Tenn. Comp. R. & Regs. 0720 — Health Facilities Commission

Chapter 0720-01 Repealed

Tenn. Comp. R. & Regs. 0720-01 Repealed

RULES

OF TENNESSEE HEALTH SERVICES AND DEVELOPMENT AGENCY

Authority: T.C.A §§4-5-202, 10-7-506, 68-11-105(2) (as amended, P.C. 120, Section 3), 68-11-106(d)(5) (as amended, P.C. 120, Section 4), and Section 5 of Public Chapter 780, Acts of 2002. Administrative History:

Original rule filed October 22, 1975; effective November 21, 1975. Repealed by Section 5 of Public Chapter 780, Acts of 2002. -- 1 of 1 --

Chapter 0720-02 Repealed

Tenn. Comp. R. & Regs. 0720-02 Repealed

RULES

OF TENNESSEE HEALTH SERVICES AND DEVELOPMENT AGENCY

Authority: T.C.A. §§ 4-5-202, 68-11-105(2) (as amended, P.C. 120, Acts of 1993, Section 3), and Section 5, of Public Chapter 780, Acts of 2002. Administrative History: Original rule filed October 22, 1975; effective November 21, 1975. Repealed by Section 5 of Public Chapter 780, Acts of 2002.

Chapter 0720-03 Repealed

Tenn. Comp. R. & Regs. 0720-03 Repealed

RULES

OF TENNESSEE HEALTH SERVICES AND DEVELOPMENT AGENCY

Authority: T.C.A. §§ 4-5-202; 68-11-12(a) (2), 68-11-102 (as amended, P. C. 120, Acts of 1993, Section 1); 68-11- 105(2), 68-11-105(2) (as amended, P.C. 120, Acts of 1993, Section 3); 68-11-106(a)(6) (as amended, P.C.. 119, Acts of 1993, Section 2); 68-11-106(b) (as amended, P.C.120, Acts of 1993, Section 4); 68-1-106(g) (as amended, P.C. 120, Acts of 1993, Section 4); 68-11-107; 68-11-107(d) (as amended, P.C.120, Acts of 1993, Section 5); 68-11- 108(a)(1)(ii) (as amended, P.C. 120, Acts of 1993, Section 6); 68-11-108(c) (as amended, P.C. 120, Acts of 1993,

Section 6); 68-11 -108(f); P.C. 120, Acts of 1993, Section 10; 68-11-121 (f)(5); P.C. 371, Acts of 1993. Section 1; and Section 5 of Public Chapter 780, Acts of 2002. Administrative History: Original rule filed October 22, 1975; effective November 21, 1975. Repealed by Section 5 of Public Chapter 780, Acts of 2002. -- 1 of 1 --

Chapter 0720-04 Repealed

Tenn. Comp. R. & Regs. 0720-04 Repealed

RULES

OF TENNESSEE HEALTH SERVICES AND DEVELOPMENT AGENCY

Authority: T.C.A. §§4-5-202, 68-11-105(2) (as amended,, P.C. 120, Acts of 1993, Section 3), 68-11-108(b) (as amended, P.C.120, Acts of 1993, Section 6), and Section 5 of Chapter 780, Public Acts of 2002. Administrative

History: Original rule filed October 22, 1975; effective November 21, 1975. Repealed by Section 5 of Chapter 780, Public Acts of 2002.

Chapter 0720-05 Repealed

Tenn. Comp. R. & Regs. 0720-05 Repealed

RULES

OF TENNESSEE HEALTH SERVICES AND DEVELOPMENT AGENCY

Authority: T.C.A. §§4-5-202; 68-11-l05(2) (as amended, P.C. 120, Acts of 1993, Section 3); 68-11-106(1) (as amended, P.C. 120, Section 4); 68-11-106(4)(7) (as amended, P.C.120, Acts of 1993, Section 4); 68-11-106(a)(6)

(as amended, P.C. 119, Acts of 1993, Section 2); 68-11-106(b)(1) (as amended, P.C. 120, Acts of 1993, Section 4): 68-11-106(d) (as amended, P.C. 120, Acts of 1993, Section 4); 68-11-106(d)(7) (as amended, P.C. 120, Acts of 1993, Section 4); 68-11-106(f) (as amended, P.C. 120, Section 4); P.C. 120, Acts of 1993, Section 10; P.C. 371, Acts of 1993, Section 10; Section 5 of Public Chapter 780, Acts of 2002. Administrative History: Original rule filed December 28, 1979; effective February 11, 1980. Repealed by Section 5 of Public Chapter 780, Acts of 2002.

Chapter 0720-06 Repealed

Tenn. Comp. R. & Regs. 0720-06 Repealed

RULES

OF TENNESSEE HEALTH SERVICES AND DEVELOPMENT AGENCY

Authority: T.C.A. §§4-5-202; 4-5-223; 4-5-310; 4-5-314; 68-11-105(2) (as amended, P.C. 120, Acts of 1993,

Section 3); 68-11-109 (as amended, P.C. 120 Acts of 1993, Section 7); and Section 5 of Public Chapter 780, Acts of 2002. Administrative History: Original rule filed December 1, 1982; effective January 3, 1983. Repealed by

Section 5 of Public Chapter 780, Acts of 2002. -- 1 of 1 --

Chapter 0720-07 Repealed

Tenn. Comp. R. & Regs. 0720-07 Repealed

RULES

OF TENNESSEE HEALTH SERVICES AND DEVELOPMENT AGENCY

Authority T.C.A. §§4-5-202; 68-11-105(2); Public Chapter 944, §4, Acts of 1992; and Section 5 of Public Chapter 780, Acts of 2002. Administrative History: Original rule filed October 30, l992; effective December 14, 1992.

Repealed by Section 5 of Public Chapter 780; Acts of 2002.

Chapter 0720-08 Conduct of Business

Tenn. Comp. R. & Regs. 0720-08-.01 COMMUNICATIONS

(1) All documents, information, and written communications which are required to be filed with the Tennessee Health Facilities Commission (hereinafter the “Commission”) must be received during normal business hours at the Commission’s business office located in Nashville, Tennessee, or electronically pursuant to the Commission’s instructions.

(2) The filing date of any document shall be the actual date of receipt in the Commission office or delivery electronically during normal business hours pursuant to the Commission’s instructions. In the event the last appropriate filing date falls on a Saturday, Sunday, or legal holiday, such filing must occur no later than the next regular business day.

(3) Such documents, information, and written communications shall not be sent by facsimile transmission. Any such documents, information, and written communications which are received by facsimile transmission will not be considered as having been “filed” with the Commission.

History

Authority: T.C.A §§ 4-5-202, 68-11-1605, and 68-11-1607.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Emergency rules filed September 28, 2021; effective through March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-08-.02 CONFLICT OF INTEREST

(1) Definitions (a) “Conflict of interest” means any matter before the Commission in which the member or employee of the Commission has a direct or indirect interest that is in conflict or gives the appearance of conflict with the discharge of the member’s or employee’s duties;

(b) “Direct interest” means a pecuniary interest in the persons involved in a matter before the Commission. This interest applies to the Commission member or employee, the Commission member’s or employee’s relatives or an individual with whom or business as to which the member or employee has a pecuniary interest. For the purposes of this

part, a relative is a spouse, parent, child, stepparent, stepchild, grandparent, grandchild, brother, sister, half-brother, half-sister, aunt, uncle, niece, or nephew by blood, marriage or adoption; and (c) “Indirect interest” means a personal interest in the persons involved in a matter before the Commission that is in conflict or gives the appearance of conflict with the discharge of the Commission member’s or employee’s duties;

(2) All Commission members shall annually review and sign a statement acknowledging the statute, rules and policies concerning conflicts of interest.

(3) Any member, upon determining that a matter scheduled for consideration by the Commission results in a conflict with a direct interest, shall immediately notify the executive director and shall be recused from any deliberation of the matter, from making any recommendation, from testifying concerning the matter, or from voting on the matter. The member shall join the public during the proceedings.

(a) Any member with an indirect interest shall publicly acknowledge such interest.

(b) All members shall make every reasonable effort to avoid even the appearance of a conflict of interest. If a member is uncertain whether the relationship justifies recusal, the member shall follow the determination by the legal counsel for the Commission.

(c) A determination by the Commission or any court that a member of the Commission with a direct interest failed to provide notice and be recused from deliberations of the matter, from making any recommendation, from testifying concerning the matter, or from voting on the matter, shall result in the member’s automatic termination from the Commission and the position shall be considered vacant. The member shall not be eligible for appointment to any agency, board or commission of the state for a period of two (2) years.

(d) The executive director, upon determining that a conflict exists for the executive director or any member of the staff, shall notify the chair of the Commission and take such action as the chair prescribes and pursuant to this part.

History

Authority: T.C.A §§ 68-11-1602, 68-11-1604, and 68-11-1605.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-08-.03 STAFF AND COMMISSION DETERMINATIONS

(1) Persons seeking information and/or guidance from the Commission or staff may receive such information and/or guidance by any of three methods: informal staff advice, staff determinations, or official Commission determinations.

(2) Staff Advice. Staff members may give advice or guidance orally or in writing when requested.

Such informal staff advice is merely the personal opinion of the staff member, and does not represent the positio n of the Commission or any member thereof. Such advice is not binding on the Commission, and creates no precedent.

(3) Staff Determinations. A staff determination may be issued in writing, and signed by the executive director or general counsel. While a staff determination represents the considered position of staff, it does not necessarily represent the position of the Commission. A staff determination is not required to be officially adopted by the Commission, and creates no binding precedent on the Commission.

(a) When an inquiry is received which does not specifically request an official Commission determination, the executive director will determine whether the inquiry should be handled as a staff determination or as a Commission determination.

(4) Commission Determinations. A Commission determination represents a formal opinion of the Commission. Commission determinations are initially analyzed and drafted by staff, and presented to the full Commission during a regularly scheduled Commission meeting. The Commission may then adopt, reject, or modify staff’s recommendation.

(a) Written requests for Commission determinations should be received by the last business day of the preceding month to be included on the Commission’s agenda for that month. In the discretion of the executive director, the first inclusion of the request for determination on the Commission’s agenda may be for the purpose of public notice; the request may then be placed on the agenda for the next succeeding Commission meeting for the Commission’s consideration and decision. The executive director may waive the provisions of this subsection, and place the request for determination before the Commission for consideration on the first inclusion on the agenda.

(b) If the issue upon which a request for determination is based has been addressed by the Commission in prior determinations, or if the issue is otherwise not appropriate for a request for determination, staff will notify the person making the request and the request will not be placed on the Commission's agenda.

History

Authority: T.C.A. §§ 4-5-202, 68-11-1605, 68-11-1606, and 68-11-1607.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-08-.04 ACCESS TO COMMISSION RECORDS

(1) Public Inspection. All public records of the Commission are available for inspection during normal business hours in accordance with reasonable office policies.

(2) Copies. Upon a request for records under Tennessee’s Public Records Act, Tenn. Code Ann. §§ 10-7-501 et seq., the Commission shall assess charges for the copying and labor based on the most current version of the Schedule of Reasonable Charges, issued by the Office of Open Records Counsel. Should any charge assessed under this rule total ten dollars ($10.00) or less, the Commission shall waive the charge and provide the requested documents without payment. The Executive Director, or his or her designee, may reduce any

part of the charges calculated under these rules upon a written determination that such a reduction would be in the best interests of the public.

(3) Audio Recordings of meetings of the Commission are available for review and duplication.

For each audio tape or disc to be duplicated, the person requesting the duplication shall pay a fee of fifteen dollars ($15.00).

History

Authority: T.C.A. §§ 4-5-201, et seq., 4-5-202, 8-4-604, 10-7-501, 10-7-506, 68-11-1605, and 68-11- 1606.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Amendment filed June 22, 2012; effective November 28, 2012. Amendments filed October 24, 2017; effective January 22, 2018. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-08-.05 CONDUCTING COMMISSION MEETINGS

(1) The Commission will hold regularly scheduled, public meetings to consider applications for certificates of need, and to conduct other business.

(2) Meetings of the Commission will be under the direction of the Chair, or in the Chair’s absence or at his/her request, the Vice-Chair or other designated member as determined by the Chair.

The meetings will be conducted in accordance with Robert’s Rules of Order, except where otherwise provided by rule or statute.

(3) All motions for the approval or disapproval of certificates of need and for Commission Determinations will be determined by roll call vote. Except where otherwise provided by rule or by statute, matters other than the approval or disapproval of a certificate of need and Commission Determinations may, at the discretion of the Chair or acting Chair, be determined by voice vote.

(a) Any Commission member present and voting on a matter which has been determined by a voice vote may request that a roll call vote be taken. In the event such a request is made, a roll call vote will be taken. No additional debate or discussion will be allowed on the matter, unless otherwise appropriate under applicable rules of parliamentary procedure.

(b) Conditions placed upon the granting of a certificate of need should be included in the motion for approval, or an amendment thereto, and determined in accordance with these rules.

History

Authority: T.C.A. §§ 4-5-202, 68-11-1604, 68-11-1605, 68-11-1607, and 68-11-1609.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-08-.06 REPEALED

History

Authority: T.C.A. §§ 4-5-202, 68-11-1602, 68-11-1605, and 68-11-1607 and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Emergency rules filed September 28, 2021; effective through March 27, 2022. Repeal filed December 27, 2021; effective March 27, 2022.

Chapter 0720-09 Definitions

Tenn. Comp. R. & Regs. 0720-09-.01 DEFINITIONS

The following terms shall have the following meanings.

(1) “Commission” means the Tennessee Health Facilities Commission.

(2) “Ambulatory surgical treatment center” is as defined in T.C.A. § 68-11-201.

(3) “Capital expenditure” in relation to a project, means any series of expenditures by or on behalf of an applicant which, under generally accepted accounting principles, is directed toward the accomplishment of the project.

(a) “Capital expenditure” includes the amount per construction bid or total amount of invoices for the single project.

(b) “Capital expenditure” includes the cost of all medical equipment, whether fixed or moveable, and is considered in calculating the amount of the examination fee. The cost for such fixed and moveable equipment includes, but is not necessarily limited to all costs, expenditures, charges, fees and assessments which are reasonably necessary to put the equipment into use for the purpose applied for. Such costs specifically include, but are not limited to, the following:

Maintenance agreements, covering the expected useful life of the equipment;
Federal, state and local taxes, and other government assessments; and 3. Installation charges, excluding capital expenditures for physical plant renovation or in-wall shielding.

If the acquisition is by lease, the cost is either the fair market value of the equipment or the total amount of lease payments for the initial term of the lease, whichever is greater.

(c) Lease, loan, or gift. In calculating the value of a lease, loan, or gift, the “cost” is the fair market value of the above-described expenditures. In the case of a lease, the cost is the fair market value of the lease or the total amount of the lease payments for the initial term of the lease, whichever is greater.

(4) “Certification period” means the period of time beginning on the date of issuance of a certificate of need and ending on the expiration date of a certificate of need, as established by statute, rule, or order of the Commission.

(5) “Change of location” means a change of the specific location of an existing institution, facility, or service.

(6) “Executive director” means the chief administrative officer of the Commission and the appointing authority, exercising general supervision over all persons employed by the Commission, as defined in T.C.A. § 68-11-1606.

(7) “Expiration date” is the date by which activity authorized by a certificate of need must be implemented. The expiration date may be established by statute, by rule, or by order of the Commission.

(8) “Home health service” is as defined in T.C.A. § 68-11-201.

(9) “Hospital” is as defined in T.C.A. § 68-11-201.

(10) “Intellectual disability institutional habilitation facility” means a facility which offers on a regular

basis health related services to individuals with intellectual disabilities who do not require the degree of care and treatment which a hospital or skilled nursing facility is designed to provide but, because of physical or mental condition require residential care and services (more than room and board) and involves health related care under the supervision of a physician. Such a facility also offers an intensive program of habilitative services, as licensed by the Department of Intellectual and Developmental Disabilities.

(11) “Long-term categories” includes nursing home services, regardless of the length of stay, and any other health service which is intended or reasonably expected to result in an average length of stay of 2l days or longer.

(12) “Neonatal intensive care unit” means a special care unit staffed and equipped to provide professional intensive treatment for the care of newborns with severe or complicated illnesses and/or high-risk newborn infants, staffed by a neonatolgist and specialized nurses and in which bassinets are used as licensed beds.

(13) “Not directly related to patient care” may include the following types of single, isolated expenditures:

(a) Telephone systems;

(b) Non-clinical data processing systems;

(d) Energy conservation devices;

(e) Parking facilities;

(f) Roof repairs;

(g) Medical office buildings;

(h) Warehouses; and (i) Cafeterias.

(14) “Nursing home” is as defined in T.C.A. § 68-11-201.

(15) “Outpatient diagnostic center” is as defined in T.C.A. § 68-11-201.

(16) “Person” where the context requires, may refer to any natural person, legal entity, facility, or institution, as defined in T.C.A. § 68-11-1602.

(17) “Residential hospice” is as defined in T.C.A. § 68-11-201.

(18) “Service area” means the county or counties, or portions thereof, representing a reasonable area in which a health care institution intends to provide services and in which the majority of its service recipients reside.

(19) “Substantive amendment” as used in T.C.A. § 68-11-1607 means any amendment which has the effect of increasing the number of beds, square footage, cost, or other elements which are reasonably considered in the discretion of the Commission to be integral components of the application. A reduction of the above referenced components may be considered a substantive amendment if the amendment and supporting documentation are not received by the staff and Commission in a timely manner, necessary to allow the Commission to make an informed decision. Nothing in this rule shall be interpreted as limiting the Commission’s

authority to approve or deny all or part of any given application.

History

Authority: T.C.A. §§ 4-5-201, et seq., 4-5-202, and 68-11-1605; 2016 Tenn. Pub. Acts Ch. 1043; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Amendments filed October 24, 2017; effective January 22, 2018. Emergency rules filed September 28, 2021; effective through March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-10 Certificate of Need Program - Scope and Procedures

Tenn. Comp. R. & Regs. 0720-10-.01 PRIVATE PROFESSIONAL PRACTICE EXEMPTION

(1) Seeking licensure of a place, building, or facility as a health care institution is inconsistent with an assertion that such place, building, or facility is being occupied “exclusively as the professional practice office” of a medical doctor, osteopath, or dentist. Therefore, any person who seeks licensure as a health care institution as set forth in T.C.A. § 68-11-1602 must secure a certificate of need.

(2) To establish or maintain a health care institution that does not require licensure, a certificate of need is required unless the place, building, or facility is occupied exclusively as the professional practice of a medical doctor, osteopathic doctor, or dentist. In determining whether the professional practice exemption is met, the Commission may consider all relevant factors, including but not limited to, form of facility ownership, types of service reimbursement sought and/or received, patient referral sources, advertising/marketing efforts, and whether the private practitioner retains complete responsibility for management and business control.

(3) The “private professional practice” exemption has no application in regard to initiation of services or other actions requiring a certificate of need. The applicability of the exemption, as defined above, is limited to the definition of a “health care institution.”

History

Authority: T.C.A. §§ 4-5-202, 68-11-1602, 68-11-1605, and 68-11-1607 and 2016 Tenn. Pub. Acts Ch. 1043.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-10-.02 filed October 24, 2017; effective January 22, 2018. Amendments filed October 24, 2017; effective January 22, 2018. Emergency rules filed September 28, 2021; effective through March 27, 2022.

Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-10-.03 EMERGENCY CERTIFICATE OF NEED

(1) Where an unforeseen event necessitates action of a type requiring a certificate of need and the public health, safety, or welfare would be unavoidably jeopardized by compliance with the standard procedures for application and granting of a certificate of need, the Commission may issue an emergency certificate of need.

