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Welcome to the Health Facilities Administration Educational Programs and How To Page.

Why do we need Home Health and Hospice Notes for Visits?
As part of the survey process, the surveyors are required to access and review patient records to ensure each facility is in compliance with the administrative rules set forth by the department. Many of our facility types, including Assisted Livings, are required by rule, to have documentation that includes the name of the agency or individual providing the services, the date services were provided, a brief summary of the services provided, and any care or treatment plans created by the agency. For Home Health and Hospice providers caring for individuals in residential care and nursing facilities, the licensing surveyors are finding that the Home Health and Hospice staff are not leaving notes in patient records after each visit.

I am an Education Health Center, may I perform Lab Tests?
If you provide these services in a licensed facility, please leave appropriate documentation of the services provided in each record to assist the facility in compliance with their regulations.

Under NH Administrative Rule He-P 816.16, Education Health Centers (EHC) may perform certain CLIA waived tests without requiring a New Hampshire Laboratory License. These tests include Rapid Strep Testing, Urine Dip Stick Testing, Finger Stick Glucose Testing, and Rapid Flu Testing. All other tests conducted within the laboratory require a laboratory license.

If you are performing any test other than those exempted by rule, please apply for a laboratory license. If you are performing CLIA waived testing for the sole purpose of risk assessment and which test results are not used for the diagnosis or treatment of disease, then a laboratory license is not required under He-P 808. In addition, if you are collecting specimens to send out to a laboratory, you will require a collecting station license under He-P 817.

What do I need to have available for Personnel Records?
As part of the survey process, the surveyors are required to access and review personnel records to ensure each facility is in compliance with the administrative rules set forth by the department. Many facilities are keeping personnel records off premises at a main office or holding location. This practice has made it difficult for the surveyors to gain access to these records during the survey, or the process is significantly delayed. The rule states that “the licensee shall admit and allow any department representative at any time to inspect the following: (1) The licensed premises; (2) All programs and services provided by the [applicable facility]; and (3) Any records required by RSA 151 and [the applicable] He-P.” This includes personnel records.

The personnel records held off site must be accessible during survey. If a surveyor arrives to conduct a compliance inspection, the personnel records must be available within two hours of the surveyor’s arrival. The surveyor will continue with the inspection until the personnel records are provided. If the surveyor has completed all other aspects of the survey and the personnel records are not available, the facility will be cited. The personnel records are reviewed for many different aspects of compliance and if the surveyor is unable to verify whether or not each of the areas is in compliance, the facility can be cited for multiple deficiencies. We would like to avoid this and encourage you to ensure the personnel records are accessible.

What is reportable?
Each rule has a provision regarding reportable or unusual incidents. Although each licensing rule differs in language, the requirements are generally the same. Listed below is the definition and duty section that details the facility’s responsibility to report and what should be reported.

Definitions Duties and Responsibilities of Licensee
803.03 (bk) 803.14 (t)(1)-(4)
804.03 (bp) 804.14 (l)(1)-(4)
805.03 (u) 805.14 (j)(1)-(3)
807.03 (bo) 807.14 (l)(1)-(4)
809.03 (bd) 809.14 (o)(1)-(11)
810.03 (an) 810.14 (o)(1)-(2)
811.03 (av) 811.14 (x)(1)-(3)
814.03 (bb) 814.15 (q)(1)-(6)
816.03 (av) 816.14 (q)(1)-(5)
817.03 (z) 817.14 (k)(1)-(2)
818.03 (bf) 818.14 (s)(1)-(6)
822.03 (ay) 822.14 (l)(1)-(11)
823.03 (bd) 823.14 (o)(1)-(2)
824.03 (bl) 824.14 (t)(1)-(2)

Please review your applicable licensing category’s rules for the appropriate reporting requirements. Recently, the department has not received many reports as required by rule. For example, most rules state that an unexplained absence by a resident from a facility is reportable if the facility has searched the facility and its grounds and is unable to locate the resident. Even if the resident is found in 15 minutes down the street by a staff member and brought back safely, this would still be a reportable incident. We expect that each facility report to the department based on the time frame, such as 3 days or 24 hours, and type of incident, such as elopement, detailed in the rule.

Communication Systems in Facilities

Most licensing categories contain a provision in the rule that dictates the licensee’s responsibility for a communication system that allows residents/clients/patients to contact staff when they are in need. Please make sure to evaluate the communication system within your facility to ensure the appropriate equipment or system is in place. The most important aspect of the communication system is whether or not it is effective. The surveyor’s will determine effectiveness by testing the equipment, interviewing residents, attempting to use the system, reviewing the written system that is in place, and more. Please make sure that you do have communication system in place and that it is effective.

RSA 151:2-f

As of July 1, 2016, RSA 151:2-f put further requirements on those licensed by the Department of Health and Human Services to assist the financially vulnerable and uninsured in obtaining health care services. The law states:

151:2-f Policies Required for Health Facilities and Special Health Care Service Licenses. – Every facility licensed under RSA 151:2, I(a) or (d) and every person holding a special health care service license under RSA 151:2-e shall:

I. Adopt and enforce a written policy to assure that the facility provides its services to all persons who require the services the facility provides regardless of the source of payment for the services provided to any person; and

II. Adopt, publicize, and apply an assistance plan for persons who are uninsured or who do not have the financial resources to pay for the facility's services due to financial hardship.

The licensing staff will begin enforcing the requirements of RSA 151:2-f immediately. As the law states, this only applies to those licensed under RSA 151:2(a) or (d) and not to all licensed providers. Perhaps some of you have already begun this processing and have an established protocol to meet these requirements. For those who have not, you must meet these requirements as soon as possible in order to be in compliance with this law. The Department also wants to reiterate to all licensees that it is the licensee’s responsibility to monitor changes with the law to ensure compliance. The Department cannot and will not notify licensees every time there is a change to the law.

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New Hampshire Department of Health and Human Services
129 Pleasant Street | Concord, NH | 03301-3852

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