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 827 - FREESTANDING MEGAVOLTAGE RADIATION THERAPY FACILITY
Section He-P 827.14 - Duties and Responsibilities of the Licensee

Universal Citation: NH Admin Rules He-P 827.14

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, including RSA 161-F:49 and rules promulgated under CMS regulation at 42 CFR Part 482;

(b) The licensee shall comply with the patients' bill of rights as set forth in RSA 151:19-21.

(c) The licensee shall define, in writing, the scope and type of services to be provided by the FMRTF, which shall include, at a minimum, the required services listed in He-P 827.16.

(d) The licensee shall develop and implement written policies and procedures governing the operation and all services provided by the facility.

(e) All policies and procedures shall be reviewed per licensee policy.

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

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

(h) Except for the requirements of RSA 151:4, III(a) (5) , the licensee shall not:

(1) Advertise or otherwise represent itself as operating as a special health care service provider, unless it is licensed; and

(2) Advertise that it provides services that it is not authorized to provide.

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

(j) Licensees shall:

(1) Meet the needs of the patients during those hours that the patients are in the care of the special health care service provider;

(2) Initiate action to maintain the FMRFT 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 provision of FMRTF;

(4) Appoint an administrator;

(5) Appoint a medical director;

(6) Appoint a chief of radiation therapy who shall be a medical radiation oncologist or a consulting medical radiation oncologist that meets the qualifications according to He-P 4000;

(7) Appoint a radiation therapy physicist who shall be a qualified medical physicist that meets the qualifications of He-P 4000;

(8) Verify the qualifications of all personnel;

(9) Provide sufficient numbers of qualified personnel who are present in the facility and are qualified to meet the needs of patients during all hours of operation;

(10) Provide the facility with sufficient supplies, equipment, and lighting to meet the needs of the patients; and

(11) Implement any POC that has been accepted by the department.

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

(1) Has a guardian appointed by a court;

(2) Has a durable power of attorney for health care or surrogate that has been activated; or

(3) Is an un-emancipated minor.

(l) The licensee shall not exceed the number of occupants authorized by NFPA 101 as adopted by the commissioner of the department of safety under Saf-C 6000 under RSA 153, and as amended pursuant to RSA 153:5, I, by the state fire marshal with the board of fire control, and identified on the licensing certificate.

(m) If the licensee accepts a patient who is known to have a disease reportable under He-P 301 or an infectious disease, the licensee shall follow the required procedures for the care of the patients, as specified by the 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.

(n) 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.

(o) The licensee shall implement measures to ensure the safety of patients who are assessed as a danger to self or others.

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

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

(2) All inspection reports issued in accordance with He-P 827.09(b), for the previous 12 months;

(3) A copy of the patients' bill of rights;

(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) 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, Health Facilities Administration, 129 Pleasant Street, Concord, NH 03301 or by calling 1-800-852-3345, the address and phone number of the department to which complaints may also be made, which shall also be posted on the hospital website if available; and

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

(q) The licensee shall admit and allow any department representative to inspect the premises and all programs and services that are being provided by the licensee at any time for the purpose of determining compliance with RSA 151 and He-P 827 as authorized by RSA 151:6 and RSA 151:6-a.

(r) Licensees shall, in accordance with He-P 827.15:

(1) Report all adverse events to the department as required by He-P 827.15(a) -(c);

(2) Submit additional information if required by the department; and

(3) Report the event to other agencies as required by law.

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

(t) The licensee shall provide cleaning and maintenance services, as needed to protect patients, personnel, and the public.

(u) The building housing the licensee shall comply with all state and local:

(1) Health requirements;

(2) Building ordinances;

(3) Fire ordinances; and

(4) Zoning ordinances.

(v) Smoking shall be prohibited in the facility as required by RSA 155:66, I(b) .

(w) If the licensee is not on a public water supply, the water used by the licensee shall be suitable for human consumption, pursuant to Env-DW 702.02 and Env-DW 704.02.

(x) If the licensee holds or manages a patient's funds or possessions, it shall first receive 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 or other patients.

(y) At the time of admission, the licensee shall give a patient and the patient's guardian, agent, or personal representative, a listing of all known applicable charges and identify what care and services are included in the charge.

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