(1) Abuse. The willful infliction of injury,
unreasonable confinement, intimidation or punishment with resulting physical
harm, pain or mental anguish.
Acceptable Plan of Correction. The Licensing Division shall approve a
hospital's acceptable plan to correct deficiencies identified during an on-site
survey conducted by the Survey Division or its designated representative. The
plan of correction shall be a written document and shall provide, but not
limited to, the following information:
How the deficiency will be corrected.
(b) Who will be responsible for correcting
(c) The date the
deficiency will be corrected.
How the facility will prevent the same deficiency from re-occurring.
(3) Adult. An individual who has
capacity and is at least 18 years of age.
(4) Advance Directive. An individual
instruction or a written statement relating to the subsequent provision of
health care for the individual, including, but not limited to, a living will or
a durable power of attorney for health care.
(5) Agent. An individual designated in an
advance directive for health care to make a health care decision for the
individual granting the power.
Board. The Tennessee Board for Licensing Health Care Facilities.
(7) Capacity. An individual's ability to
understand the significant benefits, risks, and alternatives to proposed health
care and to make and communicate a health care decision. These regulations do
not affect the right of a patient to make health care decisions while having
the capacity to do so. A patient shall be presumed to have capacity to make a
health care decision, to give or revoke an advance directive, and to designate
or disqualify a surrogate. Any person who challenges the capacity of a patient
shall have the burden of proving lack of capacity.
(8) Cardiopulmonary Resuscitation (CPR). The
administering of any means or device to support cardiopulmonary functions in a
patient, whether by mechanical devices, chest compressions, mouth-to-mouth
resuscitation, cardiac massage, tracheal intubation, manual or mechanical
ventilators or respirations, defibrillation, the administration of drugs and/or
chemical agents intended to restore cardiac and/or respiratory functions in a
patient where cardiac or respiratory arrest has occurred or is believed to be
(9) Certified Master
Social Worker. A person currently certified as such by the Tennessee Board of
Social Worker Certification and Licensure.
(10) Certified Nurse Practitioner. A person
who is licensed as a registered nurse and has further been issued a certificate
of fitness to prescribe and/or issue legend drugs by the Tennessee Board of
(11) Certified Registered
Nurse Anesthetist. A registered nurse currently licensed by the Tennessee Board
of Nursing who is currently certified as such by the American Association of
Respiratory Therapist. A person currently certified as such by the Tennessee
Board of Medical Examiners' Council on Respiratory Care.
(13) Certified Respiratory Therapy
Technician. A person currently certified as such by the Tennessee Board of
Medical Examiners' Council on Respiratory Care.
(14) Clinical Laboratory Improvement Act
(CLIA). The federal law requiring that clinical laboratories be approved by the
U.S. Department of Health and Human Services, Health Care Financing
Practice. The implementation of the collaborative plan that outlines procedures
for consultation and collaboration with other health care professional, e.g.,
licensed physicians and mid-level practitioners.
(16) Collaborative Plan. The formal written
plan between the mid-level practitioners and a licensed physician.
(17) Commissioner. The Commissioner of the
Tennessee Department of Health or his or her authorized
(18) Competent. A
patient who has capacity.
Critical Access Hospital. A hospital located in a rural area, certified by the
Department as being a necessary provider of health care services to residents
of the area, which makes available twenty-four (24) hour emergency care; is a
designated provider in a rural health network; provides not more than
twenty-five (25) acute care inpatient beds for providing inpatient care not to
exceed an annual average of ninety-six (96) hours, and has a quality assessment
and performance improvement program and procedures for utilization review. If
swing-bed approval has been granted, all twenty-five (25) beds can be used
interchangeably for acute or Skilled Nursing Facility (SNF/swing-bed) level of
(20) Dentist. A
person currently licensed as such by the Tennessee Board of
(21) Department. The
Tennessee Department of Health.
(22) Designated Physician. A physician
designated by an individual or the individual's agent, guardian, or surrogate,
to have primary responsibility for the individual's health care or, in the
absence of a designation or if the designated physician is not reasonably
available, a physician who undertakes such responsibility.