(2) An emergency certificate of need may be issued upon request of the applicant when the Executive Director and officers of the Commission concur, after consultation with the appropriate licensing agency. Prior to an emergency certificate of need being granted, the applicant must publish notice of the application in a newspaper of general circulation and submit any written documentation requested by the Executive Director. Commission members must be notified by Commission staff of the request.

(3) A decision regarding whether to issue an emergency certificate of need will be considered at the next regularly scheduled Commission meeting unless the applicant’s request is necessitated by an event that has rendered its facility, equipment or service inoperable. In such case, the Commission’s Chair, Vice-Chair, and Executive Director may act immediately to consider the application for an emergency certificate of need.

(4) Said certificate is valid for a period not to exceed one hundred twenty (120) days: when the applicant has applied for a certificate of need under standard Commission procedures, an extension of the emergency certificate of need may be granted.

History

Authority: T.C.A. §§ 4-5-201, et seq., 4-5-202, and 68-11-1605; 2016 Tenn. Pub. Acts Ch. 1043; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Rule was previously numbered 0720-10-.04 but was renumbered 0720-10-.03 with the deletion of the original rule 0720-10-.02 filed October 24, 2017; effective January 22, 2018. Amendments filed October 24, 2017; effective January 22, 2018. Emergency rules filed September 28, 2021; effective through March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-10-.04 CONSENT CALENDAR

(1) Each meeting’s agenda will be available for both a consent calendar and a regular calendar.

(2) In order to be placed on the consent calendar, an application must not be opposed by any person with legal standing to oppose and the application must appear to be necessary to provide needed health care in the area to be served, provide health care that meets appropriate quality standards, and demonstrate that the effects attributed to competition or duplication would be positive for the consumers.

(3) If opposition is stated in writing prior to the application being formally considered by the Commission then the application must be taken off the consent calendar and placed on the next regular agenda, unless waived by the parties.

(a) For purposes of this rule, the “next regular agenda” means the next regular calendar to be considered at the same meeting.

(4) Applications on the Consent Calendar will be considered and voted upon by the Commission by a single roll-call vote for the entire Consent Calendar, unless a Commission member or the Executive Director requests otherwise for specific applications.

History

Authority: T.C.A. §§ 4-5-201, et seq., 4-5-202, 68-11-1605, 68-11-1606, and 68-11-1608; 2016 Tenn. Pub. Acts Ch. 1043; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Rule was previously numbered 0720-10-.05 but was renumbered 0720-10-.04 with the deletion of the original rule 0720-10-.02 filed October 24, 2017; effective January 22, 2018. Amendments filed October 24, 2017; effective January 22, 2018. Emergency rules filed September 28, 2021; effective through March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-10-.05 EXPIRATION, REVOCATION, AND MODIFICATION OF ISSUED CERTIFICATES

(1) Prolonged certification periods and extensions of expiration dates of certificates are disfavored. Any request for a prolonged certification period must be clearly set forth in the application in order to be considered. A request for an extension of the expiration date must be made in writing to the Commission and filed prior to the first day of the month in which the request is to be considered by the Commission, and will be processed in accordance with policies established by staff.

(2) Prolonged certification period. A prolonged certification period will be granted only where exceptional circumstances are shown to exist which make completion of the project within the time limits prescribed by statute unachievable using all reasonable means.

(3) Extension of expiration date may be granted due to unforeseen occurrences. All requests for extension of the expiration date must be filed at the Commission's office and be accompanied by a filing fee. The filing fee shall be an amount which bears the same ratio to the initial examination fee submitted with the application, as the requested extension of time bears to the original certification period.

(4) Extension of expiration date due to appeal. In the event of a proper and timely appeal of the Commission’s decision to grant a certificate of need, the certification period will be automatically extended, and the expiration date will be automatically stayed, during the pendency of the appeal.

(a) The time period of the extension/stay will be equal to the period of time beginning with the date the petition is received at the Commission’s office, and ending with the effective date of the decision of the appellate court of last resort, or the expiration of the time period available for seeking further appellate review (where such appellate review is not sought), whichever occurs first.

(b) At the conclusion of the appellate process, as described in subparagraph (4)(a) above, a revised certificate of need, reflecting the new expiration date, may be issued upon request of the certificate holder.

(5) The Commission will conduct an annual review of progress of each project for which a certificate of need has been granted. The certificate holder shall timely respond to staff requests for information in connection with such progress reviews, and otherwise cooperate with staff in such progress reviews. As part of this progress review, the certificate holder shall submit to the Commission a copy of any signed agreements with TennCare managed care organizations executed after the date the certificate of need was granted, or a status update on any pending negotiations with such entities, within six (6) months after issuance of the certificate of need, and again at twelve (12) months. The certificate holder must show that it is making substantial and timely progress in implementing the project. In the absence of such a showing, the Commission may initiate proceedings to revoke the certificate of need.

(6) Special corrections and revised certificates. Any issued certificate of need containing typographical errors or requiring similar clerical changes on its face, should be reported by the certificate holder and/or may be recalled by the Commission or staff. In the event of such non-substantive changes, or technical errors or omissions the Executive Director may issue a “revised” certificate in correct form. The certificate holder shall surrender the original certificate prior to its reissuance in corrected form.

(a) Examples of errors and omissions and other nonsubstantive changes which may be made through a revised certificate include:

A typographical error;
A change in the “doing business as” name of an institution or facility;
An extension of the expiration date due to a completed appeal; and 4. Other non-substantive changes as approved by the Executive Director;

(b) Except for changing the expiration date due to a completed appeal as provided above, a revised certificate pursuant to this subdivision shall not be construed as extending the expiration date.

(7) Modifications and/or addendums to issued certificates. In the event a certificate holder wishes to make substantive changes relating to the scope, cost, or duration of the project, written request must be made to, and formally approved by, the Commission in its discretion. If approved, such changes may be reflected in either the issuance of a modified certificate of need, or by the issuance of an addendum to the original certificate. If the request is denied, the Commission’s decision is final, and no appeal shall be allowed.

(a) Changes included within the provisions of this subdivision may include, but are not limited to, cost increases or decreases, downscaling or increasing the scope or square footage of a project, requests for an extension of the expiration date and changes of ownership where allowed by law and Commission rules. Generally, such changes resulting in either a thirty (30) percent increase or decrease shall be presumed substantive, though there will be instances where changes greater than thirty (30) percent would not be substantive and instances where changes less than thirty (30) percent would be substantive, depending upon the totality of the circumstances. In no event will any change in cost of less than $100,000 be deemed a substantive cost modification. In no event will any change which would independently require a certificate of need be considered for a modification or addendum. Multiple requests for modifications of a certificate of need, and such other modifications which in the discretion of the Commission would have significantly impacted public participation in the Commission's consideration of the original application, may be considered by the Commission as requiring a separate certificate of need.

Certain changes of ownership (“change of control”), prior to licensure constitute the transfer of a certificate of need, and will render the certificate null and void, as provided in T.C.A. § 68-11-1618.

In addition to the circumstances constituting a change of ownership (“change of control”) as specified in T.C.A. § 68-11-1618, the termination of interest of over 50% of the membership of a non-profit corporation constitutes a change of ownership/change of control. If the change is made from a non-profit, membership corporation to a non-profit, non-membership corporation, there is no change of control if the boards of directors of the corporations are interlocking to the extent that there is no actual change of control of the corporate powers of the corporation which will hold the certificate of need.

(b) Any certificate holder seeking a modification or addendum must make a formal request in writing to the Commission, in accordance with policies adopted by the Commission staff. Such written request must be accompanied by the appropriate supporting documentation justifying the requested modification. Simultaneously with the submission of such written request, the certificate holder shall also file written notice with all parties who sought simultaneous review, filed competing applications, or who opposed the original application. Where an extension of the expiration date is sought, the request must be accompanied by the fee referred to elsewhere in this rule.

(c) A change of site may not be approved through a modification or addendum; a separate certificate of need or exemption is required.

(8) Any certificate holder seeking the removal of a condition which was placed on the certificate of need may make an application in writing to the Commission, in accordance with policies adopted by the Commission staff. At the time it makes such written application with the Commission, the certificate holder shall also file written notice with all parties who sought simultaneous review, filed competing applications, or who opposed the original application, and shall publish notice thereof in a newspaper of general circulation. In order to show “good cause” for removing a condition, the certificate holder has the burden of showing that circumstances have significantly changed, which necessitate the removal of the condition.

Mere disagreement or dissatisfaction with the condition will normally not be considered to be good cause for removing the condition.

(a) Application to the Commission for the addition of a specialty to an issued certificate that is limited to either a single specialty or specific multiple specialties shall be made by the filing of a new certificate of need application form.

(b) Application to the Commission for the addition of therapeutic cardiac catheterization to an issued certificate that is limited to diagnostic cardiac catheterization shall be made by the filing of a new certificate of need application.

History

Authority: T.C.A. §§ 4-5-201, et seq., 4-5-202, 68-11-1605, 68-11-1606, 68-11-1607, 68-11-1609, 68-11- 1611, and 68-11-1620; 2016 Tenn. Pub. Acts Ch. 1043; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Rule was previously numbered 0720-10-.06 but was renumbered 0720-10-.05 with the deletion of the original rule

Tenn. Comp. R. & Regs. 0720-10-.06 EXEMPTION FROM CERTIFICATE OF NEED FOR RELOCATION OF HEALTH CARE

INSTITUTIONS OR SERVICES.

(1) The Executive Director may issue an exemption for the relocation of existing healthcare institutions and approved services when the Executive Director determines that:

(a) At least seventy-five percent (75%) of patients to be served are reasonably expected to reside in the same zip codes as the existing patient population; and (b) The relocation will not reduce access to consumers, particularly those in underserved communities; those who are uninsured or underinsured; women and racial and ethnic minorities; TennCare or medicaid recipients; and low income groups.

(2) The Executive Director will issue the exemption only upon receipt of a completed exemption application on forms provided by the Commission and proof of publication of notice of the application in a newspaper of general circulation in both the county of the existing facility or service and the county where the service or facility is to be relocated;

(a) Prior to deeming an application complete, the Executive Director shall ensure Commission staff’s independent review and verification of information submitted to the Commission in applications, presentations, or otherwise. The purpose of the independent review and verification is to ensure that the information is accurate, complete, comprehensive, timely, and relevant to the decision. The independent review and verification must be applied to, but not necessarily be limited to, applicantprovided information as to any critical information submitted or requested concerning an application; and staff examinations of data sources, data input, data processing, and data output, and verification of critical information;

(b) The application, supporting documentation and staff review must be posted on the Commission’s website no later than 21 days prior to issuing an exemption;

(3) Opposition to an exemption application must be filed with the Commission no later than 15 days after the application, supporting documentation and staff review have been posted; any opposition must be limited to the basis for review detailed in 0720-10-.06(1)(a) and (1)(b).

(4) The exemption determination shall be made at a time and place to be posted on the Commission’s website, no sooner than 21 days after the notice is posted.

(5) A relocation exemption granted by the Executive Director is subject to Commission review as provided by law.

History

Authority: T.C.A. § 68-11-1605 and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Emergency rules filed September 28, 2021; effective through March 27, 2022. New rules filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-10-.07 EXEMPTION FROM VOIDING A CERTIFICATE OF NEED AND ANY ACTIVITY

AUTHORIZED BY A CERTIFICATE OF NEED.

(1) The Commission may issue a temporary exemption to the voiding of a certificate of need and any activity authorized by the certificate of need upon finding that sufficient cause for the temporary cessation of the activity has been presented to the Commission along with a plan to resume the activity in the future;

(2) Any person seeking a temporary exemption must file an application for the exemption on forms provided by the Commission prior to the month of the Commission’s meeting where the request is to be considered;

(3) The application must include reasons for the temporary cessation of the activity, a detailed plan to resume the activity, and an estimated date for resumption of the activity;

(4) Opposition to an exemption request must be filed no later than 15 days prior to the meeting where the Commission is scheduled to consider the request, and must provide a detailed reason for the opposition with any supporting facts, law or documentation to be considered by the Commission;

(5) Any temporary exemption issued by the Commission must expire at a date certain;

(6) An additional temporary exemption may be requested prior to the expiration of a temporary exemption;

(7) There is no limit on the number of temporary exemptions that may be issued by the Commission upon finding that sufficient cause for the temporary cessation of the activity has been presented to the Commission along with a plan to resume the activity in the future.

History

Authority: T.C.A. § 68-11-1605 and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Emergency rules filed September 28, 2021; effective through March 27, 2022. New rules filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-10-.08 TRANSFER OF A CERTIFICATE OF NEED

(1) The Commission may approve the transfer of a certificate of need after the Commission determines that the new holder of the certificate of need would provide health care that meets appropriate quality standards, and that the transfer would not reduce access to consumers, particularly those in underserved communities; those who are uninsured or underinsured; women and racial and ethnic minorities; TennCare or medicaid recipients; and low income groups;

(2) The Commission will consider a written request with supporting evidence at the first Commission meeting occurring two (2) weeks after the Executive Director has deemed the submission complete. The Executive Director’s deeming the written submission complete shall not be considered to be a determination that the statutory requirements for approval have been satisfied. The Executive Director may make a recommendation for approval or denial of the request.

History

Authority: T.C.A. § 68-11-1605 and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Emergency rules filed September 28, 2021; effective through March 27, 2022. New rules filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-10-.09 STANDARD PROCEDURES FOR OPPOSITION TO CERTIFICATE OF NEED

APPLICATIONS.

Opposition to certificate of need applications may be made only pursuant to T.C.A. § 68-11-1609(g).

History

Authority: T.C.A. § 68-11-1605 and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: New rules filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-10-.10 STANDARD PROCEDURES FOR SUBMISSION OF VISUAL AIDS TO BE USED AT

COMMISSION MEETINGS.

Copies of all visual aids must be submitted to Commission staff no later than the Friday prior to the Commission’s meeting at which the visual aids will be used. Visual aids not submitted in compliance with this rule may not be used at the meeting.

History

Authority: T.C.A. § 68-11-1605.
Administrative History: New rules filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-11 Certificate of Need Program - General Criteria

Tenn. Comp. R. & Regs. 0720-11-.01 GENERAL CRITERIA FOR CERTIFICATE OF NEED

The Commission will consider the following general criteria in determining whether an application for a certificate of need should be granted:

(1) Need. The health care needed in the area to be served may be evaluated upon the following factors:

(a) The relationship of the proposal to any existing applicable plans;

(b) The population served by the proposal;

(d) The reasonableness of the service area;

(e) The special needs of the service area population, including the accessibility to consumers, particularly women, racial and ethnic minorities, TennCare participants, and low-income groups;

(f) Comparison of utilization/occupancy trends and services offered by other area providers;

(g) The extent to which Medicare, Medicaid, TennCare, medically indigent, charity care patients and low-income patients will be served by the project. In determining whether this criteria is met, the Commission shall consider how the applicant has assessed that providers of services which will operate in conjunction with the project will also meet these needs.

(2) Quality. Whether the proposal will provide health care that meets appropriate quality standards may be evaluated upon the following factors:

(a) Whether the applicant commits to maintaining staffing comparable to the staffing chart presented in its CON application;

(b) Whether the applicant will obtain and maintain all applicable state licenses in good standing;

(c) Whether the applicant will obtain and maintain TennCare and Medicare certification(s), if participation in such programs was indicated in the application;

(d) Whether an existing healthcare institution applying for a CON has maintained substantial compliance with applicable federal and state regulation for the three years prior to the CON application. In the event of non-compliance, the nature of noncompliance and corrective action shall be considered;

(e) Whether an existing health care institution applying for a CON has been decertified within the prior three years. This provision shall not apply if a new, unrelated owner applies for a CON related to a previously decertified facility;

(f) Whether the applicant will participate, within 2 years of implementation of the project, in self-assessment and external assessment against nationally available benchmark data to accurately assess its level of performance in relation to established standards and to implement ways to continuously improve.

This may include accreditation by any organization approved by Centers for Medicare and Medicaid Services (CMS) and other nationally recognized programs. The Joint Commission or its successor, for example, would be acceptable if applicable. Other acceptable accrediting organizations may include, but are not limited to, the following:

(i) Those having the same accrediting standards as the licensed hospital of which it will be a department, for a Freestanding Emergency Department;

(ii) Accreditation Association for Ambulatory Health Care, and where applicable, American Association for Accreditation of Ambulatory Surgical Facilities, for Ambulatory Surgical Treatment Center projects;

(iii) Commission on Accreditation of Rehabilitation Facilities (CARF), for Comprehensive Inpatient Rehabilitation Services and Inpatient Psychiatric projects;

(iv) American Society of Therapeutic Radiation and Oncology (ASTRO), the American College of Radiology (ACR), the American College of Radiation Oncology (ACRO), National Cancer Institute (NCI), or a similar accrediting

authority, for Megavoltage Radiation Therapy projects;

(v) American College of Radiology, for Positron Emission Tomography, Magnetic Resonance Imaging and Outpatient Diagnostic Center projects;

(vi) Community Health Accreditation Program, Inc., Accreditation Commission for Health Care, or another accrediting body with deeming authority for hospice services from CMS or state licensing survey, and/or other third party quality oversight organization, for Hospice projects;

(vii) Behavioral Health Care accreditation by the Joint Commission for Nonresidential Substitution Based Treatment Center, for Opiate Addiction projects;

(viii) American Society of Transplantation or Scientific Registry of Transplant Recipients, for Organ Transplant projects;

(ix) Joint Commission or another appropriate accrediting authority recognized by CMS, or other nationally recognized accrediting organization, for a Cardiac Catheterization project that is not required by law to be licensed by the Department of Health;

(x) Participation in the National Cardiovascular Data Registry, for any Cardiac Catheterization project;

(xi) Participation in the National Burn Repository, for Burn Unit projects;

(xii) Community Health Accreditation Program, Inc., Accreditation Commission for Health Care, and/or other accrediting body with deeming authority for home health services from CMS and participation in the Medicare Quality Initiatives, Outcome and Assessment Information Set, and Home Health Compare, or other nationally recognized accrediting organization, for Home Health projects;

(xiii) Participation in the National Palliative Care Registry, for Hospice projects; and (xiv) As an alternative to the provision of third party accreditation information, applicants may provide information on any other state, federal, or national quality improvement initiatives, for Nursing Home projects.

(g) For Ambulatory Surgical Treatment Center projects, whether the applicant has estimated the number of physicians by specialty expected to utilize the facility, developed criteria to be used by the facility in extending surgical and anesthesia privileges to medical personnel, and documented the availability of appropriate and qualified staff that will provide ancillary support services, whether on- or off-site.

(h) For Cardiac Catheterization projects:

Whether the applicant has documented a plan to monitor the quality of its cardiac catheterization program, including but not limited to, program outcomes and efficiencies;
Whether the applicant has agreed to cooperate with quality enhancement efforts sponsored or endorsed by the State of Tennessee; and 3. Whether the applicant will staff and maintain at least one cardiologist who has performed 75 cases annually averaged over the previous 5 years (for an adult program), and 50 cases annually averaged over the previous 5 years (for a pediatric program).

