Tenn. Comp. R. & Regs. 1200-08-15-.04 - ADMINISTRATION

(1) The residential hospice shall have a full-time (working at least 32 hours per week) administrator. Any change of administrators shall be reported in writing to the department within fifteen (15) days. The administrator shall designate in writing an individual to act in his/her absence in order to provide the residential hospice with administrative direction at all times. The administrator shall assure the provision of appropriate fiscal resources and personnel required to meet the needs of the patients and/or residents.
(2) The residential hospice must organize, manage, and administer its hospice and HIV care services to attain and maintain the highest obtainable quality of life for each patient and resident in a manner consistent with acceptable standards of practice.
(3) The residential hospice shall ensure a framework for addressing issues related to care at the end of life.
(4) The residential hospice shall provide a process that assesses pain in all patients. There shall be an appropriate and effective pain management program.
(5) Nursing services, physician services, drugs and biologicals shall routinely be available on a 24-hour basis.
(6) All other hospice services shall be available on a 24-hour basis to the extent necessary to meet the needs of individuals for care that is reasonable and necessary for the palliation and management of terminal illness or conditions directly attributable to the terminal diagnosis.
(7) A residential hospice may contract for another individual or entity to furnish services, other than core services, to the residential hospice's patients or HIV residents. If services are provided under agreement or contract, the residential hospice must meet the following standards:
(a) Continuity of care. The residential hospice assures the continuity of resident and patient/family care.
(b) Written agreement. The residential hospice has a legally binding written agreement for the provision of contracted hospice services. The agreement must include at least the following:
1. Identification of the services to be provided.
2. A stipulation that services may be provided only with the express authorization of the residential hospice.
3. The manner in which the contracted services are coordinated, supervised, and evaluated by the residential hospice.
4. The delineation of the role(s) of the residential hospice and the contractor in the admission process, resident and patient/family assessment, and the interdisciplinary group care conferences.
5. Requirements for documenting that services are furnished in accordance with the agreement.
6. The qualifications of the personnel providing the services.
(c) Professional management responsibility. The residential hospice retains professional management responsibility for those contracted services and ensures that they are furnished in a safe and effective manner by persons meeting the qualifications of this part, and in accordance with the patient's and/or HIV resident's plan of care and the other requirements of this part.
(d) Financial responsibility. The residential hospice retains responsibility for payment for services.
(8) The facility shall make reasonable efforts to safeguard personal property and promptly investigate complaints of such loss. A record shall be prepared of all clothing, personal possessions, and money brought by the patient and/or HIV resident to the residential hospice at the time of admission. The record shall be filled out in duplicate. One copy of the record shall be given to the patient or resident or the patient's or resident's representative and the original shall be maintained in the residential hospice record. This record shall be updated as additional personal property is brought to the facility.
(9) If the facility keeps patient or resident funds, such funds shall be kept in an account separate from the facility's funds. Patient or resident funds shall not be used by the facility. The facility shall maintain and allow each patient or resident access to a written record of all financial arrangements and transactions involving the individual patient's or resident's funds. The facility shall provide each patient and resident or his/her representative with a written itemized statement at least quarterly of all financial transactions involving the patient's or resident's funds.
(10) Within thirty (30) days of a patient's or resident's death, the facility shall provide an accounting of the patient's or resident's funds held by the facility and an inventory of the patient's or resident's personal property held by the facility to the patient's or resident's executor, administrator or other person authorized by law to receive the decedent's property. The facility shall obtain a signed receipt from any person to whom the decedent's property is transferred.
(11) Upon the sale of the facility, the seller shall provide written verification that all the patient's or resident's funds and property have been transferred and shall obtain a signed receipt from the new owner. Upon receipt, the buyer shall provide, to the patients and resident's, an accounting of funds and property held on their behalf.
(12) When licensure is applicable for a particular job, verification of the current license must be included as a part of the personnel file. Each personnel file shall contain accurate information as to the education, training, experience and personnel background of the employee. Documentation that references were verified shall be on file. Adequate medical screenings to exclude communicable disease shall be required of each employee.
(13) 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 residential hospice which violates a required policy also violates the rule and regulation establishing the requirement.
(14) Policies and procedures shall be consistent with professionally recognized standards of practice.
(15) No residential hospice 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 Department of Human Services Adult Protective Services, the long term care ombudsman, the Comptroller of the State Treasury, or any government agency. A residential hospice 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.
(16) Each residential hospice shall adopt safety policies for the protection of patients and residents from accident and injury.
(17) A record pertaining to the payment agreement between the residential hospice and the patient or resident shall be accomplished prior to admission. A copy of the agreement record shall be given to the patient or resident and the original shall be maintained in the facility's records.
(18) 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.

(19) "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.
(20) The facility shall develop a concise statement of its charity care policies and shall post such statement in a place accessible to the public.


Tenn. Comp. R. & Regs. 1200-08-15-.04
Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendment filed April 20, 2006; effective July 4, 2006. Amendment filed July 18, 2007; effective October 1, 2007. Amendment filed February 22, 2010; effective May 23, 2010.

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

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