Tenn. Comp. R. & Regs. 0940-05-38-.06 - POLICIES AND PROCEDURES

(1) The licensee shall maintain written policies and procedures that include the following:
(a) A description of services provided by the licensee. The description shall include enrollment and termination criteria;
(b) An organizational chart which clearly shows or describes the lines of authority;
(c) A policy and procedure which outlines the plan of action to be followed when the personal support worker is absent including, but not limited to, notice to the service recipient, the action that shall be taken, and the timeframes for action;
(d) A schedule of fees when applicable;
(e) A statement of service recipient rights as listed in 0940-05-38-.10 and the grievance procedures to be followed when a suspected violation of rights has been reported;
(f) A policy which ensures the confidentiality of service recipients' information and which includes the following provisions:
1. The licensee's personal support services workers shall comply with applicable confidentiality laws and regulations;
2. The service recipient shall not be required to make public statements which acknowledge gratitude to the licensee or for the licensee's services; and
3. Identifiable photographs of service recipients shall not be used without the written and signed consent of the individual or the individual's legal guardian and/or conservator.
(g) The plans and procedures to be followed in the event of an emergency including, but not limited to, fire evacuation and natural disaster emergencies;
(h) Policy and procedures to be followed in the reporting and investigation of suspected or alleged abuse or neglect of a service recipient, or other critical incidents. The procedures shall include provisions for corrective action, if any, to be taken as a result of such reporting and investigation, and reporting to the department's Office of Licensure and to any authority as required by law;
(i) Requirement that personal support services workers comply with procedures for detection and prevention of communicable diseases according to procedures of the Tennessee Department of Health;
(j) Receipt and disbursement of money on behalf of service recipients;
(k) Access by department licensure staff to personal support services workers to discuss investigation of any service provided under this chapter;
(l) Procedures to be followed if a worker will be providing medication assistance if the licensee provides that service. Written policy shall minimally include the following elements:
1. Medication assistance shall be provided only after written authorization has been obtained from the service recipient or the service recipient's authorized representative.
2. Medication assistance training shall be provided to personal support services workers prior to providing assistance and training shall be documented in the personal support service worker's record.
3. Personal support workers shall have procedures for collecting information about medications taken by service recipients.
(m) Polices to ensure that licensees or personal support services workers providing transportation to service recipients meet the following requirements:
1. All vehicles shall be maintained and operated in a safe manner;
2. All licensees or personal support services workers providing transportation shall possess an appropriate driver's license from the Tennessee Department of Safety and documentation of such license shall be maintained in the licensee's records; and
3. All vehicles used for service recipient transportation and owned by the licensee or personal support services worker shall be adequately covered by vehicular liability insurance for personal injury to occupants of the vehicle, and documentation of such insurance shall be maintained in the facility's records.
(n) Polices to address use of devices such as a hoyer lift or gait belt, after training, to assist the service recipient in getting out of or into bed, a chair, toilet or shower but not as part of a therapeutic regimen.
(o) Polices to address categorization of the majority (over fifty-percent (50%)) of the agency's client population base.
(p) Policy that the agency will cooperate with the department when investigating any case of alleged abuse, neglect, mistreatment, misappropriation or exploitation of a service recipient.
(q) Policy that an alternate plan for staffing will be prepared in case of absence or the assigned personal support services worker.


Tenn. Comp. R. & Regs. 0940-05-38-.06
Original rule filed July 21, 2004; effective November 26, 2004. Repeal and new rule filed November 20, 2009; effective February 18, 2010. Repeal and new rules filed March 4, 2016; effective 6/2/2016.

Authority: T.C.A. ยงยง 4-4-103, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302, 33-2-404, and 33-2-407.

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