N.H. Admin. Code § He-P 808.17

Current through Register No. 50, December 12, 2024

Section He-P 808.17 - Personnel

(a) All personnel shall:

(1) Meet the educational and physical qualifications of the position and in accordance with the requirements of 42 CFR § 493;

(2) Be licensed, registered, or certified if required by state statute;

(3) Receive an orientation within the first 7 days of work that includes:

a. The duties and responsibilities of the position;

b. The laboratory's infection control program; and

c. The laboratory's fire, evacuation, and emergency plans, which outline the responsibilities of personnel in an emergency; and

(4) Prior to testing patient samples, the employee shall have an orientation in the applicable policies, procedures, of the laboratory.

(b) All personnel shall complete annual in-service education in the laboratory:

(1) Policies and procedures on patients' rights;

(2) Infection control program; and

(3) Fire and emergency procedures.

(c) All licensees using the service of independent clinical contractors shall:

(1) Provide the clinical contractors with an orientation as specified in (a)(3) above;

(2) Maintain a copy of the clinical contractors' licenses as required by (a)(2) above, if applicable;

(3) Have a written agreement with each clinical contractor that describes the services that will be provided and agrees to comply with the requirements of (a)(1) through (3) above; and

(4) Have documentation of the criminal record check or employee waiver, as applicable.

(d) For all new hires, including volunteers and independent contractors whose scope of employment will involve direct contact with a patient, patient records, or patient tissue, body fluids, or other biological material, the licensee shall:

(1) Obtain and review a criminal records check, which shall include results of criminal history from the state of New Hampshire;

(2) Review the results of the criminal records check in accordance with (e) below and verify the qualifications of all applicants prior to employment;

(3) Require the employee to submit the results of a physical examination or pre-employment health screening performed by a licensed nurse or a licensed practitioner and 2 step tuberculosis testing, Mantoux method, or other method approved by the Centers for Disease Control, conducted not more than 12 months prior to employment;

(4) Allow the employee to work while waiting for the results of the second step of the TB test when the results of the first test are negative for TB;

(5) Comply with the requirements of the United States Centers for Disease Control and Prevention, "Guidelines for Preventing the Transmission of M. tuberculosis in Health-Care Settings" (2005 edition), available as noted in Appendix A, if the person has either a positive TB test, or has had direct contact or potential for occupational exposure to M. tuberculosis through shared air space with persons with infectious tuberculosis; and

(6) Report all positive tuberculosis (TB) test results for personnel to the department's TB program in accordance with RSA 141-C:7, He-P 301.02, and 301.03.

(e) Unless a waiver is granted in accordance with (f) below, the licensee shall not offer employment for any position if the individual:

(1) Has been convicted for sexual assault, other violent crime, assault, fraud, theft, abuse, neglect, or exploitation;

(2) Has been found by the department or any administrative agency in this or any other state for assault, fraud, theft, abuse, neglect, or exploitation of any person; or

(3) Otherwise poses a threat to the health, safety, or well-being of the patients.

(f) The department shall grant a waiver of (e) above if, after reviewing the underlying circumstances, it determines that the person does not pose a threat to the health, safety, or well-being of patients.

(g) The waiver in (f) above shall be permanent for as long as the individual remains in the same job unless additional convictions or findings under (e) above occur.

(h) If the information identified in (e) above regarding any employee is learned after the person is hired, the licensee shall immediately notify the department.

(i) An employee shall not be permitted to maintain their employment if they have been convicted of a felony, sexual assault, other violent crime, assault, fraud, theft, abuse, neglect, or exploitation of any person in this or any other state by a court of law or had a complaint investigation for abuse, neglect, or exploitation adjudicated and founded by the department unless a waiver has been granted by the department.

(j) All personnel shall sign a statement at the time the initial offer of employment is made and then annually thereafter stating that they:

(1) Do not have a felony conviction in this or any other state;

(2) Have not been convicted of a sexual assault, other violent crime, assault, fraud, theft, abuse, neglect, or exploitation or pose a threat to the health, safety, or well-being of a patient; and

(3) Have not had a finding by the department or any administrative agency in this or any other state for assault, fraud, theft, abuse, neglect, or exploitation of any person.

(k) For individuals with the waiver described in (f) above, the statement required by (j) above shall cover the period of time since the waiver was granted.

(l) An individual shall not be required to re-disclose any of the matters in (f) above if the documentation is available and the department has previously reviewed the material and determined that the individual can continue employment.

(m) Current and complete personnel files shall be maintained at the licensed premises, except as allowed by (p) below.

(n) Personnel files shall include:

(1) Identification data;

(2) Qualifications and work experience;

(3) Record of satisfactory completion of the orientation program required by (a)(3) above;

(4) A copy of each current New Hampshire license, registration, or certification in health care field, if applicable;

(5) Documentation of annual in-service education as required by (b) above; and

(6) The statement required by (j) above.

(o) Personnel files shall be:

(1) Maintained on an individual basis, separate and distinct from other employees, and contain only information relating to the specific personnel member;

(2) Stored in locked containers or cabinets or in a locked room on the premises; and

(3) Maintained for at least 5 years following termination of employment.

(p) Personnel files may be stored in a central location provided that:

(1) The personnel file is available to the department at the licensed premises within 30 minutes of being requested; and

(2) The files are in accordance with (n) and (o) above.

(q) All testing personnel shall have a competency review for each test procedure performed prior to testing patient samples, as well as twice in the first year and annually thereafter.

(r) The competency review shall include:

(1) Monitoring the pre-analytic, analytic, and post analytic phases of the testing procedure;

(2) Direct observation of the testing personnel in the performance of the test procedure; and

(3) Documentation of test results and awareness of test parameters and limitations as described in the package insert.

N.H. Admin. Code § He-P 808.17

#2192, eff 11-25-82; ss by #3193, eff 1-28-86; ss by #5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92

New. #5758, eff 12-20-93, EXPIRED: 12-20-99

New. #8409, eff 8-19-05; ss by #8852, eff 3-24-07; ss by #10267, eff 2-2-13

Amended by Number 37, Filed September 14, 2023, Proposed by #13710, Effective 8/2/2023, Expires 8/2/2033