1. (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, as applicable.
2. (b) The licensee shall provide services to only those patients whose needs are compatible with the facility and the services and programs offered, and whose needs can be met by the NEWCC.
3. (c) The licensee shall comply with the patients’ bill of rights as set forth in RSA 151:19–21.
4. (d) The licensee shall define, in writing, the scope and type of services to be provided by the NEWCC, including the mobile NEWCC vehicle, and shall post the same in the facility and on the facility’s website.

5. (e) The licensee shall have a written policies and procedures setting forth:

   1. (1) The rights and responsibilities of registered patients in accordance with the patients’ bill of rights under RSA 151:19-21;
   2. (2) A policy that ensures the safety of all persons present on the licensed premises where firearms are permitted; and
   3. (3) All other polices described in He-P 806.

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

   1. (1) Reviewing the policies and procedures every 3 years; and
   2. (2) Revising them as needed.
7. (g) The licensee shall have a written policy, as described in RSA 151:41, establishing procedures for the prevention, detection, and resolution of substance abuse, misuse, and diversion.

8. (h) The policy in (g) above shall apply to all personnel, be the responsibility of a designated employee or interdisciplinary team, and include:

   1. (1) Education;
   2. (2) Procedures for monitoring the distribution and storage of controlled substances;
   3. (3) Voluntary self-referral by employees who are addicted;
   4. (4) Co-worker reporting procedures;
   5. (5) Drug testing procedures to include at a minimum, testing where reasonable suspicion exists;
   6. (6) Employee assistance procedures;
   7. (7) Confidentiality;
   8. (8) Investigation, reporting, and resolution of controlled drug misuse or diversion as required per He-P 805.14(j); and
   9. (9) The consequences for violation of the controlled substance abuse, misuse, and diversion prevention policy.
9. (i) All policies and procedures shall be reviewed and approved by the medical director.
10. (j) The licensee shall assess and monitor the quality of care and service provided to patients on an ongoing basis.
11. (k) The licensee or any employee shall not falsify any documentation or provide false or misleading information to the department.
12. (l) The licensee shall not advertise or provide services that it is not licensed to provide pursuant to RSA 151:2, III.
13. (m) The licensee shall comply with all conditions of warnings and administrative remedies issued by the department, and all court orders.

14. (n) Licensees shall:

    1. (1) Have the responsibility and authority for managing, controlling, and operating the NEWCC;
    2. (2) Meet the needs of the patients during those hours that the patients are in the care of the NEWCC;
    3. (3) Establish, in writing, a chain of command that sets forth the line of authority for the operation of the NEWCC;
    4. (4) Appoint an administrator;
    5. (5) Verify the qualifications of all personnel;
    6. (6) Provide sufficient numbers of qualified personnel who are available to meet the needs of patients during all hours that the NEWCC has told the patients that they will provide services;
    7. (7) Provide personnel with sufficient supplies, equipment, and lighting to meet the needs of the patients;
    8. (8) Require all personnel to follow the orders of the licensed practitioner for every patient and encourage the patient to follow the licensed practitioner’s orders;
    9. (9) Initiate action to maintain the NEWCC in full compliance at all times with all relevant health and safety requirements contained in applicable federal, state, and local laws, rules, regulations, and ordinances;
    10. (10) Implement any POC that has been accepted by the department; and
    11. (11) Develop and implement a process for determining staffing levels. The plan shall include an assessment, to be conducted at least quarterly but more frequently if required, of the appropriateness of staffing levels.

15. (o) The licensee shall consider all patients to be competent and capable of making all decisions relative to their own health care unless the patient:

    1. (1) Has a guardian or conservator appointed by a court of competent jurisdiction;
    2. (2) Has a durable power of attorney for health care that has been activated in accordance with RSA 137-J;
    3. (3) Has a surrogate designated in accordance with RSA 137-J; or
    4. (4) Is an un-emancipated minor.

16. (p) In accordance with RSA 141-C:7, He-P 301.02, and He-P 301.03 the licensee shall report all positive tuberculosis test results for personnel to the office of infectious disease control by:

    1. (1) Telephone at 603-271-4496;
    2. (2) Telephone at 603-271-5300 after business hours; or
    3. (3) Fax to 603-271-0545.
17. (q) If the licensee registers or treats 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 and personnel training for the care of the patients, as specified by the Centers for Disease Control and Prevention “2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings” (June 2007 edition), available as noted in Appendix A.

