(1) The Outpatient Diagnostic Center must
have an effective governing body legally responsible for the conduct of the
Outpatient Diagnostic Center. If an Outpatient Diagnostic Center does not have
an organized governing body, the persons legally responsible for the conduct of
the Outpatient Diagnostic Center must carry out the functions specified in this
(2) The governing body or
individual responsible shall appoint a chief executive officer or administrator
who is responsible for managing the Outpatient Diagnostic Center. The chief
executive officer or administrator shall designate an individual to act for him
or her in his or her absence, in order to provide the Outpatient Diagnostic
Center with administrative direction at all times.
(3) Where the physician-owner-operator serves
as the governing body, the articles of incorporation or other written
organizational plan shall describe the manner in which the owner-operator
executes the governing body responsibility.
(4) The governing body or individual
responsible, whether it be that of the center alone or that of a parent
organization, shall establish effective mechanisms to ensure the accountability
of the center's medical staff and other professional personnel.
(5) The governing body or individual
responsible shall assure that the Outpatient Diagnostic Center has the
financial resources to provide the services essential to the operation of the
(6) Staffing shall be
adequate to provide the services essential to the operation of the Outpatient
Outpatient Diagnostic Center shall assess and provide adequate comfort measures
(8) The Outpatient
Diagnostic Center shall perform only those diagnostic procedures which can be
safely and effectively carried out on an outpatient basis.
(9) Each Outpatient Diagnostic Center shall
have at all times a licensed physician who shall be responsible for the
direction and coordination of medical programs.
(10) Staff education programs and training
sessions shall include life safety, medical equipment, utility systems,
infection control and hazardous waste practices. At least two (2) on duty
members of the facility shall be trained in emergency resuscitation.
(11) 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.
(12) 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. An Outpatient Diagnostic Center which violates a required policy
also violates the rule and regulation establishing the requirement.
(13) Policies and procedures shall be
consistent with professionally recognized standards of practice.
(14) No Outpatient Diagnostic 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. An
Outpatient Diagnostic 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.
(15) When services such as dietary, laundry,
laboratory or therapy services are purchased from others, the governing body or
responsible individual shall be responsible to assure the supplier(s) meet the
same local and state standards the facility would have to meet if it were
providing those services itself using its own staff.
(16) The governing body or responsible
individual shall provide for the appointment, reappointment or dismissal of
members of the medical, dental, and other health professions and provide for
the granting of clinical privileges.
(17) The governing body or responsible
individual shall ensure that there is a written facility agreement with one or
more acute care general hospitals licensed by the state, which will admit any
patient referral who requires continuing care.
All health care facilities licensed
pursuant to T.C.A.68-11-201 shall post the following in the main public
(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;
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
(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.