Tenn. Comp. R. & Regs. 1200-08-35-.04 - ADMINISTRATION

(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 chapter.
(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 facility.
(6) Staffing shall be adequate to provide the services essential to the operation of the Outpatient Diagnostic Center.
(7) The Outpatient Diagnostic Center shall assess and provide adequate comfort measures as needed.
(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.
(18) All health care facilities licensed pursuant to T.C.A.68-11-201 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.

(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 entrance.
(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.


Tenn. Comp. R. & Regs. 1200-08-35-.04
Original rule filed October 26, 2005; effective January 9, 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, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-216, 68-11-268 and 71-6-121.

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