an advance directive, such as a living will or durable power of attorney for health care, established in accordance with RSA 137-H or RSA 137-J.

(o) The patient shall be transferred or discharged, as defined under RSA 151:19, I-a and VII, in accordance with RSA 151:21, V, for reasons including, but not limited to, the following:

(1) The patient's medical or other needs exceed the services offered by the licensee or are not otherwise met by third party providers that the licensee has contracted with;

(2) The patient cannot be safely evacuated in accordance with Saf-C 6000;

(3) The patient or the patient's guardian, if any, determines that the patient shall leave the facility; or

(4) The patients' medical condition is no longer compatible with the facility and the services and programs offered.

(p) The licensee shall develop a discharge plan with the input of the patient and the guardian or agent, if any.

(q) The following documents shall accompany the patient upon transfer:

(1) The most recent patient assessment tool, care plan, and quarterly progress notes;

(2) The most recent nursing assessment, if applicable;

(3) The most recent multi-disciplinary care plan, if applicable;

(4) Current medication records; and

(5) A licensed practitioner's order for transfer, if applicable.

(r) If the transfer or discharge referenced in (d) above is required by the reasons listed in RSA 151:26, II(b), a written notice shall be given to the patient as soon as practicable prior to transfer or discharge.

(s) The licensee shall not exceed the maximum number of patients or beds licensed by the department, unless authorized by the department, such as during an emergency.

(t) In addition to the posting requirements specified in RSA 151:29, the HH shall post the following documents in a public area:

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

(2) All inspection reports issued in accordance with He-P 824.09(c) and He-P 824.11(d), for the previous 12 months;

(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 patient rights and responsibilities as required by RSA 151:20;

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

(6) Information on how to contact the office of the long-term care ombudsman.

(u) The HH shall admit and allow any department representative to inspect the HH and all programs and services that are being provided at any time for the purpose of determining compliance with RSA 151 and He-P 824 as authorized by RSA 151:6 and RSA 151:6-a.

(v) Physical or chemical restraints shall only be used in the case of an emergency, pursuant to RSA 151:21, IX. Immediately after the use of a physical or chemical restraint, the patient's guardian or agent, if any, and the department shall be notified of the use of restraints.

(w) The HH shall:

(1) Have policies and procedures on:
a. What type of emergency restraints may be used;

b. When restraints may be used; and

c. What professional personnel may authorize the use of restraints; and

(2) Provide personnel with education and training on the limitations and the correct use of restraints.

(x) The use of mechanical restraints shall be allowed only as defined under He-P 824.03(ak).

(y) The following methods of mechanical restraints shall be prohibited:

(1) Full bed rails;

(2) Gates, if they prohibit a patient's free movement throughout the living areas of the HH;

(3) Half doors, if they prohibit a patient's free movement throughout the living areas of the HH;

(4) Geri chairs, when used in a manner that prevents or restricts a patient from getting out of the chair at will;

(5) Wrist or ankle restraints;

(6) Vests or pelvic restraints; and

(7) Other similar devices that prevent a patient's free movement.

(z) 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 603-271-5574 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 HH 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 patient involved and the name of any witnesses to 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) 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;

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

(5) Provide the information required by (3) above in writing within 3 business days 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

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

(aa) The HH shall respond to a notice of deficiencies by providing a POC in accordance with He-P 824.12(c).

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

(ac) The HH shall, upon request, provide a patient or their legal guardian or agent, if applicable, with a copy of his or her patient record pursuant to the provisions of RSA 151:21, X.

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

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

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

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

(ag) At the time of admission, the HH shall give a patient, their guardian or agent, if applicable, a listing of all HH's charges and identify what care and services are included in the charge.

(ah) The licensee shall give a patient a written notice as follows:

(1) For an increase in the cost or fees for any HH services 30 days advance notice; or

(2) For an involuntary change in room or bed location 14 day advance notice, unless the change is required to protect the health, safety, and well-being of the patient or other patients, in such case the notice shall be as soon as practicable.

(ai) The HH shall provide all personnel with education in hospice philosophy and hospice care in compliance with the CMS conditions of participation.

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

(ak) If smoking is to be allowed, the licensee shall develop and implement smoking policies and designate smoking areas in accordance with RSA 155:66, RSA 155:68 and RSA 155:69 and He-P 824.24(h).

(al) If the HH holds or manages a patient's funds or possessions, the facility shall have written authorization in accordance with RSA 151:24 and RSA 151:21, VII, and such funds shall not be used for the benefit of the licensee, other patients, or other household members.

(am) The HH shall not falsify any documentation required by law or provide false or misleading information to the department.

#9317, eff 11-8-08

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