CHAPTER He-P 800  RESIDENTIAL CARE AND HEALTH FACILITY RULES

 

Statutory Authority:  RSA 151:9

 

PART He-P 801  GENERAL REQUIREMENTS FOR ALL FACILITIES

 

          He-P 801.01 - EXPIRED

 

Source.  #1665, eff 11-30-80; ss by #2628, eff 2-21-84; ss by #2792, eff 8-2-84; ss by #3193, eff 1-28-86; amd by #4133, eff 9-23-86; amd by #4405, eff 4-21-88; ss by #5647, eff 6-25-93; amd by #5933, eff 12-8-94; amd by #7020, INTERIM, eff 6-23-99, EXPIRED: 10-21-99, paragraph (r) EXPIRED: 12-8-00

 

          He-P 801.02 - 801.06 - EXPIRED

 

Source.  #1665, eff 11-30-80; ss by #2628, eff 2-21-84; ss by #2792, eff 8-2-84; ss by #3193, eff 1-28-86; amd by #4133, eff 9-23-86; amd by #4405, eff 4-21-88; ss by #5647, eff 6-25-93; ss by #7020, INTERIM, eff 6-23-99, EXPIRED: 10-21-99

 

          He-P 801.07 - EXPIRED

 

Source.  #1665, eff 11-30-80; ss by #2628, eff 2-21-84; ss by #2792, eff 8-2-84; ss by #3193, eff 1-28-86; amd by #4133, eff 9-23-86; amd by #4405, eff 4-21-88; ss by #5647, eff 6-25-93; amd by #5933, eff 12-8-94; amd by #7020, INTERIM, eff 6-23-99, EXPIRED: 10-21-99, paragraphs (b) through (e) EXPIRED: 12-8-00

 

          He-P 801.08 - 801.26 - EXPIRED

 

Source.  #1665, eff 11-30-80; ss by #2628, eff 2-21-84; ss by #2792, eff 8-2-84; ss by #3193, eff 1-28-86; amd by #4133, eff 9-23-86; amd by #4405, eff 4-21-88; ss by #5647, eff 6-25-93; ss by #7020, INTERIM, eff 6-23-99, EXPIRED: 10-21-99

 

PART He-P 802  RULES FOR HOSPITALS AND SPECIAL HEALTH CARE SERVICES

 

          He-P 802.01  Purpose.  The purpose of this part is to set forth the licensing requirements for all hospitals pursuant to RSA 151:2, I(a) and the special health care services offered by hospitals pursuant to RSA 151:2-e.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff 10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.02  Scope.  This part shall apply to any individual, agency, partnership, corporation, government entity, association, or other legal entity operating a hospital, except:

 

          (a)  All facilities listed in RSA 151:2, II(a)-(h); and

 

          (b)  All entities which are owned or operated by the state of New Hampshire, pursuant to RSA 151:2, II(i).

 

Source.  #2044, eff 6-3-82; amd by #2793, eff 8-2-84; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New. #9580, eff 10-24-09; ss by #12407, INTERIM, eff 10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.03  Definitions.

 

          (a)  “Abuse” means any one of the following:

 

(1)  “Emotional abuse” means the misuse of power, authority, or both, verbal harassment, or confinement which results or could result in the mental anguish or emotional distress of patients;

 

(2)  “Physical abuse” means the misuse of physical force which results or could result in physical injury to patients; and

 

(3)  “Sexual abuse” means contact or interaction of a sexual nature involving patients without his or her informed consent.

 

          (b)  “Activities of daily living (ADL)” means basic daily routine tasks such as eating, transferring, toileting, bathing, dressing, and medication management.

 

          (c)  “Addition” means an increase in the building area, aggregate floor area, building height, or number of stories of a structure.

 

          (d)  “Administer” means an act whereby one or more doses of a medication is instilled into the body, applied to the body of, or otherwise given to a person for immediate consumption or use by an individual authorized by law, pursuant to RSA 318-B and RSA 326-B.

 

          (e)  “Administrator” means the person responsible for the management of the licensed premises and who reports to and is accountable to the governing body.

 

          (f)  “Admission” means the point in time when a patient has been accepted by a licensee for the provision of services. This term also includes “admitted”.

 

          (g)  “Advance directive” means a directive allowing a person to give directions about future medical care or to designate another person to make medical decisions if he or she should lose the capacity to make health care decisions. The term “advance directive” includes living wills, durable powers of attorney for health care, or surrogate decision maker in accordance with RSA 137-J.

 

          (h)  “Adverse event” means a consequence of care that results in an undesired outcome which may or may not have been preventable, and which is listed in RSA 151:38.

 

          (i)  “Affiliated or related parties” means companies or individuals that serve as operators, landlords, management companies or advisors, real estate or consulting companies, members of limited liability companies, administrative services companies, lenders and companies providing financial guarantees, and captive or affiliated insurance companies.

 

          (j)  “Agent” means an adult to whom authority to make health care decisions is delegated under an activated durable power of attorney for health care executed in accordance with RSA 137-J, or a surrogate decision maker identified under RSA 137-J:34-37.

 

          (k)  “Applicant” means an individual, agency, partnership, corporation, government entity, association, or other legal entity seeking a license to operate a hospital pursuant to RSA 151:2, I(a) or provide a special health care service pursuant to RSA 151:2-e.

 

          (l) “Area of non-compliance” means any action, failure to act, or other set of circumstances that cause a licensee to be out of compliance with RSA 151, He-P 802, or other applicable federal or state requirements.

 

          (m) “Cardiac catheterization laboratory services” mean those cardiac catheterization procedures that are performed in a cardiac catheterization laboratory, including diagnostic and interventional cardiac catheterization procedures.

 

          (n)  “Care plan or treatment plan” means a documented guide developed by the licensee, in consultation with personnel, the patient, and the patient’s guardian or agent, if any, as a result of the assessment process for the provision of care and services.

 

          (o)  “Change of ownership” means a change in the controlling interest of an established hospital or provider of special health care services to any individual, agency, partnership, corporation, government entity, association, or other legal entity.

 

          (p)  “Chemical restraint” means a drug or medication that is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.

 

          (q)  “Commissioner” means the commissioner of the department of health and human services or his or her designee.

 

          (r)  “Critical access hospital (CAH)” means a hospital that has been so designated by the state in which it is located and has been surveyed by the state survey agency or by Centers for Medicare and Medicaid Services (CMS) pursuant to 42 CFR Subpart F § 485.606.

 

          (s)   “Critical incident stress management (CISM)” means an adaptive, short-term psychological

helping-process that focuses solely on an immediate and identifiable problem.  Its purpose is to enable people to return to their daily routine more quickly and with less likelihood of experiencing post-traumatic stress disorder.

 

          (t)  “Days” means calendar days unless otherwise specified in the rule.

 

          (u)  “Deficiency” means any action, failure to act, or other set of circumstances that cause a licensee to be out of compliance with RSA 151 or He-P 802.

 

          (v) “Demonstrated competency” means the ability of the employee to demonstrate to an evaluator that he or she is able to complete the required task in a way that reflects the minimum standard including, but not limited to, a certificate of completion of course material or a post-test to the training provided.

 

          (w)  “Department” means the department of health and human services, at 129 Pleasant St, Concord, NH 03301.

 

          (x)  “Direct care” means hands on care or services to a patient, including but not limited to medical, nursing, psychological, or rehabilitative treatments.

 

          (y)  “Directed plan of correction” means a plan developed and written by the department that specifies the actions the licensee must take to correct identified deficiencies.

 

          (z)  “Dietitian” means a person who is licensed under RSA 326-H.

 

          (aa)  “Do not resuscitate order (DNR order)” means an order, signed by a licensed provider, that in the event of an actual or imminent cardiac or respiratory arrest, chest compression, and ventricular defibrillation will not be performed, the patient will not be intubated or manually ventilated, and there will be no administration of resuscitation drugs. This term also includes “do not attempt resuscitation order (DNAR order)”.

 

          (ab)  “Elopement” means an event in which a patient who is cognitively, physically, mentally, emotionally, or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves the facility unsupervised, unnoticed, or prior to their scheduled discharge.

 

          (ac) “Emergency” means an unexpected occurrence or set of circumstances, which require immediate remedial attention.

 

          (ad)  “Emergency plan” means a document outlining the responsibilities of personnel in an emergency.

 

          (ae) “Emergency psychiatric services” means the ability to admit patients for psychiatric services on a 24-hour basis for immediate treatment.

 

          (af)  “Employee” means anyone employed by the licensee and for whom the licensee has direct supervisory authority.

 

          (ag) “Equipment” means “any plumbing, heating, electrical, ventilating, air-conditioning, refrigerating, and fire protection equipment, and any elevators, dumbwaiters, escalators, boilers, pressure vessels, or other mechanical facilities or installations related to building services. This term includes fixtures.

 

          (ah)  “Exploitation” means the illegal use of a patient’s person or property for another person’s profit or advantage, or the breach of a fiduciary relationship through the use of a person or person’s property for any purpose not in the proper and lawful execution of a trust, including, but not limited to, situations where a person obtains money, property, or services from a patient through the use of undue influence, harassment, duress, deception or fraud.

 

          (ai)  “Facility” means “facility” as defined in RSA 151:19, II, including the part of the hospital where special health care services are rendered in accordance with RSA 151:2-e.

 

          (aj)  “Freestanding hospital emergency facility (FHEF)” means a hospital geographically separate from the parent hospital, which is owned or operated, directly or indirectly, by the parent hospital and which provides emergency acute care identical to those services provided by the parent hospital.

 

          (ak)  “Governing body” means  a group of designated person(s) functioning as a governing body that appoints the administrator and is legally responsible for establishing and implementing policies regarding management and operation of the facility.

 

          (al)  “Guardian” means a person appointed in accordance with RSA 463, RSA 464-A or the laws of another state, to make informed decisions relative to the patient’s health care and other personal needs.

 

          (am)  “Hospital” means “hospital” as defined in RSA 151:2, I(a).

 

          (an)  “Incident Command System (ICS)” means a standardized on-scene emergency management system specifically designed to provide for the adoption of an integrated organizational structure that reflects the complexity and demands of single or multiple incidents, without being hindered by jurisdictional boundaries. ICS is the combination of facilities, equipment, personnel, procedures, and communications operating within a common organizational structure, designed to aid in the management of resources during incidents.

 

          (ao)  “Independent contractor” means an individual or business entity working under the supervision of the licensee but not employed by the licensee.

 

          (ap)  “Infectious waste” means those items specified by Env-Sw 904.

 

          (aq)  “Informed consent” means the decision by a person, his or her guardian or agent, or surrogate decision-maker, to agree to a proposed course of treatment, after the person, his or her guardian or agent, or surrogate decision-maker has received full disclosure of the facts, including information about the risks and benefits of the treatment and available alternatives, needed to make the decision competently.

