(a) If the hospital provides
surgical services, the services must be well organized and provided in
accordance with acceptable standards of practice. If outpatient surgical
services are offered, the services must be consistent in quality with inpatient
care in accordance with the complexity of services offered.
(b) The organization of the surgical services
must be appropriate to the scope of the services offered.
(c) The operating rooms must be supervised by
an experienced registered nurse or a doctor of medicine or
(d) A hospital may use
scrub nurses in its operating rooms. For the purposes of this rule, a "scrub
nurse" is defined as a registered nurse or either a licensed practical nurse
(LPN) or a surgical technologist (operating room technician) supervised by a
registered nurse who works directly with a surgeon within the sterile field,
passing instruments, sponges, and other items needed during the procedure and
who scrubs his or her hands and arms with special disinfecting soap and wears
surgical gowns, caps, eyewear, and gloves, when appropriate.
(e) Qualified registered nurses may perform
circulating duties in the operating room. In accordance with applicable state
laws and approved medical staff policies and procedures, LPNs and surgical
technologists may assist in circulatory duties under the supervision of a
qualified registered nurse who is immediately available to respond to
privileges must be delineated for all practitioners performing surgery in
accordance with the competencies of each practitioner. The surgical service
must maintain a roster of practitioners specifying the surgical privileges of
services must be consistent with needs and resources. Policies covering
surgical care must be designed to assure the achievement and maintenance of
high standards of medical practice and patient care.
Surgical technologists must:
1. Hold current national certification
established by the Liaison Council on Certification for the Surgical
Technologist (LCC-ST); or
completed a program for surgical technology accredited by the Commission on
Accreditation of Allied Health Education Programs (CAAHEP); or
3. Have completed an appropriate training
program for surgical technologists in the armed forces or at a CAAHEP
accredited hospital or CAAHEP accredited ambulatory surgical treatment center;
4. Successfully complete the
surgical technologists LCC-ST certifying exam; or
5. Provide sufficient evidence that, prior to
May 21, 2007, the person was at any time employed as a surgical technologist
for not less than eighteen (18) months in the three (3) years preceding May 21,
2007 in a hospital, medical office, surgery center, or an accredited school of
surgical technology; or has begun the appropriate training to be a surgical
technologist prior to May 21, 2007, provided that such training is completed
within three (3) years of May 21, 2007.
(i) A hospital can petition the director of
health care facilities of the department for a waiver from the provisions of
1200-08-01-.07(1)(h) if they are unable to employ a sufficient number of
surgical technologists who meet the requirements. The facility shall
demonstrate to the director that a diligent and thorough effort has been made
to employ surgical technologist who meet the requirements. The director shall
refuse to grant a waiver upon finding that a diligent and thorough effort has
not been made. A waiver shall exempt a facility from meeting the requirements
for not more than nine (9) months. Additional waivers may be granted, but all
exemptions greater than twelve (12) months shall be approved by the Board for
Licensing Health Care Facilities.
(j) Surgical technologists shall demonstrate
continued competence in order to perform their professional duties in surgical
technology. The employer shall maintain evidence of the continued competence of
such individuals. Continued competence activities may include but are not
limited to continuing education, in-service training, or certification renewal.
Persons qualified to be employed as surgical technologists shall complete
fifteen (15) hours of continuing education or contact hours annually. Current
certification by the National Board of Surgical Technology and Surgical
Assisting shall satisfy this requirement.
(k) There must be a complete history and
physical work-up in the chart of every patient prior to surgery, except in
emergencies. If the history has been dictated, but not yet recorded in the
patient's chart, there must be a statement to that effect and an admission note
in the chart by the practitioner who admitted the patient.
(l) Properly executed informed consent,
advance directive, and organ donation forms, when applicable, must be in the
patient's chart before surgery, except in emergencies.
The following equipment must be available
to the operating room suites:
5. Aspirator; and
6. Tracheotomy set.
(n) There must be adequate provisions for
immediate pre and post-operative care.