(23) Designation. An official finding and
recognition by the Department of Health that an acute care hospital meets
Tennessee State Rural Health Care Plan requirements to be a Critical Access
Dietitian. As used
in the chapter, the term "dietitian" means:
(a) A person who is currently licensed by the
Tennessee Board of Dietitian/Nutritionist Examiners as a
employee of a Tennessee hospital who is exempt from Tennessee licensure
pursuant to T.C.A. §
but holds the credential of Registered Dietitian (RD) or Registered Dietitian
Nutritionist (RDN) from the Commission on Dietetic Registration.
(25) Do-Not-Resuscitate Order
(DNR). A written order, other than a POST, not to resuscitate a patient in
cardiac or respiratory arrest in accordance with accepted medical
Signature. The authentication of a health record document or documentation in
an electronic form achieved through electronic entry of an exclusively
assigned, unique identification code entered by the author of the
Minor. Any minor who is or has been married or has by court order or otherwise
been freed from the care, custody and control of the minor's parents.
(28) Emergency Responder. A paid or volunteer
firefighter, law enforcement officer, or other public safety official or
volunteer acting within the scope of his or her proper function under law or
rendering emergency care at the scene of an emergency.
(29) Graduate Registered Nurse Anesthetist. A
registered nurse currently licensed in Tennessee who is a graduate of a nurse
anesthesia educational program that is accredited by the American Association
of Nurse Anesthetist's Council on Accreditation of Nurse Anesthesia Educational
Programs and awaiting initial certification examination results, provided that
initial certification is accomplished within eighteen (18) months of completion
of an accredited nurse anesthesia educational program.
(30) Guardian. A judicially appointed
guardian or conservator having authority to make a health care decision for an
(31) Hazardous Waste.
Materials whose handling, use, storage, and disposal are governed by local,
state or federal regulations.
Health Care. Any care, treatment, service or procedure to maintain, diagnose,
treat, or otherwise affect an individual's physical or mental condition, and
includes medical care as defined in T.C.A. §
(33) Health Care Decision. Consent, refusal
of consent or withdrawal of consent to health care.
Health Care Decision-maker. In the case
of a patient who lacks capacity, the patient's health care decision-maker is
one of the following: the patient's health care agent as specified in an
advance directive, the patient's court-appointed guardian or conservator with
health care decision-making authority, the patient's surrogate as determined
pursuant to Rule
or T.C.A. §
the designated physician pursuant to these Rules or in the case of a minor
child, the person having custody or legal guardianship.
(35) Health Care Institution. A health care
institution as defined in T.C.A. §
(36) Health Care Provider. A person who is
licensed, certified or otherwise authorized or permitted by the laws of this
state to administer health care in the ordinary course of business or practice
of a profession.
institution, place, building or agency represented and held out to the general
public as ready, willing and able to furnish care, accommodations, facilities
and equipment for the use, in connection with services of a physician or
dentist, to one (1) or more nonrelated persons who may be suffering from
deformity, injury or disease or from any other condition for which nursing,
medical or surgical services would be appropriate for care, diagnosis or
treatment. All hospitals shall provide basic hospital functions and may provide
optional services as delineated in these rules. A hospital shall be designated
according to its classification and shall confine its services to those
classifications described below.
Hospital. To be licensed as a general hospital, the institution shall maintain
and operate organized facilities and services to accommodate one or more
non-related persons for a period exceeding twenty-four (24) hours for the
diagnosis, treatment or care of such persons and shall provide medical and
surgical care of acute illness, injury or infirmity and obstetrical care. All
diagnosis, treatment and care shall be administered by or performed under the
direction of persons currently licensed to practice the healing arts in the
State of Tennessee. In addition, a general hospital must specifically provide:
1. An organized staff of professional,
technical and administrative personnel.
2. A laboratory with sufficient equipment and
personnel necessary to perform biochemical, bacteriological, serological and
facilities which shall include, as a minimum requirement, a complete diagnostic
4. A separate
surgical unit which shall include, as minimum requirements, one operating room,
a sterilizing room, a scrub-up area and workroom.
5. Obstetrical facilities which shall
include, as minimum requirements, one delivery room, a labor room, a newborn
nursery, an isolation nursery, and patient rooms designated exclusively for
emergency department in accordance with rule
of these standards and regulations.
(b) Satellite Hospital. A satellite hospital
may be licensed with a parent hospital upon approval by the Board for Licensing
Health Care Facilities when they are on separate premises and are operated
under the same management.
