Tenn. Comp. R. & Regs. 1200-08-01-.07 - OPTIONAL HOSPITAL SERVICES

(1) Surgical Services.
(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 osteopathy.
(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 emergencies.
(f) Surgical 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 each practitioner.
(g) Surgical 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.
(h) Surgical technologists must:
1. Hold current national certification established by the Liaison Council on Certification for the Surgical Technologist (LCC-ST); or
2. Have 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; or
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.
(m) The following equipment must be available to the operating room suites:
1. Call-in system;
2. Cardiac monitor;
3. Resuscitator;
4. Defibrillator;
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.
(p) An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon.
(2) Anesthesia Services.
(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 hospital.
(b) The organization of anesthesia services must be appropriate to the scope of the services offered. Anesthesia must be administered only by:
1. A qualified anesthesiologist;
2. A 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 (CRNA); or
5. A graduate registered nurse anesthetist under the supervision of an anesthesiologist who is immediately available if needed.
(c) 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 record;
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; and
4. For each outpatient, a post-anesthesia evaluation of anesthesia recovery prepared in accordance with policies and procedures approved by the medical staff.
(3) 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 offered.
(c) There must be a director who is a doctor of medicine or osteopathy qualified in nuclear medicine.
(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 osteopathy.
(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 §§ 68-29-101, et seq.
(h) 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; and,
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.
(j) The 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.
(4) Outpatient Services.
(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 services.
(d) Patient's rights, including a phone number to call regarding questions or concerns, shall be made readily available to outpatients.
(e) 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. § 68-29-121;
2. Any out of state practitioner who has a Tennessee telemedicine license issued pursuant to rule 0880-02-.16; or
3. Any duly licensed out of state health care professional as listed in T.C.A. § 68-29-121 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 0880-02-.14(7)(a) 1., 2., and 3.
(f) Outpatient diagnostic testing in Tennessee hospitals may be ordered by the following:
1. Any Tennessee practitioner licensed under Title 63 who is authorized to do so by his or her practice act;
2. Any out of state practitioner who has a Tennessee telemedicine license issued pursuant to rule 0880-02-.16; or
3. 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 rule 0880-02-.14(7)(a) 1., 2., and 3.
(5) Emergency Services.
(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.
(b) 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 boundaries; or
2. Ambulances owned and operated by the hospital, whenever in operation, whether or not on hospital grounds.
(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 status.
(d) If emergency services are provided at the hospital:
1. The services must be organized under the direction of a qualified member of the medical staff;
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 transfer patients.
(e) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.
(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.
(h) Legend 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.
(i) Emergency Room medical records shall include the following:
1. Identification data;
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 findings;
6. Treatment rendered;
7. Condition of the patient on discharge or transfer;
8. Diagnosis on discharge;
9. Instructions given to the patient or his family; and
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 register.
(j) Emergency patients and their families are made aware of their rights, including a number to call regarding concerns or questions.
(6) Rehabilitation Services.
(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.
(b) The organization of the service must be appropriate to the scope of the services offered.
(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 law.
(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 record.
(7) Obstetrical Services.
(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 newborns.
(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 designated room.
(d) Designated 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.
(e) A delivery record shall be kept that must indicate:
1. The name of the patient;
2. Her maiden name;
3. Date of delivery;
4. Sex of infant;
5. Name of physician;
6. Names of persons assisting;
7. What complications, if any, occurred;
8. Type of anesthesia used;
9. Name of person administering anesthesia; and
10. Other persons present.
(8) Pediatric Services.
(a) If the hospital provides pediatric services, it shall provide appropriate pediatric equipment and supplies.
(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 practice.
(c) The hospital must have appropriate professional and non-professional personnel available to provide pediatric services.
(9) 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 offered.
(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.
(d) There 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 law.
(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.
(10) 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 counseling.
(11) Psychiatric Services.
(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 satisfied.
(12) Alcohol 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.

Notes

Tenn. Comp. R. & Regs. 1200-08-01-.07
Original rule filed March 18, 2000; effective May 30, 2000. Amendment filed April 17, 2000; effective July 1, 2000. Amendment filed June 12, 2003; effective August 26, 2003. Amendment filed July 27, 2005; effective October 10, 2005. Amendment filed February 23, 2006; effective May 9, 2006. Amendment filed February 23, 2007; effective May 9, 2007. Amendment filed February 22, 2010; effective May 23, 2010. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed July 10, 2018; effective 10/8/2018.

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-3-511, 68-11-202, 68-11-204, 68-11-209, 68-57-101, 68-57-102, 68-57-104, and 68-57-105.

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