 

          (ar)  “Inspection” means the process followed by the department to determine an applicant’s or a licensee’s compliance with RSA 151 and He-P 802 or to respond to allegations pursuant to RSA 151:6, of non-compliance with RSA 151 and He-P 802.

 

          (as)  “License” means the document issued by the department to an applicant, at the start of operation as a hospital or provider of special health care services which authorizes operation of a hospital or special health care services in accordance with RSA 151 and He-P 802, and includes the name of the licensee, the name of the business, the physical address, the license category, the effective date and license number.

 

          (at)  “License certificate” means the document issued by the department to an applicant or licensee that contains the information on a license, and includes the name of the administrator, the type(s) of services authorized, and the number of beds for which the hospital is licensed.

 

          (au)  “Licensed practitioner” means:

 

(1)  Medical doctor;

 

(2)  Physician's assistant;

 

(3)  Advanced practice registered nurse (APRN);

 

(4)  Doctor of osteopathy;

 

(5)  Doctor of naturopathic medicine; or

 

(6)  Any other practitioner with diagnostic and prescriptive powers licensed by the appropriate state licensing board.

 

          (av)  “Licensed premises” means the building, or portion thereof, that comprises the physical location that the department has approved for the licensee to conduct operations in accordance with its license.

 

          (aw)  “Licensee” means any person or legal entity to which a license has been issued pursuant to RSA 151.

 

          (ax)  “Life safety code” means the National Fire Protection Association (NFPA) 101, as adopted pursuant to RSA 153:1, VI-a and amended in Saf-Fmo 300 by the fire marshal with the board of fire control, pursuant to RSA 153:5.

 

          (ay)  “Locked unit” means a locked, secured, or alarmed hospital or units within a hospital, or anklets, bracelets or similar devices that cause a door to close automatically and lock when approached, thereby preventing a patient from freely exiting the hospital or unit within.

         

          (az ) “Medical director” means a physician licensed in New Hampshire pursuant to RSA 329, who is responsible for the implementation of patient care policies and the coordination of medical care in the hospital.

 

          (ba)  “Medical staff” means those physicians and other licensed practitioners permitted by law and licensee policies to provide patient care services independently within their scope of practice.

 

          (bb)  “Medication” means a substance available with or without a prescription, which is used as a curative, remedial, or palliative, supportive substance.

 

          (bc)  “Megavoltage radiation therapy equipment” means therapeutic equipment having a minimum power rating in excess of one MeV which utilizes directed beams of ionizing radiation to kill cancerous tissues.  The term includes, but is not limited to, Cobalt-60 and linear accelerator machines.

 

          (bd)  “Modification” means the reconfiguration of any space, the addition, relocation, or elimination of any door or window, the addition or elimination of load-bearing elements, the reconfiguration or extension of any system, or the installation of any additional equipment.  This term does not include repair or replacement of interior finishes.

 

          (be)  “Neglect” means an act or omission which results or could result in the deprivation of essential services or supports necessary to maintain the minimum mental, emotional, or physical health and safety of any patient.

 

          (bf)  “Nursing care” means the provision or oversight of a patient’s physical, mental, or emotional condition or diagnosis by a nurse, that if not monitored on a routine basis by a nurse, would or could result in physical or mental harm to a patient.

 

          (bg)  “Open heart surgery (OHS)” means open surgical procedures on the heart muscle, valves, coronary arteries, or other heart structures, including coronary artery bypass graft surgery.

 

          (bh)  “Orders” means an electronic or written document, or a verbal direction , by a licensed practitioner for medications, treatments, recommendations, and referrals, and signed by the licensed practitioner using terms such as authorized by, authenticated by, approved by, reviewed by, or any other term that denotes approval by the licensed practitioner.

 

          (bi)  “Owner” means a person or organization who has controlling interest in the hospital.

 

          (bj) “Parent hospital” means the hospital which owns and operates a freestanding hospital emergency facility.

 

          (bk)  “Patient” means any person admitted to or in any way receiving care, services, or both from a hospital licensed in accordance with RSA 151 and He-P 802.

 

          (bl)  “Patient record” means a separate file maintained for each person receiving care and services by the licensee, which includes all documentation required by RSA 151 and He-P 802 and all documentation as required by other federal and state requirements.

 

          (bm)  “Patient rights” means the privileges and responsibilities possessed by each patient pursuant to RSA 151:21.

 

          (bn)  “Performance-based design” means a flexible, informed design approach that allows for design freedom while specifically addressing fire and life safety concerns of a specific building project, and that makes use of computer fire models or other fire engineering calculation methodologies, such as timed egress studies, to help assess if proposed fire safety solutions meet fire safety goals under specific conditions.

 

          (bo)  “Personal care” means personal care services that are non-medical, hands-on services provided to a patient including, but not limited to, assistance with activities of daily living such as grooming, toileting, eating, dressing, bathing, getting into or out of a bed or chair, walking, or reminding the patient to take medications.

 

          (bp)  “Personnel” means an individual who is employed by, a volunteer of, or an independent contractor of the hospital who provides services to patients. 

 

          (bq)  “Physical restraint” means the use of hands-on or other physically applied technique to physically limit a patient’s freedom of movement, such as forced escorts, holding, prone restraints, or other containment techniques. This term does not include orthopedic appliances.

 

          (br)  “Physician” means medical doctor or doctor of osteopathy currently licensed in the state of New Hampshire pursuant to RSA 329.

 

          (bs)  “Plan of correction (POC)” means a plan developed and written by the licensee, which specifies the actions that will be taken to correct identified deficiencies with applicable rules or codes identified at the time of a clinical or life safety code inspection conducted pursuant to RSA 151:6-a or during the course of a complaint investigation conducted pursuant to RSA 151:6.

 

          (bt)  “Primary interventional cardiac catheterization” means those catheter-based procedures that involve modification of the coronary arterial system under emergency conditions.

 

          (bu)  “Pro re nata (PRN) medication” means medication administered as circumstances might require in accordance with licensed practitioner’s orders.

 

          (bv)  “Procedure” means a licensee’s written, standardized method of performing duties and providing services.

 

          (bw)  “Protective care” means the provision of patient monitoring services, including but not limited to:

 

(1)  Knowledge of patient whereabouts; and

 

(2)  Minimizing the likelihood of accident or injury.

 

          (bx)  “Psychiatric hospital” means a:

 

(1)  Hospital that has been verified by CMS as an inpatient psychiatric hospital; or

 

(2)  Hospital designated by CMS to provide psychiatric services in a distinct part unit.

 

          (by) “Qualified personnel” means personnel that have been trained and have demonstrated competency to adequately perform the tasks which they are assigned, such as nursing staff, clinical staff, housekeeping staff trained in infection control, and kitchen staff trained in food safety protocols.

 

          (bz)  “Radiographic images” means x-rays or other images which are either on film, paper, or stored electronically.

 

          (ca) “Reconstruction” means the reconfiguration of a space that affects an exit or a corridor shared by more than one occupant space, or the reconfiguration of a space such that the rehabilitation work area is not permitted to be occupied because existing means of egress and fire protection systems, or their equivalent, are not in place or continuously maintained.

 

          (cb)  “Renovation” means the replacement in kind or strengthening of building elements, or upgrading of building elements, material, equipment, or fixtures, without involving the reconfiguration of spaces.

 

          (cc)  “Rehabilitation hospital” means a:

 

(1)  Hospital that has been certified by CMS as an inpatient rehabilitation hospital; or

 

(2)  Hospital designated by CMS to provide comprehensive physical rehabilitation services in a distinct part unit.

 

          (cd)  “Repair” means the patching, restoration, or painting of materials, elements, equipment, or fixtures for the purpose of maintain such materials, elements, equipment, or fixtures in good or sound condition.

 

          (ce)  “Service” means a specific activity performed by the licensee, either directly or indirectly, to benefit or assist a patient, such as dietary, laboratory, nursing, or surgery.

 

          (cf) “Special health care service” means cardiac catheterization laboratory services, open heart surgery, or treatment using megavoltage radiation therapy equipment.

 

          (cg)  “Swing beds” means beds within a hospital or critical access hospital participating in Medicare that are approved by the Centers for Medicare and Medicaid Services for the provision of a skilled level of care.

 

          (ch)  “Volunteer” means an unpaid person who assists with the provision of services such as personal care services, food services, entertainment, or activities, and who does not provide direct care or assist with direct care. This term does not include visitors or those persons who provide religious services.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.04  Initial License Application Requirements.

 

          (a)  Each applicant for a license shall comply with the requirements of RSA 151:4, I-III(a), and submit the following to the department:

 

(1)  A completed application form entitled “Application for Residential, Health Care License or Special Health Care Services” (March 2019), signed by the applicant or 2 of the corporate officers affirming to the following:

 

a. “I affirm that I am familiar with the requirements of RSA 151 and the rules adopted thereunder and that the premises are in full compliance. I understand that providing false information shall be grounds for denial, suspension, or revocation of the license, and the imposition of a fine.”;

 

b.  For any hospital or special health care service to be newly licensed:

 

“I certify that I have notified the public of the intent to file this application with a description of the facility to be licensed by publishing a notice in a newspaper of general circulation covering the area where the facility is to be located in at least 2 separate issues of the newspaper no less than 10 business days prior to the filing of this application.”;

 

c.  For any facility to be newly licensed and to be located within a radius of 15 miles of a hospital certified as a critical access hospital, pursuant to 42 C.F.R. section 485.610 (b) and (c):

 

“I certify that the facility is to be located within a radius of 15 miles of a hospital certified as a critical access hospital, pursuant to 42 C.F.R. section 485.610 (b) and (c), and that I have given written notice of the intent to file this application with a description of the facility to be licensed to the chief executive officer of the hospital by registered mail no less than 10 business days prior to the filing of this application.”; and

 

d.  For facilities to be licensed under the listed categories:

 

“I understand that, in accordance with RSA 151:4, III(a)(7), this facility cannot be licensed pursuant to He-P 802, 806, 810, 811, 812, 816, 823, or 824 if it is within a radius of 15 miles of a hospital certified as a critical access hospital, pursuant to 42  C.F.R. 485.610(b) and (c), until the Commissioner makes a determination that the proposed new facility will not have a material adverse impact on the essential health care services provided in the service area of the critical access hospital. I also understand that if the Commissioner is not able to make such a determination, the license will not be issued.”;

 

(2)  A floor plan of the prospective hospital;

 

(3)  If applicable, proof of authorization from the New Hampshire secretary of state to do business in New Hampshire in the form of one of the following:

 

a.  “Certificate of Authority,” if a corporation;