(i) For Open Heart projects:

Whether the applicant will staff with the number of cardiac surgeons who will perform the volume of cases consistent with the State Health Plan (annual average of the previous 2 years), and whether the applicant will maintain this volume in the future;
Whether the applicant will staff and maintain at least one surgeon with 5 years of experience; and 3. Whether the applicant will participate in a data reporting, quality improvement, outcome monitoring, and external assessment system that benchmarks outcomes based on national norms (demonstrated active participation in the STS National Database is expected and shall be considered evidence of meeting this standard);

(j) For Comprehensive Inpatient Rehabilitation Services projects, whether the applicant will have a board-certified physiatrist on staff (preferred);

(k) For Home Health projects, whether the applicant has documented its existing or proposed plan for quality data reporting, quality improvement, and an outcome and process monitoring system;

(l) For Hospice projects, whether the applicant has documented its existing or proposed plan for quality data reporting, quality improvement, and an outcome and process monitoring system;

(m) For Megavoltage Radiation Therapy projects, whether the applicant has demonstrated that it will meet the staffing and quality assurance requirements of the American Society of Therapeutic Radiation and Oncology (ASTRO), the American College of Radiology (ACR), the American College of Radiation Oncology (ACRO), National Cancer Institute (NCI), or a similar accrediting authority;

(n) For Neonatal Intensive Care Unit projects, whether the applicant has documented its existing or proposed plan for data reporting, quality improvement, and outcome and process monitoring systems; whether the applicant has documented the intention and ability to comply with the staffing guidelines and qualifications set forth by the Tennessee Perinatal Care System Guidelines for Regionalization, Hospital Care Levels, Staffing and Facilities; and whether the applicant will participate in the Tennessee Initiative for Perinatal Quality Care (TIPQC);

(o) For Nursing Home projects, whether the applicant has documented its existing or proposed plan for data reporting, quality improvement, and outcome and process monitoring systems, including in particular details on its Quality Assurance and Performance Improvement program;

(p) For Freestanding Emergency Department projects, whether the applicant has demonstrated that it will be accredited with the Joint Commission or other applicable accrediting agency, subject to the same accrediting standards as the licensed hospital with which it is associated;

(q) For Organ Transplant projects, whether the applicant has demonstrated that it will achieve and maintain institutional membership in the national Organ Procurement and Transportation Network (OPTN), currently operating as the United Network for Organ Sharing (UNOS), within one year of program initiation; additionally, the applicant shall comply with CMS regulations set forth by 42 CFR Parts 405, 482, and 498, Medicare Program; Hospital Conditions of Participation: Requirements for Approval and Re- Approval of Transplant Centers To Perform Organ Transplants; and (r) For Relocation and/or Replacement of Health Care Institution projects:

For hospital projects, Acute Care Bed Need Services measures are applicable; and 2. For all other healthcare institutions, applicable facility and/or service specific measures are applicable.

(s) The Commission will notify the applicant and any applicable licensing agency if any quality measure has not been met.

(t) Within one month of notification the applicant must submit a corrective action plan and must report on the progress of the plan within one year of that submission.

(3) The effects attributed to competition or duplication would be positive for the consumers.

Whether the effects attributed to competition or duplication would be positive for the consumers may be evaluated upon the following factors:

(a) Access to high quality, cost-effective healthcare services;

(b) The impact upon patient charges;

(c) Participation in TennCare, Medicare and other federal and state reimbursement programs; participation in other insurance plans; and charity care;

(d) Whether the applicant commits to maintaining an actual payor mix that is comparable to the payor mix projected in its CON application, particularly as it relates to Medicare, TennCare/Medicaid, Charity Care, and the Medically Indigent; and (e) The availability and accessibility of human resources required by the proposal, including those required by existing providers.

(4) Applications for Change of Site. When considering a certificate of need application which is limited to a request for a change of site, the Commission may consider, in addition to the foregoing factors, the following factors:

(a) Need. The applicant should show the proposed new site will serve the health care needs in the area to be served at least as well as the original site. The applicant should show that there is some significant legal, financial, or practical need to change to the proposed new site.

(b) Quality of Health Care to be provided. The applicant should show the quality of health care to be provided will be served at least as well as at the original site.

The applicant should address whether the effects attributed to competition or duplication would be positive for the consumers.

(5) Certificate of need conditions. In accordance with T.C.A. § 68-11-1609, the Commission, in its discretion, may place such conditions upon a certificate of need it deems appropriate and enforceable to meet the applicable criteria as defined in statute and in these rules.

History

Authority: T.C.A. §§ 4-5-201, et seq., 4-5-202, 68-11-1605, 68-11-1607, 68-11-1609, and 68-11-1633; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Emergency rule filed May 31, 2017; effective through November 27, 2017. The emergency rule expired November 28, 2017 and reverted to its previous status. Amendments filed October 24, 2017; effective January 22, 2018. Emergency rules filed September 28, 2021; effective through March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-12 Certificate of Need Program - Application, Disclosure of Information and Reporting Requirements

Tenn. Comp. R. & Regs. 0720-12-.01 STANDARD APPLICATION

(1) Application for a certificate of need shall be made on form(s) provided by the Commission.

The applicant must provide all information requested in the application forms. The information which may be required in the application form(s) includes, but is not necessarily limited to, the following:

(a) Facility identification, including legal interests and status, operator and owners;

(b) Detailed project description;

(d) Project operating costs and revenues, patient charges, and occupancy rate;

(e) Information on whether the proposed project will provide health care that meets appropriate quality standards;

(f) Information on the project’s relationship to public needs and the existing health service system; and (g) A copy of any signed agreement between the applicant and TennCare managed care organizations; if a signed agreement has not been executed prior to the Commission’s consideration of the application, the applicant shall provide a list of any such organizations with whom the applicant is negotiating, or a statement that the applicant does not intend to contract with any TennCare managed care organization(s).

(2) The accuracy of the information provided must be attested to by the responsible party or his agent in a notarized statement. Providing false, incorrect, misleading, or fraudulent information is grounds for revocation of the certificate of need.

History

Authority: T.C.A. §§ 4-5-201, et seq., 4-5-202, 68-11-1605, 68-11-1607, and 68-11-1619; 2016 Tenn. Pub. Acts Ch. 1043; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Amendments filed October 24, 2017; effective January 22, 2018. Emergency rules filed September 28, 2021; effective through March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-12-.02 REPORT OF BED INCREASES NOT REQUIRING A CERTIFICATE OF NEED

(1) Any rehabilitation facility, nursing home or hospital which is increasing the number of its licensed beds without the necessity of obtaining a certificate of need, as provided by law, shall report such activity on forms provided by the Commission.

(2) Any rehabilitation facility, nursing home or hospital reporting such increases must provide all information requested in the form(s). Information required to be provided by the forms may include, but not be limited to, the following:

(a) Facility identification;

(b) Date of most recent prior increase in number of licensed beds not requiring a certificate of need, number of beds increased, and type of beds;

(d) Number of beds being increased, by licensure category; and (e) Anticipated date of licensure/certification.

History

Authority: T.C.A. §§ 4-5-201, et seq., 4-5-202, 68-11-1605, and 68-11-1607; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Amendments filed October 24, 2017; effective January 22, 2018. Emergency rules filed September 28, 2021; effective through March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-12-.03 REGISTRATION OF EQUIPMENT

(1) Ownership of computerized axial tomographers, magnetic resonance imagers, linear accelerators, positron emission tomography, and any other piece of equipment specified by law, must be made on forms provided by the Commission within ninety (90) days of acquisition of the equipment.

(2) The person registering such equipment must provide all information requested in the form(s) provided by Commission staff. Information which may be required by the form(s) may include, but not be limited to, the following:

(a) Identification of the owner of such equipment;

(b) The location of the equipment, including facility identification;

(d) The date of delivery of the equipment; and (e) The expected useful life of the equipment.

(3) All such equipment shall be filed on an annual inventory survey developed by Commission staff. The survey shall include, but not be limited to, the identification of the equipment and utilization data according to source of payment. The survey shall be filed no later than thirty (30) days following the end of each state fiscal year. The Commission is authorized to impose a penalty not to exceed fifty dollars ($50) for each day the filing of the survey is late.

History

Authority: T.C.A. §§ 4-5-202, 68-11-1605, and 68-11-1607; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Rule was previously numbered 0720-12-.05 but was renumbered 0720-12-.04 with the deletion of original rule

Tenn. Comp. R. & Regs. 0720-12-.04 ANNUAL REPORTS CONCERNING MAGNETIC RESONANCE IMAGING SERVICES

Any person who provides magnetic resonance imaging services shall file an annual report each year with the Commission that details the mix of payors by percentage of cases for the prior calendar year for its patients, including private pay, private insurance, uncompensated care, charity care, Medicare, and Medicaid. Any person who provides magnetic resonance imaging services in a county with a population in excess of one hundred seventy-five thousand shall indicate whether magnetic resonance imaging services have been provided to a patient who is fourteen (14) years of age or younger on more than five (5) occasions during the prior calendar year if the service has been initiated without a certificate of need.

These reports shall be filed on forms provided by the Commission, and shall be due as provided by law.

History

Authority: T.C.A. §§ 4-5-201, et seq., 68-11-1605, and 68-11-1607; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: New rule filed October 24, 2017; effective January 22, 2018. Rule was previously numbered 0720-12-.05 but was renumbered 0720-12-.04 with the deletion of rule 0720-12-.03 filed September 28, 2021; effective through March 27, 2022. Emergency rules filed September 28, 2021; effective through March 27, 2022. Rule was previously numbered 0720-12-.05 but was renumbered 0720- 12-.04 with the deletion of rule 0720-12-.03 filed December 27, 2021; effective March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-12-.05 ANNUAL REPORT CONCERNING APPROPRIATE QUALITY MEASURES

For every certificate of need issued after July 1, 2016, reporting shall be made to the Health Facilities Commission each year on the anniversary date of implementation of the certificate of need, on forms prescribed by the Commission. Reporting shall include an assessment of each applicable quality standard and shall include results of any surveys or disciplinary actions by state licensing agencies, payors, or CMS, which are relevant to the health care institution or service authorized by the certificate of need. The existence and results of any remedial action, including any plan of correction, shall also be provided, unless the information is considered confidential under state or federal law. Reporting may be made for the entire health care institution, relevant department, service, equipment or beds, rather than segregating the portion authorized by the particular certificate of need; reporting for the portion authorized by the particular certificate of need is preferred if the data is easily segregated and doing so would not be unduly burdensome or costly to the provider.

History

Authority: T.C.A. §§ 4-5-201, et seq., 68-11-1605, 68-11-1609, and 68-11-1633; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed October 24, 2017; effective January 22, 2018. Rule was previously numbered 0720-12-.06 but was renumbered 0720-12-.05 with the deletion of rule

Tenn. Comp. R. & Regs. 0720-12-.06 REPORTS CONCERNING OUTPATIENT DIAGNOSTIC CENTERS

For every certificate of need for the establishment of an outpatient diagnostic center, reporting shall be made to the Health Facilities Commission within two (2) years after the date of receiving a certificate of need as to whether the outpatient diagnostic center has become accredited by the American College of Radiology in the modalities provided by that facility.

History

Authority: T.C.A. § 68-11-1605 and 2016 Tenn. Pub. Acts Ch. 1043.
Administrative History: Emergency rules filed September 28, 2021; effective through March 27, 2022. New rules filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-12-.07 REPORTS CONCERNING ACTIVITY IN ECONOMICALLY DISTRESSED COUNTIES

(1) Reporting shall be made to the Health Facilities Commission on forms provided by the Commission by any person who establishes a health care institution or initiates any service specified in T.C.A. § 68-11-1607(a)(3) pursuant to the exemption provided in T.C.A. § 68-11- 1607(q) within ninety (90) days of initiation of the exempted activity.

(2) Any person who provides positron emission tomography services or magnetic resonance imaging services pursuant to T.C.A. § 68-11-1607(q) must be accredited by The Joint Commission or the American College of Radiology in the modalities provided by that person and submit proof of the accreditation to the Commission within two (2) years of the initiation of service.

History

Authority: T.C.A. § 68-11-1605 and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Emergency rules filed September 28, 2021; effective through March 27, 2022. New rules filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-12-.08 REPORTS CONCERNING ACCREDITATION OF HOME HEALTH AGENCIES

OPERATING PURSUANT TO CERTIFICATE OF NEED EXEMPTIONS.

Reporting shall be made to the Health Facilities Commission within two (2) years of the licensure of the home health agency, on forms prescribed by the Commission, by each home health agency established pursuant to a certificate of need exemption in T.C.A. § 68-11-1607(r) or T.C.A. § 68-11-1607(s).

Reporting shall include whether the home health agency has been accredited, and if so, by which accrediting organization.

History

Authority: T.C.A. § 68-11-1605 and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Emergency rules filed September 28, 2021; effective through March 27, 2022. New rules filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-12-.09 REPORTS CONCERNING ACCREDITATION OF POSITRON EMISSION TOMOGRAPHY

PROVIDERS OPERATING PURSUANT TO CERTIFICATE OF NEED EXEMPTIONS.

A provider of positron emission tomography established without a certificate of need pursuant to T.C.A. § 68-11-1607(u) must become accredited by the American College of Radiology and provide to the Commission proof of the accreditation within two (2) years of the date of licensure.

History

Authority: T.C.A. § 68-11-1605 and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Emergency rules filed September 28, 2021; effective through March 27, 2022. New rules filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-13 Rules of Procedure for Hearing Contested Cases

Tenn. Comp. R. & Regs. 0720-13-.01 GENERAL PROCEDURES FOR CONTESTED CASES

(1) Except as otherwise provided herein, all contested cases before the Commission will be conducted in accordance with T.C.A. §§ 4-5-301 et seq., 68-11-1610, with these Rules, and with the Rules of the Secretary of State Chapter 1360-04-01.

(2) Eligibility to appeal. Any person with legal standing, and who meets the requirements of T.C.A. § 68-11-1610 may petition the Commission for a contested case hearing to appeal the grant or denial of a certificate of need.

(3) Filing of petitions. Petitions for contested case hearings must be filed with the Commission pursuant to Rule 0720-08-.01 of the Health Facilities Commission, and must be filed with the Commission within fifteen (15) days of the date of the Commission’s meeting at which the action which is the subject of the petition took place. Simultaneous with filing, the petitioner shall serve copies of the petition on all other parties in the matter. The petitioner shall have the burden of proving, by a preponderance of the evidence, that a certificate of need should be granted or should be denied.

(4) Intervention. Any person with legal standing and who meets the requirements of T.C.A. § 4-5- 310 may file a petition for intervention in a contested case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-223, 4-5-310, 4-5-314, 68-11-1605, and 68-11-1610.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Emergency rules filed September 28, 2021; effective through March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-13-.02 CONTESTED CASES BEFORE ADMINISTRATIVE JUDGES SITTING ALONE

(1) With the exception of declaratory orders referenced below, all petitions for a contested case hearing shall routinely be referred to the Administrative Procedures Division, Department of State for hearing by an Administrative Judge sitting alone on behalf of the Commission. The Commission retains the right, however, to hear any particular contested case on its own behalf.

(2) In all cases, whether heard by an Administrative Judge sitting alone, or by the full Commission, the petitioner and other parties with the exception of the Commission shall bear the cost for all court reporters and transcriptions, and charges billed to the Commission for the Administrative Judge’s work/time; in a contested case where the petition is dismissed, whether voluntarily or involuntarily, the petitioning party or parties shall be considered a “losing party” under T.C.A. § 68-11-1610. The original transcript and one copy of the transcript for each member of the Commission shall be provided to the Commission by the other parties, if the case is to be reviewed by the full Commission.

(3) Unless agreed otherwise by the parties, at the beginning of all contested case hearings, Commission counsel shall provide a summary of what the case is about, description of the project, and introduce into evidence the application, the reviewing agency’s report (for applications considered by the Commission prior to October 1, 2021) or staff report (for applications submitted on or after October 1, 2021), the staff summary, and the minutes of the Commission reflecting the action that was taken before the Commission. In no event shall this provision mean that the Commission is a neutral party in contested cases, or that its counsel represents the interests of any party other than the Commission.

(4) In all cases, whether heard by an Administrative Judge sitting alone, or by the full Commission, the party petitioning for such hearing shall present its case first, unless the parties agree otherwise.

History

Authority: T.C.A. §§ 4-5-202, 4-5-223, 4-5-310, 4-5-314, 68-11-1605, 68-11-1609, and 68-11-1610; 2016 Tenn. Pub. Acts Ch. 1043; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Emergency rule filed July 1, 2016; effective through December 28, 2016. The emergency rule expired on December 29, 2016 and reverted to its previous status. Amendments filed November 15, 2016; effective February 13, 2017. Emergency rules filed September 28, 2021; effective through March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-13-.04 DECLARATORY ORDERS

(1) Any affected person may petition the Commission for a declaratory order, as provided in T.C.A. § 4-5-223, as to the interpretation, validity, or applicability of a statute or rule within the primary jurisdiction of the Commission. Such petition shall be filed with the Commission in triplicate, and must specifically identify the statute or rule at issue, and the nature of the ruling sought.

(2) A petition for declaratory order is viewed as primarily involving questions of law and statutory or rule interpretation. The parties should strive to limit the amount of evidence presented, and to stipulate the facts to the extent possible.

(3) In the event the petition for declaratory order arises out of the Commission’s action on a specific project or issue, the petition for declaratory order shall be filed within thirty (30) days of the date of the Commission meeting at which the action at issue was taken.

(4) No person may file a petition for declaratory order as to any action or issue which is the subject of a pending or completed contested case proceeding involving the same person.

History

Authority: T.C.A. §§ 4-5-202, 4-5-223, 4-5-310, 4-5-314, 68-11-1605, and 68-11-1610.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-13-.03 COMMISSION REVIEW OF INITIAL ORDERS

(1) An Initial Order issued by an Administrative Judge, sitting alone, may be reviewed by the Commission pursuant to T.C.A §§ 4-5-301, et seq., these Rules, and the Rules of the Secretary of State Chapter 1360-04-01. Such review shall be limited to legal conclusions contained in the Initial Order. The Commission may, in its discretion, decline to exercise any review of an Initial Order issued by an Administrative Judge, in which event the Initial Order issued by an Administrative Judge shall become a Final Order as provided by the Administrative Procedures Act.

(2) In such a review proceeding, the Commission’s review is strictly limited to the record which was developed before the Administrative Judge. No additional evidence is to be received or considered by the Commission.

(3) Such a review proceeding is in the nature of appellate review. Each party will be given the opportunity to file a brief which should specify what action the party maintains the Commission should take on the Initial Order. The Commission may place reasonable page limitations on such briefs.

(4) In such a review proceeding, each party will normally be limited to oral argument of thirty (30) minutes in length, including rebuttal.

(5) At the conclusion of the review proceeding the Commission may decide that the Initial Order should be adopted in its entirety, or it may make such modifications to the Initial Order as it deems appropriate.

(a) Alternatively, the Commission may take the matter under advisement, and subsequently reconvene, after reasonable notice to the parties, to hold its public deliberations and to render a Final Order.

History

Authority: T.C.A. §§ 4-5-202, 4-5-223, 4-5-310, 4-5-314, 68-11-1605, and 68-11-1610; and 2021 Tenn. Pub. Acts Ch. 557.
Administrative History: Original rule filed August 31, 2005; effective November 14, 2005. Emergency rules filed September 28, 2021; effective through March 27, 2022. Amendments filed December 27, 2021; effective March 27, 2022. Administrative changes made pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-14 Standards for Hospitals (Transferred from 1200-08-01)

Tenn. Comp. R. & Regs. 0720-14-.01 DEFINITIONS

(1) Abuse. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) Acceptable Plan of Correction. The Licensing Division shall approve a hospital’s acceptable plan to correct deficiencies identified during an on-site survey conducted by the Survey Division or its designated representative. The plan of correction shall be a written document and shall provide, but not limited to, the following information:

(a) How the deficiency will be corrected.

(b) Who will be responsible for correcting the deficiency.

(d) How the facility will prevent the same deficiency from re-occurring.

(3) Adult. An individual who has capacity and is at least 18 years of age.

(4) Advance Directive. An individual instruction or a written statement relating to the subsequent provision of health care for the individual, including, but not limited to, a living will or a durable power of attorney for health care.

(5) Agent. An individual designated in an advance directive for health care to make a health care decision for the individual granting the power.

(6) Board. The Tennessee Board for Licensing Health Care Facilities.

