1. (a) The department shall conduct quality assurance monitoring visits and reviews in accordance with RSA 126-A:4, IV (a), RSA 170-G:4 XVIII, and RSA 169-F:9 for each residential treatment program certified by the department under this part, consisting of the following:

   1. (1) An annual review of the recertification application as described in He-C 6350.05;
   2. (2) An annual analysis of the referral data, statistics, and outcomes provided at recertification;
   3. (3) Quality assurance monitoring visits at least twice per year, of which at least one shall be unannounced, to all facilities where New Hampshire children are currently placed pursuant to RSA 169-F;
   4. (4) A visit conducted within the first year of a residential treatment program’s operation;
   5. (5) For currently certified residential treatment programs, a site review once every 2 years;
   6. (6) A technical assistance visit in the year when a site review does not occur; and
   7. (7) Ongoing quality assurance monitoring visits and collaboration as needed throughout the year.

2. (b) The program shall make the below available during a quality assurance monitoring visit as requested by the department including but not limited to:

   1. (1) The facility;
   2. (2) The staff and available sub-contracted providers;
   3. (3) The children and their records who were placed by the department or in an episode of treatment; and
   4. (4) Staff records.
3. (c) In accordance with RSA 169-F:9, V, if a program is found not in compliance with this part or the program’s contract during quality assurance monitoring visit, if applicable, the department shall issue the program a notice of non-compliance indicating the specific violation(s).

4. (d) In accordance with RSA 169-F:9, V when there are areas of non-compliance the department shall notify the following:

   1. (1) The program’s licensing agency; and
   2. (2) The New Hampshire office of the child advocate.
5. (e) The program shall submit a corrective action plan to the department within 30 calendar days of the date of receipt of the notice of non-compliance.
6. (f) An acceptable corrective action plan shall, at a minimum, include the plan for the corrections and a timeline for when those corrections areas will be completed.

7. (g) Exceptions to (e) above shall include the following:

   1. (1) If the program seeks clarification after receiving the notice of non-compliance and requests an extension of time to complete and submit the corrective action plan;
   2. (2) When the program has initiated the informal dispute process, as described in (k) below, with the certification team;
   3. (3) When there is a request and an approval for a waiver for the rule, as a result of the non-compliance and as a means to correct the non-compliance; and
   4. (4) When there is a request for an extension to the corrective action plan beyond the 30 calendar days in (e) above.
8. (h) In accordance with RSA 169-F:9, V, failure to respond to the notice with an acceptable plan as described in (f) above or to take the necessary corrective actions as described in (i) below shall result in the removal of all New Hampshire children from the program’s facility and shall result in revocation of certification for payment.
9. (i) Failure to take the necessary corrective action as referenced in (h) above shall be a result of a program refusing to submit a corrective action plan or deliberately failing to acknowledge and address the areas of correction which are documented in the notice of non-compliance.
10. (j) The department shall offer an opportunity for an informal dispute resolution to any program who disagrees with a non-compliance cited by the department as a result of a quality assurance monitoring activity for any program who can provide documented evidence that they were in compliance when the non-compliance was issued.
11. (k) The program shall submit a request for an informal dispute resolution in writing, no later than 14 calendar days from the date the site review report or notice of non-compliance was issued by the department.

12. (l) Included in the request by the program shall be evidence of the following:

    1. (1) The rule which was cited for non-compliance; and
    2. (2) The documentation which disputes the citation.
13. (m) The department shall review the evidence presented in (l) above and provide a written notice to the program of its decision within 30 calendar days of receipt of (l).
14. (n) An informal dispute resolution shall not be available for any program against whom the department has initiated action to deny or revoke their certification.

Source. #4442, eff 7-1-88; amd by #4906, eff 8-10-90; amd by #5122, eff 4-25-91, EXPIRED 4-25-97 New. #6617, eff 10-25-97; ss by #8453, INTERIM, eff 10-25-05, EXPIRED: 4-23-06 New. #8693, eff 7-27-06; ss by #10759, eff 1-17-15; ss by #14178, INTERIM, eff 1-18-25; ss by #14490, eff 1-22-26, EXPIRES: 1-22-36