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 827.18 - Personnel

Universal Citation: NH Admin Rules He-P 827.18

Current through Register No. 52, December 26, 2024

(a) The licensee shall ensure that sufficient numbers of qualified personnel are present at the FMTRF to meet the needs of patients.

(b) For all applicants for employment, for all volunteers, and for all independent contractors who will provide direct care to patients or who will be unaccompanied by an employee while performing non-direct care within the facility, the licensee shall:

(1) Obtain and review a criminal records check from the New Hampshire department of safety, except, pursuant to RSA 151:2-d, VI, for those licensed by the New Hampshire board of nursing;

(2) Review the results of the criminal records check in (1) above in accordance with (e) below; and

(3) Verify the qualifications of all applicants prior to employment; and

(4) Check the names of the persons in (b) above against the bureau of elderly and adult services (BEAS) state registry maintained pursuant to RSA 161-F:49 and He-E 720 and the NH board of nursing, nursing assistant registry, maintained pursuant to RSA 326-B:26 and 42 CFR 483.156.

(c) Unless a waiver is granted in accordance with (e) (2) below, the licensee shall not offer employment, contract with, or engage a person in (b) above if the person:

(1) Has been convicted of a felony in this or any other state;

(2) Has been convicted of a sexual assault, other violent crime, assault, fraud, theft, abuse, neglect, or exploitation in this or any other state;

(3) Has had a finding by the department or any administrative agency in this or any other state for assault, fraud, theft, abuse, neglect, or exploitation of any person; or

(4) Otherwise poses a threat to the health, safety, or well-being of patients.

(d) If the information identified in (c) above regarding any person in (b) above is learned after the person is hired, contracted with, or engaged, the licensee shall immediately notify the department and either:

(1) Cease employing, contracting with, or engaging the person; or

(2) Request a waiver of (c) above.

(e) If a waiver of (c) above is requested, the department shall review all relevant information and the underlying circumstances and either:

(1) Notify the licensee that the person cannot or can no longer be employed, contracted with, or engaged by the licensee if, after investigation, it determines that the person poses a threat to the health, safety, or well-being of patients; or

(2) Grant a waiver of (c) above if, after investigation, it determines that the person does not pose a current threat to the health, safety, or well-being of patients.

(f) The licensee shall:

(1) Not employ, contract with, or engage, any person in (b) above who is listed on the BEAS state registry unless a waiver is granted by BEAS; and

(2) Only employ, contract with, or engage board of nursing licensees who are listed on the licensing site with the New Hampshire board of nursing or with a compact state.

(g) In lieu of (b) above, the licensee may accept from independent agencies contracted by the licensee a signed statement that the agency's employees have complied with (b) and do not meet the criteria in (c) and (f) (1) above.

(h) Each FMRTF shall have a full time administrator who:

(1) Has a master's degree from an accredited institution and at least 4 years of experience working in a health related field or has a bachelor's degree from an accredited institution and at least 8 years of experience working in a health related field; and

(2) Shall be responsible to the governing body for the daily management and operation of the FMRTF including:

a. Management and fiscal matters;

b. The employment and termination of managers and staff necessary for the efficient operation of the FMRTF;

c. The designation of an alternate, in writing, who shall be responsible for the daily management and operation of the FMRTF in the absence of the administrator;

d. To serve as a liaison to the parent hospital;

e. The planning, organizing, and directing of such other activities as may be delegated by the parent hospital;

f. The delegation of responsibility to subordinates as appropriate;

g. Ensuring development and implementation of hospital policies and procedures on:

1. Patient's rights as required by RSA 151:20;

2. Advanced directives as required by RSA 137-J;

3. Discharge planning as required by RSA 151:26;

5. Withholding of resuscitative services from patients pursuant to RSA 137-H and RSA 137-J;

6. Adverse event reporting; and

7. Any other policies and procedures required by law or rule; and

h. Notifying the department, directly or through delegation, as specified in He-P 827.15 of any adverse event involving a patient.

(i) All administrators shall obtain and document 12 hours of continuing education related to the operation and services of the FMRTF each annual licensing period, in accordance with (p) and (q) below.

(j) All direct care personnel shall be at least 18 years of age unless they are:

(1) A licensed nursing assistant working under the supervision of a nurse in accordance with Nur 700; or

(2) Involved in an established educational program working under the supervision of a nurse or radiation therapist.

(k) The licensee shall inform personnel of the line of authority at the FMRTF.

(l) The licensee shall educate personnel about the needs and services required by the patients under its care.

(m) Prior to having contact with patients, personnel shall:

(1) Submit to the licensee the results of a physical examination or a health screening performed by a licensed nurse or a licensed practitioner and the results of a 2-step tuberculosis (TB) test, Mantoux method, or other method approved by the Centers for Disease Control, both conducted not more than 12 months prior to employment, contract, or engagement;

(2) Be allowed to work while waiting for the results of the second step of the TB test when the results of the first step are negative for TB; and

(3) Comply with the requirements of the Centers for Disease Control and Prevention "Guidelines for Preventing the Transmission of M. tuberculosis in Health-Care Settings" (2005 edition), available as noted in Appendix A, if the person has either a positive TB test, or has had direct contact or potential for occupational exposure to M. tuberculosis through shared air space with persons with infectious tuberculosis.