(7) Capacity. An individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. These regulations do not affect the right of a patient to make health care decisions while having the capacity to do so. A patient shall be presumed to have capacity to make a health care decision, to give or revoke an advance directive, and to designate or disqualify a surrogate.

Any person who challenges the capacity of a patient shall have the burden of proving lack of capacity.

(8) Cardiopulmonary Resuscitation (CPR). The administering of any means or device to support cardiopulmonary functions in a patient, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilators or respirations, defibrillation, the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a patient where cardiac or respiratory arrest has occurred or is believed to be imminent.

(9) Certified Master Social Worker. A person currently certified as such by the Tennessee Board of Social Worker Certification and Licensure.

(10) Certified Nurse Practitioner. A person who is licensed as a registered nurse and has further been issued a certificate of fitness to prescribe and/or issue legend drugs by the Tennessee Board of Nursing.

(11) Certified Registered Nurse Anesthetist. A registered nurse currently licensed by the Tennessee Board of Nursing who is currently certified as such by the American Association of Nurse Anesthetists.

(12) Certified Respiratory Therapist. A person currently certified as such by the Tennessee Board of Medical Examiners’ Council on Respiratory Care.

(13) Certified Respiratory Therapy Technician. A person currently certified as such by the Tennessee Board of Medical Examiners’ Council on Respiratory Care.

(14) Clinical Laboratory Improvement Act (CLIA). The federal law requiring that clinical laboratories be approved by the U.S. Department of Health and Human Services, Health Care Financing Administration.

(15) Collaborative Practice. The implementation of the collaborative plan that outlines procedures for consultation and collaboration with other health care professionals, e.g., licensed physicians and mid-level practitioners.

(16) Collaborative Plan. The formal written plan between the mid-level practitioners and a licensed physician.

(17) Commissioner. The Commissioner of the Tennessee Department of Health or his or her authorized representative.

(18) Competent. A patient who has capacity.

(19) Critical Access Hospital. A hospital located in a rural area, designated by the Center for Medicare and Medicaid Services (CMS), which makes available twenty-four (24) hour emergency care; is a designated provider in a rural health network; provides not more than twenty-five (25) acute care inpatient beds for providing inpatient care not to exceed an annual average of ninety-six (96) hours, and has a quality assessment and performance improvement program and procedures for utilization review. If swing-bed approval has been granted, all twenty-five (25) beds can be used interchangeably for acute or Skilled Nursing Facility (SNF/swing-bed) level of care services.

(20) Dentist. A person currently licensed as such by the Tennessee Board of Dentistry.

(21) Department. The Tennessee Department of Health.

(22) Designated Physician. A physician designated by an individual or the individual’s agent, guardian, or surrogate, to have primary responsibility for the individual’s health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes such responsibility.

(23) Designation. An official finding and recognition by the Commission that an acute care hospital meets the requirements to be designated by CMS as a Critical Access Hospital, Rural Emergency Hospital, or a hospital deemed as a necessary provider prior to January 1, 2006.

(24) Dietitian. As used in the chapter, the term “dietitian” means:

(a) A person who is currently licensed by the Tennessee Board of Dietitian/Nutritionist Examiners as a dietitian/nutritionist; or (b) An employee of a Tennessee hospital who is exempt from Tennessee licensure pursuant to T.C.A. § 63-25-104(b)(6) but holds the credential of Registered Dietitian (RD) or Registered Dietitian Nutritionist (RDN) from the Commission on Dietetic Registration.

(25) Do-Not-Resuscitate Order (DNR). A written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(26) Dual Licensure Designation. A hospital may be designated as a dual licensed facility with the Commission and the Department of Mental Health and Substance Abuse Services. Such a designation will be indicated on the license. A dual licensed facility must meet all plans review requirements under Tenn. Comp. R. and Regs. 0720-43-.01, et seq.

(27) Electronic Signature. The authentication of a health record document or documentation in an electronic form achieved through electronic entry of an exclusively assigned, unique identification code entered by the author of the documentation.

(28) Emancipated Minor. Any minor who is or has been married or has by court order or otherwise been freed from the care, custody and control of the minor’s parents.

(29) Emergency Responder. A paid or volunteer firefighter, law enforcement officer, or other public safety official or volunteer acting within the scope of his or her proper function under law or rendering emergency care at the scene of an emergency.

(30) Graduate Registered Nurse Anesthetist. A registered nurse currently licensed in Tennessee who is a graduate of a nurse anesthesia educational program that is accredited by the American Association of Nurse Anesthetist’s Council on Accreditation of Nurse Anesthesia Educational Programs and awaiting initial certification examination results, provided that initial certification is accomplished within eighteen (18) months of completion of an accredited nurse anesthesia educational program.

(31) Guardian. A judicially appointed guardian or conservator having authority to make a health care decision for an individual.

(32) Hazardous Waste. Materials whose handling, use, storage, and disposal are governed by local, state or federal regulations.

(33) Health Care. Any care, treatment, service or procedure to maintain, diagnose, treat, or otherwise affect an individual’s physical or mental condition, and includes medical care as defined in T.C.A. § 32-11-103(5).

(34) Health Care Decision. Consent, refusal of consent or withdrawal of consent to health care.

(35) Health Care Decision-Maker. In the case of a patient who lacks capacity, the patient’s health care decision-maker is one of the following: the patient’s health care agent as specified in an advance directive, the patient’s court-appointed guardian or conservator with health care decision-making authority, the patient’s surrogate as determined pursuant to Rule 0720-14- .13 or T.C.A. § 33-3-220, the designated physician pursuant to these rules or in the case of a minor child, the person having custody or legal guardianship.

(36) Health Care Institution. A health care institution as defined in T.C.A. § 68-11-1602.

(37) Health Care Provider. A person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care in the ordinary course of business or practice of a profession.

(38) Hospital. Any institution, place, building or agency represented and held out to the general public as ready, willing and able to furnish care, accommodations, facilities and equipment for the use, in connection with services of a physician or dentist, to one (1) or more non-related persons who may be suffering from deformity, injury or disease or from any other condition for which nursing, medical or surgical services would be appropriate for care, diagnosis or treatment. All hospitals shall provide basic hospital functions and may provide optional services as delineated in these rules. A hospital shall be designated according to its classification and shall confine its services to those classifications described below.

(a) General Hospital. To be licensed as a general hospital, the institution shall maintain and operate organized facilities and services to accommodate one or more non-related persons for a period exceeding twenty-four (24) hours for the diagnosis, treatment or care of such persons and shall provide medical and surgical care of acute illness, injury or infirmity and obstetrical care. All diagnosis, treatment and care shall be administered by or performed under the direction of persons currently licensed to practice the healing arts in the State of Tennessee. In addition, a general hospital must specifically provide:

An organized staff of professional, technical and administrative personnel.
A laboratory with sufficient equipment and personnel necessary to perform biochemical, bacteriological, serological and parasitological tests.
X-ray facilities which shall include, as a minimum requirement, a complete diagnostic radiographic unit.
A separate surgical unit which shall include, as minimum requirements, one operating room, a sterilizing room, a scrub-up area and workroom.
Obstetrical facilities which shall include, as minimum requirements, one delivery room, a labor room, a newborn nursery, an isolation nursery, and patient rooms designated exclusively for obstetrical patients.
An emergency department in accordance with Rule 0720-14-.07(5) of these standards and regulations.

(b) Satellite Hospital. A satellite hospital may be licensed with a parent hospital upon approval by the Board for Licensing Health Care Facilities when they are on separate premises and are operated under the same management.

(c) Chronic Disease Hospital. To be licensed as a chronic disease hospital, the institution shall be devoted exclusively to the diagnosis, treatment or care of persons needing medical, surgical or rehabilitative care for chronic or long-term illness, injury, or infirmity. The diagnosis, treatment or care shall be administered by or performed under the direction of persons currently licensed to practice the healing arts in the State of Tennessee. A chronic disease hospital shall meet the requirements for a general hospital except that obstetrical facilities are not required and, if the hospital provides no surgical services, an emergency department is not required.

(d) Orthopedic Hospital. To be licensed as an orthopedic hospital, the institution shall be devoted primarily to the diagnosis and treatment of orthopedic conditions. An orthopedic hospital shall meet the requirements for a general hospital except that obstetrical services are not required and, if the hospital provides no surgical services, an emergency department is not required.

(e) Pediatric Hospital. To be licensed as a pediatric hospital, the institution shall be devoted primarily to the diagnosis and treatment of pediatric cases and have on staff professional personnel especially qualified in the diagnosis and treatment of the diseases of children. A pediatric hospital shall meet the requirements of a general hospital except that obstetrical facilities are not required and if the hospital provides no surgical services, an emergency department is not required.

(f) Eye, Ear, Nose, and Throat Hospital or any one of these. To be licensed as an eye, ear, nose and throat hospital, the institution shall be devoted primarily to the diagnosis and treatment of the diseases of the eye, ear, nose, and throat. The hospital shall have on staff professional personnel especially qualified in the diagnosis and treatment of diseases of the eye, ear, nose and throat. An eye, ear, nose and throat hospital shall meet the requirements for a general hospital except that obstetrical facilities are not required and, if the hospital provides no surgical services, an emergency department is not required.

(g) Rehabilitation Hospital. To be licensed as a rehabilitation hospital, the institution shall be devoted primarily to the diagnosis and treatment of persons requiring rehabilitative services. A rehabilitation hospital shall meet the requirement of a general hospital except that radiology services, a surgical unit, obstetrical facilities, and an emergency department are not required.

(h) Medical-Psychiatric Hospital. To be dually licensed as a medical-psychiatric hospital with Health Facilities Commission and Mental Health and Substance Abuse Services, the institution shall be primarily devoted to the diagnosis and treatment of persons requiring psychiatric services with the ability to treat the medical comorbidities of such person. A medical-psychiatric hospital shall meet the requirement of a general hospital except that radiology services, a surgical unit and maternity facilities are not required, and that the institution shall make the appropriate arrangements for such services as radiology and laboratory. A medical-psychiatric hospital may offer emergency services for psychiatric patients only.

(39) Hospitalization. The reception and care of any person for a continuous period longer than twenty-four (24) hours, for the purpose of giving advice, diagnosis, nursing service or treatment bearing on the physical health of such persons, and maternity care involving labor and delivery for any period of time.

(40) Incompetent. A patient who has been adjudicated incompetent by a court of competent jurisdiction and has not been restored to legal capacity.

(41) Individual Instruction. An individual’s direction concerning a health care decision for the individual.

(42) Infectious Waste. Solid or liquid wastes which contain pathogens with sufficient virulence and quantity such that exposure to the waste by a susceptible host could result in an infectious disease.

(43) Involuntary Transfer. The movement of a patient between hospitals, without the consent of the patient, the patient’s legal guardian, next of kin or representative.

(44) Justified Emergency. Includes, but is not limited to, the following events/occurrences:

(a) An influx of mass casualties;

(b) Localized and/or regional catastrophes such as storms, earthquakes, tornadoes, etc. or, (c) Epidemics or episodes of mass illness such as influenza, salmonella, etc.

(45) Licensed Clinical Social Worker. A person currently licensed as such by the Tennessee Board of Social Workers.

(46) Licensed Health Care Professional. Any health care professional currently licensed by the State of Tennessee to practice within the scope of a regulated profession, such as a nurse practitioner, dietitian, dentist, occupational therapist, pharmacist, physical therapist, physician, physician assistant, podiatrist, psychologist, clinical social worker, speech language pathologist, and emergency service personnel.

(47) Licensed Practical Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(48) Licensee. The person or entity to whom the license is issued. The licensee is held responsible for compliance with all rules and regulations.

(49) Life Threatening or Serious Injury. Injury requiring the patient to undergo significant additional diagnostic or treatment measures.

(50) Medical Emergency. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part, which includes labor when delivery is imminent, when there is inadequate time to effect safe transfer to another hospital prior to delivery, or when a transfer may pose a threat to the health and safety of the patient or the unborn child.

(51) Medical Record. Medical histories, records, reports, summaries, diagnoses, prognoses, records of treatment and medication ordered and given, entries, x-rays, radiology interpretations and other written electronics, or graphic data prepared, kept, made or maintained in a facility that pertains to confinement or services rendered to patients admitted or receiving care.

(52) Medical Staff. An organized body composed of individuals appointed by the hospital governing board that operates under bylaws approved by the governing body and is responsible for the quality of medical care provided to patients by the hospital. All members of the medical staff shall be licensed to practice in Tennessee, with the exception of interns and residents.

(53) Medically Inappropriate Treatment. Resuscitation efforts that cannot be expected either to restore cardiac or respiratory function to the patient or other medical or surgical treatments to achieve the expressed goals of the informed patient. In the case of the incompetent patient, the patient’s representative expresses the goals of the patient.

(54) Member of the Professional Medical Community. A professional employed by the hospital and on the premises at the time of a voluntary delivery.

(55) Mid-Level Practitioner. Either a certified nurse practitioner or a physician assistant.

(56) Misappropriation of Patient/Resident Property. The deliberate misplacement, exploitation or wrongful, temporary or permanent use of an individual’s belongings or money without the individual’s consent.

(57) Neglect. The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; however, the withholding of authorization for or provision of medical care to any terminally ill person who has executed an irrevocable living will in accordance with the Tennessee Right to Natural Death Law, or other applicable state law, if the provision of such medical care would conflict with the terms of the living will, shall not be deemed “neglect” for purposes of these rules.

(58) N.F.P.A. The National Fire Protection Association.

(59) Nuclear Medicine Technologist. A person currently registered as such by the National Association for Nuclear Medicine Technology.

(60) Nurse-Midwife. A person currently licensed by the Tennessee Board of Nursing as a registered nurse (R.N.) and qualified to deliver midwifery services or certified by the American College of Nurse-Midwives.

(61) Occupational Therapist. A person currently certified as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(62) Occupational Therapy Assistant. A person currently certified as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(63) Optometrist. A person currently licensed as such by the Tennessee Board of Optometry.

(64) Patient. Includes but is not limited to any person who is suffering from an acute or chronic illness or injury or who is crippled, convalescent or infirm, or who is in need of obstetrical, surgical, medical, nursing or supervisory care.

(65) Person. An individual, corporation, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency, or instrumentality, or any other legal or commercial entity.

(66) Personally Informing. A communication by any effective means from the patient directly to a health care provider.

(67) Pharmacist. A person currently licensed as such by the Tennessee Board of Pharmacy.

(68) Physical Therapist. A person currently certified as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(69) Physical Therapy Assistant. A person currently certified as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(70) Physician. An individual authorized to practice medicine or osteopathy under Tennessee Code Annotated, Title 63, Chapters 6 or 9.

(71) Physician Assistant. A person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(72) Physician Orders for Scope of Treatment or POST. Written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

(b) Apply regardless of the treatment setting and that are signed as required herein by the patient’s physician, physician assistant, nurse practitioner, or clinical nurse specialist; and (c) 1. Specify whether, in the event the patient suffers cardiac or respiratory arrest, cardiopulmonary resuscitation should or should not be attempted;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(73) Podiatrist. A person currently licensed as such by the Tennessee Board of Registration in Podiatry.

(74) Power of Attorney for Health Care. The designation of an agent to make health care decisions for the individual granting the power under T.C.A. Title 34, Chapter 6, Part 2.

(75) Psychologist. A person currently licensed as such by the Tennessee Board of Examiners in Psychology.

(76) Qualified Emergency Medical Service Personnel. Includes, but shall not be limited to, emergency medical technicians, paramedics, or other emergency services personnel, providers, or entities acting within the usual course of their professions, and other emergency responders.

(77) Radiological Technologist. A person currently registered as such by the American Society of Radiological Technologists.

(78) Reasonably Available. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the patient’s health care needs. Such availability shall include, but not be limited to, availability by telephone.

(79) Registered Health Information Administrator (RHIA). A person currently registered as such by the American Health Information Management Association.

(80) Registered Health Information Technician (RHIT). A person currently accredited as such by the American Health Information Management Association.

(81) Registered Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(82) Rural Area. A county classified by the federal Office of Management and Budget (OMB) as rural, all counties, excluding Davidson, Hamilton, Knox, and Shelby, currently defined as rural in Chapter 1200-20-11 of the Tennessee Comprehensive Rules and Regulations, or an area outside of a county or part of a county previously classified as rural by the OMB and reclassified by the OMB as a metropolitan statistical area as of June 6, 2003.

(83) Rural Emergency Hospital. A Rural Emergency Hospital (“REH”) is a facility that:

(a) Meets the eligibility requirements for a licensed hospital in Tennessee pursuant to Tenn. Comp. R. & Regs. 0720-14-.01(37), and the following additional requirements:

Is enrolled for reimbursement as a rural emergency hospital by the federal Centers for Medicare and Medicaid Services pursuant to 42 U.S.C. §§ 1395x(kkk) et. seq. and 42 U.S.C. § 1395cc(j), or any successor statute;
Provides rural emergency hospital services;
Provides an emergency department which maintains:

(i) Availability twenty-four (24) hours a day seven (7) days per week.

(ii) A physician, physician assistant, or nurse practitioner, who performs such services as such individual is legally authorized to perform in accordance with state law and who meets training, education, and experience requirements required by state law.

(iii) Such clinician must be on call at all times and available on-site within thirty (30) minutes to sixty (60) minutes depending on the facility’s location.

(iv) Staffed twenty-four (24) hours per day and (7) seven days per week by individuals competent in the skills needed to address emergency medical care and must be able to receive patients and activate appropriate medical resources to meet the care needed by patients.

Has a transfer agreement in effect with a level I or level II trauma center; and 5. Meets such other licensure, staff training and education requirements as the Health Facilities Commission finds necessary in the interest of the health and safety of individuals who are provided rural emergency hospital services.
A Rural Emergency Hospital does not have inpatient beds or provide any acute inpatient services, other than those which are rendered by a licensed skilled nursing facility to furnish post-hospital extended care services, which is a distinct

part unit of the Rural Emergency Hospital.

Nothing in this definition expands on the scope of a licensed healthcare professional’s ability to practice under their respective regulated profession.

(84) Rural Emergency Hospital Services. The term “rural emergency hospital services” means the following services, provided by a Rural Emergency Hospital, that do not exceed an annual per-patient average of twenty-four (24) hours in such Rural Emergency Hospital:

(a) Emergency department services, and observation care; and (b) At the election of the Rural Emergency Hospital, for services provided on an outpatient

basis, other medical and health services as specified in regulations adopted by the United States Secretary of Health and Human Services and authorized by the applicable rules or statutes of the Health Facilities Commission.

(85) Satellite Hospital. A freestanding hospital licensed with a parent hospital that is on separate premises and operated under the same management.

(86) Shall or Must. Compliance is mandatory.

(87) Social Worker. A person who has at least a bachelor’s degree in Social Work or related field, and preferably, two (2) years medical social work or other community based work experience.

(88) Stabilize. To provide such medical treatment of the emergency medical condition as may be necessary to assure, within reasonable medical probability, that the condition will not materially deteriorate due to the transfer as determined by a physician or other qualified medical personnel when a physician is not readily available.

(89) State. A state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States.

(90) Student. A person currently enrolled in a course of study that is approved by the appropriate licensing board.

(91) Supervising Health Care Provider. The designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual’s health care.

(92) Surgical Technologist. A person who works under supervision to facilitate the safe and effective conduct of invasive surgical procedures. This individual is usually employed by a hospital, medical office, or surgical center and supervised during the surgical procedure according to institutional policy and procedure to assist in providing a safe operating room environment that maximizes patient safety by performing certain tasks including, but not limited to:

(a) Preparation of the operating room and the sterile field for surgical procedures by preparing sterile supplies, instruments, and equipment using sterile technique;

(b) Preparation of the operating room for surgical procedures by ensuring that surgical equipment is functioning properly and safely; and (c) Passing instruments, equipment or supplies to a surgeon, sponging or suctioning an operative site, preparing and cutting suture material, holding retractors, transferring but not administering fluids or drugs, assisting in counting sponges, needles, supplies, and instruments, and performing other similar tasks as directed during a surgical procedure.

