N.H. Code Admin. R. He-P 810.15 – Duties and Responsibilities of All Licensees

(a) The licensee shall comply with all relevant federal, state, and local laws, rules, codes, and ordinances as applicable.
(b) The licensee shall have a written policy and procedures setting forth the rights and responsibilities of patients admitted to the birthing center in accordance with RSA 151:20 and151:21.
(c) Pursuant to RSA 151:41, the licensee shall have a written policy establishing procedures for the prevention, detection, and resolution of substance abuse, misuse, and diversion that apply to all personnel, and which shall be the responsibility of a designated employee or interdisciplinary team.
(d) The written policy in (c) above shall 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; and
9. (9) The consequences for violation of the controlled substance abuse, misuse, and diversion
  prevention policy.
(e) The licensee shall define, in writing, the scope and type of services to be provided at the birthing center, which shall include at a minimum, the required services listed in He-P 810.16.
(f) The licensee shall develop and implement written policies and procedures governing all operation and services and shall assess and monitor the quality of care and services provided to patients on an ongoing basis.
(g) All policies and procedures shall be reviewed annually and revised as needed.
(h) The licensee shall not falsify any documentation or provide false or misleading information to the department.
(i) The licensee shall not advertise or provide services for which they are not licensed to provide, pursuant to RSA 151:2, III .
(j) The licensee shall comply with all conditions of warnings and administrative remedies issued by the department and all court orders.
(k) Licensees shall have responsibility and authority for:
1. (1) Managing, controlling, and operating the birthing center;
2. (2) Meeting the needs of a patient when the patient is in the care of the birthing center;
3. (3) Initiating action to maintain the birthing center 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;
4. (4) The continuity of inpatient care;
5. (5) Establishing, in writing, a chain of command that sets forth the line of authority for the operation of the birthing center;
6. (6) Appointing an administrator;
7. (7) Appointing a medical director;
8. (8) Verifying the qualifications of all personnel;
9. (9) Providing sufficient numbers of personnel who are present in the birthing center and are qualified and available to meet the needs of patients during all hours of operation;
10. (10) Reporting all positive tuberculosis test (TB) results for personnel to the department’s TB program in accordance with RSA 141-C:7, He-P 301.02, and He-P 301.03;
11. (11) Providing personnel with sufficient supplies, equipment, and lighting to ensure that the needs of patients are met; and
12. (12) Implementing any POC that has been accepted or issued by the department.
(l) The licensee shall consider all patients to be competent and capable of making health care decisions 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) Is a minor; or
4. (4) Has a surrogate decision maker designated in accordance with RSA 137-J.
(m) The licensee shall only admit an individual or retain a patient whose needs can be met through the programs and services offered under the current license.
(n) If the licensee has a patient whose needs cannot be met by the programs and services offered at the birthing center, the licensee shall transfer the patient to a licensed facility whose current license classification will allow it to meet the needs of the patient.
(o) The birthing center shall not exceed the maximum number of patients or licensed beds approved by its license, unless authorized by the department, such as during an emergency.
(p) In addition to the posting requirements specified in RSA 151:29, the licensee shall post the following documents in an area of the birthing center that is conspicuous and open to patients and the general public:
1. (1) The current license issued in accordance with RSA 151:2;
2. (2) All statements of findings 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) 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, N.H. 03301 or by calling 1-800-852-3345; and
6. (6) The licensee’s plan for fire safety, evacuation, emergencies, and floor plan identifying the location of and access to all fire exits.
(q) The licensee shall admit and allow any department representative to inspect the birthing center and all programs and services that are being provided at any time for the purpose of determining compliance with RSA 151 and He-P 810 as authorized by RSA 151:6 and RSA 151:6-a.
(r) For reportable incidents, the licensee shall:
1. (1) Fax to 603-271-4968 or convey by email to hfa-licensing@dhhs.nh.gov or regular mail, postmarked within 2 business days 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 as defined in He-P 810.03(ch):
  1. a. The birthing center’s 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. Whether the patient’s guardian, personal representative, or agent, if any, was notified;
  9. i. The signature of the person reporting the reportable incident; and
  10. j. The date and time the patient’s licensed practitioner was notified, if applicable;
2. (2) 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; and
3. (3) Submit any further information requested by the department.
(s) A licensee shall provide a patient, guardian, personal representative, or agent, or anyone else authorized in writing by the patient with a copy of the patient’s record pursuant to the provisions of RSA 151:21, X, upon request.
(t) All records required for licensing shall:
1. (1) Be available to the department during an inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a;
2. (2) Be legible, current and accurate; and
3. (3) Be maintained in a secure manner that safeguards confidentiality and prevents tampering with data.
(u) Any licensee that maintains electronic records shall develop a system with written policies and procedures to protect the privacy of patients and staff that, at a minimum, include:
1. (1) Procedures for backing up files to prevent loss of data;
2. (2) Safeguards to ensure the confidentiality of information pertaining to patients and staff; and
3. (3) Systems to prevent tampering with information pertaining to patients and staff.
(v) The licensee shall comply with the patient’s bill of rights as set forth in RSA 151:21.
(w) The licensee shall provide housekeeping and maintenance service, as needed to protect patients, personnel, and the public.
(x) The licensee shall develop policies and procedures regarding the release of information contained in patient records.
(y) Applicants, licensees, and staff shall cooperate with the department during all departmental visits authorized under RSA 151 and He-P 810, including allowing representatives of the department to:
1. (1) Enter and complete an inspection of the premises;
2. (2) Review and reproduce any forms or reports which are required to be maintained or made available to the department; and
3. (3) Interview staff and patients of the birthing center.
(z) The licensee shall not falsify any documentation required by law or provide false or misleading information to the department.
(aa) The birthing center shall respond to a notice of deficiencies by providing a POC in accordance with He-P 810.13(c).
(ab) The birthing center shall comply with all conditions of warnings and administrative remedies issued by the department and all court orders.
(ac) 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. #8957, eff 7-27-07, EXPIRED: 7-27-15 New. #11039, INTERIM, eff 2-24-16, EXPIRES: 8-22-16; ss by #11161, eff 8-20-16; ss by #14074, eff 9-20-24, EXPIRES: 9-20-34 (formerly He-P 810.14)