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)
The licensee shall have written policies and procedures to include:
(1) The rights and responsibilities of
clients in accordance with the patients' bill of rights under
RSA 151:20,
II;
(2) A policy that ensures the safety of all
persons present on the licensed premises where firearms are permitted;
and
(3) All other policies required
by He-P 826.
(c) The
licensee shall define, in writing, the scope and type of services to be
provided at the SUD-RTF.
(d) The
licensee shall have a system to regularly identify the SUD-RTF's daily census,
including times client is absent from the SUD-RTF.
(e) The licensee shall comply with the
patients' bill of rights as set forth in
RSA
151:19-30.
(f) The licensee shall develop and implement
written policies and procedures governing the operation of the SUD-RTF to
include a clinical care manual covering the policies and procedures for all
clinical services provided.
(g) All
policies and procedures shall be reviewed annually and revised as
needed.
(h) All clinical services
provided by the licensee shall:
(1) Focus on
the clients strengths;
(2) Be
sensitive and relevant to the diversity of the clients;
(3) Be client and family centered;
(4) Be evidence-based by meeting one of the
following:
a. The service shall be included
as an evidence-based mental health and substance abuse intervention on the
SAMHSA Evidence-Based Practices Resource Center (April 2018 edition) available
at
https://www.samhsa.gov/ebp-resource-center,
or as listed in Appendix A;
b. The
services are published in a peer reviewed journal and found to have positive
effects; or
c. The treatment and
support service provider shall be able to document the services effectiveness
based on a theoretical model with validated research or a documented body of
research generated from similar services that indicates
effectiveness;
(5) Be
designed to acknowledge the impact of violence and trauma on client's lives
which shall be addressed in the services provided; and
(6) Be delivered in accordance with the
following:
a. The American Society of
Addiction Medicine (ASAM) Criteria, 2013 edition, available as listed in
Appendix A; or
b. The Treatment
Improvement Protocols and Technical Assistance Publications promulgated by
SAMSHA:
https://www.samhsa.gov/kap/resources,
September 2017 edition, available as listed in Appendix A.
(i) The licensee shall assess and
monitor the quality of care and services it provides to clients on an ongoing
basis.
(j) The licensee or
personnel shall not falsify any documentation or provide false or misleading
information to the department.
(k)
The licensee shall not advertise or otherwise represent the SUD-RTF as having
residential care or health care programs or services for which it is not
licensed to provide.
(l) The
licensee shall comply with all conditions of warnings and administrative
remedies issued by the department, and all court orders.
(m) Licensees shall:
(1) Meet the needs of the clients during the
hours that the clients are in the care of the SUD-RTF;
(2) Initiate action to maintain the SUD-RTF
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;
(3)
Establish, in writing, a chain of command that sets forth the line of authority
for the operation of the SUD-RTF;
(4) Appoint a medical director who shall meet
the requirements of
He-P 826.18(k)
;
(5) Appoint an administrator who shall meet
the requirements of
He-P 826.18(i)
;
(6) Verify the qualifications of all
personnel;
(7) Provide sufficient
numbers of personnel who are present in the SUD-RTF and are qualified to meet
the needs of clients during all hours of operation;
(8) All unlicensed clinical staff providing
treatment, education, and/or recovery support services shall be under the
direct supervision of a licensed clinical supervisor;
(9) Licensed clinical supervisors must
provide at least one hour of supervision for all unlicensed clinical staff for
every 40 hours of direct client contact which shall include:
a. Review of case records;
b. Observation of interactions with
clients;
c. Skill
development;
d. Review of case
management activities; and
e. The
maintenance of a log of the supervision date, duration, content, and the
identity of the participants;
(10) Ensure that personnel, licensed or
certified, by the NH board of licensing for alcohol and other drug use
professionals or any other licensing or certification board, receive
supervision in accordance with the requirements set forth for the licenses or
certifications held by the individual;
(11) Ensure that no LADC or MLADC shall
supervise more than 12 unlicensed staff;
(12) Provide the SUD-RTF with sufficient
supplies, equipment, and lighting to ensure that the needs of clients are
met;
(12) Implement any POC that
has been accepted or issued by the department; and
(13) Require that all personnel follow the
orders of the licensed practitioner for each client and encourage the clients
to follow the licensed practitioner's orders.
(n) The licensee shall employ or contract
with a nurse who is currently licensed in the state of New Hampshire pursuant
to RSA 326-B, or licensed pursuant to the multi-state compact, and who is an RN
or LPN with at least 2 year's relevant experience in substance use disorder
treatment or behavioral health services.
(o) The licensee shall employ or contract
with a clinical services director who is a LADC or MLADC licensed by the NH
board of licensing for alcohol and other drug use professionals or an
individual licensed by the board of mental health practice and who has at least
2 year's relevant experience in substance use disorder treatment or behavioral
health services.