(93) Surrogate. An individual, other than a patient’s agent or guardian, authorized to make a health care decision for the patient.

(94) Transfer. The movement of a patient between hospitals at the direction of a physician or other qualified medical personnel when a physician is not readily available but does not include such movement of a patient who leaves the facility against medical advice. The term does not apply to the commitment and movement of mentally ill and mentally retarded persons and does not apply to the discharge or release of a patient no longer in medical need of hospital care or to a hospital’s refusal, after an appropriate medical screening, to render any medical care on the grounds that the person does not have a medical need for hospital care.

(95) Treating Health Care Provider. A health care provider who at the time is directly or indirectly involved in providing health care to the patient.

(96) Treating Physician. The physician selected by or assigned to the patient and who has the primary responsibility for the treatment and care of the patient. Where more than one physician shares such responsibility, any such person may be deemed to be the “treating physician.”

(97) Voluntary Delivery. The action of a mother in leaving an unharmed infant aged seventy-two (72) hours or younger on the premises of a hospital with any hospital employee or member of the professional medical community without expressing any intention to return for such infant, and failing to visit or seek contact with such infant for a period of thirty (30) days thereafter.

History

Authority: T.C.A. §§ 39-11-106, 68-11-202, 68-11-204, 68-11-207, 68-11-209, 68-11-210, 68-11-211, 68-11-213, 68-11-224, 68-11-255, 68-11-1802, 68-57-101, 68-57-102, and 68-57-105; 42 U.S.C. § 1395x(kkk); and 42 U.S.C. § 1395cc(j).
Administrative History: Original rule certified June 7, 1974. Amendment filed April 3, 1974; effective May 3, 1974. Amendment filed November 30, 1984; effective December 30, 1984. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Amendment filed April 26, 1996; effective July 8, 1996. Amendment filed November 30, 1999; effective February 6, 2000. Repeal, except for Paragraphs (1), (5), (8), (10), (11), (13), (16), (29), and (37) as promulgated February 6, 2000, and new rule filed March 18, 2000; effective May 30, 2000. Amendment filed April 17, 2000; effective July 1, 2000. Amendment filed September 17, 2002; effective December 1, 2002. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed April 28, 2003; effective July 12, 2003. Amendment filed August 27, 2004; effective November 10, 2004. Amendments filed September 6, 2005; effective November 20, 2005. Amendment filed February 23, 2006; effective May 9, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendment filed February 22, 2010; effective May 23, 2010. Amendments filed March 18, 2010; effective June 16, 2010. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendment filed April 25, 2016; effective July 24, 2016. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Emergency rules filed December 27, 2022; effective through June 25, 2023. Emergency rules expired effective June 26, 2023, and the rules reverted to their previous statuses. Amendments filed August 11, 2023; effective November 9, 2023. Amendments filed October 21, 2025; effective January 19, 2026.

Tenn. Comp. R. & Regs. 0720-14-.02 LICENSING PROCEDURES

Burn Unit, MRI Unit, NICU, or PET Unit without having a license. A license shall be issued only to the applicant named and only for the premises listed in the application for licensure.

Licenses are not transferable or assignable and shall expire and become invalid annually on the anniversary date of their original issuance. The license shall be conspicuously posted in the hospital.

(2) In order to make application for a license:

(a) The applicant shall submit an application on a form prepared by the Commission.

(b) Each applicant for a license shall pay an annual license fee based on the number of hospital beds. The fee must be submitted with the application and is not refundable.

(c) The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the Commission.

Patients shall not be admitted to the hospital until a license has been issued.

Applicants shall not hold themselves out to the public as being a hospital until the license has been issued. A license shall not be issued until the facility is in substantial compliance with these rules and regulations including submission of all information required by T.C.A. § 68-11-206(1), or as later amended, and of all information required by the Commission.

(d) The applicant must prove the ability to meet the financial needs of the facility.

(e) The applicant shall not use subterfuge or other evasive means to obtain a license, such as filing for a license through a second party when an individual has been denied a license or has had a license disciplined or has attempted to avoid inspection and review process.

(f) The applicant shall allow the hospital to be inspected by a Commission surveyor. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action to the Commission that must be accepted by the Commission. Once the deficiencies have been corrected, then the Commission shall consider the application for licensure.

(3) A proposed change of ownership, including a change in a controlling interest, must be reported to the Commission a minimum of thirty (30) days prior to the change. A new application and fee must be received by the Commission before the license may be issued.

(a) For the purposes of licensing, the licensee of a hospital has the ultimate responsibility for the operation of the facility, including the final authority to make or control operational decisions and legal responsibility for the business management. A change of ownership occurs whenever this ultimate legal authority for the responsibility of the hospital’s operation is transferred.

(b) A change of ownership occurs whenever there is a change in the legal structure by which the hospital is owned and operated.

Transfer of the facility’s legal title;
Lease of the facility’s operations;
Dissolution of any partnership that owns, or owns a controlling interest in, the facility;
One partnership is replaced by another through the removal, addition or substitution of a partner;
Removal of the general partner or general partners, if the facility is owned by a limited partnership;
Merger of a facility owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are cancelled;
The consolidation of a corporate facility owner with one or more corporations;
Transfers between levels of government; or, 9. Temporary management where ultimate authority and operational control is surrendered and transferred from the owner to a new manager.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors or board of trustees;
Two (2) or more corporations merge and the originally licensed corporation survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government;
Corporate stock transfers or sales, even when a controlling interest;
For a member-managed or manager-managed Limited Liability Company (LLC), an equity transfer or sale, even when a controlling interest; or, 7. Management agreements where the owner continues to retain ultimate authority for the operation of the facility.

(e) Sale/lease-back agreements shall not be treated as changes in ownership if the lease involves the facility’s entire real and personal property and if the identity of the leasee, who shall continue the operation, retains the exact same legal form as the former owner.

(4) Each hospital, except those operated by the U.S. Government or the State of Tennessee, making application for license under this chapter shall pay annually to the Commission a fee based on the number of hospital beds, as follows:

(a) Less than 25 beds $1,040.00 (b) 25 to 49 beds, inclusive $1,300.00 (c) 50 to 74 beds, inclusive $1,560.00 (d) 75 to 99 beds, inclusive $1,820.00 (e) 100 to 124 beds, inclusive $2,080.00 (f) 125 to 149 beds, inclusive $2,340.00 (g) 150 to 174 beds, inclusive $2,600.00 (h) 175 to 199 beds, inclusive $2,860.00 For hospitals of two hundred (200) beds or more the fee shall be two thousand eight hundred and sixty dollars ($2,860.00) plus two hundred dollars ($200.00) for each twenty-five (25) beds or fraction thereof in excess of one hundred ninety-nine (199) beds. The fee shall be submitted with the application or renewal and is not refundable.

(5) Each hospital choosing to operate one of the following optional services shall pay annually to the Commission a per unit non-refundable fee, as follows:

(a) Burn Unit $1,040.00 (b) NICU $1,040.00 (c) MRI Unit $500.00 (d) PET Unit $500.00 (6) Renewal.

(a) In order to renew a license, each hospital shall submit to periodic inspections by Commission surveyors for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action and shall remedy the deficiencies. In addition, each licensee shall submit a renewal form approved by the Commission and applicable renewal fee prior to the expiration date of the license.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late, provided that the late penalty shall not exceed twice the renewal fee.

(c) In the event that a licensee fails to renew its license within the sixty (60) day grace period following the license expiration date, then the licensee shall reapply for a license by submitting the following to the Commission:

A completed application for licensure;
The license fee provided in Rule 0720-14-.02(4); and 3. Any other information required by the Commission.

(d) Upon reapplication, the licensee shall submit to an inspection of the hospital by Commission surveyors.

History

Authority: T.C.A. §§ 4-5-201, 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11- 206(a)(5), 68-11-209, 68-11-210, and 68-11-216.
Administrative History: Original rule certified June 7, 1974. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Amendment filed January 16, 1992; effective March 2, 1992. Repeal and new rule filed March 18, 2000; effective May 30, 2000. Amendment filed December 2, 2003; effective February 15, 2004. Amendment filed January 19, 2007; effective April 4, 2007. Public necessity rules filed April 29, 2009; effective through October 11, 2009. Emergency rules filed October 9, 2009; effective through April 7, 2010. Amendments filed September 24, 2009; effective December 23, 2009. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed March 21, 2018; to have been effective June 19, 2018. However, on May 24, 2018, the Government Operations Committee filed a 5-day stay; new effective date June 24, 2018. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.03 DISCIPLINARY PROCEDURES

(1) The Commission may suspend or revoke a license for:

(a) Violation of federal or state statutes;

(b) Violation of the rules as set forth in this chapter;

(d) Conduct or practice found by the Commission to be detrimental to the health, safety, or welfare of the patients of the hospital; and (e) Failure to renew license.

(2) The Commission may consider all factors which it deems relevant, including but not limited to the following when determining sanctions:

(a) The degree of sanctions necessary to ensure immediate and continued compliance;

(b) The character and degree of impact of the violation on the health, safety and welfare of the patients in the facility;

(c) The conduct of the facility in taking all feasible steps or procedures necessary or appropriate to comply or correct the violation; and (d) Any prior violations by the facility of statutes, regulations or orders of the Commission.

(3) Inappropriate transfers are prohibited and violation of the transfer provisions shall be deemed sufficient grounds to suspend or revoke a hospital’s license.

(4) When a hospital is found by the Commission to have committed a violation of this chapter, the Commission will issue to the facility a statement of deficiencies. Within ten (10) calendar days of the receipt of the deficiencies, the hospital must return a plan of correction indicating the following:

(a) How the deficiency will be corrected;

(b) The date upon which each deficiency will be corrected;

(c) What measures or systemic changes will be put in place to ensure that the deficient practice does not recur; and (d) How the corrective action will be monitored to ensure that the deficient practice does not recur.

(5) Either failure to submit a plan of correction in a timely manner or a finding by the Commission that the plan of correction is unacceptable shall subject the hospital’s license to possible disciplinary action.

(6) Any licensee or applicant for a license, aggrieved by a decision or action of the Commission, pursuant to this chapter, may request a hearing before the Commission. The proceedings and judicial review of the Commission’s decision shall be in accordance with the Uniform Procedures Act, T.C.A. §§ 4-5-101, et seq.

(7) Reconsideration and Stays. The Commission authorizes the member who chaired the Commission for a contested case to be the Commission member to make the decisions authorized pursuant to Rule 1360-04-01-.18 regarding petitions for reconsideration and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-202, 68-11-204, 68-11- 206, 68-11-208, 68-11-209, and 68-11-216.
Administrative History: Original rule certified June 7, 1974. Amendment filed April 3, 1974; effective May 3, 1974. Amendment filed February 26, 1985; effective March 28, 1985. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Amendment filed December 30, 1986; effective February 13, 1987. Repeal and new rule filed March 18, 2000; effective May 30, 2000. Amendment filed March 1, 2007; effective May 15, 2007. Transferred from chapter 1200- 08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.04 ADMINISTRATION

(1) The hospital must have an effective governing body legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this

chapter.

(2) The governing body shall appoint a chief executive officer or administrator who is responsible for managing the hospital. 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 hospital with administrative direction at all times.

(3) When licensure is applicable for a particular job, the number and renewal number of the current license or a copy of the internet verification of such license must be maintained in personnel. 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.

(4) 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. A hospital which violates a required policy also violates the rule and regulation establishing the requirement.

(5) Policies and procedures shall be consistent with professionally recognized standards of practice.

(6) No hospital shall retaliate against or, in any manner, discriminate against any person because of a complaint made in good faith and without malice to the Commission, Adult Protective Services, or the Comptroller of the State Treasury. A hospital 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.

(7) The hospital shall ensure a framework for addressing issues related to care at the end of life.

(8) The hospital shall provide a process that assesses pain in all patients. There shall be an appropriate and effective pain management program.

(9) Critical Access Hospital.

(a) The facility shall enter into agreements with one or more hospitals participating in the Medicare/Medicaid programs to provide services which the Critical Access Hospital is unable to provide.

(b) When there are no inpatients, the facility is not required to be staffed by licensed medical professionals, but must maintain a receptionist or other staff person on duty to provide emergency communication access. The hospital shall provide an effective system to ensure that a physician or a mid-level practitioner with training and experience in emergency care is on call and immediately available by telephone or radio and available on-site within thirty (30) minutes, twenty-four (24) hours a day.

(10) 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.

(11) “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.

(12) 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.

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

(14) Informed Consent.

(a) Any hospital in which abortions, other than abortions necessary to prevent the death of the pregnant female, are performed shall conspicuously post a sign in a location defined below so as to be clearly visible to patients, which reads:

Notice: It is against the law for anyone, regardless of the person’s relationship to you, to coerce you into having or to force you to have an abortion. By law, we cannot perform an abortion on you unless we have your freely given and voluntary consent. It is against the law to perform an abortion on you against your will. You have the right to contact any local or state law enforcement agency to receive protection from any actual or threatened criminal offense to coerce an abortion.

(b) The sign shall be printed in languages appropriate for the majority of clients of the hospital with lettering that is legible and that is Arial font, at least 40-point bold-faced type.

(c) A hospital in which abortions are performed that is not a private physician’s office or ambulatory surgical treatment center shall post the required sign in the admissions or registration department used by patients on whom abortions are performed.

(d) A hospital shall be assessed a civil penalty by the Commission of two thousand five hundred dollars ($2,500.00) for each day of violation in which:

The sign required above was not posted during business hours when patients or prospective patients are present; and 2. An abortion other than an abortion necessary to prevent the death of the pregnant female was performed in the hospital.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-15-202, 39-17-1803, 39-17-1805, 68-11-201, 68-11-202, 68- 11-204, 68-11-206, 68-11-209, 68-11-216, 68-11-268, and 71-6-121.
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendment filed December 2, 2003; effective February 15, 2004. 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 December 23, 2009; effective March 23, 2010. Amendments filed February 22, 2010; effective May 23, 2010. Amendment filed December 16, 2013; effective March 16, 2014. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.05 ADMISSIONS, DISCHARGES, AND TRANSFERS

(1) Every person admitted for care or treatment as an inpatient to any hospital covered by these rules shall be under the supervision of a physician who holds an unlimited license to practice in Tennessee. The name of the patient’s attending physician shall be recorded in the patient’s medical record.

(2) The above does not preclude the admission of a patient to a hospital by licensed health care professional, licensed to practice in Tennessee with the concurrence of a credentialed MD/DO also licensed to practice in Tennessee if admission by a category of licensed health care professionals is provided for in the medical staff bylaws. The licensed health care professional may also provide on call services to patients in the hospital if on call services for a category of licensed health care professionals is so provided for in the medical staff bylaws.

The name of the attending licensed health care professional shall be recorded in the patient medical record as well as the name of the credentialed MD/DO. If a hospital allows these licensed health care professionals to admit and care for patients, as allowed by state law, the governing body and medical staff shall establish policies and bylaws, if necessary, to ensure that the requirements of 42 CFR part 482 are met.

(3) This does not preclude qualified oral and maxillo-facial surgeons from admitting patients and completing the admission history and physical examination and assessing the medical risk of the procedure on their patients. A physician member of the medical staff is responsible for the management of medical problems.

(4) A diagnosis must be entered in the admission records of the hospital for every person admitted for care or treatment.

(5) Except in emergency situations, no medication or treatment shall be given or administered to any inpatient in a hospital except on the order of a physician, dentist, or podiatrist lawfully authorized to give such an order. This requirement shall not apply to physical therapy, occupational therapy or speech language pathology services being provided in an outpatient setting when the services are being provided consistent with the scope of practice of physical therapists, occupational therapists and speech language pathologists as set forth in their respective practice acts found in Tennessee Code Annotated, Title 63, Chapters 13 and 17.

(6) The facility shall ensure that no person on the grounds of race, color, national origin, or handicap, will be excluded from participation in, be denied benefits of, or otherwise subjected to discrimination in the provision of any care or service of the facility. The facility shall protect the civil rights of residents under the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

(7) For purposes of this chapter, the requirements for signature or countersignature by a physician, dentist, podiatrist or other person responsible for signing, countersigning or authenticating an entry may be satisfied by the electronic entry by such person of a unique code assigned exclusively to him or her, or by entry of other unique electronic or mechanical symbols, provided that such person has adopted same as his or her signature in accordance with established hospital protocol or rules.

(8) The hospital must ensure continuity of care and provide an effective discharge planning process that applies to all patients. The hospital’s discharge planning process, including discharge policies and procedures, must be specified in writing and must:

(a) Be developed and/or supervised by a registered nurse, social worker or other appropriately qualified personnel;

(b) Begin upon admission of any patient who is likely to suffer adverse health consequences;

(d) Include the likelihood of a patient’s capacity for self-care or the possibility of the patient returning to his or her pre-hospitalization environment;

(e) Identify the patient’s continuing physical, emotional, housekeeping, transportation, social and other needs and must make arrangements to meet those needs;

(f) Be completed on a timely basis to allow for arrangement of post-hospital care and to avoid unnecessary delays in discharge;

(g) Involve the patient, the patient’s family or individual acting on the patient’s behalf, the attending physician, nursing and social work professionals and other appropriate staff, and must be documented in the patient’s medical record; and (h) Be conducted on an ongoing basis throughout the continuum of hospital care.

Coordination of services may involve promoting communication to facilitate family support, social work, nursing care, consultation, referral or other follow-up.

(9) A discharge plan is required on every patient, even if the discharge is to home.

(10) The hospital must arrange for the initial implementation of the patient’s discharge plan and must reassess the patient’s discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan.

(11) As needed, the patient and family members or interested persons must be taught and/or counseled to prepare them for post-hospital care.

(12) The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.

(13) The governing body of each hospital must adopt transfer and acceptance policies and procedures in accordance with these rules and the provisions of T.C.A. §§ 68-11-701 through 68-11-705. These policies must include a review of all such involuntary transfers, with special emphasis on those originating in the emergency room.

(14) Transfer agreements with other health care facilities are subject to these statutory and regulatory provisions.

(15) When a hospital proceeding in compliance with these rules seeks to appropriately transfer a patient to another hospital, the proposed receiving hospital may not decline the transfer for reasons related to the patient’s ability to pay or source of payment, rather than the patient’s need for medical services. The determination of the availability of space at the receiving hospital may not be based on the patient’s ability to pay or source of payment.

(16) Anyone arriving at a hospital and/or the emergency department of a hospital requesting or requiring an examination or treatment for a medical condition must be provided an appropriate medical screening examination within the capability of the hospital’s staff to determine whether or not a medical emergency exists.

(17) The hospital must provide further medical examination and treatment as may be required to stabilize the medical emergency within the hospital’s available staff and facilities. Such treatment may include, but is not limited to, the following:

(a) Establishing and assuring an adequate airway and adequate ventilation;

(b) Initiating control of hemorrhage;

(d) Establishing and maintaining adequate access routes for fluid administration;

(e) Initiating adequate fluid and/or blood replacement; and (f) Determining that the patient’s vital signs (including blood pressure, pulse, respiration, and urinary output, if indicated) are sufficient to sustain adequate perfusion.

(18) A hospital is deemed to meet the requirements of this section with respect to an individual if:

(a) The hospital offers to provide the further medical examination and treatment necessary but the individual, or legally responsible person acting on the individual’s behalf, refuses to consent to the examination or treatment; or (b) The hospital offers to transfer the individual to another hospital in accordance with this

section but the individual, or legally responsible person acting on the individual’s behalf, refuses to consent to the transfer.