 

b.  “Certificate of Formation,” if a limited liability corporation; or

 

c.  “Certificate of Trade Name,” where applicable;

 

(4)  List of affiliated or related parties;

 

(5)  The applicable fee in accordance with RSA 151:5, payable in cash in the exact amount of the fee or, if paid by check or money order, the exact amount of the fee made payable to the “Treasurer, State of New Hampshire”;

 

(6)  A resume identifying the name and qualifications of the administrator and medical director;

 

(7)  Copies of applicable licenses, certificates, or both, for the administrator and medical director;

 

(8)  Written local approvals as follows:

 

a.  For an existing building, the following written local approvals shall be obtained no more than 90 days prior to submission of the application, from the following local officials, or if there is no such official(s), from the board of selectmen or mayor:

 

1.  The health officer verifying that the applicant complies with all applicable local health requirements and drinking water and wastewater requirements;

 

2.  The building official verifying that the applicant complies with all applicable state building codes and local building ordinances;

 

3.  The zoning officer verifying that the applicant complies with all applicable local zoning ordinances; and

 

4.  The fire chief verifying that the applicant complies with the state fire code, RSA 153:1, VI-a, including the health care chapter of the Life Safety Code 101 and the Uniform Fire Code, NFPA 1, as published by the National Fire Protection Association and as amended by the state board of fire control and ratified by the general court pursuant to RSA 153:5; and

 

b.  For a building under construction, the written approvals required by a. above shall be submitted at the time of the application based on the local official’s review of the building plans and their final inspection upon completion of the construction project;

 

(9)  If the hospital uses a private water supply, documentation that the water supply has been tested in accordance with RSA 485 and Env-Dw 702.02 and Env-Dw 704.02, or if public water supply is used, a copy of a water bill;

 

(10)  A written statement from the applicant, proposed licensee, administrator, and medical director stating that he or she:

 

a.  Does not have a felony conviction in this or any other state;

 

b.  Has not been convicted of a sexual assault, other violent crime, assault, fraud, abuse, neglect or exploitation or pose a threat to the health, safety or well-being of a patient in this or any other state;

 

c. Does not have any permanent restraining or protective orders against the applicant, licensee, or administrator;

 

d.  Has not had a finding by the department or any administrative agency in this or any other state for assault, fraud, abuse, neglect, or exploitation of any person in this or any other state; and

 

(11)  If any of the items in (10) above have occurred, the individual shall include a detailed explanation of the circumstances surrounding the occurrences; and

 

(12)  The results of a criminal records check from the NH department of safety for the applicant(s), licensee if different than the applicant, administrator, and medical director.

 

          (b)  The applicant shall mail or hand-deliver the documents to:

 

Department of Health and Human Services

Office of Legal and Regulatory Services

Health Facilities Administration

129 Pleasant Street

Concord, NH 03301

 

          (c)  If a hospital has not previously performed a special health care service but plans to do so, the hospital shall complete a new application including all of the above application requirements and any information required under He-P 802.38, He-P 802.39, and He-P 802.40.

 

          (d)  A previously operating special health care service, which means a special health care service as defined by RSA 151:2-e that was being offered by a hospital prior to July 1, 2016 and has continued to be offered since July 1, 2016, shall not require additional licensure separate from the hospital license but shall still comply with RSA 151 and all applicable He-P 802 provisions.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.05  Processing of Applications and Issuance of Licenses.

 

          (a)  An application for an initial license shall be complete when the department determines that all items required by RSA 151 and He-P 802.04(a) have been received.

 

          (b)  Following both a clinical and life safety code inspection, a license and license certificate shall be issued to the applicant if the department determines that an applicant requesting an initial license is in full compliance with RSA 151 and He-P 802.09.

 

          (c)  If an application does not contain all of the items required by He-P 802.04(a), the department shall notify the applicant in writing of the items required before the application can be processed.

 

          (d)  Any licensing fee submitted to the department in the form of a check or money order and returned to the state for any reason shall be processed in accordance with RSA 6:11-a.

 

          (e)  Licensing fees shall not be transferable to any other application(s).

 

          (f)  Unless a waiver has been granted, the department shall deny a licensing request in accordance with He-P 802.13 if it determines that the applicant, proposed licensee, medical director, or administrator:

 

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

 

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

 

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

 

             (g)  All licenses issued in accordance with RSA 151 shall be non-transferable.

 

          (h)  A written notification of denial, pursuant to He-P 802.13(b), shall be sent to an applicant applying for an initial license, if it has been determined by the inspection in He-P 802.05(g) and a maximum of 2 follow-up inspections that the prospective premises are not in full compliance with RSA 151 and He-P 802.

 

          (i)  A written notification of denial, pursuant to He-P 802.13(b)(4), shall be sent to an applicant applying for an initial license if the department has received no communication from the applicant within 3 months of sending written notification to the applicant that their application is complete and an inspection needs to be scheduled.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.06  License Expirations and Procedures for Renewals.

 

          (a)  A license shall be valid on the date of issuance for one full calendar year unless a completed application for renewal has been received.

 

          (b)  Each licensee shall complete and submit to the department an application form pursuant to He-P 802.04(a)(1) at least 120 days prior to the expiration of the current license.

 

          (c)  The licensee shall submit with the renewal application:

 

(1)  The materials required by He-P 802.04(a)(1) and (5);

 

(2)  The current license number;

 

(3)  A request for renewal of any existing non-permanent waivers previously granted by the department, in accordance with He-P 802.10(f), if applicable;

 

(4)  A list of any current employees who have a permanent waiver granted in accordance with He-P 802.17(e)(2);

 

(5)  A copy of any new exceptions or variances granted by the state fire marshal, in accordance with Saf-C 6005;

 

(6)  A copy of any new variances granted by the local building inspector or state building code review board in accordance with He-P 802.07(g)(3); and

 

(7)  If a private water supply is used, documentation that every 3 years the water supply has been tested for bacteria and nitrates and determined to be at acceptable levels, in accordance with Env-Dw 702.02 for bacteria and Env-Dw 704.02 for nitrates.

 

          (d)  If the request in (c)(3) above is not received at the time of renewal, the rule(s) for which the waiver was previously requested shall not continue to be waived beyond the expiration of the current license.

 

          (e)  Following an inspection as described in He-P 802.09, a license shall be renewed if the department determines that the licensee:

 

(1)  Submitted an application containing all the items required by (b) and (c) above as applicable, prior to the expiration of the current license; and

 

(2)  Is found to be in compliance with RSA 151, He-P 802, and all federal requirements at the renewal inspection, or has submitted a POC that has been accepted by the department and implemented by the licensee if deficiencies were cited at the renewal inspection.

 

          (f)  Any licensee who does not submit a complete application for renewal prior to the expiration of an existing license shall not operate.

 

          (g)  If a licensee fails to submit an application for renewal prior to the expiration of the license and continues to operate:

 

(1)  The licensee shall be considered an initial licensee and shall follow all application requirements set forth for an initial license pursuant to He-P 802.04; and

 

(2)  The licensee shall be subject to a fine in accordance with He-P 802.13(e).

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.07  Hospital Construction, Modifications, or Structural Alterations.

 

          (a)  At least 60 days prior to construction, the licensee shall submit to the department accurate architectural plans, including sprinkler and fire alarm plans or drawings, that show the room designation(s) and exact measurements of each area to be licensed, including windows and door sizes and each room’s use, for the following:

 

(1)  A new building;

 

(2)  An addition or renovation to an existing building;

 

(3)  Structural alterations to any patient area;

 

(4)  Alterations that require approval from local or state authorities; and

 

(5)  Alterations that might affect compliance with the health and safety, fire, or building codes, including but not limited to, fire suppression, detection systems, and means of egress.

 

             (b)  Sprinkler and fire alarm plans shall be submitted to the NH state fire marshal’s office as required by RSA 153:10-b, V.

 

          (c)  Any licensee or applicant who wants to use performance-based standards to meet the fire safety requirements shall provide the department with documentation of fire marshal approval for such methods.

 

          (d)  The department shall review and approve plans for construction, modification, or structural alterations of a facility for compliance with all applicable sections of RSA 151 and He-P 802 and notify the applicant of the approval prior to construction, modification, or structural alterations.

 

          (e)  A licensee or applicant constructing, modifying, or structurally altering a building shall comply with the following:

 

(1)  Saf-C 6000 and the state fire code, under RSA 153:1, VI-a , including, but not limited to, NFPA 1 and NFPA 101 and as amended in Saf- Fmo 300 by the fire marshal with the  board of fire control and ratified by the general court pursuant to RSA 153:5; 

 

(2)  The state building code as defined in RSA 155-A:1, IV, as amended by the building code Review Board pursuant to RSA 155-A:10, V; and

 

(3)  Federal, state, and local laws, regulations, and ordinances.

 

          (f)  Any newly constructed, modified, or structurally altered hospital or FHEF shall follow and comply with the Facility Guidelines Institutes (FGI)’s “Guidelines for Design and Construction of Hospitals” (2018 edition), available as noted in Appendix A, and FGI’s “Guidelines for Design and Construction of Outpatient Facilities” (2018 edition), available as noted in Appendix A.

 

          (g) The authority for waivers shall be as follows:

 

(1)  The department shall be responsible for granting waivers pursuant to the FGI guidelines above and these rules;

 

(2)  The state fire marshal shall be responsible for granting exceptions or variances pertaining to the state fire code; and

 

(3)  The local building official or state building code review board shall be responsible for granting variances to the local or state building code, respectively.

 

             (h)  Waivers granted by the department for construction or modifications under the FGI guidelines above shall be permanent and not require annual renewal unless the underlying reason or circumstances for the waiver changes.

 

          (i)  Existing hospitals shall be deemed compliant with (f) above, unless and until modifications or changes are implemented in the facility.

 

          (j)  The completed building shall be subject to an inspection pursuant to He-P 802.09 prior to its use.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.08  Requirements for Organizational Changes.

 

          (a)  The licensee shall provide the department with written notice at least 30 days prior to changes in any of the following:

 

(1)  Ownership;

 

(2)  Physical location;

 

(3)  Address;

 

(4)  Name;

 

(5)  Capacity;

 

(6)  Administrator;

 

(7)  Medical director; or

 

(8)  Affiliated or related parties.

 

          (b)  When there is a change in the name, the licensee shall submit to the department a copy of the certificate of amendment from the New Hampshire secretary of state, if applicable.

 

          (c)  The licensee shall complete and submit a new application and obtain a new license and license certificate prior to operating, for:

 

(1)  A change in ownership;

 

(2)  A change in the physical location; or

 

(3)  An increase in the number of beds beyond what was authorized under the initial license.

 

          (d)  When there is a change in address without a change in location, the licensee shall provide the department with a copy of the notification from the local, state, or federal agency that requires the change.

