Tenn. Comp. R. & Regs. 1200-08-24-.04 - ADMINISTRATION

(1) Birthing centers must have a governing body which is legally responsible for:
(a) The overall operation and maintenance of the facility;
(b) The provision of personnel, facilities, equipment, supplies, and services to mothers and families;
(c) Adopting administrative policies regarding patient care;
(d) Appointing an administrator or director responsible for implementing the adopted policies;
(e) Establishing and maintaining a written organizational plan;
(f) Appointing a clinical staff and assuring its competence; and
(g) Documenting all of the above.
(2) When licensure is applicable for a particular job, a copy 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. Adequate medical screenings to exclude communicable disease shall be required of each employee.
(3) 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 birthing center which violates a required policy also violates the rule and regulation establishing the requirement.
(4) Policies and procedures shall be consistent with professionally recognized standards of practice.
(5) The facility shall develop policies and procedures for testing a patient's blood for the presence of the hepatitis B virus and the HIV virus in the event that an employee of the facility, a student studying at the facility; or other health care provider rendering services at the facility is exposed to a patient's blood or other body fluid. The testing shall be performed at no charge to the patient, and the test results shall be confidential.
(6) The facility and its employees shall adopt and utilize standard precautions of the Centers for Disease Control (CDC) for preventing transmission of infections, HIV, and communicable diseases.
(7) All birthing centers shall adopt appropriate policies regarding the testing of patients and staff for human immunodeficiency virus (HIV) and any other identified causative agent of acquired immune deficiency syndrome.
(8) Each birthing center utilizing students shall establish policies and procedures for their supervision.
(9) Each birthing center shall establish policies for permitting visitors.
(10) No birthing center 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 birthing center 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.
(11) 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.

(12) "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.
(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.


Tenn. Comp. R. & Regs. 1200-08-24-.04
Original rule filed March 31, 1998; effective June 12, 1998. 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, 68-11-222, 68-11-268 and 71-6-121.

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