(n) In lieu of (m) (1) and (3) above, independent agencies contracted by the facility to provide direct care may provide the licensee with a signed statement that its employees have complied with (m) (1) and (3) above before working at the FMRTF.

(o) Prior to having contact with patients, personnel shall receive a tour of and orientation to the FMRTF that includes the following:

(1) The patient's rights in accordance with RSA 151:20;

(2) The FMRTF patient complaint procedures;

(3) The duties and responsibilities of the position;

(4) The emergency medical procedures;

(5) The emergency and evacuation procedures;

(6) The infection control procedures as required by He-P 827.20;

(7) The facility confidentiality requirements;

(8) The grievance procedures for both staff and patients; and

(9) The mandatory reporting requirements including RSA 161-F:46 and RSA 169-C:29.

(p) The licensee shall provide all personnel with an annual continuing education or in-service education training, which at a minimum contains the following:

(1) The licensee's patients' rights and complaint procedures required under RSA 151;

(2) The licensee's infection control program;

(3) The licensee's written emergency plan;

(4) The licensee's policies and procedures; and

(5) The mandatory reporting requirements including RSA 161-F:46 and RSA 169-C:29.

(q) The FMRTF or parent hospital shall maintain a separate employee file for each employee, which shall include the following:

(1) A completed application for employment or a resume;

(2) Proof that the individual meets the minimum age requirements;

(3) A statement signed by each individual that he or she has received a copy of and received training on the implementation of the licensee's policy setting forth the patient's rights and responsibilities as required by RSA 151:21;

(4) A copy of the results of the criminal record check as described in (b) above;

(5) A job description signed by the individual that identifies the:

a. Position title;

b. Qualifications and experience; and

c. Duties required by the position;

(6) Record of satisfactory completion of the orientation program required by (p) above;

(7) Information as to the general content and length of all in-service or educational programs attended;

(8) Record of satisfactory completion of all required education programs and demonstrated competencies that are signed and dated by the employee;

(9) A copy of each current driver's license, including proof of insurance, if the employee transports patients using their own vehicle;

(10) Documentation that the required physical examinations or health screenings, TB test results, and radiology reports of chest x-rays, if required, have been completed by the appropriate health professionals;

(11) The statement required by (w) below; and

(12) The results of the registry checks in (h) above.

(r) Personnel records may be stored at a parent hospital provided that:

(1) The personnel record is available to the department at the licensed premises within 2 hours of being requested; and

(2) The records are maintained in accordance with (q) above.

(s) The FMRTF shall maintain the records for all volunteers, and for all independent contractors who provide direct care to patients or who will be unaccompanied by an employee while performing non-direct care services within the facility, as follows:

(1) For volunteers, the information in (q) (1), (3), (4), (6), and (8) -(12) above; and

(2) For independent contractors, the information in (q) (3), (4), (6), and (8) -(12) above, except that the letter in (g) and (n) above may be substituted for (q) (4), (10), and (12) above, if applicable.

(t) All personnel shall sign a statement at the time the initial offer of employment, contract, or engagement is made and then annually thereafter stating that they:

(1) Do not have a felony conviction in this or any other state;

(2) Have not been convicted of a sexual assault, other violent crime, assault, theft, fraud, abuse, neglect, or exploitation or pose a threat to the health, safety, or well-being of a patient; and

(3) Have not had a finding upheld by the department or any administrative agency in this or any other state for assault, fraud, theft, abuse, neglect, or exploitation of any person.

(u) An individual shall not have to re-disclose any of the matters in (t) above if the documentation is available and the department has previously reviewed the material and determined that the individual can continue employment, contract, or engagement.

(v) The licensee shall protect and store in a secure and confidential manner all records described in (q) and (r) above.

(w) Personnel shall not be impaired while on the job by any substances including, but not limited to, legally prescribed medication, therapeutic cannabis, or alcohol.

(x) The FMRTF shall have a written policy, as described in RSA 151:41, establishing procedures for the prevention, detection, and resolution of controlled substance abuse, misuse, and diversion, which shall apply to all personnel, and which shall be the responsibility of a designated employee or interdisciplinary team.

(y) The policy in (x) above shall include:

(1) Education;

(2) Procedures for monitoring the distribution and storage of controlled substances;

(3) Voluntary self-referral by employees who are addicted;

(4) Co-worker reporting procedures;

(5) Drug testing procedures to include at a minimum, testing where reasonable suspicion exists;

(6) Employee assistance procedures;

(7) Confidentiality;

(8) Investigation, reporting, and resolution of controlled drug misuse or diversion; and

(9) The consequences for violation of the controlled substance abuse, misuse, and diversion prevention policy.

(See Revision Note at part heading for He-P 827) #12751, eff 3-26-19

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