Tenn. Comp. R. & Regs. 1200-08-27-.04 - ADMINISTRATION

(1) Governing Body. A hospice service program must have a governing body that assumes full legal responsibility for determining, implementing and monitoring policies governing the hospice program's total operation. The governing body must designate an individual who is responsible for the day to day management of the hospice program. The governing body must also ensure that all hospice services provided are consistent with accepted standards of practice.
(2) The hospice agency must organize, manage and administer its hospice services to attain and maintain the highest practicable functional capacity for each patient in a manner consistent with acceptable standards of practice.
(3) The hospice agency shall ensure a framework for addressing issues related to care at the end of life.
(4) The hospice agency 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) Professional Management. A hospice service program may contract for another individual or entity to furnish services, other than core services, to the hospice program's patients. If services are provided under agreement or contract, the hospice program must meet the following standards:
(a) Continuity of care. The hospice program assures the continuity of patient/family care.
(b) Written agreement. The hospice service program has a legally binding written agreement for the provision of hospice services. The agreement includes 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 hospice program.
3. The manner in which the contracted services are coordinated, supervised and evaluated by the hospice program.
4. The delineation of the role(s) of the hospice program and the contractor in the admission process, 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 hospice program 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 chapter, and in accordance with the patient's plan of care and the other requirements of this chapter.
(d) Financial responsibility. The hospice program retains responsibility for payment for services.
(8) The organizational structure, hospice 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 hospice services not provided directly by the licensed agency shall be monitored and controlled by that agency. Supervisory functions shall not be delegated to another home care organization. When a home care organization provides hospice services at more than one location, it must comply with the following:
(a) Each location must provide the same full range of services that is required of the hospice issued license (parent);
(b) Each location must be responsible to the same governing body and central administration that governs the hospice issued license (parent), and the governing body and central administration must be able to adequately manage each location;
(c) Clinical records must be maintained for all patients, regardless of where services are provided; and
(d) All hospice patients' clinical records requested by the surveyor must be available at the hospice site issued the license (parent).

If a home care organization providing hospice services at an additional location is unable to comply with these requirements, it is operating as a separate entity, and must be separately licensed.

(9) Hospice services may be provided in an area designated by a hospital for exclusive use by a home care organization certified as a hospice provider to provide care at the hospice inpatient or respite level of care in accordance with the hospice's Medicare certification. Admission to the hospital is not required in order for a patient to receive such hospice services, regardless of the patient's length of stay. The designation by a hospital of a portion of its facility for exclusive use by a home care organization to provide hospice services to its patients shall not:
(a) alter the license to bed complement of such hospital, or
(b) result in the establishment of a residential hospice.
(10) The administrator shall organize and direct the organization's ongoing functions; maintain ongoing liaison among the governing body, 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.
(11) 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.
(12) 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.
(13) The agency shall maintain an office with a working telephone and be staffed during normal business hours.
(14) When licensure is applicable for a particular job, a copy of the current license or the number and renewal number of the current license must be maintained in the 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.
(15) 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.
(16) 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 hospice 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.
(17) 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 hospice 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 hospice 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.
(18) 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.
(19) Policies and procedures shall be consistent with professionally recognized standards of practice.
(20) 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.
(21) Each agency utilizing students shall establish policies and procedures for their supervision.
(22) 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.
(23) 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.

(24) "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.
(25) 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. 1200-08-27-.04
Original filed April 25, 1996; effective July 9, 1996. Repeal and new rule filed April 17, 2000; effective July 1, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendment filed April 20, 2006; effective July 4, 2006. Amendment filed February 23, 2007; effective May 9, 2007. 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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