Chronic Disease Hospital. To be licensed as a chronic disease hospital, the
institution shall be devoted exclusively to the diagnosis, treatment or care of
persons needing medical, surgical or rehabilitative care for chronic or
long-term illness, injury, or infirmity. The diagnosis, treatment or care shall
be administered by or performed under the direction of persons currently
licensed to practice the healing arts in the State of Tennessee. A chronic
disease hospital shall meet the requirements for a general hospital except that
obstetrical facilities are not required and, if the hospital provides no
surgical services, an emergency department is not required.
(d) Orthopedic Hospital. To be licensed as an
orthopedic hospital, the institution shall be devoted primarily to the
diagnosis and treatment of orthopedic conditions. An orthopedic hospital shall
meet the requirements for a general hospital except that obstetrical services
are not required and, if the hospital provides no surgical services, an
emergency department is not required.
(e) Pediatric Hospital. To be licensed as a
pediatric hospital, the institution shall be devoted primarily to the diagnosis
and treatment of pediatric cases and have on staff professional personnel
especially qualified in the diagnosis and treatment of the diseases of
children. A pediatric hospital shall meet the requirements of a general
hospital except that obstetrical facilities are not required and if the
hospital provides no surgical services, an emergency department is not
(f) Eye, Ear, Nose, and
Throat Hospital or any one of these. To be licensed as an eye, ear, nose and
throat hospital, the institution shall be devoted primarily to the diagnosis
and treatment of the diseases of the eye, ear, nose, and throat. The hospital
shall have on staff professional personnel especially qualified in the
diagnosis and treatment of diseases of the eye, ear, nose and throat. An eye,
ear, nose and throat hospital shall meet the requirements for a general
hospital except that obstetrical facilities are not required and, if the
hospital provides no surgical services, an emergency department is not
Hospital. To be licensed as a rehabilitation hospital, the institution shall be
devoted primarily to the diagnosis and treatment of persons requiring
rehabilitative services. A rehabilitation hospital shall meet the requirement
of a general hospital except that radiology services, a surgical unit,
obstetrical facilities, and an emergency department are not required.
(38) Hospitalization. The
reception and care of any person for a continuous period longer than
twenty-four (24) hours, for the purpose of giving advice, diagnosis, nursing
service or treatment bearing on the physical health of such persons, and
maternity care involving labor and delivery for any period of time.
(39) Incompetent. A patient who has been
adjudicated incompetent by a court of competent jurisdiction and has not been
restored to legal capacity.
Individual instruction. An individual's direction concerning a health care
decision for the individual.
Infectious Waste. Solid or liquid wastes which contain pathogens with
sufficient virulence and quantity such that exposure to the waste by a
susceptible host could result in an infectious disease.
(42) Involuntary Transfer. The movement of a
patient between hospitals, without the consent of the patient, the patient's
legal guardian, next of kin or representative.
Justified Emergency. Includes, but is
not limited to, the following events/ occurrences:
(a) An influx of mass casualties;
(b) Localized and/or regional catastrophes
such as storms, earthquakes, tornadoes, etc. or,
(c) Epidemics or episodes of mass illness
such as influenza, salmonella, etc.
(44) Licensed Clinical Social Worker. A
person currently licensed as such by the Tennessee Board of Social
(45) Licensed health care
professional. Any health care professional currently licensed by the State of
Tennessee to practice within the scope of a regulated profession, such as a
nurse practitioner, dietitian, dentist, occupational therapist, pharmacist,
physical therapist, physician, physician assistant, podiatrist, psychologist,
clinical social worker, speech language pathologist, and emergency service
(46) Licensed Practical
Nurse. A person currently licensed as such by the Tennessee Board of
(47) Licensee. The person
or entity to whom the license is issued. The licensee is held responsible for
compliance with all rules and regulations.
(48) Life Threatening Or Serious Injury.
Injury requiring the patient to undergo significant additional diagnostic or
Emergency. A medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that the absence of immediate
medical attention could reasonably be expected to result in placing the
patient's health in serious jeopardy, serious impairment to bodily functions or
serious dysfunction of any bodily organ or part, which includes labor when
delivery is imminent, when there is inadequate time to effect safe transfer to
another hospital prior to delivery, or when a transfer may pose a threat to the
health and safety of the patient or the unborn child.
