Tenn. Comp. R. & Regs. 1200-08-26-.04 - ADMINISTRATION

(1) The home health agency must organize, manage and administer its home health services to attain and maintain the highest practicable functional capacity for each patient regarding medical, nursing and rehabilitative needs as indicated by the plan of care.
(2) The home health agency shall ensure a framework for addressing issues related to care at the end of life.
(3) The home health agency shall provide a process that assesses pain in all patients. There shall be an appropriate and effective pain management program.
(4) The agency develops and maintains administrative control of any branch office.
(5) The organizational structure, home health services provided, administrative control and lines of authority for the delegation of responsibility down to the patient care level shall be clearly set forth in writing and shall be readily identifiable. Administrative and supervisory functions shall not be delegated to another agency. All home health services not provided directly by the licensed agency shall be monitored and controlled by that agency.
(6) A governing body (or designated persons so functioning) must: assume full legal authority and responsibility for the management and provision of all home health services; fiscal operations; quality assessment and performance improvement programs. The governing body shall appoint a qualified administrator who is responsible for the day-to-day operation of the organization and is responsible for designating people to carry out these functions.
(7) The administrator shall organize and direct the organization's ongoing functions; the professional personnel and the staff; employ qualified personnel and ensure adequate staff education and evaluation for all personnel involved in direct patient care; ensure the accuracy of public information materials and activities; and implement an effective budgeting and accounting system. A person with sufficient experience and training shall be authorized in writing to assume temporary duty during the administrator's short-term absence.
(8) An agency shall have a duly qualified administrator accessible during normal operating hours. Any change of administrators shall be reported to the Department within fifteen (15) days.
(9) An administrator shall serve no more than one (1) licensed home care organization unless that home care organization provides other categories of home care organization services under the same ownership and at the same location.
(10) The agency shall maintain an office with a working telephone and be staffed during normal business hours.
(11) When licensure is applicable for a particular position of employment, a copy of the current license or the number and renewal number of the employee's current license must be maintained in the employee's personnel file. Each personnel file shall contain accurate information as to the education, training, experience and personnel background of the employee. Proof of adequate medical screenings to exclude communicable disease shall be maintained in the file of each employee.
(12) Personnel practices shall be supported by written personnel policies. Personnel records shall include at a minimum: job descriptions, verification of references and credentials, and performance evaluations. Personnel records must be kept current.
(13) An ongoing educational program shall be planned and conducted for the development and improvement of skills of all the organization's personnel engaged in delivery of home health services. Each employee shall receive appropriate orientation to the organization, its policies, the employee's position, and the employee's duties. Records shall be maintained which indicate the subject of and attendance at such staff development programs.
(14) If personnel, under hourly or per visit contracts, are utilized by the agency, there shall be a written contract between such personnel and the organization clearly designating:
(a) That patients are accepted for care only by the agency;
(b) Which home health services are to be provided;
(c) That it is necessary to conform to all applicable organization policies including personnel qualifications;
(d) The responsibility for participating in developing plans of care;
(e) The manner in which home health services will be controlled, coordinated and evaluated by the agency;
(f) The procedures for submitting clinical and progress notes, scheduling visits and periodic patient evaluations; and
(g) The procedures for determining charges and reimbursement.
(15) Whenever the rules 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. An agency which violates a required policy also violates the rule establishing the requirement.
(16) Policies and procedures shall be consistent with professionally recognized standards of practice.
(17) All agencies 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.
(18) Each agency utilizing students shall establish policies and procedures for their supervision.
(19) No agency 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 or the Comptroller of the State Treasury. An agency 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.
(20) 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.

(21) "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.
(22) The facility shall develop a concise statement of its charity care policies and shall post such statement in a place accessible to the public.

Notes

Tenn. Comp. R. & Regs. 1200-08-26-.04
Original rule filed May 31, 2000; effective August 14, 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. Amendment filed March 27, 2015; effective 6/25/2015.

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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