1. (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.

2. (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. (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" https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/LSC, as available and noted in Appendix A; and
   2. (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.

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

   1. (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. (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. (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. (4) Require the licensee to submit a POC in accordance with He-P 802.13(c) if the inspection results in deficiencies being cited.

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

   1. (1) Requests for additional information from the complainant;
   2. (2) A physical inspection of the premises;
   3. (3) Review of any records that might be relevant and have probative value;
   4. (4) Interviews with individuals who might have information that is relevant to the investigation and might have probative value; and
   5. (5) Any other relevant investigative techniques.

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

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

      1. a. The date of inspection;
      2. b. The reasons for the inspection; and
      3. c. Whether or not the inspection resulted in a determination that the services being provided require licensing under RSA 151;
   2. (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. (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:

      1. a. Issue a written warning to immediately comply with RSA 151 and He-P 802; and
      2. b. Provide notice stating that the individual has the right to appeal the warning in accordance with RSA 151:7-a, III; and
   4. (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.

6. (f) Complaint investigation files shall:

   1. (1) Be confidential in accordance with RSA 151:13;
   2. (2) Not be disclosed publicly; and

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

      1. a. To the department of justice when relevant to a specific investigation;
      2. b. To law enforcement when relevant to a specific criminal investigation;
      3. c. When a court of competent jurisdiction orders the department to release such information; or
      4. 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; ss by #14081, eff 9-25-24, EXPIRES: 9-25-34 (formerly He-P 802.11)