Tenn. Comp. R. & Regs. 1200-08-29-.04 - ADMINISTRATION

(1) Governing Body. The licensee shall assume full legal authority and responsibility for the operation of the agency. The governing body shall appoint a qualified administrator, arrange for professional advice, adopt and periodically review written bylaws or an acceptable equivalent, and oversee the management and fiscal affairs of the agency. The name and address of each officer, director, and owner shall be disclosed. If the agency is a corporation, all ownership interests of five (5) percent or more (direct or indirect) shall also be disclosed.
(2) Administrator. The administrator shall organize and direct the agency's ongoing functions; maintain ongoing communication between and among the governing body, the professional personnel and the staff; employ qualified personnel, ensure adequate staff education and evaluation for all personnel involved in direct care of the patient; ensure the accuracy of public information materials and activities; and implement an effective 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. Any change of administrators shall be reported to the Department within fifteen (15) days.
(3) 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.
(4) Organization Structure. The agency's structure is such that responsibility and accountability for the program are clearly defined. An organizational chart (A) shows the relationship of the administrator to the governing body; (B) clearly identifies lines of supervision; and (C) accurately defines the chain of command for in-home personnel.
(5) Accreditation. Any home medical equipment provider accredited by the Joint Commission on Accreditation of Health Care Organizations, Community Health Accreditation Program or other approved accrediting bodies may submit documents evidencing current accreditation and shall be presumed to comply with the requirements of the Board. Licensing of a home medical equipment provider which has been accredited by the Joint Commission on Accreditation of Health Care Organizations, Community Health Accreditation Program or other approved accrediting bodies shall become effective upon written notification from the Board's staff that the accreditation meets the standards set out in the rules and regulations promulgated pursuant to T.C.A. §§ 68-11-201, et seq.
(6) Personnel. Employees shall be qualified for the positions they hold and meet the education, training, and experience requirements defined by the agency.
(a) All employees shall receive and participate in an orientation program prior to assuming patient care responsibilities. The agency's written orientation plan shall outline topics to be covered; attendance requirements; method to verify topics discussed; a description of the orientation process; and the orientation plan shall include, but is not limited to:
1. Review of the individual's job description and duties to be performed;
2. Organizational chart;
3. Supervision;
4. Recordkeeping and reporting;
5. Confidentiality;
6. Patient's rights and responsibilities;
7. Pertinent personnel policies; and
8. Skills validation, as applicable.
(b) The agency shall maintain a personnel file for each employee which contains the following information:
1. A completed application;
2. References;
3. Work experience;
4. Educational preparation;
5. Job description which lists the minimum education, training, and experience requirement; job responsibilities; and title of immediate supervisor;
6. Annual performance appraisal or individual evaluations on specific job descriptions which include demonstrated current competency and proof that performance appraisal results were shared with employee;
7. Prior training;
8. Proof of orientation; and
9. Evidence of current license, if applicable.
(c) Medical equipment delivery technicians who deliver and install respiratory equipment shall be determined to be competent by their employer prior to independently delivering and setting up the respiratory equipment in a patient's home. The home medical equipment supplier must maintain documentation to demonstrate that competency requirements are met. Standard competencies will include at a minimum the following:
1. Role responsibilities;
2. Cylinders;
3. Pressure regulators/Flow controllers;
4. Home liquid oxygen systems;
5. Oxygen concentrators;
6. Oxygen analyzers;
7. Humidifiers;
8. Low flow nasal cannula; and
9. Small volume medication nebulizers with air compressors.
(d) Medical equipment delivery technicians shall be determined by their employer to be competent in their understanding of which acts they may and may not perform.
(e) The Board may in its discretion, after consultation with the Tennessee Association for Home Care and the Tennessee Society for Respiratory Care, encourage the use of certain competency documents developed by these two organizations to ensure compliance with the provisions of (c) and (d).
(7) 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.

(8) "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.
(9) 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. 1200-08-29-.04
Original rule filed August 24, 2000; effective November 7, 2000. Amendment filed April 20, 2006; effective July 4, 2006. Amendment filed June 25, 2007; effective September 8, 2007. 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, 68-1-222, 68-11-226, 68-11-268, and 71-6-121.

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