Current through Register No. 40, October 3, 2024
(a) The department
shall impose administrative remedies for violations of RSA 151, He-P 827, 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
licensee.
(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 imposed.
(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 a
written POC for each item, written in the appropriate place on the statement or
notice 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 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 to develop
and submit the POC within the 21 calendar day period but has been unable to do
so; and
b. The department
determines that the health, safety, or well-being of patients 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 827;
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 827 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 is applicable;
(5) If the POC is not acceptable:
a. The department shall notify the licensee
in writing 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
well-being 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 827.13(c) (12) below;
(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 onsite
follow-up inspection; or
c.
Reviewing compliance during the next annual 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 or
revised 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 (b) above; and
b. Issued a directed POC in accordance with
(d) below and shall be subject to a fine, as appropriate, in accordance with
He-P 827.13(c) (13) below.
(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 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) Impose a fine;
(2) Deny the application for a renewal of a
license in accordance with He-P 827.13(b); or
(3) Revoke the license in accordance with
He-P 827.13(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 or a notice to correct,
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 administrator no later than
14 days from the date the statement of findings or notice to correct was issued
by the department.
(h) The
department shall change the statement of findings or notice to correct 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-P 827.12(c) 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 resolution
as describe 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 the health, safety, or well-being of
patients; or
(2) The presence of
conditions in the FMRTF that negatively impact the health, safety, or
well-being of patients.