(o) The operating room register must be
complete and up-to-date.
operative report describing techniques, findings, and tissues removed or
altered must be written or dictated immediately following surgery and signed by
(a) If the hospital
furnishes anesthesia services, they must be provided in a well organized manner
under the direction of a qualified doctor of medicine or osteopathy. The
service is responsible for all anesthesia administered in the
The organization of
anesthesia services must be appropriate to the scope of the services offered.
Anesthesia must be administered only by:
doctor of medicine or osteopathy (other than an anesthesiologist);
3. A dentist, oral surgeon, or podiatrist who
is qualified to administer anesthesia under State law;
4. A certified registered nurse anesthetist
5. A graduate registered
nurse anesthetist under the supervision of an anesthesiologist who is
immediately available if needed.
Anesthesia services must be consistent
with needs and resources. Policies on anesthesia procedures must include the
delineation of pre-anesthesia and post-anesthesia responsibilities. The
policies must ensure that the following are provided for each patient:
1. A pre-anesthesia evaluation or evaluation
update conducted within forty-eight (48) hours prior to surgery by an
individual qualified to administer anesthesia;
2. An intraoperative anesthesia
3. For each inpatient, a
written post-anesthesia follow-up report prepared within forty-eight (48) hours
following surgery by an individual qualified to administer anesthesia or by the
person who administered the anesthesia and submits the report by telephone;
4. For each outpatient, a
post-anesthesia evaluation of anesthesia recovery prepared in accordance with
policies and procedures approved by the medical staff.
Nuclear Medicine Services.
(a) If the hospital provides nuclear medicine
services, those services must meet the needs of the patients in accordance with
acceptable standards of practice.
(b) The organization of the nuclear medicine
service must be appropriate to the scope and complexity of the services
(c) There must be a
director who is a doctor of medicine or osteopathy qualified in nuclear
(d) The qualifications,
training, functions, and responsibilities of nuclear medicine personnel must be
specified by the service director and approved by the medical staff.
(e) Radioactive materials must be prepared,
labeled, used, transported, stored, and disposed of in accordance with
acceptable standards of practice.
(f) In-house preparation of
radiopharmaceuticals is by, or under, the direct supervision of an
appropriately trained registered pharmacist or a doctor of medicine or
(g) If laboratory tests
are performed in the nuclear medicine service, the service must meet the
applicable requirements for laboratory services as specified in TCA
Equipment and supplies
must be appropriate for the types of nuclear medicine services offered and must
be maintained for safe and efficient performance. The equipment must be:
1. Maintained in safe operating condition;
2. Inspected, tested, and
calibrated at least annually by qualified personnel.
(i) The hospital must maintain signed and
dated reports of nuclear medicine interpretations, consultations, and
procedures. Copies of nuclear medicine reports must be maintained for at least
ten (10) years.
practitioner approved by the medical staff to interpret diagnostic procedures
must sign and date the interpretation of these tests.
(k) The hospital must maintain records of the
receipt and disposition of radiopharmaceuticals.
(l) Nuclear medicine services must be ordered
only by a practitioner whose scope of federal or state licensure and whose
defined staff privileges allow such referrals.
(m) Patients are not left unattended in pre
and post procedure areas.
(a) If the hospital provides outpatient
services, the services must meet the needs of the patients in accordance with
acceptable standards of practice.
(b) Outpatient services must be appropriately
organized and integrated with inpatient services.
(c) The hospital must have appropriate
professional and non-professional personnel available to provide outpatient
(d) Patient's rights,
including a phone number to call regarding questions or concerns, shall be made
readily available to outpatients.
Outpatient laboratory testing in
Tennessee hospitals may be ordered by the following:
1. Any licensed Tennessee practitioner who is
authorized to do so by T.C.A. §
Any out of state practitioner who has a
Tennessee telemedicine license issued pursuant to rule
Any duly licensed out of
state health care professional as listed in T.C.A. §
who is authorized by his or her state board to order outpatient laboratory
testing in hospitals for individuals with whom that practitioner has an
existing face-to-face patient relationship as outlined in rule
1., 2., and 3.
