Tenn. Comp. R. & Regs. 1200-08-01-.04 - ADMINISTRATION

(1) The hospital must have an effective governing body legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this chapter.
(2) The governing body shall appoint a chief executive officer or administrator who is responsible for managing the hospital. The chief executive officer or administrator shall designate an individual to act for him or her in his or her absence, in order to provide the hospital with administrative direction at all times.
(3) When licensure is applicable for a particular job, the number and renewal number of the current license or a copy of the internet verification of such license must be maintained in personnel. Each personnel file shall contain accurate information as to the education , training, experience and personnel background of the employee. Adequate medical screenings to exclude communicable disease shall be required of each employee.
(4) Whenever the rules and regulations of this chapter require that a licensee develop a written policy, plan, procedure, technique, or system concerning a subject, the licensee shall develop the required policy, maintain it and adhere to its provisions. A hospital which violates a required policy also violates the rule and regulation establishing the requirement.
(5) Policies and procedures shall be consistent with professionally recognized standards of practice.
(6) No hospital shall retaliate against or, in any manner, discriminate against any person because of a complaint made in good faith and without malice to the board, the department, the Adult Protective Services, or the Comptroller of the State Treasury. A hospital shall neither retaliate, nor discriminate, because of information lawfully provided to these authorities, because of a person's cooperation with them, or because a person is subpoenaed to testify at a hearing involving one of these authorities.
(7) The hospital shall ensure a framework for addressing issues related to care at the end of life.
(8) The hospital shall provide a process that assesses pain in all patients. There shall be an appropriate and effective pain management program.
(9) Critical Access Hospital.
(a) The facility shall enter into agreements with one or more hospitals participating in the Medicare/Medicaid programs to provide services which the Critical Access Hospital is unable to provide.
(b) When there are no inpatients, the facility is not required to be staffed by licensed medical professionals, but must maintain a receptionist or other staff person on duty to provide emergency communication access. The hospital shall provide an effective system to ensure that a physician or a mid-level practitioner with training and experience in emergency care is on call and immediately available by telephone or radio and available on site within thirty (30) minutes, twenty-four (24) hours a day.
(10) All health care facilities licensed pursuant to T.C.A. §§ 68-11-201, et seq. shall post the following in the main public entrance:
(a) Contact information including statewide toll-free number of the division of adult protective services, and the number for the local district attorney's office;
(b) A statement that a person of advanced age who may be the victim of abuse, neglect, or exploitation may seek assistance or file a complaint with the division concerning abuse, neglect and exploitation; and
(c) A statement that any person, regardless of age, who may be the victim of domestic violence may call the nationwide domestic violence hotline, with that number printed in boldface type, for immediate assistance and posted on a sign no smaller than eight and one-half inches (8½") in width and eleven inches (11") in height.

Postings of (a) and (b) shall be on a sign no smaller than eleven inches (11") in width and seventeen inches (17") in height.

(11) "No smoking" signs or the international "No Smoking" symbol, consisting of a pictorial representation of a burning cigarette enclosed in a red circle with a red bar across it, shall be clearly and conspicuously posted at every entrance.
(12) Hospice services may be provided in an area designated by a hospital for exclusive use by a home care organization certified as a hospice provider to provide care at the hospice inpatient or respite level of care in accordance with the hospice's Medicare certification. Admission to the hospital is not required in order for a patient to receive such hospice services, regardless of the patient's length of stay. The designation by a hospital of a portion of its facility for exclusive use by a home care organization to provide hospice services to its patients shall not:
(a) alter the license to bed complement of such hospital, or
(b) result in the establishment of a residential hospice.
(13) The facility shall develop a concise statement of its charity care policies and shall post such statement in a place accessible to the public.
(14) Informed Consent
(a) Any hospital in which abortions, other than abortions necessary to prevent the death of the pregnant female, are performed shall conspicuously post a sign in a location defined below so as to be clearly visible to patients, which reads:

Notice: It is against the law for anyone, regardless of the person's relationship to you, to coerce you into having or to force you to have an abortion. By law, we cannot perform an abortion on you unless we have your freely given and voluntary consent. It is against the law to perform an abortion on you against your will. You have the right to contact any local or state law enforcement agency to receive protection from any actual or threatened criminal offense to coerce an abortion.

(b) The sign shall be printed in languages appropriate for the majority of clients of the hospital with lettering that is legible and that is Arial font, at least 40-point bold-faced type.
(c) A hospital in which abortions are performed that is not a private physician's office or ambulatory surgical treatment center shall post the required sign in the admissions or registration department used by patients on whom abortions are performed.
(d) A hospital shall be assessed a civil penalty by the board for licensing health care facilities of two thousand five hundred dollars ($2,500.00) for each day of violation in which:
1. The sign required above was not posted during business hours when patients or prospective patients are present; and
2. An abortion other than an abortion necessary to prevent the death of the pregnant female was performed in the hospital.

Notes

Tenn. Comp. R. & Regs. 1200-08-01-.04
Original rule filed March 18, 2000; effective May 30, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendment filed December 2, 2003; effective February 15, 2004. Amendment filed April 20, 2006; effective July 4, 2006. Amendment filed February 23, 2007; effective May 9, 2007. Amendment filed July 18, 2007; effective October 1, 2007. Amendment filed December 23, 2009; effective March 23, 2010. Amendments filed February 22, 2010; effective May 23, 2010. Amendment filed December 16, 2013; effective March 16, 2014.

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-15-202, 39-17-1803, 39-17-1805, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-216, 68-11-268 and 71-6-121.

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