(50) Medical Record. Medical histories,
records, reports, summaries, diagnoses, prognoses, records of treatment and
medication ordered and given, entries, x-rays, radiology interpretations. and
other written electronics, or graphic data prepared, kept, made or maintained
in a facility that pertains to confinement or services rendered to patients
admitted or receiving care.
Medical Staff. An organized body composed of individuals appointed by the
hospital governing board that operates under bylaws approved by the governing
body and is responsible for the quality of medical care provided to patients by
the hospital. All members of the medical staff shall be licensed to practice in
Tennessee, with the exception of interns and residents.
(52) Medically Inappropriate Treatment.
Resuscitation efforts that cannot be expected either to restore cardiac or
respiratory function to the patient or other medical or surgical treatments to
achieve the expressed goals of the informed patient. In the case of the
incompetent patient, the patient's representative expresses the goals of the
(53) Member of the
Professional Medical Community. A professional employed by the hospital and on
the premises at the time of a voluntary delivery.
(54) Mid-Level Practitioner. Either a
certified nurse practitioner or a physician assistant.
(55) Misappropriation of Patient/Resident
Property. The deliberate misplacement, exploitation or wrongful, temporary or
permanent use of an individual's belongings or money without the individual's
(56) Neglect. The failure
to provide goods and services necessary to avoid physical harm, mental anguish
or mental illness; however, the withholding of authorization for or provision
of medical care to any terminally ill person who has executed an irrevocable
living will in accordance with the Tennessee Right to Natural Death Law, or
other applicable state law, if the provision of such medical care would
conflict with the terms of the living will, shall not be deemed "neglect" for
purposes of these rules.
N.F.P.A. The National Fire Protection Association.
(58) Nuclear Medicine Technologist. A person
currently registered as such by the National Association for Nuclear Medicine
(59) Nurse Midwife. A
person currently licensed by the Tennessee Board of Nursing as a registered
nurse (R.N.) and qualified to deliver midwifery services or certified by the
American College of Nurse-Midwives.
(60) Occupational Therapist. A person
currently certified as such by the Tennessee Board of Occupational and Physical
Occupational Therapy Assistant. A person currently certified as such by the
Tennessee Board of Occupational and Physical Therapy Examiners.
(62) Optometrist. A person currently licensed
as such by the Tennessee Board of Optometry.
(63) Patient. Includes but is not limited to
any person who is suffering from an acute or chronic illness or injury or who
is crippled, convalescent or infirm, or who is in need of obstetrical,
surgical, medical, nursing or supervisory care.
(64) Person. An individual, corporation,
estate, trust, partnership, association, joint venture, government,
governmental subdivision, agency, or instrumentality, or any other legal or
Informing. A communication by any effective means from the patient directly to
a health care provider.
Pharmacist. A person currently licensed as such by the Tennessee Board of
(67) Physical Therapist.
A person currently certified as such by the Tennessee Board of Occupational and
Physical Therapy Examiners.
Physical Therapy Assistant. A person currently certified as such by the
Tennessee Board of Occupational and Physical Therapy Examiners.
(69) Physician. An individual authorized to
practice medicine or osteopathy under Tennessee Code Annotated, Title 63,
Chapters 6 or 9.
Assistant. A person who has graduated from a physician assistant educational
program accredited by the Accreditation Review Commission on Education for the
Physician Assistant, has passed the Physician Assistant National Certifying
Examination, and is currently licensed in Tennessee as a physician assistant
under title 63, chapter 19.
Physician Orders for Scope of Treatment or POST. Written orders that:
(a) Are on a form approved by the Board for
Licensing Health Care Facilities;
(b) Apply regardless of the treatment setting
and that are signed as required herein by the patient's physician, physician
assistant, nurse practitioner, or clinical nurse specialist; and
Specify whether, in the event the patient suffers cardiac or respiratory
arrest, cardiopulmonary resuscitation should or should not be
2. Specify other medical
interventions that are to be provided or withheld; or
3. Specify both 1 and 2.
(72) Podiatrist. A person
currently licensed as such by the Tennessee Board of Registration in
(73) Power of Attorney
for Health Care. The designation of an agent to make health care decisions for
the individual granting the power under T.C.A. Title 34, Chapter 6, Part
(74) Psychologist. A person
currently licensed as such by the Tennessee Board of Examiners in
Emergency Medical Service Personnel. Includes, but shall not be limited to,
emergency medical technicians, paramedics, or other emergency services
personnel, providers, or entities acting within the usual course of their
professions, and other emergency responders.