(p) The licensee
shall:
(1) Make available basic supplies
necessary for clients to maintain grooming and personal hygiene, such as soap,
shampoo, toothpaste, toothbrush, and toilet paper. Such basic supplies shall be
included in the basic rate, except that there may be an additional charge for
specific brands or items required to meet individual clients' needs or
requests;
(2) Not be responsible
for the cost of purchasing a specific brand of product at a client's
request;
(3) Identify in the
admission agreement the cost, if any, of basic supplies or other services for
which there will be a charge;
(5)
Ensure that all personnel have received the training necessary to be qualified
personnel to include demonstrated competency in the training given with
documentation maintained in the employee personnel file;
(6) Require any paid provider providing
direct care, other than an employee, to provide a brief written, signed, and
dated note describing the reason for the service(s), and the next planned
visit, if known;
(7) Have a
clearly identified policy for CPR that includes the following:
a. If CPR is not performed, the policy shall
include a statement that 911 shall be called in an emergency;
b. If CPR is performed, the policy shall
include a statement that 911 shall be called and there shall be either at least
one person on duty per shift who is certified to perform CPR or an AED
available for use; and
c. This
policy shall be signed by each client and their guardian, agent, surrogate
decision-maker or personal representative, if any, and be located in the
client's file with their admission agreement; and
(8) There shall be at least one personnel on
the premises during all hours the facility is open.
(q) The licensee shall educate personnel
about the needs and services required by the clients under their care and
document such education to include demonstrated competencies.
(r) Physical or chemical restraints shall
only be used in the case of an emergency, pursuant to
RSA
151:21, IX.
(s) As soon as is practicable but no longer
than 24 hours after the use of a physical or chemical restraint, the client's
licensed practitioner, the department, and the client's guardian, agent,
surrogate decision-maker or personal representative, if any, shall be notified
of the use of such restraints.
(t)
The SUD-RTF shall:
(1) Have policies and
procedures on:
a. What type of emergency
restraints can be used;
b. When
restraints can be used; and
c. Who
may authorize the use of restraints; and
(2) Provide personnel with education and
training on the limitations and the correct use of restraints.
(u) The use of physical restraints
shall be allowed only as defined under
He-P 826.03(bl)
.
(v) Separation from a situation may be used
as an alternative to physical restraint and shall not be considered a form of
restraint.
(w) For reportable
incidents, licensees shall have responsibility for:
(1) Completing an investigation to determine
if abuse or neglect could have been a contributing factor to the
incident;
(2) Faxing to 271-4968
or, if a fax machine is not available, submit via regular mail, postmarked
within 48 hours off 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 48 hours of a
reportable incident:
a. The SUD-RTF
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 client(s) involved 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.
When the client's guardian, agent, surrogate decision-maker or personal
representative, if any, was notified;
i. The signature of the person reporting the
reportable incident; and
j. The
date and time the client's licensed practitioner was notified, if applicable;
and
k. The date the facility
performed the investigation required by (1) above;
(3) As soon as practicable, notifying the
local police department, the department, and the guardian, agent, surrogate
decision-maker, or personal representative, if any, when a client has an
unexplained absence and the licensee has searched the building and the grounds
of the SUD-RTF without finding the client and it has been determined by the
facility that the client is a danger to themselves or others; and
(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.
(x) The licensee shall not exceed the maximum
number of clients or beds licensed by the department, unless authorized by the
department, such as during an emergency.
(y) The licensee shall give a client a
written notice as follows:
(1) For an
increase in the cost or fees for any SUD-RTF services, 30 days advanced notice
shall be required except for clients receiving Medicaid whose financial
liability is determined by the state's standard of need; or
(2) For an involuntary change in room or bed
location, the facility shall make reasonable accommodation of individual needs
and preferences and give 14 days advanced notice, unless the change is required
to protect the health, safety, and well-being of the client or other clients,
in such case the notice shall be as soon as practicable.
(z) In addition to the posting requirements
specified in
RSA 151:29,
the licensee shall post the following documents in a conspicuous area
accessible to clients, employees, and visitors:
(1) The current license and license
certificate issued in accordance with
RSA
151:2;
(2) All statement of findings for the last 12
months in accordance with
He-P 826.09(d)
and
He-P 826.11(d)
;
(3) A copy of the patient's bill of rights
specified by
RSA
151:21; and
(4) 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, N.H.
03301 or by calling 1-800-852-3345, and information on how to contact the
office of the long-term care ombudsman.
(aa) The licensee shall not allow smoking in
the facility at any time.
(ab) If
smoking is allowed on the grounds of the SUD-RTF, the licensee shall develop
and implement smoking policies and designate smoking areas in accordance with
RSA 155:66-69
and
He-P
826.26.
(ac) The licensee may hold or manage a
client's funds or possessions only when the facility receives 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 clients, or other
household members.
(ad) The SUD-RTF
may perform the following Clinical Laboratory Improvement Amendments (CLIA)
waived tests, as per 42 CFR Part 493.15, without obtaining a NH state
laboratory license:
(1) Urine drug
screen;
(2) Alcohol screen;
and
(3) Urine pregnancy.
(ae) If the licensee collects
urine specimens for laboratory testing, the licensee shall follow the
manufacturer's instructions and the reference laboratory's instructions for
collection, transporting, and storage of urine specimens.
(af) If the licensee collects other human
specimens it shall be licensed as a collection station in accordance with He-P
817.
(ag) If the SUD-RTF performs
any laboratory test other than those exempted by (ad) above, the licensee shall
be licensed as a laboratory in accordance with He-P 808.
(ah) The SUD-RTF shall hold the appropriate
CLIA certificate to perform any laboratory tests.
(ai) The licensee shall maintain the
manufacturer's test system instructions including package inserts and
operator's manuals.
(See Revision Note at Part Heading for He-P 826) #12658,
eff 11-1-18