(19) If a patient at a hospital has not been or cannot be stabilized within the meaning of this

section, the hospital may not transfer the patient unless:

(a) The patient, or legally responsible person acting on the patient’s behalf, requests that a transfer be implemented after having been given complete and accurate information about matters pertaining to the transfer decision including:

The medical necessity of the movement;
The availability of appropriate medical services at both the transferring and receiving hospitals;
The availability of indigent care at the hospital initiating the transfer and the facility’s legal obligations, if any, to provide medical services without regard to the patient’s ability to pay; and, 4. Any obligation of the hospital through its participation in medical assistance programs of the federal, state or local government to accept the medical assistance program’s reimbursement as payment in full for the needed medical care.

(b) A physician, or other appropriately qualified medical personnel when a physician is not available, makes a determination based upon the reasonable risk, expected benefits to the patient, and current available information that the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risk to the individual’s medical condition resulting from a transfer; and (c) The transfer is appropriate within the meaning of this section.

(20) An appropriate transfer includes:

(a) A physician at the receiving hospital agreeing to accept transfer of the patient and to provide appropriate medical treatment;

(b) The receiving hospital having space available and personnel qualified to treat the patient;

(c) The transferring hospital providing the receiving hospital with appropriate medical records, or copies thereof, of any examination and/or treatment initiated by the transferring hospital; and (d) The transfer being effected with qualified personnel, appropriate transportation equipment, and the use of necessary and medically appropriate life support measures as required.

(21) Transfers made pursuant to a regionalized plan for the delivery of health care services, approved by the Commission or other authorized governmental planning agency, are presumed to be appropriate.

(22) After an appropriate transfer has been effected, the receiving hospital may transfer the patient back to the original hospital, and the original hospital may accept the patient, if:

(a) The original receiving hospital has stabilized the medical emergency or provided treatment of the active labor and the patient no longer has a medical emergency; and (b) The transfer is made in accordance with (21) of this section.

(23) When a hospital determines the need to exceed its licensed bed capacity upon an occurrence of a justified emergency, one of the following procedures must be followed:

(a) Short term need to exceed licensed bed capacity for a justified emergency:

The hospital’s administrator must make written notification to the Commission within forty-eight (48) hours of exceeding its licensed bed capacity.
The notification must include a detailed description of the emergency including:

(i) Why the licensed bed capacity was exceeded, i.e., lack of hospital beds in vicinity, specialized resources only available at the facility, etc.;

(ii) The estimated length of time the licensed bed capacity is expected to be exceeded; and, (iii) The number of admissions in excess of the facility’s licensed bed capacity.

As soon as the hospital returns to its licensed bed capacity, the administrator must notify the Commission in writing of the effective date of its return to compliance.
Staff will review all notifications of excess bed capacity with the Chairman of the Commission. If, upon review of the notification, Commission staff concurs that a justified emergency existed, staff will notify the facility in writing. A report of the occurrence will be made to the Commission at the next regularly scheduled meeting as information purposes only.
However, if Commission staff does not concur that a justified emergency existed, the facility will be notified in writing that a representative is required to appear at the next regularly scheduled Commission meeting to justify the need for exceeding its licensed bed capacity.

(b) Request a waiver of bed capacity not to exceed three (3) months.

If a waiver is being requested, notification must be given at the next regularly scheduled Commission meeting and include all of the following:

(i) Provide the number of beds requested under the waiver;

(ii) Provide the reason for the increase in bed capacity to include a description of the illness causing the need;

(iii) Provide an attestation that the required staffing levels can be met;

(iv) Provide the average expected length of stay;

(v) Provide an attestation that staffing levels can be maintained if the expected length of stay is exceeded; and (vi) Provide a description of the location and area of the overflow.

Administrative staff will review the request and may:

(i) Administratively approve the waiver;

(ii) Administratively approve the waiver with conditions to protect the health, safety, and the welfare of the patients; or (iii) Deny the waiver and request appearance before the Commission at the next regularly scheduled commission meeting.

(24) Infant Abandonment.

(a) A facility shall receive possession of a newborn infant left on facility premises with a facility employee or member of the professional medical community, or in a newborn safety device, if the newborn infant:

Was born within the preceding forty-five-day period, as determined within a reasonable degree of medical certainty;
Is left in an unharmed condition; and 3. Is voluntarily left by a person who purports to be the newborn infant’s mother and who does not express an intention of returning for the newborn infant.

(b) The hospital, any hospital employee and any member of the professional medical community at such hospital shall inquire whenever possible about the medical history of the mother or newborn and whenever possible shall seek the identity of the mother, infant, or the father of the infant. The hospital shall also inform the mother that she is not required to respond, but that such information will facilitate the adoption of the child.

Any information obtained concerning the identity of the mother, infant or other parent shall be kept confidential and may only be disclosed to the Department of Children’s Services. The hospital may provide the parent contact information regarding relevant social service agencies, shall provide the mother the name, address and phone number of the department contact person, and shall encourage the mother to involve the Department of Children’s Services in the relinquishment of the infant. If practicable, the hospital shall also provide the mother with both orally delivered and written information concerning the requirements of these rules relating to recovery of the child and abandonment of the child.

(c) The hospital, any hospital employee and any member of the professional medical community at such hospital shall perform any act necessary to protect the physical health or safety of the child.

(d) As soon as reasonably possible, and no later than twenty-four (24) hours after receiving a newborn infant, the hospital shall contact the Department of Children’s Services, but shall not do so before the mother leaves the hospital premises. Upon receipt of notification, the department shall immediately assume care, custody and control of the infant.

(e) Notwithstanding any provision of law to the contrary, any hospital, any hospital employee and any member of the professional medical community shall be immune from any criminal or civil liability for damages as a result of any actions taken pursuant to the requirements of these rules, and no lawsuit shall be predicated thereon.

However, that nothing in these rules shall be construed to abrogate any existing standard of care for medical treatment or to preclude a cause of action based upon violation of such existing standard of care for medical treatment.

(25) Caregiver.

(a) The hospital shall give a patient admitted to the hospital the opportunity to designate a caregiver who will assist the patient with continuing care after discharge from the hospital.

Caregiver means any individual designated as a caregiver by a patient who provides after-care assistance to a patient in a private residence. The term includes, but is not limited to, a relative, spouse, partner, friend or neighbor who has a significant relationship with the patient.
The hospital shall document the designated caregiver in the patient record and include contact information; and 3. If the patient declines to designate a caregiver, the hospital shall document the patient’s choice in the medical record.

(b) The hospital shall notify the designated caregiver as soon as practicable before the patient is discharged back to a private residence.

(c) If the hospital is unable to contact the designated caregiver when changes occur, the lack of contact shall not interfere with, delay or otherwise affect the medical care provided to the patient or the transfer or discharge of the patient. Nothing in this paragraph shall interfere with, delay or otherwise affect the medical care provided to the patient or the transfer or discharge of the patient.

(d) The hospital shall make reasonable efforts to contact the designated caregiver and document those efforts in the patient record, to include dates and times attempted.

(e) The patient may give written consent to allow the hospital to release medical information to the designated caregiver, pursuant to the hospital’s established procedures for the release of personal health information.

(f) Prior to the patient being discharged, the hospital shall provide discharge instructions for continuing care needs to the patient and designated caregiver, which shall include:

The name and contact information of the designated caregiver and relation to the patient;
A description of continuing care tasks that the patient requires, communicated in a culturally competent manner; and 3. Contact information for any health care, community resources, and long-term services and supports necessary to successfully carry out the patient’s discharge instructions.

(g) Prior to the patient being discharged, the hospital shall provide the designated caregiver with an opportunity for instruction in continuing care tasks outlined in the discharge instructions, which shall include:

Demonstration of the continuing care tasks by hospital personnel; and 2. Opportunity for the patient and designated caregiver to ask questions and receive answers regarding the continuing care tasks; and 3. Education and counseling about medications, including dosing and proper use of delivery devices.

(h) The hospital shall document the instruction given to the patient and designated caregiver in the patient record, to include the date, time and contents of the instructions.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, and 68-11-255.
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Amendment filed April 17, 2000; effective July 1, 2000. Amendment filed September 17, 2002; effective December 1, 2002. Amendments filed July 10, 2018; effective October 8, 2018. Amendments filed January 7, 2019; to have become effective April 7, 2019. However, the Government Operations Committee filed a 60-day stay of pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.06 BASIC HOSPITAL FUNCTIONS

(1) Performance Improvement.

(a) The hospital must ensure that there is an effective, hospital-wide performance improvement program to evaluate and continually improve patient care and performance of the organization.

(b) The performance improvement program must be ongoing and have a written plan of implementation which assures that:

All organized services including services furnished by a contractor, are evaluated (all departments including engineering, housekeeping, and accounting need to show evidence of process improvement);
Nosocomial infections and medication therapy are evaluated;
All medical and surgical services performed in the hospital are evaluated as to the appropriateness of diagnosis and treatment;
The competency of all staff is evaluated at least annually; and 5. The facility shall develop and implement a system for measuring improvements in adherence to the hand hygiene program, central venous catheter insertion process, and influenza vaccination program.

(c) The hospital must have an ongoing plan, consistent with available community and hospital resources, to provide or make available social work, psychological, and educational services to meet the medically related needs of its patients which assures that:

Discharge planning is initiated in a timely manner; and 2. Patients, along with their necessary medical information, are transferred or referred to appropriate facilities, agencies or outpatient services, as needed, for follow-up or ancillary care.

(d) The hospital must develop and implement plans for improvement to address deficiencies identified by the performance improvement program and must document the outcome of the remedial action.

(e) The hospital must demonstrate that the appropriate governing board or board committee is regularly apprised of process improvement activities, including identified deficiencies and the outcomes of remedial action.

(2) Medical Staff.

(a) The hospital shall have an organized medical staff operating under bylaws adopted by the medical staff and approved by the governing body, to facilitate the medical staff’s responsibility in working toward improvement of the quality of patient care.

(b) The hospital and medical staff bylaws shall contain procedures, governing decisions or recommendations of appropriate authorities concerning the granting, revocation, suspension, and renewal of medical staff appointments, reappointments, and/or delineation of privileges. At a minimum, such procedures shall include the following elements: A procedure for appeal and hearing by the governing body or other designated committee if the applicant or medical staff feels the decision is unfair or wrong.

(c) The governing body shall be responsible for appointing medical staff and for delineating privileges. Criteria for appointment and delineation of privileges shall be clearly defined and included in the medical staff bylaws, and related to standards of patient care, patient welfare, the objectives of the institution or the character or competency of the individual practitioner. Independent patient admission privileges shall only be granted to currently licensed doctors of medicine, osteopathy, podiatry, or dentistry.

(d) The medical staff must adopt and enforce bylaws to effectively carry out its responsibilities and the bylaws must:

Be approved by the governing body;
Include a statement of the duties and privileges of each category of medical staff;
Describe the organization of the medical staff;
Describe the qualifications to be met by a candidate in order for the medical staff to recommend that the candidate be appointed by the governing body;
Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges; and 6. Include provisions for medical staff appointments granting active, associate, or courtesy medical staff membership, and/or provisions for the granting of clinical privileges. Such individuals must practice within the scope of their current Tennessee license, and the overall care of each patient must be under the supervision of a physician member of the medical staff.

(e) To be eligible for staff membership, an applicant must be a graduate of an approved program of medicine, dentistry, osteopathy, podiatry, optometry, psychology, or nursemidwifery, currently licensed in Tennessee, competent in his or her respective field, and worthy in character and in matters of professional ethics.

(f) The medical staff shall be composed of currently licensed doctors of medicine, osteopathy, dentistry, and podiatry and may include optometrists, psychologists, and nurse-midwives. The medical staff must:

Periodically conduct appraisals of its members;
Examine the credentials of candidates for medical staff membership and make recommendations to the hospital on the appointment of the candidates; and 3. Participate actively in the hospital’s process improvement plan implementation for the improvement of patient care delivery plans.

(g) The medical staff must be structured in a manner approved by the hospital or its governing body, well-organized, and accountable to the hospital for the quality of the medical care provided to the patient. Disciplinary action involving medical staff taken by the hospital shall be reported to the appropriate licensing board or professional society.

(h) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy.

(i) The responsibility for organization and conduct of the medical staff must be assigned only to an individual doctor of medicine or osteopathy, or a doctor of dental surgery or dental medicine.

(j) All physicians and non-employee medical personnel working in the hospital must adhere to the policies and procedures of the hospital. The Chief Executive officer or his or her designee shall provide for the adequate supervision and evaluation of the clinical activities of non-employee medical personnel which occur within the responsibility of the medical staff service.

(3) Infection Control.

(a) The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active performance improvement program for the prevention, control, and investigation of infections and communicable diseases.

(b) The chief executive officer or administrator shall assure that an infection control committee including members of the medical staff, nursing staff and administrative staff develop guidelines and techniques for the prevention, surveillance, control and reporting of hospital infections. Duties of the committee shall include the establishment of:

Written infection control policies;
Techniques and systems for identifying, reporting, investigating and controlling infections in the hospital;
Written procedures governing the use of aseptic techniques and procedures in all areas of the hospital, including adoption of a standardized central venous catheter insertion process which shall contain these key components:

(i) Hand hygiene (as defined in 0720-14-.06(3)(g));

(ii) Maximal barrier precautions to include the use of sterile gowns, gloves, mask and hat, and large drape on patient;

(iii) Chlorhexidine skin antisepsis;

(iv) Optimal site selection;

(v) Daily review of line necessity; and (vi) Development and utilization of a procedure checklist;

Written procedures concerning food handling, laundry practices, disposal of environmental and patient wastes, traffic control and visiting rules in high-risk areas, sources of air pollution, and routine culturing of autoclaves and sterilizers;
A log of incidents related to infectious and communicable diseases;
A method of control used in relation to the sterilization of supplies and water, and a written policy addressing reprocessing of sterile supplies;
Formal provisions to educate and orient all appropriate personnel in the practice of aseptic techniques such as handwashing and scrubbing practices, proper grooming, masking and dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of patient care equipment and supplies; and 8. Continuing education provided for all hospital personnel on the cause, effect, transmission, prevention, and elimination of infections, as evidenced by front line employees verbalizing understanding of basic techniques.

(c) The administrative staff shall ensure the hospital prepares, and has readily available on-site, an Infection Control Risk Assessment for any renovation or construction within existing hospitals. Components of the Infection Control Risk Assessment may include, but are not limited to, identification of the area to be renovated or constructed, patient risk groups that will potentially be affected, precautions to be implemented, utility services subject to outages, risk of water damage, containment measures, work hours for project, management of traffic flow, housekeeping, barriers, debris removal, plans for air sampling during or following project, anticipated noise or vibration generated during project.

(d) The chief executive officer, the medical staff and the chief nursing officer must ensure that the hospital wide performance improvement program and training programs address problems identified by the infection control committee and must be responsible for the implementation of successful corrective action plans in affected problem areas.

(e) The facility shall develop policies and procedures for testing a patient’s blood for the presence of the hepatitis B virus and the HIV (AIDS) virus in the event that an employee of the facility, a student studying at the facility, or other health care provider rendering services at the facility is exposed to a patient’s blood or other body fluid. The testing shall be performed at no charge to the patient, and the test results shall be confidential.

(f) A hospital shall have an annual influenza vaccination program which shall include at least:

The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The hospital will encourage all staff and independent practitioners to obtain an influenza vaccination;
A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at https://www.tn.gov/content/dam/tn/health/documents/SampleIndividualFluForm.p df);
Education of all employees about the following:

(i) Flu vaccination, (ii) Non-vaccine control measures, and (iii) The diagnosis, transmission, and potential impact of influenza;

An annual evaluation of the influenza vaccination program and reasons for nonparticipation; and 5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commission.

(g) All hospitals shall each year from October 1 through March 1 offer the immunization for influenza and pneumococcal diseases to any inpatient who is sixty-five (65) years of age or older prior to discharging. This condition is subject to the availability of the vaccine.

(h) The facility and its employees shall adopt and utilize standard precautions (per CDC) for preventing transmission of infections, HIV, and communicable diseases, including adherence to a hand hygiene program which shall include:

Use of alcohol-based hand rubs or use of non-antimicrobial or antimicrobial soap and water before and after each patient contact if hands are not visibly soiled;
Use of gloves during each patient contact with blood or where other potentially infectious materials, mucous membranes, and non-intact skin could occur and gloves changed before and after each patient contact;
Use of either a non-antimicrobial soap and water or an antimicrobial soap and water for visibly soiled hands; and 4. Health care worker education programs which may include:

(i) Types of patient care activities that can result in hand contamination;

(ii) Advantages and disadvantages of various methods used to clean hands;

(iii) Potential risks of health care workers’ colonization or infection caused by organisms acquired from patients; and (iv) Morbidity, mortality, and costs associated with health care associated infections.

(i) All hospitals 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.

(j) Each department of the hospital performing decontamination and sterilization activities must develop policies and procedures in accordance with the current editions of the CDC guidelines for “Prevention and Control of Nosocomial Diseases” and “Isolation in Hospitals.”

(k) The central sterile supply area(s) shall be supervised by an employee, qualified by education and/or experience with a basic knowledge of bacteriology and sterilization principles, who is responsible for developing and implementing written policies and procedures for the daily operation of the central sterile supply area, including:

Receiving, decontaminating, cleaning, preparing, and disinfecting or sterilizing reusable items;
Assembling, wrapping, removal of outer shipping cartons, storage, distribution, and quality control of sterile equipment and medical supplies;
Proper utilization of sterilization process monitors, including temperature and pressure recordings, and use and frequency of appropriate chemical indicator or bacteriological spore tests for all sterilizers; and 4. Provisions for maintenance of package integrity and designation of event-related shelf life for hospital-sterilized and commercially prepared supplies;
Procedures for recall and disposal or reprocessing of sterile supplies; and 6. Procedures for emergency collection and disposition of supplies and the timely notification of attending physicians, general medical staff, administration and the hospital’s risk management program when special warnings have been issued or when warranted by the hospital’s performance improvement process.

(l) Precautions shall be taken to prevent the contamination of sterile supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents. Sterile supplies may not be stored in their outermost shipping carton. This would include both hospital and commercially prepared supplies.

Decontamination and preparation areas shall be separated.

(m) Space and facilities for housekeeping equipment and supply storage shall be provided in each hospital service area. Storage for bulk supplies and equipment shall be located away from patient care areas. Storage shall not be allowed in the outermost shipping carton. The building shall be kept in good repair, clean, sanitary and safe at all times.

(n) The hospital shall appoint a housekeeping supervisor who is qualified for the position by education, training and experience. The housekeeping supervisor shall be responsible for:

Organizing and coordinating the hospital’s housekeeping service;
Acquiring and storing sufficient housekeeping supplies and equipment for hospital maintenance;
Assuring the clean and sanitary condition of the hospital to provide a safe and hygienic environment for patients and staff. Cleaning shall be accomplished in accordance with the infection control rules and regulations herein and hospital policy; and 4. Verifying regular continuing education and competency for basic housekeeping principles.

(o) Laundry facilities located in the hospital shall:

Be equipped with an area for receiving, processing, storing and distributing clean linen;
Be located in an area that does not require transportation for storage of soiled or contaminated linen through food preparation, storage or dining areas;
Provide space for storage of clean linen within nursing units and for bulk storage within clean areas of the hospital. Linen may not be stored in cardboard containers or other containers which offer housing for bugs; and, 4. Provide carts, bags or other acceptable containers appropriately marked to identify those used for soiled linen and those used for clean linen to prevent dual utilization of the equipment and cross contamination.

(p) The hospital shall appoint a laundry service supervisor who is qualified for the position by education, training and experience. The laundry service supervisor shall be responsible for:

Establishing a laundry service, either within the hospital or by contract, that provides the hospital with sufficient clean, sanitary linen at all times;
Knowing and enforcing infection control rules and regulations for the laundry service;
Assuring the collection, packaging, transportation and storage of soiled, contaminated, and clean linen is in accordance with all applicable infection control rules, regulations and procedures;
Assuring that a contract laundry service complies with all applicable infection control rules, regulations and procedures; and, 5. Conducting periodic inspections of any contract laundry facility.

