1. (a) The licensee shall comply with all relevant federal, state, and local laws, rules, codes, and ordinances, 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 ESRDDC.
3. (c) The licensee shall comply with the patients’ bill of rights as set forth in RSA 151:21.
4. (d) The licensee shall define, in writing, the scope and type of services to be provided by the ESRDDC, which shall include, at a minimum, the core services listed in He-P 811.16.

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

   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 required polices described in He-P 811.

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) The review of the policies and procedures every 3 years; and
   2. (2) The revision of the policies and procedures, as needed.
7. (g) 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, which shall apply to all personnel, contractors, and agents of the facility and which shall be the responsibility of a designated employee or interdisciplinary team.

8. (h) The written policy in (g) 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.
9. (i) The licensee shall educate personnel about the needs and services required by the patients under their care.
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, in any form or manner, as providing or being able to provide services other than those for which they are licensed 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) The licensee shall not exceed the maximum number of dialysis stations authorized by the department, unless authorized by the department, such as during an emergency.

15. (o) The licensee shall establish and maintain by-laws that:

    1. (1) Define the operation and performance of the ESRDDC;
    2. (2) Establish a credentialing process; and
    3. (3) Maintain documentation of all medical staff privileges.
16. (p) The licensee shall respond to a notice of deficiencies by providing a POC in accordance with He-P 811.13.

17. (q) Licensees shall:

    1. (1) Have the responsibility and authority for managing, controlling, and operating the ESRDDC;
    2. (2) Ensure that the dialysis needs of the patients are met during those hours that the patients are in the care of the ESRDDC;
    3. (3) Establish, in writing, a chain of command that sets forth the line of authority for the operational responsibilities of the ESRDDC;
    4. (4) Appoint an administrator who shall meet the requirements of He-P 811.16(a);
    5. (5) Appoint a medical director, who shall meet the requirements of He-P 811.16(f);
    6. (6) Verify the qualifications of all personnel;
    7. (7) Initiate action to maintain the ESRDDC 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;
    8. (8) Provide sufficient numbers of personnel who are present in the ESRDDC and are qualified to meet the needs of patients during all hours of operation;
    9. (9) Provide the ESRDDC with sufficient supplies, equipment, and lighting to meet the needs of patients;
    10. (10) Implement any POC that has been accepted or issued by the department;
    11. (11) Initiate, implement, and continue action to correct any issue identified by the quality improvement committee; and
    12. (12) 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.
18. (r) The licensee shall provide housekeeping and maintenance adequate to protect patients, personnel, and the public.

19. (s) 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 an agent or durable power of attorney for health care that has been activated in accordance with RSA 137-J; or
    3. (3) Is an un-emancipated minor.
20. (t) The licensee shall have a written affiliation agreement with at least one acute care hospital for the provision of inpatient care and other acute care hospital services.

21. (u) 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.
22. (v) If the licensee registers, treats, or 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 and personnel training 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.

23. (w) 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 patients’ 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; and
    6. (6) A copy of the licensee’s complaint procedure, including the address and phone number of the department to which complaints may also be made, which shall also be posted on the ESRDDC website if available.
24. (x) The licensee shall develop policies and procedures regarding the release of information contained in patient records.
25. (y) The licensee shall ensure that all personnel required to be licensed in the state of New Hampshire are licensed in accordance with the appropriate practice act and the rules adopted there under.
26. (z) The licensee shall not exceed the number of occupants identified on the licensing certificate.
27. (aa) 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.
28. (ab) The licensee shall admit and allow any department representative to inspect the ESRDDC and all programs, services, and any records for the purpose of determining compliance with RSA 151 and He-P 811 as authorized by RSA 151:6 and RSA 151:6-a.

29. (ac) The licensee shall ensure that all records required for licensing:

    1. (1) Be available to the department during an inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a; and
    2. (2) Be legible, current, and accurate.
30. (ad) Smoking shall be prohibited in an ESRDDC per RSA 155:66, I(b), except as permitted by RSA 155:67. If allowed, smoking shall be restricted to designated smoking areas as per the licensee’s official smoking policy, but in no case shall smoking be permitted in any room containing an oxygen cylinder or oxygen delivery system or in a patient’s bedroom.
31. (ae) The water used in the ESRDDC shall be suitable for human consumption pursuant to Env-Dw 702.02 and Env-Dw 704.02.

32. (af) For reportable incidents, allegations of abuse, neglect, mistreatment, or misappropriation of property, the licensee shall:

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

    2. (2) Fax to 603-271-4968 or email to hfa-licensing@dhhs.nh.gov the following information to the department within 48 hours of a reportable incident as defined in He-P 811.03(cg):

       1. a. The ESRDDC 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 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 incident;
       6. f. The action taken in direct response to the 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, agent, or personal representative was notified;
       9. i. The signature of the person reporting the incident; and
       10. j. The date and time the patient’s licensed practitioner was notified;
    3. (3) As soon as practicable, notify the local police department, the department, and the guardian, agent, or personal representative, if any, when a patient has an unexplained absence, and the licensee has searched the building and the grounds of the ESRDDC without finding the patient, and it has been determined by the facility that the patient is a danger to themselves or others;
    4. (4) If abuse or neglect is suspected, 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;
    5. (5) Contact the department immediately by telephone, fax, or e-mail to report the information required by (2) above in the case of the death of any patient who dies within 10 days of a reportable incident;
    6. (6) Provide the information required by (2) above, in writing, within 3 business days of the unexpected death of a patient or if a patient dies within 10 days of a reportable incident after contact was made pursuant to (5) above, or if additional information becomes available subsequent to the time the initial contact was made; and
    7. (7) Submit additional information requested by the department.
33. (ag) The licensee shall comply with all conditions of warnings and administrative remedies issued by the department and all court orders.
34. (ah) 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. #9963, eff 7-28-11; ss by #12827, INTERIM, eff 7-20-19, EXPIRED: 1-16-20 New. #12985, eff 1-29-20; ss by #14206, eff 2-28-25-(formerly He-P 811.13)