 

          (e)  An inspection by the department shall be conducted prior to operation when there are changes in the following:

 

(1)  Ownership, unless the current licensee has no outstanding administrative actions in process and there will be no changes made by the new owner in the scope of services provided;

 

(2)  The physical location;

 

(3)  A change in the licensing classification;

 

(4)  A change that places the facility under a different life safety code occupancy chapter; or

 

(5)  An increase in the number of beds beyond what is authorized under the license.

 

          (f)  A revised license certificate shall be issued for any of the following:

 

(1)  A change of administrator;

 

(2)  An increase in the number of beds beyond what is authorized under the license;

 

(3)  A change in the scope of services provided;

 

(4)  A change in the address without a change in physical location; or

 

(5)  When a waiver has been granted.

 

            (g) The licensee shall inform the department in writing no later than 30 days prior to a change in

administrator or medical director, or as soon as practicable in the event of a death or other extenuating circumstances requiring an administrator or medical director change, and provide the department with the following:

 

(1)  A resume identifying the name and qualifications of the new administrator or medical director;

 

(2)  Copies of applicable licenses for the new administrator or medical director;

 

(3)  The results of a criminal records check from the department of safety for the new administrator or medical director; and

 

(4)  A statement, which shall be signed at the time the initial offer of employment, contract, or engagement and then annually thereafter, stating that he or she:

 

a.  Does not have a felony conviction in this or any other state;

 

b.  Has not been convicted of a sexual assault, other violent crime, assault, fraud, abuse, neglect or exploitation or pose a threat to the health, safety or well-being of a patient in this or any other state; and

 

c.  Has not had a finding by the department or any administrative agency in this or any other state for assault, fraud, abuse, neglect, or exploitation of any person in this or any other state.

 

          (h)  Upon review of the materials submitted in accordance with He-P 802.08(g), the department shall make a determination as to whether the new administrator or medical director meets the qualifications for the position, as specified in He-P 802.16(b) and He-P 802.16(c) respectively.

 

          (i)  If the department determines that the new administrator or medical director does not meet the qualifications for the position as specified in (h) above, it shall notify the licensee in writing so that a waiver can be sought or the licensee can search for a qualified candidate.

 

          (j)  The licensee shall inform the department in writing via e-mail, fax, or mail of any change in the licensee’s e-mail address as soon as practicable and in no case later than 10 days of the change.

 

          (k)  A restructuring of an established hospital that does not result in a transfer of the controlling interest of the licensee, but which might result in a change in the name of the licensee or corporation, shall not constitute a change in ownership.

 

          (l)  Licenses issued for a change of ownership shall expire on the date the license issued to the previous owner would have expired.

 

          (m)  If a licensee chooses to cease the operation of the hospital or special health care service, the licensee shall submit written notification to the department at least 60 days in advance.

 

          (n)  The licensee shall return the previous license to the division within 10 days of the licensee ceasing operations.

 

          (o)  If the licensee is changing its ownership, physical location, address, or name, a new license shall not be issued if the licensee fails to return its previous license.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.09  Inspections.

 

          (a)  For the purpose of determining compliance with RSA 151 and He-P 802, as authorized by RSA 151:6 and RSA 151:6-a, the licensee shall admit and allow any department representative at any time to inspect the following:

 

(1)  The licensed premises;

 

(2)  All programs and services provided by the licensee; and

 

(3)  Any records required by RSA 151 and He-P 802.

 

          (b)  The department shall conduct a clinical and life safety code inspection to determine full compliance with RSA 151 and He-P 802, to include a clinical and a life safety inspection, prior to:

 

(1)  The issuance of an initial license;

 

(2)  A change in ownership, except as allowed by He-P 802.08(e)(1);

 

(3)  A change in the licensee’s physical location;

 

(4)  An increase in the number of beds beyond what is authorized under the license;

 

(5)  Occupation of space after construction, modifications, or structural alterations; or

 

(6)  The renewal of a license, if not deemed under RSA 151:5-b.

 

          (c)  In addition to (b) above, the department shall conduct an inspection as necessary to verify the implementation of any POC accepted or issued by the department.

 

          (d) A deficiency report or notice to correct shall be issued when, as a result of any inspection, the department determines that the licensee is in violation of any of the provisions of He-P 802, RSA 151, or any applicable state or federal law, administrative rule, or code.

 

          (e)  If deficiencies were cited, the licensee shall submit a POC, in accordance with He-P 802.12(c) within 21 days of the date on the letter that transmits the inspection report.

 

          (f)  A written notification of denial shall be sent to an applicant applying for an initial license if it has been determined by the inspection in (b) above that the prospective premises is not in full compliance with RSA 151, He-P 802, or any applicable federal, state, or local law, regulation, or code.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.10  Waivers.

 

          (a)  Applicants or licensees seeking waivers of specific rules in He-P 802 shall submit a written request for a waiver to the commissioner that includes:

 

(1)  The specific reference to the rule for which a waiver is being sought;

 

(2)  A full explanation of why a waiver is necessary; and

 

(3)  A full explanation of alternatives proposed by the applicant or license holder, which shall be equally as protective of public health and patients as the rule from which a waiver is sought or provide a reasonable explanation why the applicable rule should be waived.

 

          (b)  Waivers shall be permanent unless the department specifically places a time limit on the waiver.

 

          (c)  A request for waiver shall be granted if the department determines that the alternative proposed by the applicant or licensee:

 

(1)  Meets the objective or intent of the rule;

 

(2)  Does not have the potential to negatively impact the health or safety of the patients; and

 

(3)  Does not negatively affect the quality of patient services.

 

          (d)  The licensee’s subsequent compliance with the alternatives approved in the waiver shall be considered equivalent to complying with the rule from which waiver was sought.

 

          (e)  Waivers shall not be transferable.

 

          (f)  When a licensee wishes to renew a non-permanent waiver beyond the approved period of time, the licensee shall apply for a new waiver with the renewal application or at least 60 days prior to expiration of the existing waiver, as appropriate, by submitting the information required by (a) above.

 

          (g)  The request to renew a waiver shall be subject to (b) through (f) above.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.11  Complaints.

 

          (a)  The department shall investigate a complaint against a licensed, non-CMS certified hospital when there is sufficient specific information for the department to determine that the allegation(s), if proven to be true, would constitute a violation of any of the provisions of RSA 151 or He-P 802.

 

          (b) The bureau of licensing and certification shall refer for investigation to the department’s health facilities administration-certification unit or to the accrediting organization, as appropriate, any complaint against a CMS certified hospital that meets the following conditions:

 

(1) There is sufficient specific information to determine that if the allegation(s) were proven to be true, a violation would be determined to exist of the applicable requirements at 42 CFR 482, 42 CFR 485, 42 CFR 489, or the CMS, “Life Safety Code & Health Care Facilities Code Requirements" (2017 update)  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/LSC, as available and noted in Appendix A; and

 

(2) Investigations shall be conducted in accordance with CMS Publication #100-07, “State Operations Manual”, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984, including Chapter 5-Complaint Procedures, and applicable appendices, as available and noted in Appendix A.

 

          (c)  For complaints alleging violations of RSA 151 or He-P 802, the department shall:

 

(1)  Provide written notification of the results of the investigation to the licensee along with an inspection report if deficiencies were found as a result of the investigation;

 

(2)  Notify any other federal, state or local agencies of alleged violations of their statutes or rules based on the results of the investigation, as appropriate;

 

(3)  Notify the licensee in writing and take no further action if the department determines that the complaint is unfounded or does not violate any statutes or rules; and

 

(4)  Require the licensee to submit a POC in accordance with He-P 802.12(c) if the inspection results in deficiencies being cited.

 

             (d)  Investigations shall include all techniques and methods for gathering information which are appropriate to the circumstances of the complaint, including:

 

(1)  Requests for additional information from the complainant;

 

(2)  A physical inspection of the premises;

 

(3)  Review of any records that might be relevant and have probative value;

 

(4)  Interviews with individuals who might have information that is relevant to the investigation and might have probative value; and

 

(5)  Any other relevant investigative techniques.

 

          (e)  For complaints regarding an unlicensed individual or entity:

 

(1)  The department shall provide written notification to the owner or person responsible that includes:

 

a.  The date of inspection;

 

b.  The reasons for the inspection; and

 

c.  Whether or not the inspection resulted in a determination that the services being provided require licensing under RSA 151;

 

(2)  The owner or person responsible shall be allowed 7 days from the date of receipt of the notice required by (1) above to respond to a finding that they are operating without a license or submit a completed application for a license in accordance with RSA 151:7-a, II;

 

(3)  If the owner of an unlicensed hospital does not comply with (2) above, or if the department does not agree with the owner’s response, the department shall:

 

a.  Issue a written warning to immediately comply with RSA 151 and He-P 802; and

 

b.  Provide notice stating that the individual has the right to appeal the warning in accordance with RSA 151:7-a, III; and

 

(4)  Any person or entity who fails to comply after receiving a warning, as described in (3)a. above, shall be subject to an action by the department for injunctive relief under RSA 151:17.Whether or not the department takes action for injunctive relief under RSA 151:17 shall not preclude the department from taking other action under RSA 151, He-P 802, or other applicable laws.

 

          (f)  Complaint investigation files shall:

 

(1)  Be confidential in accordance with RSA 151:13;

 

(2)  Not be disclosed publicly; and

 

(3)  Be released by the department on written request only:

 

a.  To the department of justice when relevant to a specific investigation;

 

b.  To law enforcement when relevant to a specific criminal investigation;

 

c.  When a court of competent jurisdiction orders the department to release such information; or

 

d.  In connection with any adjudicative proceedings relative to the licensee.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.12  Administrative Remedies.

 

          (a)  The department shall impose administrative remedies for violations of RSA 151, He-P 802, 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 on a licensee; or

 

(4)  Monitoring of a license.