Outpatient diagnostic testing in Tennessee hospitals may be ordered by the
1. Any Tennessee practitioner
licensed under Title 63 who is authorized to do so by his or her practice
Any out of state
practitioner who has a Tennessee telemedicine license issued pursuant to rule
Any duly licensed out of
state health care professional who is authorized by his or her state board to
order outpatient diagnostic testing in hospitals for individuals with whom that
practitioner has an existing face-to-face patient relationship as outlined in
1., 2., and 3.
(a) Hospitals that elect to provide surgical
services, other than in a separately licensed Ambulatory Surgical Treatment
Center, must maintain and operate an emergency room.
If emergency services are provided, the
hospital must meet the emergency needs of patients in accordance with
acceptable standards of practice. Each hospital must have a policy which
assures that all patients who present to the emergency department, are
screened/triaged to determine if a medical emergency exists and stabilized when
a medical emergency does exist. A hospital may deny access to patients when it
is on diversionary status only because it does not have the staff or facilities
in the emergency department to accept any additional emergency patients at that
time. If an ambulance disregards the hospital's instructions and brings an
individual on to the hospital grounds, the individual has arrived on hospital
property and cannot be denied access to hospital services. Hospital property,
for the purpose of this subparagraph, is considered to be:
1. The hospital's physical geographic
2. Ambulances owned
and operated by the hospital, whenever in operation, whether or not on hospital
(c) A hospital
may not delay provision of an appropriate medical screening examination in
order to inquire about the individual's method of payment or insurance
If emergency services
are provided at the hospital:
1. The services
must be organized under the direction of a qualified member of the medical
2. The services must be
integrated with other departments of the hospital; and
3. The policies and procedures governing
medical care provided in the emergency service or department are established by
and are a continuing responsibility of the medical staff. These policies and
procedures must define how the hospital will assess, stabilize, treat and/or
There must be adequate medical and nursing personnel qualified in emergency
care to meet the written emergency procedures and needs anticipated by the
(f) There shall be a
sufficient number of emergency rooms and adequate equipment and supplies to
accommodate the caseload of the emergency services.
(g) The entrance to the emergency department
shall be clearly marked.
drugs in emergency rooms shall be stored in locked cabinets, except as
otherwise provided for emergency drugs by the written policies and procedures
of the hospital. Discharge medications may be dispensed to out-patients upon
written physician orders provided that they have been packaged in containers by
the pharmacist in amounts not to exceed twelve (12) hours dosage and labeled in
accordance with Pharmacy Board rules.
Emergency Room medical records shall
include the following:
2. Information concerning the
time of arrival, means and by whom transported;
3. Pertinent history of the injury or illness
to include chief complaint and onset of injuries or illness;
4. Significant physical findings;
5. Description of laboratory, x-ray and EKG
7. Condition of the
patient on discharge or transfer;
8. Diagnosis on discharge;
9. Instructions given to the patient or his
10. A control register
listing chronologically the patient visits to the emergency room. The record
shall contain at least the patient's name, date and time of arrival and record
number. The name of those dead on arrival shall be entered in the
patients and their families are made aware of their rights, including a number
to call regarding concerns or questions.
(a) If the hospital provides rehabilitation,
physical therapy, occupational therapy, audiology, or speech pathology
services, the services must be organized and staffed to ensure the health and
safety of patients. These disciplines should document their contribution to the
plan for patient care.
organization of the service must be appropriate to the scope of the services
(c) The director of the
service must have the necessary knowledge, experience, and capabilities to
properly supervise and administer the services.
(d) Physical therapy, occupational therapy,
speech therapy, or audiology services, if provided, must be provided by staff
who meet the qualifications specified by hospital policy, consistent with state
(e) Services must be furnished
in accordance with a written plan of treatment in accordance with the practice
acts of the practitioners who are authorized by medical staff to provide the
services. The written plan of treatment must be incorporated in the patient's
(a) If a hospital provides
obstetrical services it shall have space, facilities, equipment and qualified
personnel to assure appropriate treatment of all maternity patients and
(b) The hospital must
have written policies and procedures governing medical care provided in the
obstetrical service which are established by and are a continuing
responsibility of the medical staff.