(q) The physical environment of the facility shall be maintained in a safe, clean and sanitary manner.

Any condition on the hospital site conducive to the harboring or breeding of insects, rodents or other vermin shall be prohibited. Chemical substances of a poisonous nature used to control or eliminate vermin shall be properly identified.

Such substances shall not be stored with or near food or medications.

Cats, dogs or other animals shall not be allowed in any part of the hospital except for specially trained animals for the handicapped and except as addressed by facility policy for pet therapy programs. The facility shall designate in its policies and procedures those areas where animals will be excluded. The areas designated shall be determined based upon an assessment of the facility performed by medically trained personnel.
A bed complete with mattress and pillow shall be provided. In addition, patient units shall be provided with at least one chair, a bedside table, an over bed tray and adequate storage space for toilet articles, clothing and personal belongings.
Individual wash cloths, towels and bed linens must be provided for each patient.

Linen shall not be interchanged from patient to patient until it has been properly laundered.

Bath basin water service, emesis basin, bedpan and urinal shall be individually provided.
Water pitchers, glasses, thermometers, emesis basins, douche apparatus, enema apparatus, urinals, mouthwash cups, bedpans and similar items of equipment coming into intimate contact with patients shall be disinfected or sterilized after each use unless individual equipment for each is provided and then sterilized or disinfected between patients and as often as necessary to maintain them in a clean and sanitary condition. Single use, patient disposable items are acceptable but shall not be reused.

(4) Nursing Services.

(a) The hospital must have an organized nursing service that provides twenty-four (24) hour nursing services furnished or supervised by a registered nurse, and have a licensed practical nurse or registered nurse on duty at all times.

(b) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The chief nursing officer must be a licensed registered nurse who is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital.

(c) The nursing service must have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.

(d) There must be a procedure to ensure that hospital nursing personnel for whom licensure is required have valid and current licenses.

(e) A registered nurse must assess, supervise and evaluate the nursing care for each patient.

(f) The hospital must ensure that an appropriate individualized plan of care is available for each patient.

(g) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. All nursing personnel assigned to special care units shall have specialized training and a program in-service and continuing education commensurate with the duties and responsibilities of the individual. All training shall be documented for each individual so employed, along with documentation of annual competency skills.

(h) A registered nurse may make the actual determination and pronouncement of death under the following circumstances:

The deceased was a patient at a hospital as defined by T.C.A. § 68-11-201(31);
Death was anticipated, and the attending physician has agreed in writing to sign the death certificate. Such agreement by the attending physician must be present with the deceased at the place of death;
The nurse is licensed by the state; and 4. The nurse is employed by the hospital providing services to the deceased.

(i) Non-employee licensed nurses who are working in the hospital must adhere to the policies and procedures of the hospital. The chief nursing officer must provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing service. Annual competency and skill documentation must be demonstrated on these individuals just as employees, if they perform clinical activities.

(j) All drugs, devices and related materials must be administered by, or under the supervision of, nursing or other personnel in accordance with federal and state laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures.

(k) All orders for drugs, devices and related materials must be in writing and signed by the practitioner or practitioners responsible for the care of the patient. Electronic and computer-generated records and signature entries are acceptable. When telephone or oral orders must be used, they must be:

Accepted only by personnel that are authorized to do so by the medical staff policies and procedures, consistent with federal and state law; and 2. Signed or initialed by the prescribing practitioner according to hospital policy.

(l) Blood transfusions and intravenous medications must be administered in accordance with state law and approved medical staff policies and procedures.

(m) There must be a hospital procedure for reporting transfusion reactions, adverse drug reactions, and errors in administration of drugs.

(5) Medical Records.

(a) The hospital shall comply with the Tennessee Medical Records Act, T.C.A. §§ 68-11- 301, et seq. A hospital shall transfer copies of patient medical records in a timely manner to requesting practitioners and facilities.

(b) The hospital must have a medical record service that has administrative responsibility for medical records. The service shall be supervised by a Registered Health Information Administrator (RHIA), a Registered Health Information Technician (RHIT), or a person qualified by work experience. A medical record must be maintained for every individual evaluated or treated in the hospital.

(c) The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to ensure prompt completion, filing and retrieval of records.

(d) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurate, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

(e) All medical records, either written, electronic, graphic or otherwise acceptable form, must be retained in their original or legally reproduced form for a minimum period of at least ten (10) years, or for the period of minority plus one year for newborns, after which such records may be destroyed. Records destruction shall be accomplished by burning, shredding or other effective method in keeping with the confidential nature of its contents. The destruction of records must be made in the ordinary course of business, must be documented and in accordance with the hospital’s policies and procedures, and no record may be destroyed on an individual basis.

(f) When a hospital closes with no plans of reopening, an authorized representative of the hospital may request final storage or disposition of the hospital’s medical records by the Tennessee Department of Health. Upon transfer to the Tennessee Department of Health, the hospital relinquishes all control over final storage of the records in the files of the Tennessee Department of Finance and Administration and the files shall become property of the State of Tennessee.

(g) The hospital must have a system of coding and indexing medical records. The system must allow for timely retrieval by diagnosis and procedure.

(h) The hospital must have a procedure for ensuring the confidentiality of patient records.

Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with federal and state laws, court orders or subpoenas.

(i) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services.

(j) All entries must be legible, complete, dated and authenticated according to hospital policy.

(k) All records must document the following:

Evidence of a physical examination, including a health history, performed and/or updated no more than forty-five (45) days prior to admission or within forty-eight (48) hours following admission;
Admitting diagnosis;
Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient;
Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia;
Properly executed informed consent forms for procedures and treatments specified by hospital policy, or by federal or state law if applicable, as requiring written patient consent;
All practitioners’ orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition;
Discharge summary with outcome of hospitalization, disposition of case and plan for follow-up care; and 8. Final diagnosis with completion of medical records within thirty (30) days following discharge.

(l) Electronic and computer-generated records and signature entries are acceptable.

(6) Pharmaceutical Services.

(a) The hospital must have pharmaceutical services that meet the needs of the patients and are in accordance with the Tennessee Board of Pharmacy statutes and regulations. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.

(b) A full-time, part-time or consulting pharmacist must be responsible for developing, supervising and coordinating all the activities of the pharmacy services.

(d) Adverse drug events, both adverse reactions and medication errors, shall be reported according to established guidelines to the hospital performance improvement/risk management program and as appropriate to physicians, the hospital governing body and regulatory agencies.

(e) Abuses and losses of controlled substances must be reported, in accordance with federal and state laws, to the individual responsible for the pharmaceutical service, and to the chief executive officer, as appropriate.

(f) Current reference materials relating to drug interactions and information of drug therapy, side effects, toxicology, dosage, indications for use, and routes of administration must be available to the professional staff in the pharmacy and in areas where medication is administered.

(g) Any unused portions of prescriptions shall be either turned over to the patient only on a written authorization including directions by the physician, or returned to the pharmacy for proper disposition by the pharmacist.

(h) Whenever patients bring drugs into an institution, such drugs shall not be administered unless they can be identified and ordered to be given by a physician.

(7) Radiologic Services.

(a) The hospital must maintain, or have available, diagnostic radiologic services according to the needs of the patients. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.

(b) The radiologic services must be free from hazards for patients and personnel.

(c) Patients, employees and the general public shall be provided protection from radiation in accordance with “State Regulations for Protection Against Radiation.” All radiation producing equipment shall be registered and all radioactive material shall be licensed by the Division of Radiological Health of the Tennessee Department of Environment and Conservation.

(d) Periodic inspections of equipment must be made and hazards identified must be promptly corrected.

(e) Radiologic services must be provided only on the order of practitioners with clinical privileges or of other practitioners authorized by the medical staff and the governing body to order the services.

(f) X-ray personnel shall be qualified by education, training and experience for the type of service rendered.

(g) All x-ray equipment must be registered with the Tennessee Department of Environment and Conservation, Division of Radiological Health.

(h) X-rays shall be retained for four (4) years and may be retired thereafter provided that a signed interpretation by a radiologist is maintained in the patient’s record under T.C.A. § 68-11-305.

(i) Patients must not be left unattended in pre- and post-radiology areas.

(8) Laboratory Services.

(a) The hospital must maintain, or have available, either directly or through a contractual agreement, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility licensed in accordance with the Tennessee Medical Laboratory Act. All technical laboratory staff shall be licensed in accordance with the TMLA and shall be qualified by education, training and experience for the type of services rendered.

(b) Emergency laboratory services must be available 24 hours a day.

(d) The laboratory must make provision for proper receipt and reporting of tissue specimens.

(e) The medical staff and a pathologist must determine which tissue specimens require a macroscopic (gross) examination and which require both macroscopic and microscopic examination.

(f) Laboratory services must be provided in keeping with services rendered by the hospital. This shall include suitable arrangements for blood and plasma at all times.

Written policies and procedures shall be developed in concert with the Standards of American Association of Blood Banks. Documentation and record keeping shall be maintained for tracking and performance monitoring.

(9) Food and Dietetic Services.

(a) The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. A hospital may contract with an outside food management company if the company has a dietitian who serves the hospital on a fulltime, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. If an outside contract is utilized for management of its dietary services, the hospital shall designate a full-time employee to be responsible for the overall management of the services.

(b) The hospital must designate a person, either directly or by contractual agreement, to serve as the food and dietetic services director with responsibility for the daily management of the dietary services. The food and dietetic services director shall be:

A qualified dietitian; or, 2. A graduate of a dietetic technician or dietetic assistant training program, correspondence or classroom, approved by the Academy of Nutrition and Dietetics; or, 3. An individual who has successfully completed in-person or online coursework that provided ninety (90) or more hours of classroom instruction in food service supervision. If the course has not been completed, this person shall be enrolled in a course and making satisfactory progress for completion within the time limit specified by the course requirement; or, 4. An individual who is a certified dietary manager (CDM), or certified food protection professional (CFPP); or, 5. A current or former member of the U.S. military who has graduated from an approved military dietary manager training program.

(c) There must be a qualified dietitian, full-time, part-time, or on a consultant basis who is responsible for the development and implementation of a nutrition care process to meet the needs of patients for health maintenance, disease prevention and, when necessary, medical nutrition therapy to treat an illness, injury or condition. Medical nutrition therapy includes assessment of the nutritional status of the patient and treatment through diet therapy, counseling and/or use of specialized nutrition supplements.

(d) There must be sufficient administrative and technical personnel competent in their respective duties.

(e) Menus must meet the needs of the patients.

Individual patient nutritional needs must be met in accordance with recognized dietary practices.
All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian to whom the physician who chairs the hospital’s medical executive committee has referred this task. The medical staff and hospital’s board of trustees shall decide the extent of ordering privileges that a qualified dietitian shall have and a mechanism to ensure that order writing by a qualified dietitian is coordinated with the responsible practitioner’s care of the patient and complies with Tennessee law governing dietitians.
A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel.

(f) Education programs, including orientation, on-the-job training, inservice education, and continuing education programs shall be offered to dietetic services personnel on a regular basis. Programs shall include instruction in personal hygiene, proper inspection, handling, preparation and serving of food and equipment.

(g) A minimum of three (3) meals in each twenty-four (24) hour period shall be served. A supplemental night meal shall be served if more than fourteen (14) hours lapse between supper and breakfast. Additional nourishment shall be provided to patients with special dietary needs.

(h) All food shall be from sources approved or considered satisfactory by the Commission and shall be clean, wholesome, free from spoilage, free from adulteration and misbranding and safe for human consumption. No food which has been processed in a place other than a commercial food processing establishment shall be used.

(i) Food shall be protected from sources of contamination whether in storage or while being prepared, served and/or transported. Perishable foods shall be stored at such temperatures as to prevent spoilage. Potentially hazardous foods shall be maintained at safe temperatures as defined in the current “U.S. Public Health Service Food Service Sanitation Manual.”

(j) Written policies and procedures shall be followed concerning the scope of food services in accordance with the current edition of the “U.S. Public Health Service Recommended Ordinance and Code Regulating Eating and Drinking Establishments” and the current “U.S. Public Health Service Sanitation Manual” should be used as a guide to food sanitation.

(10) Critical Access Hospital.

(a) Every patient shall be under the care of a physician or under the care of a mid-level practitioner supervised by a physician.

(b) Whenever a patient is admitted to the facility by a mid-level practitioner, the supervising physician shall be notified of that fact, by phone or otherwise, and within 24 hours the supervising physician shall examine the patient or before discharge if discharged within 24 hours, and a plan of care shall be placed in the patient’s chart, unless the patient is transferred to a higher level of care within 24 hours.

(c) A physician, a mid-level practitioner or a registered nurse shall be on duty and physically available in the facility when there are inpatients.

(d) A physician on staff shall:

Provide medical direction to the facility’s health care activities and consultation for non-physician health care providers.
In conjunction with the mid-level practitioner staff members, participate in developing, executing, and periodically reviewing the facility’s written policies and the services provided to patients.
Review and sign the records of each patient admitted and treated by a practitioner no later than fifteen (15) days after the patient’s discharge from the facility.
Provide health care services to the patients in the facility, whenever needed and requested.
Prepare guidelines for the medical management of health problems, including conditions requiring medical consultation and/or patient referral.
At intervals no more than two (2) weeks apart, be physically present in the facility for a sufficient time to provide medical direction, medical care services, and staff consultation as required.
When not physically present in the facility, either be available through direct telecommunication for consultation and assistance with medical emergencies and patient referral, or ensure that another physician is available for this purpose.
The physical site visit for a given two week period is not required if, during that period, no inpatients have been treated in the facility.

(e) A mid-level practitioner on staff shall:

Participate in the development, execution, and periodic review of the guidelines and written policies governing treatment in the facility.
Participate with a physician in a review of each patient’s health records.
Provide health care services to patients according to the facility’s policies.
Arrange for or refer patients to needed services that are not provided at the facility.
Assure that adequate patient health records are maintained and transferred as necessary when a patient is referred.

(f) The Critical Access Hospital, at a minimum, shall provide basic laboratory services essential to the immediate diagnosis and treatment of patients, including:

Chemical examinations of urine stick or tablet methods, or both (including urine ketoses);
Microscopic examinations of urine sediment;
Hemoglobin or hematocrit;
Blood sugar;
Gram stain;
Examination of stool specimens for occult blood;
Pregnancy test;
Primary culturing for transmittal to a CLIA certified laboratory;
Sediment rate; and, 10. CBC.

(11) Rural Emergency Hospital.

(a) A hospital shall be eligible to apply for a Rural Emergency Health (“REH”) designation as such and conversion to a Rural Emergency Hospital, if the facility, as of December 27th, 2020, was a:

Critical Access Hospital as defined under Tenn. Comp. R. & Regs. 0720-14-.01; or, 2. General hospital with no more than 50 licensed beds located in an area designated by state or federal law as a rural area; or 3. General hospital with no more than 50 licensed beds located in an area designated as rural under 42 U.S.C. § 1395ww(d)(8)(E), or any successor statute.

(b) A facility applying for designation as a Rural Emergency Hospital shall include in its licensure application:

A detailed transition plan that lists the services that the facility will retain, modify, add, and discontinue.
A description of services that the facility intends to furnish on an outpatient basis pursuant to Tenn. Comp. R. & Regs. 0720-14-.01.
A description of any additional services the hospital would be supporting, such as furnishing telehealth services and ambulance services, including operating the facility and maintaining the emergency department to provide such services covered by these rules.
Any such other information as the rules and regulations of the Health Facilities Commission may require.

(d) A licensed general hospital or Critical Access Hospital that applies for and receives licensure as a Rural Emergency Hospital and elects to operate as a Rural Emergency Hospital shall retain its original license as a general hospital or Critical Access Hospital.

Such original license shall remain inactive while the Rural Emergency Hospital license is in effect.

(e) A licensed Rural Emergency Hospital may enter into any contracts required to be eligible for federal reimbursement as a Rural Emergency Hospital.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-3-511, 68-11-201, 68-11-202, 68-11-204, 68-11- 206, 68-11-207, 68-11-209, 68-11-210, 68-11-211, 68-11-213, 68-11-216, 68-11-224, 68-11-255, 68-11- 1802, 68-57-101, 68-57-102, and 68-57-105; 42 U.S.C. § 1395x(kkk); and 42 U.S.C. § 1395cc(j).
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Amendment filed December 2, 2003; effective February 15, 2004. Amendment filed May 24, 2004; effective August 7, 2004. Amendment filed September 6, 2005; effective November 20, 2005. Amendment filed July 18, 2007; effective October 1, 2007. Amendment filed December 23, 2009; effective March 23, 2010. Amendment filed March 18, 2010; effective June 16, 2010. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed July 18, 2016; effective October 16, 2016. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Emergency rules filed December 27, 2022; effective through June 25, 2023. Emergency rules expired effective June 26, 2023, and the rules reverted to their previous statuses. Amendments filed August 11, 2023; effective November 9, 2023. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.07 OPTIONAL HOSPITAL SERVICES

(1) Surgical Services.

(a) If the hospital provides surgical services, the services must be well-organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered, the services must be consistent in quality with inpatient care in accordance with the complexity of services offered.

(b) The organization of the surgical services must be appropriate to the scope of the services offered.

(d) A hospital may use scrub nurses in its operating rooms. For the purposes of this rule, a “scrub nurse” is defined as a registered nurse or either a licensed practical nurse (LPN) or a surgical technologist (operating room technician) supervised by a registered nurse who works directly with a surgeon within the sterile field, passing instruments, sponges, and other items needed during the procedure and who scrubs his or her hands and arms with special disinfecting soap and wears surgical gowns, caps, eyewear, and gloves, when appropriate.

(e) Qualified registered nurses may perform circulating duties in the operating room. In accordance with applicable state laws and approved medical staff policies and procedures, LPNs and surgical technologists may assist in circulatory duties under the supervision of a qualified registered nurse who is immediately available to respond to emergencies.

(f) Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner.

(g) Surgical services must be consistent with needs and resources. Policies covering surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care.

(h) The Health Facilities Commission shall publish an approved list of accredited surgical technology programs.

Surgical technologists must meet one (1) or more of the following:

(i) Successfully completed a nationally accredited surgical technology program, and holds and maintains certification as a surgical technologist from a national certifying body that certifies surgical technologists and is recognized by the Health Facilities Commission;

(ii) Successfully completed an accredited surgical technologist program;

(I) Has not, as of the date of hire, obtained certification as a surgical technologist from a national certifying body that certifies surgical technologists and is recognized by the Health Facilities Commission; and (II) Obtains such certification no later than eighteen (18) months after completion of the program.

(iii) Successfully completed a training program for surgical technology in the armed forces of the United States, the national guard, or the United States public health service; or (iv) Performed surgical technology services as a surgical technologist in a healthcare facility on or before May 21, 2007, and has been designated by the healthcare facility as being competent to perform surgical technology services based on prior experience or specialized training validated by competency in current practice. The healthcare facility employing or retaining such person as a surgical technologist under this subsection (a) obtains proof of such person’s prior experience, specialized training, and current continuing competency as a surgical technologist and makes the proof available to the Health Facilities Commission upon request of the Commission.

This section does not prohibit a person from performing surgical technology services if the person is acting within the scope of the person’s license, certification, registration, permit, or designation, or is a student or intern under the direct supervision of a healthcare provider.