 

          (b)  When administrative remedies are imposed, the department shall provide a written notice, as applicable, which:

 

(1)  Identifies each deficiency in which the licensee is not in compliance with RSA 151 or He-P 802; 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 notice of deficiencies, the licensee shall submit a written POC detailing:

 

a.  How the licensee intends to correct each deficiency;

 

b.  What measures will be put in place, or what system changes will be made to ensure that the deficiency does not recur, including how the measures are evaluated for effectiveness;

 

c.  The date by which each deficiency shall be corrected; and

 

d.  The position(s) of the employee(s) responsible for the corrective action;

 

(2)  The licensee shall submit the POC in (c) above to the department within 21 days of the date on the letter that transmitted the inspection report 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 it has made a good faith effort to develop and submit the POC within the 21-day period but has been unable to do so; and

 

b.  The department determines that the health, safety, or well-being of the patients, personnel, or visitors will not be jeopardized as a result of granting the extension;

 

(3)  The department shall review and accept each POC that:

 

a.  Achieves compliance with RSA 151 and He-P 802;

 

b.  Addresses all deficiencies and deficient practices as cited in the inspection report;

 

c.  Prevents a new violation of RSA 151 or He-P 802 as a result of the implementation of the POC;

 

d.  Identifies the position(s) of the employee(s) responsible for the corrective action; and

 

e.  Specifies the date upon which the deficiencies 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, either verbally or in writing, and the department grants the extension, based on the following criteria:

 

1.  The licensee demonstrates that it 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 in accordance with this section, the licensee shall be subject to a directed POC in accordance with (d) below and a fine in accordance with He-P 802.13(c)(12);

 

(6)  Following the date of completion specified by the licensee in the POC, the department shall verify the implementation of any POC by:

 

a.  Reviewing materials submitted by the licensee;

 

b.  Conducting an onsite follow-up inspection; or

 

c.  Reviewing compliance during the next annual inspection; and

 

(7)  If the POC or revised POC has not been implemented as verified by (6) above, the licensee shall be:

 

a.  Notified by the department in accordance with (b) above;

 

b.  Issued a directed POC in accordance with (d) below; and

 

c.  Subject to a fine in accordance with He-P 802(c)(13).

 

          (d)  The department shall develop and impose a directed POC that specifies corrective actions for the licensee to implement when:

 

(1)  As a result of an inspection, deficiencies were identified that require immediate corrective action to protect the health and safety of the patients and personnel; and

 

(2) A POC or revised POC is not submitted or accepted in accordance with (c)(1) and (5) respectively.

 

          (e)  The department shall offer an opportunity for informal dispute resolution to any 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.

 

          (f)  The informal dispute resolution shall be requested in writing by the licensee or administrator no later than 14 days from the date the statement of findings or notice to correct was issued by the department.

 

          (g)  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 licensee of the determination.

 

          (h)  The deadline to submit a POC in accordance with (c)(2) above shall not apply until the notice of the determination in (g) above has been provided to the licensee.

 

          (i)  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.

 

          (j)  An informal dispute resolution shall not be available for any 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.

 

          (k)  The department shall impose state monitoring if it determines that repeated poor compliance or the conditions of the facility might negatively impact the health, safety, or well-bring of patients.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.13  Enforcement Actions and Hearings.

 

          (a)  As specified in this section, the department shall take the following enforcement actions for violation of RSA 151, He-P 802, or other applicable licensing rules:

 

(1)  Issue a warning;

 

(2)  Impose a fine in accordance with (e) below;

 

(3)  Deny the application for a renewal of a license in accordance with (c) and (d) below;

 

(4)  Immediately suspend a license; or

 

(5)  Revoke the license in accordance with (c) and (d) below.

 

          (b)  At the time of issuing a warning, imposing a fine, or denying, revoking, or suspending a license, the department shall send to the applicant or licensee a written notice that sets forth:

 

(1)  The reasons for the proposed action;

 

(2)  The action to be taken by the department;

 

(3)  If a fine is imposed, the automatic reduction of the fine by 25% if the fine is paid within 10 days of the date on the written notice from the department and the deficiency has been corrected, or a POC has been accepted and approved by the department; and

 

(4)  The right of an applicant or licensee to a hearing in accordance with RSA 151:8 or RSA 541-A:30, III, as applicable before the enforcement action becomes final.

 

          (c)  The department shall deny an application or revoke a license if:

 

(1)  An applicant or a licensee has violated provisions of RSA 151 or He-P 802, which poses a risk of to harm a patient’s health, safety, or well-being;

 

(2)  An applicant or a licensee has failed to pay a fine imposed by the department;

 

(3)  An applicant or a licensee has had a check returned to the department for insufficient funds and has not re-submitted the outstanding fee in the form of cash, money order, or certified check;

 

(4)  After being notified of and given an opportunity to supply missing information on an application, an applicant or licensee fails to submit an application that meets the requirements of He-P 802.04; or

 

(5)  An applicant, licensee or any representative or employee of the applicant or licensee:

 

a.  Provides false or misleading information to the department;

 

b.  Prevents or interferes, or fails to cooperate with any inspection or investigation conducted by the department; or

 

c.  Fails to provide requested files or documents to the department;

 

(6)  The licensee failed to implement or continue to implement a POC that has been accepted or imposed by the department in accordance with He-P 802.12(c) and (d);

 

(7)  The licensee is cited a third time under RSA 151 or He-P 802 for the same violations within the last 5 inspections;

 

(8)  A licensee, its corporate officers, or its board members has had a license revoked and submits an application during the 5-year prohibition period specified in (l) below;

 

(9)  Upon inspection, the applicant’s premises are not in compliance with RSA 151 or He-P 802 and a waiver has not been granted;

 

(10)  The department makes a determination that the administrator, licensee, medical director, or applicant are guilty of one or more of the offenses listed in He-P 802.05(f) and a waiver has not been granted;

 

(11)  The applicant or licensee employs an administrator who does not meet all of the qualifications listed in He-P 802.16(b) and a waiver has not been granted; or

 

(12)  The applicant, administrator, licensee, or medical director has had a license revoked by any division of the department 5 years prior to the filing of the application.

 

          (d)  The department shall impose fines as follows:

 

(1)  For a failure to cease providing unlicensed services after being notified by the department of the need for a license, in violation of RSA 151:2 or RSA 151:2-e, the fine shall be $2,000.00 for an applicant or unlicensed provider;

 

(2)  For a failure to cease operations after a denial of a license or after receipt of an order to cease and desist immediately, in violation of RSA 151:2, RSA 151:2-e, and RSA 541-A:30, or continuing to operate after a failure to renew the license by the expiration date, the fine for an applicant, unlicensed provider, or a licensee shall be $2,000.00;

 

(3)  For advertising services or otherwise representing that the facility has a license to provide services it is not licensed to provide, in violation of RSA 151:2, III, the fine for an applicant, licensee or unlicensed provider shall be $500.00;

 

(4)  For a failure to transfer a patient whose needs exceeds the services or programs provided by the licensee in violation of RSA 151:5-a, the fine shall be $500.00;

 

(5)  For admission of a patient whose needs exceed the services or programs authorized by the license classification, in violation of RSA 151:5-a, II, and He-P 802.18, the fine for a licensee shall be $1,000.00;

 

(6)  For a failure to comply with the directives of a warning issued by the department in violation of RSA 151:7-a and He-P 802.11, He-P 802.13, or He-P 802.14, the fine shall be $500.00;

 

(7)  For a failure to submit a renewal application for a license prior to the expiration date, in violation of He-P 802.06(b), the fine shall be $500.00;

 

(8)  For a failure to notify the department prior to a change of ownership, in violation of He-P 802.08(a)(1), the fine shall be $500.00;

 

(9)  For a failure to notify the department prior to a change in the physical location, in violation of He-P 802.08(a)(2), the fine shall be $500.00;

 

(10)  For a failure to notify the department of a change in e-mail address as required by He-P 802.08(m), the fine for a licensee shall be $500.00;

 

(11)  For a failure to allow access by the department to the licensee’s premises, programs, services or records, in violation of He-P 802.09(a), the fine for an individual or licensee shall be $2,000.00;

 

(12)  For a failure to submit a POC or revised POC, within 21 or 14 days, respectively, in violation of He-P 802.12(c)(2) or (c)(5), the fine for a licensee shall be $500.00 unless an extension has been granted by the department;

 

(13)  For a failure to implement or maintain corrective action set forth in any POC that has been accepted or issued by the department, in violation of He-P 802.12(c), the fine for a licensee shall be $1,000.00;

 

(14)  For a failure to establish, implement, or comply with all policies generated by the licensee as required under this rule, the fine for a licensee shall be $1,000.00;

 

(15)  For a failure to provide services or programs required by the licensing classification and specified by He-P 802.18, the fine for a licensee shall be $500.00;

 

(16)  For exceeding the maximum number of patients, in violation of He-P 802.14(m), the fine for a licensee shall be $500.00 per day;

 

(17)  For creating or providing false or misleading information contained on an application or on any records required to be maintained for licensing, in violation of He-P 802.14(h), the fine shall be $1,00.00 per offense;

 

(18)  For a failure to meet the needs of the patient, in violation of He-P 802.14(k)(1), the fine for a licensee shall be $1,000.00 per patient;

 

(19)  For employing, contracting with, or engaging an administrator, medical director, or other personnel who do not meet the qualifications for the position as set forth in this rule and a waiver was not received, the fine for a licensee shall be $500.00;

 

(20)  For placing a patient in a room that has not been approved or licensed by the department, in violation of He-P 802.27, the fine for a licensee shall be $500.00;

 

(21)  For failure to report an adverse event as required by He-P 802.15, the fine for a licensee shall be $2,000.00 per occurrence;

 

(22)  For failure to report infections and process measures as identified and required by He-P 802.22, the fine for a licensee shall be $1,000.00 per occurrence;

 

(23)  For failure to submit architectural plans or drawings prior to undertaking construction or renovation of the licensed facility in violation of He-P 802.07(a), the fine for a licensed facility shall be $500.00;

 

(24)  For occupying a renovated area of a licensed facility or new construction prior to approval by local and state authorities, as required by He-P 802.09(b)(6), the fine shall be $500 per day; or

 

(25)  For failing to comply with any provision of He-P 802 where a patient’s health, safety, or well-being is placed in jeopardy, the fine shall be $1,000.

 

          (e)  When an inspection determines that a violation of RSA 151 or He-P 802 has the potential to jeopardize the health, safety, or well-being of a patient, in addition to any other enforcement actions taken by the department, the fines assessed shall be as follows:

 

(1)  If the same deficiency is cited within 2 years of the original deficiency, the fine for a licensee shall be double the initial fine, but not to exceed $2,000.00; and

 

(2)  If the same deficiency is cited a third time within 2 years of being fined in a. above, the fine for a licensee shall be triple the fine, but not to exceed $2,000.00.

 

          (f) Each day that the individual or licensee continues to be in violation of the provisions of RSA 151 or He-P 802 shall constitute a separate violation and shall be fined in accordance with He-P 802.12(f). If the applicant or licensee is making good faith efforts to comply with He-P 802, the department shall not issue a daily fine.

 

          (g)  Payment of any imposed fine to the department shall meet the following requirements:

 

(1)  Payment shall be made in the form of check or money order made payable to the “Treasurer, State of New Hampshire” or cash in the exact amount due; and

 

(2)  Cash, money order, or certified check shall be required when an applicant or licensee has issued payment to the department by check, and such check was returned for insufficient funds.

 

          (h)  An applicant, licensee, or unlicensed entity shall have 30 days after receipt of the notice of enforcement action to request a hearing to contest the action.