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

    1. (1) The current license issued in accordance with RSA 151:2;
    2. (2) All statement of findings reports issued for the previous 12 months;
    3. (3) A copy of the patients’ bill of rights specified by RSA 151:21;
    4. (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. (5) The licensee’s plan for fire safety, evacuation, and emergencies, identifying the location of, and access to all fire exits, except that mobile NEWCC vehicles shall be exempt from this requirement; and
    6. (6) A copy of the licensee’s complaint procedure, including a statement that complaints may be submitted, in writing, to the department of health and human services, health facilities administration, 129 Pleasant Street, Concord, NH 03301 or by calling 1-800-852-3345.
19. (s) 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 806 as authorized by RSA 151:6 and RSA 151:6-a.
20. (t) A licensee shall, upon request, provide a patient or the patient’s guardian, agent, personal representative, or surrogate decision-maker if applicable, with a copy of their patient record pursuant to the provisions of RSA 151:21, X.
21. (u) All records required for licensing 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.

22. (v) 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. (1) Procedures for backing up files to prevent loss of data;
    2. (2) Safeguards for maintaining the confidentiality of information pertaining to patients and staff; and
    3. (3) Systems to prevent tampering with information pertaining to patients and staff.
23. (w) The licensee shall develop policies and procedures regarding the release of information contained in patient records.
24. (x) The building or mobile vehicle that houses the NEWCC shall comply with all federal, state, and local health, building, fire, and zoning laws, rules, and ordinances.
25. (y) Smoking shall be prohibited in the facility as required by RSA 155:66, I(b).

26. (z) For reportable incidents, licensees shall have responsibility for:

    1. (1) Completing an investigation to determine if abuse or neglect could have been a contributing factor to the incident;

    2. (2) Faxing to 603-271-4968 or, if a fax machine is not available, submit via regular mail, postmarked within 48 hours of the incident together with a telephone call to the department reporting the incident and notifying the department of the mailed report, the following information to the department within 48 hours of a reportable incident:

       1. a. The NEWCC name;
       2. b. A description of the incident, including identification of injuries, if applicable;
       3. c. The name of the licensee(s) or personnel involved in, witnessing, or responding to the reportable incident;
       4. d. The name of patient(s) involved and the name of any witnesses to the reportable incident;
       5. e. The date and time of the reportable incident;
       6. f. The action taken in direct response to the reportable incident, including any follow-up;
       7. g. If medical intervention was required, by whom, and the date and time;
       8. h. When the patient’s guardian, agent, surrogate decision-maker, or personal representative, if any, was notified;
       9. i. The signature of the person reporting the reportable incident;
       10. j. The date and time the patient’s licensed practitioner was notified, if applicable; and
       11. k. The date the facility performed the investigation required by (1) above;
    3. (3) As soon as practicable, notifying the local police department, the department, and the guardian, agent, surrogate decision-maker, or personal representative, if any, when a patient has an unexplained absence and the licensee has searched the building and the grounds of the NEWCC without finding the patient and it has been determined by the facility that the patient is a danger to themselves or others; and
    4. (4) If abuse or neglect is suspected, the licensee shall notify the department with a written report within 5 days describing the actions taken by personnel, the final outcome or continuation of the reportable incident, and actions taken to prevent a reoccurrence if it was not submitted in the initial report.
27. (aa) The licensee shall maintain a log in each mobile vehicle to document that all on-board water is from a verifiable potable source.
28. (ab) The licensee shall not exceed the maximum number of patients or beds licensed by the department, unless authorized by the department, such as during an emergency.
29. (ac) The licensee shall respond to a notice of deficiencies by providing a POC in accordance with He-P 806.13(c).
30. (ad) The licensee shall comply with all conditions of warnings and administrative remedies issued by the department and all court orders.
31. (ae) The licensee shall require all individuals in contact with residents to wear a form of identification which readily discloses the name, licensure status, if any, and staff position as required per RSA 151:3-b.

Source. #2349, eff 4-28-83; ss by #3193, eff 1-28-86; ss by #5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92 New. #5512, eff 11-25-92; ss by #6895, INTERIM, eff 11-26-98, EXPIRED: 3-26-99 New. #9655, eff 2-13-10, EXPIRED: 2-13-18 New. #12674, INTERIM, eff 11-19-18, EXPIRED: 5-20-19 New. #12795, eff 5-30-19; amd by #12928, eff 11-26-19; ss by #13987, eff 5-30-24 (formerly He-P 806.14)