(76) Radiological Technologist. A person
currently registered as such by the American Society of Radiological
Available. Readily able to be contacted without undue effort and willing and
able to act in a timely manner considering the urgency of the patient's health
care needs. Such availability shall include, but not be limited to,
availability by telephone.
Registered Health Information Administrator (RHIA). A person currently
registered as such by the American Health Information Management
(79) Registered Health
Information Technician (RHIT). A person currently accredited as such by the
American Health Information Management Association.
(80) Registered Nurse. A person currently
licensed as such by the Tennessee Board of Nursing.
(81) Rural Area. A county classified by the
federal Office of Management and Budget (OMB) as rural, all counties, excluding
Davidson, Hamilton, Knox, and Shelby, currently defined as rural in Chapter
1200-20-11 of the Tennessee Comprehensive Rules and Regulations, or an area
outside of a county or part of a county previously classified as rural by the
OMB and reclassified by the OMB as a metropolitan statistical area as of June
(82) Satellite Hospital. A
freestanding hospital licensed with a parent hospital that is on separate
premises and operated under the same management.
(83) Shall or Must. Compliance is
(84) Social Worker. A
person who has at least a bachelor's degree in Social Work or related field,
and preferably, two (2) years medical social work or other community based work
(85) Stabilize. To
provide such medical treatment of the emergency medical condition as may be
necessary to assure, within reasonable medical probability, that the condition
will not materially deteriorate due to the transfer as determined by a
physician or other qualified medical personnel when a physician is not readily
(86) State. A state of
the United States, the District of Columbia, the Commonwealth of Puerto Rico,
or a territory or insular possession subject to the jurisdiction of the United
(87) Student. A person
currently enrolled in a course of study that is approved by the appropriate
Health Care Provider. The designated physician or, if there is no designated
physician or the designated physician is not reasonably available, the health
care provider who has undertaken primary responsibility for an individual's
Technologist. A person who works under supervision to facilitate the safe and
effective conduct of invasive surgical procedures. This individual is usually
employed by a hospital, medical office, or surgical center and supervised
during the surgical procedure according to institutional policy and procedure
to assist in providing a safe operating room environment that maximizes patient
safety by performing certain tasks including, but not limited to:
(a) Preparation of the operating room and the
sterile field for surgical procedures by preparing sterile supplies,
instruments, and equipment using sterile technique;
(b) Preparation of the operating room for
surgical procedures by ensuring that surgical equipment is functioning properly
and safely; and
instruments, equipment or supplies to a surgeon, sponging or suctioning an
operative site, preparing and cutting suture material, holding retractors,
transferring but not administering fluids or drugs, assisting in counting
sponges, needles, supplies, and instruments, and performing other similar tasks
as directed during a surgical procedure.
(90) Surrogate. An individual, other than a
patient's agent or guardian, authorized to make a health care decision for the
(91) Transfer. The
movement of a patient between hospitals at the direction of a physician or
other qualified medical personnel when a physician is not readily available but
does not include such movement of a patient who leaves the facility against
medical advice. The term does not apply to the commitment and movement of
mentally ill and mentally retarded persons and does not apply to the discharge
or release of a patient no longer in medical need of hospital care or to a
hospital's refusal, after an appropriate medical screening, to render any
medical care on the grounds that the person does not have a medical need for
(92) Treating Health
Care Provider. A health care provider who at the time is directly or indirectly
involved in providing health care to the patient.
(93) Treating Physician. The physician
selected by or assigned to the patient and who has the primary responsibility
for the treatment and care of the patient. Where more than one physician shares
such responsibility, any such person may be deemed to be the "treating
Delivery. The action of a mother in leaving an unharmed infant aged seventy-two
(72) hours or younger on the premises of a hospital with any hospital employee
or member of the professional medical community without expressing any
intention to return for such infant, and failing to visit or seek contact with
such infant for a period of thirty (30) days thereafter.