 

          (j)  If a written request for a hearing is not made pursuant to (h) above, the action of the department shall become final.

 

          (j)  The department shall order the immediate suspension of a license, the cessation of operations, and the transfer of care of patients when it finds that the health, safety, or welfare of patients is in jeopardy and requires emergency action in accordance with RSA 541-A:30, III.

 

          (k)  If an immediate suspension is upheld, the licensee shall not resume operating until the department determines through inspection that compliance with RSA 151 and He-P 802 is achieved.

 

          (l)  Hearings under this section shall be conducted in accordance with RSA 541-A and He-C 200.

 

          (m)  When a license has been revoked for a reason listed in (c) or (d) above, the licensee shall not be eligible to reapply for a license for at least 5 years.

 

          (n)  If a license is revoked, the administrator or medical director:

 

(1)  Shall not be employed as an administrator or medical director for at least 5 years if the enforcement action pertained to their role in the hospital; and

 

(2)  Shall be reported to the appropriate licensing board.

 

          (o)  The 5-year period referenced in (m) and (n) above shall begin on:

 

(1)  The date of the department’s decision to revoke or deny the license, if no request for a hearing is requested pursuant to (h) above; or

 

(2)  The date a final decision upholding the action of the department is issued, if a request for a hearing is made and a hearing is held.

 

          (p)  Notwithstanding (o) above, the department shall consider an application submitted after the decision to revoke or deny becomes final, if the applicant demonstrates that circumstances have changed to the extent that the department now has good cause to believe that the applicant has the requisite degree of knowledge, skills, and resources necessary to maintain compliance with the provisions of RSA 151 and He-P 802.

 

          (q)  RSA 151:8 and RSA 541-A shall govern further appeals of department decisions under this section.

 

          (r)  No ongoing enforcement action shall preclude the imposition of any remedy available to the department under RSA 151, RSA 541-A:30, III, or He-P 802.

 

Source.  #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.14  Duties and Responsibilities of All Licensees.

 

         (a)  The licensee shall comply with all relevant federal, state, and local laws, rules, codes, and ordinances, including RSA 161-F:49 and rules promulgated thereunder, and:

 

(1)  For Medicare Certified Hospitals (Acute), CMS federal regulation at 42 CFR Part 482;

 

(2)  For Medicare Certified Critical Access Hospitals (CAH), CMS federal regulations at 42 CFR Part 485;

 

(3)  For Medicare Certified Psychiatric Hospitals, CMS federal regulations at 42 CFR Part 482;

 

(4)  For Medicare Certified Rehabilitation Hospitals, CMS federal regulations at 42 CFR Part 482;

 

(5)  For Medicare Certified Hospitals with Prospective Payment System Units for Psych or Rehab, CMS federal regulations at 42 CFR Part 412; and

 

(6)  For any newly licensed and certified hospital not specified as an acute, rehab, psych, or CAH hospital, all applicable CMS federal regulations for that hospital’s particular designation.

 

         (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 hospital, which shall include, at a minimum, the required services listed in He-P 802.18.

 

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

 

(e)  By January 1, 2023, the licensee shall complete and implement an operational plan for the recognition and management of patients with dementia or delirium in accordance with RSA 151:2-I. The licensee shall keep the plan on file and make the plan available to the department of health and human services, bureau of licensing and certification upon request.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

          (k)  Licensees shall:

 

(1)  Meet the needs of the patients during those hours that the patients are in the care of the licensee;

 

(2)  Establish, in writing, a chain of command that sets forth the line of authority for the operation of the hospital or special health care service;

 

(3)  Appoint an administrator;

 

(4)  Verify the qualifications of all personnel;

 

(5)  Provide sufficient numbers of qualified personnel to meet the needs of patients during all hours of operation;

 

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

 

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

 

          (l)  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 or surrogate for health care that has been activated; or

 

(3)  Is an un-emancipated minor.

 

          (m)  The licensee shall not exceed the number of occupants authorized by NFPA 101 as adopted pursuant to RSA 153:1, VI-a and amended in Saf-Fmo 300 by the fire marshal with the board of fire control, pursuant to RSA 153:5.

 

          (n)  If the licensee accepts a patient who is known to have a disease reportable under He-P 301 or an infectious disease, which is any disease caused by the growth of microorganisms in the body which might or might not be contagious, the licensee shall follow the required procedures for the care of the patients, as specified by the United States 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.

 

          (o)  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.

 

          (p)  The licensee shall implement measures to ensure the safety of patients who are assessed as an elopement risk or danger to self or others.

 

          (q)  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;

 

(2)  All inspection reports issued in accordance with He-P 802.09(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 by calling 1-800-852-3345 x 9499 or in writing, to the:

 

Department of Health and Human Services

Office of Legal and Regulatory Services

Health Facilities Administration

129 Pleasant Street, Concord, NH 03301; and

 

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

 

          (r)  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 802 as authorized by RSA 151:6 and RSA 151:6-a.

 

          (s)  Licensees shall, in accordance with He-P 802.15:

 

(1) Report all adverse events to the department;

 

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

 

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

 

          (t)  The licensee shall immediately notify the local police department, the guardian and agent if any, when a patient, who has been assessed or is known as being a danger to self or others, has an unexplained absence after the licensee has searched the building and the grounds of the hospital.

 

          (u)  A licensee shall, upon request, provide a patient or the patient’s guardian or agent, if any, with a copy of his or her patient record pursuant to the provisions of RSA 151:21, X.

 

          (v)  All records required by law or this rule 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.

 

          (w)  Any licensee that maintains electronic records shall develop written policies and procedures designed to protect the privacy of patients and personnel 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 personnel; and

 

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

 

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

 

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

 

          (z)  The building housing the licensed facility shall comply with all state and local:

 

(1)  Health requirements;

 

(2)  Building ordinances;

 

(3)  Fire ordinances; and

 

(4)  Zoning ordinances.

 

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

 

          (ab)  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.

 

          (ac)  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, other patients or other household members.

 

Source.  #2144, eff 9-28-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff
1-29-92, EXPIRED: 5-28-92

 

New.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.15  Adverse Event Reporting.

 

          (a)  Pursuant to RSA 151:38, the administrator or designee shall report to the department the following adverse events:

 

(1)  Serious reportable events and specifications published in the National Quality Forum’s “Serious Reportable Events in Healthcare- 2011 Update” http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=69573, as available as noted in Appendix A; and

(2)  The exposure of a patient to a non-aerosolized blood borne pathogen by a health care worker's intentional unsafe act. 

 

            (b)  An act by hospital or ambulatory surgery center staff resulting in an infection or disease shall be considered to be purposefully unsafe if it meets the following criteria:

 

 

(1)  There was an intentional act or reckless behavior;

 

(2)  No reasonable person with similar qualifications, training, and experience would have acted the same way under similar circumstances; and 

 

(3)  There were no extenuating circumstances that could justify the act. 

 

          (c)  If the licensee suspects an adverse event occurred, the administrator or designee shall send a report to the department in electronic or paper format, within 15working days after discovery of the event, including:

 

(1)  Licensee information;

 

(2)  Patient information;

 

(3)  Event information; and

 

(4)  Type of occurrence as listed in (a) above.

 

          (d)  For events reported in (a) above, the licensee shall, within 60 days after discovery of the event, provide the department:

 

(1)  An analysis that includes the type of harm and contributing factors; and

 

(2)  A corrective action plan that includes what corrective actions are planned, who is responsible for implementation, when the action will be implemented and what measurements will be used to evaluate the corrective action plan or the justification for not implementing a corrective action plan if the licensee determines that one is not required.

 

          (e)  If the licensee suspects that it received a patient from a sending hospital that was subject to an adverse event, then the receiving administrator or designee shall notify the sending hospital’s administrator or designee and the department. The department shall inform the sending hospital that a report is required in accordance with (a) above.

 

          (f)  Upon receipt of a report of an adverse event, the department shall:

 

(1)  Acknowledge receipt of the event and review the information for completeness;

 

(2)  Review the corrective action plan for system changes that reduce the risk repeat of similar adverse events;

 

(3)  Communicate specific concerns to the licensee if the department does not find the corrective action plan credible;

 

(4)  Track and analyze adverse events for trends and underlying system problems; and

 

(5)  Provide information and make referrals to other state agencies as appropriate.

 

Source.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.16  Organization and Administration.

 

          (a)  Each licensee shall have a governing body whose duties shall include:

 

(1)  Management and control of the operation of the hospital;

 

(2)  Assessment and improvement of the quality of care and services;

 

(3)  Appointment of the administrator;

 

(4)  Adoption of hospital by-laws defining responsibilities for the operation of the hospital, and establishment of a medical staff;

 

(5)  Approval of medical staff by-laws as described in (e)(2) below, defining the medical staff responsibilities;

 

(6)  Responsibility for management of the overall operation and fiscal viability of the hospital;

 

(7)  Responsibility for determination of the qualifications for appointment for all personnel; and

 

(8)  Ensuring compliance with all relevant health and safety requirements of federal, state, and local laws, rules, and regulations.

 

          (b)  Each hospital 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 hospital and any special health care services offered by the hospital including:

 

a.  Management and fiscal matters;

 

b.  Implementing the by-laws adopted by the governing body;

 

c.  The employment and termination of personnel necessary for the efficient operation of the hospital;

 

d.  The designation of an alternate, in writing, who shall be responsible for the daily management and operation of the hospital and any special health care services offered by the hospital in the absence of the administrator;

 

e.  Attendance at meetings of the governing body, medical staff, and personnel, to serve as a liaison to the governing body;

 

f.  The planning, organizing, and directing of such other activities as may be delegated by the governing body;

 

g.  The delegation of responsibility to subordinates as appropriate; and

 

h.  Ensuring development and implementation of all policies and procedures on:

 

1.  Patient’s rights as required by RSA 151:19-21;

 

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

 

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

 

4.  Organ and tissue donor identification and procurement;

 

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

 

6.  Adverse event reporting. 

 

          (c)  Each hospital shall have a full-time medical director who is qualified to practice medicine in the state and has at least 5-years’ experience as a physician in a hospital setting. This shall not apply to critical access hospitals.

 

          (d)  Each hospital shall have a medical staff in accordance with the by-laws adopted under (a)(4) above.