(c) Provisions must be made for care of the
patient during labor and delivery, either in the patient's room or in a
delivery rooms shall be segregated from patient areas and be located so as not
to be used as a passageway between or subject to contamination from other parts
of the hospital.
record shall be kept that must indicate:
The name of the patient;
3. Date of
4. Sex of
5. Name of
6. Names of persons
7. What complications,
if any, occurred;
8. Type of
9. Name of person
administering anesthesia; and
Other persons present.
(a) If the hospital provides pediatric
services, it shall provide appropriate pediatric equipment and
(b) Pediatric services
must be appropriate to the scope and complexity of the services offered and
must meet the needs of the patients in accordance with acceptable standards of
(c) The hospital must
have appropriate professional and non-professional personnel available to
provide pediatric services.
Respiratory Care Services.
(a) If the hospital provides respiratory care
services, the hospital must meet the needs of the patients in accordance with
acceptable standards of practice.
(b) The organization of the respiratory care
services must be appropriate to the scope and complexity of the services
(c) There must be a
director of respiratory care services who is a doctor of medicine or osteopathy
with the knowledge, experience, and capabilities to supervise and administer
the service properly.
must be adequate numbers of certified respiratory therapists, certified
respiratory therapy technicians, and other personnel who meet the
qualifications specified by the medical staff, consistent with state
(e) Services must be delivered
in accordance with medical staff directives.
(f) Personnel qualified to perform specific
procedures and the amount of supervision required for personnel to carry out
specific procedures must be designated in writing.
(g) If blood gases or other laboratory tests
are performed in the respiratory care unit, the unit must meet the applicable
requirements for clinical laboratory services specified in the Tennessee
Medical Laboratory Act.
Social Work Services.
(a) If the hospital provides social work
services, the services must be available to the patient, the patient's family
and other persons significant to the patient, in order to facilitate adjustment
of these individuals to the impact of illness and to promote maximum benefits
from the health care services provided.
(b) Social work services shall include
psychosocial assessment, counseling, coordination of discharge planning,
community liaison services, financial assistance and consultation.
(c) Social work services shall be provided by
personnel who satisfy applicable accreditation standards and who are in
compliance with Tennessee State Law governing social work practices. Social
work personnel employed by the hospital prior to the effective date of these
regulations shall be deemed to meet this requirement.
(d) Facilities for social work services shall
be readily accessible and shall permit privacy for interviews and
(a) If a hospital
provides psychiatric services, a psychiatric unit devoted exclusively for the
care and treatment of psychiatric patients and professional personnel qualified
in the diagnosis and treatment of patients with psychiatric illnesses shall be
provided. Adequate protection shall be provided for patients and the staff
against any physical injury resulting from a patient becoming violent. A
psychiatric unit shall meet the requirements as needed to care for patients
admitted, either through direct care or by contractual arrangements.
(b) A hospital licensed by the Department of
Health as a satellite hospital whose primary purpose is the provision of mental
health or mental retardation services, must verify to the Department that
Standards of the Department of Mental Health and Mental Retardation are
and Drug Services.
(a) If a hospital provides
alcohol and drug services, the service shall be devoted exclusively to the care
and treatment of alcohol and drug dependent patients and have on staff
physicians and other professional personnel qualified in the diagnosis and
treatment of alcoholism and drug addiction.
(b) Adequate protection shall be provided for
the patients and staff against any physical injury resulting from a patient
becoming disturbed or violent. Alcohol and drug services shall meet the
requirements as needed to care for patients admitted, either through direct
care or by contractual arrangements.
(13) Perinatal and/or Neonatal Care Services.
Any hospital providing perinatal and/or neonatal care services shall comply
with the Tennessee Perinatal Care System Guidelines for Regionalization,
Hospital Care Levels, Staffing and Facilities developed by the Tennessee
Department of Health's Perinatal Advisory Committee, June 1997 including
amendments as necessary.