N.H. Admin. Code § He-C 402.29

Current through Register No. 45, November 7, 2024

Section He-C 402.29 - Plans of Correction

(a) When the department issues a statement of findings, the ATC shall submit a POC that addresses the areas o f noncompliance cited in the statement.

(b) A POC shall be developed and enforced in the following manner:

(1) Upon receipt of a statement of findings, the ATC shall submit a POC containing:

a. How the ATC intends to correct each area of noncompliance;

b. What corrective action will be implemented and maintained to ensure that the noncompliance does not recur; and

c. The date by which each area of noncompliance shall be corrected;

(2) The ATC shall submit a POC to the department within 21 calendar days of the date on the cover letter that transmitted the statement of findings unless the ATC requests, either verbally or in writing, and the department agrees, to extend that deadline, based on the following criteria:

a. The ATC demonstrates that it has made a good faith effort to develop and submit the POC within the 21 calendar day period but has been unable to do so; and

b. The department determines that the health, safety, or well-being of qualifying patients or the public will not be jeopardized as a result of granting the extension;

(3) The department shall review and accept each POC that:

a. Will achieve compliance with RSA 126-X and He-C 402;

b. Corrects all areas of noncompliance as cited in the statement of findings;

c. Does not create a new violation of RSA 126-X or He-C 402 as a result of the implementation of the POC; and

d. Specifies the date upon which the deficiencies will be corrected;

(4) If the POC is acceptable, the department shall issue a registration certificate or provide written notification of acceptance of the POC, whichever is applicable;

(5) If the POC is not acceptable:

a. The department shall notify the ATC in writing of the reason for rejecting the POC;

b. The ATC shall develop and submit a revised POC within 14 days of the date of the written notification from the department that states the original POC was rejected unless, within the 14 day period, the ATC requests an extension, either verbally or in writing, and the department grants the extension, based on the following criteria:

1. The ATC demonstrates that it has made a good faith effort to develop and submit the POC within the 14 day period but has been unable to do so; and

2. The department determines that the health, safety or well-being of qualifying patients or the public will not be jeopardized as a result of granting the waiver;

c. The revised POC shall comply with (b) (1) above and be reviewed in accordance with (b) (3) above; and

d. If the revised POC is not acceptable to the department, or is not submitted within 14 days of the date of the written notification from the department that states the original POC was rejected, the ATC shall be subject to a directed POC in accordance with (c) below and a fine in accordance with He-C 402.30(c) (9) ;

(6) The department shall verify the implementation of any POC that has been submitted and accepted by:

a. Reviewing materials submitted by the ATC;

b. Conducting a follow-up inspection; or

c. Reviewing compliance during the next annual inspection;

(7) Verification of the implementation of any POC shall only occur after the date of completion specified by the ATC in the plan; and

(8) If the POC or revised POC has not been implemented by the completion date at the time of the next inspection, the ATC shall be issued a directed POC in accordance with (c) below and shall be subject to a fine, as appropriate, in accordance with He-C 402.30(c) (10) .

(c) The department shall develop and impose a directed POC that specifies corrective actions for the applicant or ATC to implement when:

(1) As a result of an inspection, investigation, or compliance monitoring, areas of noncompliance were identified that require immediate corrective action to protect the health and safety of the qualifying patients, designated caregivers, ATC agents, or the public;

(2) A POC is not submitted within 21 days of the written notification from the department;

(3) A revised POC is not submitted within 14 days of the written notification from the department; or

(4) A revised POC submitted by the ATC has not been accepted.

(d) If at the time of the next inspection the directed POC referenced in (c) above has not been implemented by the completion date stated in the directed POC, the department shall, as appropriate:

(1) Impose a fine;

(2) Deny the application for a renewal of a registration; or

(3) Revoke the registration in accordance with He-C 402.30.

(e) The department shall offer an opportunity for informal dispute resolution to any registrant who disagrees with an area of noncompliance cited by the department on a statement of findings, provided that the registrant submits a written request for an informal dispute resolution.

(f) The informal dispute resolution shall be requested in writing by the registrant no later than 14 days from the date the statement of findings was issued by the department.

(g) The department shall review the evidence presented and provide a written notice to the registrant of its decision.

(h) An informal dispute resolution shall not be available for any registrant against whom the department has initiated action to impose a fine, suspend, revoke, deny or refuse to issue or renew a registration.

N.H. Admin. Code § He-C 402.29

Adopted byVolume XXXIV Number 50, Filed December 11, 2014, Proposed by #10731, Effective 11/25/2014.

Amended by Volume XXXVIII Number 45, Filed November 8, 2018, Proposed by #12653, Effective 11/1/2018, Expires 11/1/2028.