 

          (e)  The medical staff shall be responsible for:

 

(1)  Appointment of an executive committee made up of members of the medical staff which shall make recommendations directly to the governing body with regard to:

 

a.  The process by which physicians or other licensed practitioners shall be admitted to practice for the licensee;

 

b.  Evaluation of individuals seeking medical staff membership;

 

c.  Delineation of what clinical privilege includes;

 

d.  The organization of the quality assessment and improvement activities of the medical staff; and

 

e.  The appointment of a medical director who meets the qualifications of (c) above;

 

(2)  Development of medical staff by-laws and policies in conjunction with the governing body which shall establish a mechanism for self-governance by the medical staff and accountability to the governing body;

 

(3)  Monitoring and evaluation of the quality of patient care and patient care services in the hospital including:

 

a.  Monitoring of medication use and review of pharmacy activity in the hospital;

 

b.  Review of patient record quality;

 

c.  Review of blood use in the hospital; and

 

d.  Review of other functions such as risk management, infection control, disaster planning, hospital safety, and utilization review; and

 

(4)  Identifying and making available education programs designed to maintain the medical staff’s expertise in areas related to the services provided in the hospital.

 

          (f)  There shall be a full-time director of nursing services who is currently licensed in the state of New Hampshire pursuant to RSA 326-B, or licensed pursuant to the multi-state compact, and:

 

(1)  Is an RN with a bachelor’s and a master’s degree from an accredited institution;

 

(2)  Is an RN with a bachelor’s degree and at least 4 years of relevant experience; or

 

(3)  Is an RN with a minimum of 8 years of relevant experience.

 

          (g)  The director of nursing services shall be responsible for:

 

(1)  Establishment of standards of nursing practice used in the hospital;

 

(2)  Ensuring that the admission process and patient assessment process coordinates patient requirements for nursing care with available nursing resources;

 

(3)  Participating with the governing body, administrator, and medical staff to improve the quality of nursing care at the hospital;

 

(4)  Nursing care as authorized by the nurse practice act and according to RSA 326; and

 

(5)  Nutritional monitoring.

 

Source.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.17  Personnel.

 

          (a)  The licensee shall ensure that sufficient numbers of qualified staff are present in the facility to meet the needs of patients at all times.

 

          (b)  For all applicants for employment, for all volunteers, or for all independent contractors who will  provide direct care or personal care services to patients, the licensee shall:

 

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

 

(2)  Review the results of the criminal records check in accordance with (c) below;

 

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

 

(4)  Verify that the applicant is not on the List of Excluded Individuals/Entities, maintained by the U.S. Department of Health and Human Services Office of Inspector General.

 

          (c)  Unless a waiver is granted in accordance with He-P 802.10 and (e) below, the licensee shall not employ, contract, or engage an individual if that individual:

 

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

 

(2)  Has been convicted of 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 or any person; or

 

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

 

          (d) If the licensee discovers that an individual meets one of the criteria in (c) above and that individual is already employed, contracted with, or engaged, the licensee shall immediately notify the department and either:

 

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

 

(2)  Request a waiver of (c) above.

 

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

 

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

 

(2)  Grant a waiver pursuant to He-P 802.10 if the department determines that the person does not pose a current threat to the health, safety, or well-being of a resident(s).

 

          (f)  The licensee shall check the names of the persons in (c) above against the bureau of elderly and adult services (BEAS) state registry, maintained pursuant to RSA 161-F:49 and He-E 720, the NH board of nursing, nursing assistant registry, maintained pursuant to RSA 326-B:26 and 42 CFR 483.156, and the medical technician registry, maintained pursuant to RSA 328-I prior to employing, contracting with, or engaging them.

 

          (g)  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;

 

(2)  Only employ, contract with, or engage board of nursing licensees who are listed on the nursing assistant registry; and

 

(3)  Only employ, contract with, or engage medical technicians who are listed on the medical technician registry.

 

          (h)  In lieu of (e) and (g) above, the licensee may accept from independent agencies contracted by the licensee or by an individual patient to provide direct care or personal care services a signed statement that the agency’s employees have complied with (c) and (f) above and are allowable under (e) and (g) above.

 

            (i)  Prior to having contact with patients or food, all personnel shall:

 

(1)  Receive a tour of the employee’s work environment relative to their position;

 

(2)  Receive a copy of the job description for his or her position containing:

 

a.  Duties and responsibilities of the position;

 

b.  Physical requirements of the position; and

 

c.  Education and experience requirements of the position;

 

(3)  Meet the educational and physical qualifications of the position as listed in their job description;

 

(4)  Be licensed, registered, or certified as required by state statute and as applicable;

 

(5)  Receive an orientation within the first 3 days of work or prior to the assumption of duties that includes:

 

a.  The licensee’s policies on rights and responsibilities and complaint procedures as required by RSA 151:20;

 

b.  The procedures for food safety for personnel involved in preparation, serving, and storing of food;

 

c.  The licensee’s infection control program;

 

d.  The licensee’s fire, evacuation and emergency plans which outline the responsibilities of personnel in an emergency;

 

e.  Mandatory reporting requirements for abuse or neglect such as those found in RSA 161-F and RSA 169-C:29; and

 

f.  Beginning no later than January 1, 2023, the recognition and management of patients with dementia or delirium, in accordance with the licensee’s operational plan developed pursuant to He-P 802.14(e);

 

(6)  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;

 

(7)  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;

 

(8)  Comply with the requirements of the United States Centers for Disease Control “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 Mycobacterium tuberculosis through shared air space with persons with infectious tuberculosis; and

 

(9)  Comply with all public health guidelines with requirements for infectious disease reporting and management.

 

             (j)  All personnel shall complete a mandatory annual in-service education, which includes a review of the licensee’s:

 

(1)  Policies and procedures required under He-P 802;

 

(2)  Infection control program;

 

(3)  Education program on fire and emergency procedures;

 

(4)  Mandatory reporting requirements including RSA 161-F:46 and RSA 169-C:29; and

 

(5)  Beginning no later than January 1, 2023, plan regarding the recognition and management of patients with dementia or delirium, in accordance with the licensee’s operational plan developed pursuant to He-P 802.14(e).

 

          (k)  Personnel who have direct contact with patients who have a history of TB or a positive laboratory and antigen testing shall have a symptomatology screen of a TB test.

 

          (l)  Current and complete personnel files shall be maintained and stored in a secure and confidential manner at the hospital.

 

          (m)  The licensee shall maintain a separate employee file which shall include, at a minimum, the following:

 

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

 

 (2)  A signed statement acknowledging the receipt of the licensee’s policy setting forth the patient’s rights and responsibilities, and acknowledging training and implementation of the policy as required by RSA 151:20;

 

(3)  A signed and dated job description;

 

(4)  A record of satisfactory completion of the orientation program required by (i)(5) above ;

 

(5)  A copy of each current New Hampshire license, registration, or certification in health care field and CPR certification, if applicable;

 

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

 

(7)  A record of satisfactory completion of all required education programs and demonstrated competencies that are signed and dated by the employee as required by (j) above;

 

(8)  Documentation of any performance reviews conducted;

 

(9)  Information as to the general content and length of all continuing education or educational programs attended;

 

(10)  A statement, which shall be signed at the time the initial offer of employment, contract, or engagement is made and then annually thereafter, stating that he or she:

 

a.  Does not have a felony conviction in this or any other state;

 

b.  Has not been convicted of a sexual assault, other violent crime, assault, fraud, abuse, neglect or exploitation or pose a threat to the health, safety or well-being of a patient in this or any other state; and

 

c.  Has not had a finding by the department or any administrative agency in this or any other state for assault, fraud, abuse, neglect or exploitation of any person in this or any other state;

 

(11)  A copy of the results of a criminal records check;

 

(12)  Documentation that the individual or entity is not on the List of Excluded Individuals/Entities, maintained by the U.S. Department of Health and Human Services Office of Inspector General; and

 

(13)  The results of the registry check in (f) above.

 

          (n)  The licensee shall maintain the records, but not necessarily a separate rile, for all volunteers and for all independent contractors who provide direct care or personal care services to patients, as follows:

 

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

 

(2)  For independent contractors, the information in (m)(3), (4), (6), and (8)-(12), except that the letter in (h) above may be substituted for (m)(11) and (13).

 

Source.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.18  Required Services.

 

          (a)  Each licensee shall provide the services that have been disclosed on its application and have been approved for by the department.

 

          (b)  If the licensee wishes to provide services other than the ones it is already licensed to provide, the licensee shall submit a letter of intent to provide the additional services, prior to providing the new service(s), to the department which includes:

 

(1)  A listing of the additional services to be provided;

 

(2)  The physical resources, personnel, and competency necessary to provide the additional services;

 

(3)  Floor plans describing change(s) or architectural plans if structural changes are involved;

 

(4)  The date the hospital wishes to start such services; and

 

(5)  Documentation of compliance with RSA 151 and He-P 802.

 

          (c)  If the licensee wishes to provide a special health care service, the licensee shall complete the requirements of 802.04 above.

 

          (d)  Each licensee shall ensure the availability of competent and sufficient personnel, with the required skills and experience, to provide the services in (a) and (b) above.

 

          (e)  The licensee shall have a policy governing CPR.

 

          (f)  The licensee shall establish health and safety services to minimize the likelihood of accident or injury, with protective care and oversight while the patient is at the hospital that includes: 

 

(1)  Monitoring the patient’s functioning, safety and whereabouts; and

 

(2)  Emergency response and crisis intervention.

 

          (g)  The licensee shall have social services available to the patient and patient’s family, which shall be provided by a social worker with at least a bachelor’s degree in social work or human services and includes:

 

(1)  The compilation of a social history and conducting patient psychosocial assessments;

 

(2)  The provision of emotional support to patients and families or caregivers as needed;

 

(3)  Assistance with the patient’s adaptation to the hospital and involvement in the plan of care; and

 

(4)  Advocacy for the patient’s human and civil rights and responsibilities.

 

          (h)  The licensee shall complete discharge planning on all patients admitted to the hospital including the provision of written instructions to the patient, agent, or guardian.

 

          (i)  Discharge planning shall include, as applicable:

 

(1)  The patient’s medication needs upon discharge;

 

(2)  The need for medical equipment, special diets, or potential food-drug interactions;

 

(3)  The need for further placement in another health care setting;

 

(4)  The need for home health services upon discharge; and

 

(5)  Discharge instructions and education shall be provided to the patient in writing.

 

          (j)  All laboratories operated by the licensee shall be in compliance with He-P 808, He-P 817, and CMS 42 CFR Part 493 – Laboratory Requirements.

 

          (k)  Pharmacies shall be in compliance with RSA 318 and RSA 318-B and shall employ or contract with a pharmacist who is licensed to practice pharmacy in the state of New Hampshire.

 

Source.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.19  Patient Management.

 

          (a)  Admission procedures shall include:

 

(1)  Completion of a health assessment and medical evaluation in accordance with the licensee’s policy which shall be documented for each patient accepted for care and treatment;

 

(2)  Provision of information concerning patient rights in a language the patient can understand, which might require a translator;

 

(3)  Provision of information in a clear concise manner to enable the patient to make appropriate treatment decisions;

 

(4)  Collection of specific patient medical and social history information as required by the licensee’s policy including information concerning advanced directives or alternative decision makers; and

 

(5)  Development of a treatment plan.

 

          (b)  Discharge documentation shall include:

 

(1)  The date and time of discharge;

 

(2)  The status of the patient at the time of discharge; and

 

(3)  Any discharge planning or referrals that have been conducted for the patient.

 

Source.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.20  Patient Records.

 

          (a)  The licensee shall maintain a legible, current, and accurate record for each patient based on the services provided by the licensee.

 

          (b)  Patient records shall include, at a minimum:

 

(1)  Identification data including the patient’s:

 

a.  Name;

 

b.  Home address;

 

c.  Home telephone number;

 

d.  Name, address, and telephone number for an emergency contact person;

 

e.  Date of birth;

 

f.  Guardian or agent as applicable; and

 

g.  Admitting diagnosis;

 

(2)  A signed acknowledgment of receipt of patient bill of rights by the patient, guardian,  agent, or surrogate decision maker;

 

(3)  A written or electronic record of a health examination by a licensed practitioner;

 

(4)  Written, dated, and signed orders of all medications, treatments, and therapeutic diets;

 

(5)  Documentation of all services provided including signed progress notes by:

 

a.  Nursing personnel;

 

b.  Physicians; and

 

c.  Other health professionals authorized by licensee policy;

 

(6)  Orders and results of any laboratory, x-rays, consultations,  or other diagnostic tests;

 

(7)  The patient’s health insurance information;

 

(8)  The consent for release of information signed by the patient, guardian, or agent, if any;

 

(9)  The medication record;

 

(10)  Documentation of any accident or injuries occurring while in the care of the facility;

 

(11)  Documentation of a patient’s refusal of any care or services; and

 

(12)  Transfer or discharge documentation including planning, referrals, and notification to the patient and guardian or agent if any.

 

          (c)  Patient records shall be available to authorized personnel and any other person authorized by law or rule to review such records.

 

          (d)  Patient records shall be retained, accessible, and stored in an area inaccessible to those who do not have authorized access to such records.

 

          (e)  The licensee shall create a policy to determine the method by which release of information from patient records shall occur.

 

          (f)  Patient records shall be safeguarded against loss or unauthorized use by implementation of appropriate use, handling, and storage procedures.

 

          (g)  Patient records shall be retained 7 years after discharge of a patient, and in the case of minors, patient records shall be retained until at least one year after reaching age 18, but in no case shall they be retained for less than 7 years after discharge.

 

          (h)  The licensee shall arrange for the storage of and access to medical records for 7 years in the event the hospital ceases operation.

 

          (i)  Electronic records shall be maintained according to current HIPAA regulations.

 

Source.  #5846, eff 6-22-94, EXPIRED: 6-22-00

 

New.  #9580, eff 10-24-09; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

    He-P 802.21  Medication Services.

 

          (a)  All medications shall be made available to the patient in accordance with the written and signed orders of the licensed practitioner or other professional with prescriptive powers.

 

          (b)  The licensee shall have a written policy and system in place instructing how to:

 

(1)  Obtain any medication ordered for use at the hospital;

 

(2)  Reorder medications for use at the hospital; and 

 

(3)  Receive and record new medication orders.

 

          (c)  Each medication order shall legibly display the following information:

 

(1)  The patient’s name;

 

(2)  The medication name, strength, prescribed dose, and route;

 

(3)  The frequency of administration;

 

(4)  For PRN doses, the indications for usage, to include the maximum allowed dose in a 24-hour period, for all medications that have 24-hour contra-indicated maximum doses; and

 

(5)  The dated and timed signature of the ordering practitioner.

 

          (d)  Each prescription medication container and medication record together shall collectively legibly display the following information in such a way so as to clearly identify the intended recipient:

 

(1)  The patient’s name;

 

(2)  The medication name, strength, the prescribed dose, and route of administration;

 

(3)  The frequency of administration;

 

(4)  The indications for usage of all PRN medications;

 

(5)  The date ordered;

 

(6)  The name of the prescribing practitioner; and

 

(7)  The expiration date of the medication(s).

 

          (e)  The dosage, frequency, and route of administration on the labels of all prescription medications for each patient shall be identical to the dosage, frequency, and route of administration on the facility medication record except as allowed by (h) below.

 

          (f)  The change in the dose of a medication, or the discontinuation of a medication, shall be authorized in writing by a licensed practitioner and the licensee shall indicate in writing, in the medication record, the date the dose or the discontinuance occurred.

 

          (g)  Only a pharmacist shall make changes to prescription medication container labels except as allowed by (j) below.

 

          (h)  When the licensed practitioner or other professional with prescriptive powers changes the dose and personnel are unable to obtain a new prescription label, the original container shall be clearly marked without obstructing the pharmacy label to indicate a change in the medication order.

 

          (i)  Only a licensed nurse shall accept telephone orders for medications, treatments, and therapeutic diets, and the licensed nurse shall immediately transcribe and sign the order.

 

          (j)  The transcribed order in (i) above shall be counter-signed by the authorized prescriber within 48 hours of receipt or as soon as possible but no longer than 30 days.

 

          (k)  No medications shall be given to or taken by a patient until a written order is received, except as allowed by (h) or (i) above.

 

          (l)  Faxes of signed orders or other electronic media with electronic signatures shall be acceptable to meet the requirements of (k) above.

 

          (m)  All over-the-counter medications shall have a signed practitioner’s order specifying that the patient may take the medication according to the instructions of the manufacturer, or specifying the dosage, frequency, and route.

 

          (n)  The medication storage area for medications shall be:

 

(1)  Locked and accessible only to authorized personnel;

 

(2)  Clean and organized with adequate lighting to ensure correct identification of each patient’s medication(s); and

 

(3)  Equipped to maintain medication at the proper temperature and humidity.

 

          (o)  All medication at the hospital shall be kept in the original containers as dispensed by the pharmacy and properly closed after each use.

 

          (p)  Topical liquids, ointments, patches, creams, or powder forms of products shall be stored in such a manner that cross contamination with oral, optic, ophthalmic, and parenteral products shall not occur.

 

          (q)  If controlled substances, as defined by RSA 318-B, are stored in a central storage area in the hospital, they shall be kept in a separately locked compartment within the locked medication storage area accessible only to authorized personnel.

 

          (r)  The licensee shall develop and implement written policies and procedures regarding a system for maintaining counts of controlled drugs.

 

          (s)  Except as required by (t) below, any contaminated, expired, or discontinued medication shall be destroyed within 30 days following the expiration date, the date a licensed practitioner discontinued the order, or the medication becomes contaminated, whichever occurs first.

 

          (t)  Destruction of contaminated, expired, or discontinued controlled drugs shall:

 

(1)  Be in accordance with acceptable standards of practice identified by the manufacturer, as well as federal and state law, and rules;

 

(2)  Be accomplished in the presence of at least 2 people who shall sign, date, and record the amount destroyed; and

 

(3)  Be documented in the record of the patient for whom the drug was prescribed.

 

          (u)  The licensee shall maintain a written record for each medication taken by a patient at the facility that contains the following information:

 

(1)  Any allergies or adverse reactions to medications;

 

(2)  The medication name, strength, dose, frequency, and route of administration;

 

(3)  The date and the time the medication was taken;

 

(4)  The signature, identifiable initials, and job title of the person who administers, supervises, or assists the patient taking medication;

 

(5)  For PRN medications, the reason the patient required the medication and the effect of the PRN medication; and

 

(6)  Documented reason for any medication refusal or omission.

 

          (v)  The licensee shall report to the patient’s licensed practitioner any adverse reactions and side effects to medications or medication errors, such as incorrect medications, immediately but not to exceed 24 hours depending on the severity of the reaction or error, and shall document in the patient’s record the reaction, the error, and date, time, and person notified.

 

          (w) The therapeutic use of cannabis by patients who are qualifying patients possessing a registry identification card may be permitted at a hospital as long as:

 

(1)  The licensee develops, maintains, and implements a general policy relative to patient use of cannabis at the licensed premises, including storage, security, and administration; and

 

(2)  The smoking of cannabis is not permitted on the licensed premises.

 

Source.  #9580, eff 10-24-09; amd by #9851, eff 1-14-11; amd by #10079, eff 1-26-12; ss by #12407, INTERIM, eff
10-24-17, EXPIRED: 4-22-18

 

New.  #13166, eff 1-28-21

 

          He-P 802.22  Infection Control.

 

          (a)  The licensee shall develop and implement an infection control program that educates and provides procedures for the prevention, control, and investigation of infectious and communicable diseases.

 

          (b)  The infection control program shall include written procedures for:

 

(1)  Proper hand washing techniques;

 

(2)  The utilization of universal precautions;

 

(3)  The management of patients with infectious or contagious diseases or illnesses;

 

(4)  The handling, transport and disposal of those items identified as infectious waste in Env-Sw 103.28 and regulated by Env-Sw 904;

 

(5)  Reporting of infectious and communicable diseases as required by He-P 301;

 

(6)  Evaluating and revising the infection control program in accordance with current CDC recommended actions;

 

(7)  Maintenance of a sanitary physical environment; and

 

(8)  Infection control policies specific to each department.

 

          (c)  Education on the infection control program shall be completed by all personnel on an annual basis and  address the:

 

(1)  Cause of infections;

 

(2)  Effect of infections;

 

(3)  Transmission of infections; and

 

(4)  Prevention and containment of infections.

 

          (d)  Personnel infected with a disease or illness transmissible through food, saliva, or droplets, shall not work in food service or provide direct care in any capacity without personal protective equipment until they are no longer contagious.

 

          (e)  Personnel infected with scabies or lice shall not provide direct care to patients or work in food services until such time as they are no longer infected.

 

          (f)  Pursuant to RSA 141-C:1, personnel with a newly positive Mantoux tuberculosis skin test or a diagnosis of suspected active pulmonary or laryngeal tuberculosis shall be excluded from the workplace until a diagnosis of tuberculosis is excluded or until the personnel member receives tuberculosis treatment and has been determined to be noninfectious by a licensed practitioner.

 

          (g)  Personnel with an open wound who work in food service or provide direct care in any capacity shall cover the wound at all times by an impermeable and durable bandage with secure edges.

 

          (h)  The licensee shall immunize all consenting patients for influenza and pneumococcal disease and all consenting personnel for influenza in accordance with RSA 151:9-b and report immunization data to the department’s immunization program.

 

          (i)  The licensee shall have available space, supplies, and equipment for proper handling of suspected or actual infectious conditions.

 

          (j)  The licensee shall require that licensed practitioners evaluate all patients at risk for an infection or communicable disease to ensure the detection or presence of same.

 

          (k)  The administrator shall appoint an infection control officer who shall:

 

(1)  Receive reports of communicable and infectious diseases; and