(i) A hospital can petition the Commission for a waiver from the provisions of 0720-14- .07(1)(h) if they are unable to employ a sufficient number of surgical technologists who meet the requirements. The facility shall demonstrate to the Commission that a diligent and thorough effort has been made to employ surgical technologist who meet the requirements. The Commission shall refuse to grant a waiver upon finding that a diligent and thorough effort has not been made. A waiver shall exempt a facility from meeting the requirements for not more than nine (9) months. Additional waivers may be granted, but all exemptions greater than twelve (12) months shall be approved by the Commission.

(j) Surgical technologists shall demonstrate continued competence in order to perform their professional duties in surgical technology. The employer shall maintain evidence of the continued competence of such individuals. Continued competence activities may include but are not limited to continuing education, in-service training, or certification renewal. Persons qualified to be employed as surgical technologists shall complete fifteen (15) hours of continuing education or contact hours annually. Current certification by the National Board of Surgical Technology and Surgical Assisting shall satisfy this requirement.

(k) There must be a complete history and physical work-up in the chart of every patient prior to surgery, except in emergencies. If the history has been dictated, but not yet recorded in the patient’s chart, there must be a statement to that effect and an admission note in the chart by the practitioner who admitted the patient.

(l) Properly executed informed consent, advance directive, and organ donation forms, when applicable, must be in the patient’s chart before surgery, except in emergencies.

(m) The following equipment must be available to the operating room suites:

Call-in system;
Cardiac monitor;
Resuscitator;
Defibrillator;
Aspirator; and 6. Tracheotomy set.

(n) There must be adequate provisions for immediate pre- and post-operative care.

(o) The operating room register must be complete and up-to-date.

(p) An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon.

(2) Anesthesia Services.

(a) If the hospital furnishes anesthesia services, they must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital.

(b) The organization of anesthesia services must be appropriate to the scope of the services offered. Anesthesia must be administered only by:

A qualified anesthesiologist;
A doctor of medicine or osteopathy (other than an anesthesiologist);
A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under state law;
A certified registered nurse anesthetist (CRNA); or 5. A graduate registered nurse anesthetist under the supervision of an anesthesiologist who is immediately available if needed.

(c) Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of pre-anesthesia and postanesthesia responsibilities. The policies must ensure that the following are provided for each patient:

A pre-anesthesia evaluation or evaluation update conducted within forty-eight (48) hours prior to surgery by an individual qualified to administer anesthesia;
An intraoperative anesthesia record;
For each inpatient, a written post-anesthesia follow-up report prepared within forty-eight (48) hours following surgery by an individual qualified to administer anesthesia or by the person who administered the anesthesia and submits the report by telephone; and 4. For each outpatient, a post-anesthesia evaluation of anesthesia recovery prepared in accordance with policies and procedures approved by the medical staff.

(3) Nuclear Medicine Services.

(a) If the hospital provides nuclear medicine services, those services must meet the needs of the patients in accordance with acceptable standards of practice.

(b) The organization of the nuclear medicine service must be appropriate to the scope and complexity of the services offered.

(d) The qualifications, training, functions, and responsibilities of nuclear medicine personnel must be specified by the service director and approved by the medical staff.

(e) Radioactive materials must be prepared, labeled, used, transported, stored, and disposed of in accordance with acceptable standards of practice.

(f) In-house preparation of radiopharmaceuticals is by, or under, the direct supervision of an appropriately trained registered pharmacist or a doctor of medicine or osteopathy.

(g) If laboratory tests are performed in the nuclear medicine service, the service must meet the applicable requirements for laboratory services as specified in TCA §§ 68-29-101, et seq.

(h) Equipment and supplies must be appropriate for the types of nuclear medicine services offered and must be maintained for safe and efficient performance. The equipment must be:

Maintained in safe operating condition; and, 2. Inspected, tested, and calibrated at least annually by qualified personnel.

(i) The hospital must maintain signed and dated reports of nuclear medicine interpretations, consultations, and procedures. Copies of nuclear medicine reports must be maintained for at least ten (10) years.

(j) The practitioner approved by the medical staff to interpret diagnostic procedures must sign and date the interpretation of these tests.

(k) The hospital must maintain records of the receipt and disposition of radiopharmaceuticals.

(l) Nuclear medicine services must be ordered only by a practitioner whose scope of federal or state licensure and whose defined staff privileges allow such referrals.

(m) Patients are not left unattended in pre- and post-procedure areas.

(4) Outpatient Services.

(a) If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice.

(b) Outpatient services must be appropriately organized and integrated with inpatient services.

(c) The hospital must have appropriate professional and non-professional personnel available to provide outpatient services.

(d) Patient’s rights, including a phone number to call regarding questions or concerns, shall be made readily available to outpatients.

(e) Outpatient laboratory testing in Tennessee hospitals may be ordered by the following:

Any licensed Tennessee practitioner who is authorized to do so by T.C.A. § 68- 29-121;
Any out-of-state practitioner who has a Tennessee telemedicine license issued pursuant to Rule 0880-02-.16; or 3. Any duly licensed out-of-state health care professional as listed in T.C.A. § 68- 29-121 who is authorized by his or her state board to order outpatient laboratory testing in hospitals for individuals with whom that practitioner has an existing face-to-face patient relationship as outlined in Rule 0880-02-.14(7)(a)1., 2., and 3.

(f) Outpatient diagnostic testing in Tennessee hospitals may be ordered by the following:

Any Tennessee practitioner licensed under Title 63 who is authorized to do so by his or her practice act;
Any out-of-state practitioner who has a Tennessee telemedicine license issued pursuant to Rule 0880-02-.16; or 3. Any duly licensed out-of-state health care professional who is authorized by his or her state board to order outpatient diagnostic testing in hospitals for individuals with whom that practitioner has an existing face-to-face patient relationship as outlined in Rule 0880-02-.14(7)(a)1., 2., and 3.

(5) Emergency Services.

(a) Hospitals that elect to provide surgical services, other than in a separately licensed Ambulatory Surgical Treatment Center, must maintain and operate an emergency room.

(b) If emergency services are provided, the hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. Each hospital must have a policy which assures that all patients who present to the emergency department, are screened/triaged to determine if a medical emergency exists and stabilized when a medical emergency does exist. A hospital may deny access to patients when it is on diversionary status only because it does not have the staff or facilities in the emergency department to accept any additional emergency patients at that time. If an ambulance disregards the hospital’s instructions and brings an individual on to the hospital grounds, the individual has arrived on hospital property and cannot be denied access to hospital services. Hospital property, for the purpose of this subparagraph, is considered to be:

The hospital’s physical geographic boundaries; or 2. Ambulances owned and operated by the hospital, whenever in operation, whether or not on hospital grounds.

(c) A hospital may not delay provision of an appropriate medical screening examination in order to inquire about the individual’s method of payment or insurance status.

(d) If emergency services are provided at the hospital:

The services must be organized under the direction of a qualified member of the medical staff;
The services must be integrated with other departments of the hospital; and 3. The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. These policies and procedures must define how the hospital will assess, stabilize, treat and/or transfer patients.

(e) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.

(f) There shall be a sufficient number of emergency rooms and adequate equipment and supplies to accommodate the caseload of the emergency services.

(g) The entrance to the emergency department shall be clearly marked.

(h) Legend drugs in emergency rooms shall be stored in locked cabinets, except as otherwise provided for emergency drugs by the written policies and procedures of the hospital. Discharge medications may be dispensed to out-patients upon written physician orders provided that they have been packaged in containers by the pharmacist in amounts not to exceed twelve (12) hours dosage and labeled in accordance with Pharmacy Board rules.

(i) Emergency room medical records shall include the following:

Identification data;
Information concerning the time of arrival, means and by whom transported;
Pertinent history of the injury or illness to include chief complaint and onset of injuries or illness;
Significant physical findings;
Description of laboratory, x-ray and EKG findings;
Treatment rendered;
Condition of the patient on discharge or transfer;
Diagnosis on discharge;
Instructions given to the patient or his family; and 10. A control register listing chronologically the patient visits to the emergency room.

The record shall contain at least the patient’s name, date and time of arrival and record number. The name of those dead on arrival shall be entered in the register.

(j) Emergency patients and their families are made aware of their rights, including a number to call regarding concerns or questions.

(6) Rehabilitation Services.

(a) If the hospital provides rehabilitation, physical therapy, occupational therapy, audiology, or speech pathology services, the services must be organized and staffed to ensure the health and safety of patients. These disciplines should document their contribution to the plan for patient care.

(b) The organization of the service must be appropriate to the scope of the services offered.

(c) The director of the service must have the necessary knowledge, experience, and capabilities to properly supervise and administer the services.

(d) Physical therapy, occupational therapy, speech therapy, or audiology services, if provided, must be provided by staff who meet the qualifications specified by hospital policy, consistent with state law.

(e) Services must be furnished in accordance with a written plan of treatment in accordance with the practice acts of the practitioners who are authorized by medical staff to provide the services. The written plan of treatment must be incorporated in the patient’s record.

(7) Obstetrical Services.

(a) If a hospital provides obstetrical services it shall have space, facilities, equipment and qualified personnel to assure appropriate treatment of all maternity patients and newborns.

(b) The hospital must have written policies and procedures governing medical care provided in the obstetrical service which are established by and are a continuing responsibility of the medical staff.

(c) Provisions must be made for care of the patient during labor and delivery, either in the patient’s room or in a designated room.

(d) Designated delivery rooms shall be segregated from patient areas and be located so as not to be used as a passageway between or subject to contamination from other parts of the hospital.

(e) A delivery record shall be kept that must indicate:

The name of the patient;
Her maiden name;
Date of delivery;
Sex of infant;
Name of physician;
Names of persons assisting;
What complications, if any, occurred;
Type of anesthesia used;
Name of person administering anesthesia; and 10. Other persons present.

(8) Pediatric Services.

(a) If the hospital provides pediatric services, it shall provide appropriate pediatric equipment and supplies.

(b) Pediatric services must be appropriate to the scope and complexity of the services offered and must meet the needs of the patients in accordance with acceptable standards of practice.

(c) The hospital must have appropriate professional and non-professional personnel available to provide pediatric services.

(9) Respiratory Care Services.

(a) If the hospital provides respiratory care services, the hospital must meet the needs of the patients in accordance with acceptable standards of practice.

(b) The organization of the respiratory care services must be appropriate to the scope and complexity of the services offered.

(c) There must be a director of respiratory care services who is a doctor of medicine or osteopathy with the knowledge, experience, and capabilities to supervise and administer the service properly.

(d) There must be adequate numbers of certified respiratory therapists, certified respiratory therapy technicians, and other personnel who meet the qualifications specified by the medical staff, consistent with state law.

(e) Services must be delivered in accordance with medical staff directives.

(f) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing.

(g) If blood gases or other laboratory tests are performed in the respiratory care unit, the unit must meet the applicable requirements for clinical laboratory services specified in the Tennessee Medical Laboratory Act.

(10) Social Work Services.

(a) If the hospital provides social work services, the services must be available to the patient, the patient’s family and other persons significant to the patient, in order to facilitate adjustment of these individuals to the impact of illness and to promote maximum benefits from the health care services provided.

(b) Social work services shall include psychosocial assessment, counseling, coordination of discharge planning, community liaison services, financial assistance and consultation.

(c) Social work services shall be provided by personnel who satisfy applicable accreditation standards and who are in compliance with Tennessee State Law governing social work practices. Social work personnel employed by the hospital prior to the effective date of these regulations shall be deemed to meet this requirement.

(d) Facilities for social work services shall be readily accessible and shall permit privacy for interviews and counseling.

(11) Psychiatric Services.

(a) If a hospital provides psychiatric services, a psychiatric unit devoted exclusively for the care and treatment of psychiatric patients and professional personnel qualified in the diagnosis and treatment of patients with psychiatric illnesses shall be provided.

Adequate protection shall be provided for patients and the staff against any physical injury resulting from a patient becoming violent. A psychiatric unit shall meet the requirements as needed to care for patients admitted, either through direct care or by contractual arrangements.

(b) A hospital licensed by the Commission as a satellite hospital whose primary purpose is the provision of mental health or substance abuse services, must verify to the Commission that Standards of the Department of Mental Health and Substance Abuse Services are satisfied.

(12) Alcohol and Drug Services.

(a) If a hospital provides alcohol and drug services, the service shall be devoted exclusively to the care and treatment of alcohol and drug dependent patients and have on staff physicians and other professional personnel qualified in the diagnosis and treatment of alcoholism and drug addiction.

(b) Adequate protection shall be provided for the patients and staff against any physical injury resulting from a patient becoming disturbed or violent. Alcohol and drug services shall meet the requirements as needed to care for patients admitted, either through direct care or by contractual arrangements.

(13) Perinatal and/or Neonatal Care Services. Any hospital providing perinatal and/or neonatal care services shall comply with the Tennessee Perinatal Care System Guidelines for Regionalization, Hospital Care Levels, Staffing and Facilities developed by the Tennessee Department of Health’s Perinatal Advisory Committee, the Ninth Edition effective October 14, 2020.

(14) Burn Unit Services.

(a) If a hospital provides burn unit services, the following licensing requirements apply:

The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the Commission.

Patients shall not be admitted to the burn unit until a license has been issued.

Applicants shall not hold themselves out to the public as being a burn unit until the license has been issued.

(i) The applicant shall allow the burn unit to be inspected by Commission staff. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action within ten (10) calendar days to the Commission that must be accepted by the Commission. Once the deficiencies have been corrected, then the Commission shall consider the application for licensure.

(ii) A provisional license shall be issued upon administrative approval of the initial application.

(iii) A provisional licensee must achieve American Burn Association (ABA) verification within five (5) years of obtaining a provisional license. A provisional licensee must comply with the following requirements:

(I) Provide the Commission with annual progress reports demonstrating engagement and measurable efforts toward obtaining verification.

(II) Provide data to the Burn Care Quality Platform (BCQP) and provide reports formatted in accordance with Commission reporting requirements.

(III) Participate in annual on-site visits conducted by Commission staff, consultant burn surgeons and burn nurses until ABA verification is achieved.

I. Site visits must be scheduled by within twelve (12) months of provisional licensure.

II. Costs associated with site visits shall be assessed to the provisional licensee by the Commission through the issuance of an Assessment of Costs.

A full license shall not be issued until the facility is ABA verified and written confirmation verification has been achieved is submitted to the Commission.
A fully licensed burn unit must maintain ABA verification. Loss of ABA verification will cause the full license to be reverted to a provisional license until reverification is achieved (b) If a hospital provides burn unit services, the following administrative requirements apply:
The burn unit must have a Burn Unit Director who is responsible for the following:

(i) All burn unit administrative functions.

(ii) Creation of policies and procedures regarding burn unit care.

(iii) Ensure burn unit staff are properly credentialed through the general hospital’s medical staff credentialing process.

(iv) Ensure burn unit physicians, advanced practice providers, and registered nurses obtain and maintain Advanced Burn Life Support (ABLS) certification.

The burn unit must have a Burn Nurse Leader who is responsible for the following:

(i) All burn unit nursing functions.

(ii) Ensure burn unit nurses obtain, within six (6) months of hiring, and continuously maintain Advanced Burn Life Support (ABLS) certification.

(iii) Participate in burn unit quality improvement meetings.

(15) MRI Services (a) If a hospital provides MRI services, the following licensing requirements apply to each unit:

Must become accredited within two years of licensure per machine and per diagnostic type.
Must adhere to all federal and state regulations, as well as the Nuclear Regulatory Commission Requirements.
For Pediatric MRI Units, a person who initiates magnetic resonance imaging services shall notify the commission in writing that imaging services are being initiated and shall indicate whether magnetic resonance imaging services will be provided to a patient who is fourteen (14) years of age or younger on more than five (5) occasions per year.
A facility who provides MRI services and/or PET services shall file with the commission an annual report no later than thirty (30) days following the end of each state fiscal year that details the mix of payers by percentage of cases for the prior calendar year, charity care, Medicare, and Medicaid.

(16) NICU Services (a) If a qualifying hospital provides NICU services, the following licensing requirements apply:

The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the Commission.

Patients shall not be admitted to the NICU until a license has been issued.

Applicants shall not hold themselves out to the public as being a NICU unit until the license has been issued.

(i) The applicant shall allow the NICU to receive an initial inspection by Commission staff. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action within ten (10) calendar days to the Commission that must be accepted by the Commission. Once the deficiencies have been corrected, then the Commission shall consider the application for licensure.

(ii) A provisional license shall be issued upon administrative approval of the initial application.

(iii) Within three (3) years of obtaining a provisional license, licensee must achieve either:

(I) State level verification; or (II) Verification through the American Academy of Pediatrics (AAP).

(iv) Upon application, applicant will self-designate. At verification, licensee must comply with the corresponding requirements based upon level of designation (for Levels II– IV) as illustrated in the referenced levels of care;

(I) The verification process shall be based upon the standards established by and referenced within the Tennessee Perinatal Care System, Guidelines for Regionalization, Hospital Care Levels, Staffing and Facility as published by the Tennessee Department of Health, Division of Family Health and Wellness. The Tennessee Perinatal Care System, Guidelines for Regionalization, Hospital Care Levels, Staffing and Facility shall be published by reference on the Health Facilities Commission website.

(b) Levels of Care – Neonatal Intensive Care Units II–IV Requirements:

Facility Capacity Requirements IV III II (i) Level II units provide care for infants born at >or= to 32 weeks’ gestation and weighing >or= to 1500 grams who have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis.

E (ii) Level III units have the capabilities of Level II NICUs and provide comprehensive care for infants born <32 weeks gestation and weighing <1500 grams and infants born at all gestational ages birth weights with critical illness. Provide prompt and readily available access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists, and pediatric ophthalmologists.

E (iii) Level IV units have Level III capabilities plus are located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions and maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site.

E (iv) Provide mechanical ventilation for brief duration (<24 hours) and provide continuous positive airway pressure (CPAP).

E E E

(v) Stabilize infants born at <32 weeks’ gestation and weighing <1500 grams until transfer to a neonatal intensive care facility.

E E E

(vi) Provide care for infants who are convalescing after intensive care. E E E (vii) Provide sustained life support. E E (viii) Provide prompt and readily available access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists, and pediatric ophthalmologists.

E E (ix) Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled nitric oxide.

E E (x) Perform advanced imaging with interpretation on an urgent basis, including computed tomography, MRI, and echocardiography.

E E (xi) Located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions.

E (xii) Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site.

E (xii) Facilitate transport. E E E 2. Education Services Requirement IV III II (i) Educational services should include the following:

All neonatal care providers shall maintain both current NRP and S.T.A.B.L.E. provider status. The S.T.A.B.L.E. Cardiac Module is also recommended.

E E E

(ii) Parent Education Ongoing perinatal education programs for parents. E E E (iii) Nurses’ Education Required to provide ongoing educational programs for their nurses that conform to the latest edition of the Tennessee Perinatal Care System Educational Objectives for Nurses, Level IV, for neonatal nurses, published by the Tennessee Department of Health. Outreach educational activities are not required.

E Required to provide ongoing educational programs for their nurses that conform E to the latest edition of the Tennessee Perinatal Care System Educational Objectives for Nurses, Level III, for neonatal nurses, published by the Tennessee Department of Health. Outreach educational activities are not required.

Programs for nurses that conform to the latest edition of the Tennessee Perinatal Care System Educational Objectives for Nurses, Level II, for neonatal nurses, published by the Tennessee Department of Health. These neonatal courses should be made available periodically at Level II facilities by instructors on the staff of that institution and/or the staff from a Regional Perinatal Center. Courses may also transpire at a Regional Perinatal Center or at another site remote from the Level II hospital, thus requiring that the hospital provide nurses with educational leave for attendance. Level II hospitals are responsible for the necessary arrangements for nurse education.

E (iv) Physicians’ Education NICUs are required to provide ongoing educational programs for physicians practicing in that institution. Outreach educational activities are not required.

E E E

Educational opportunities for physicians should be available upon request, provided by the qualified individuals on the staff of the Level II institution.

E 3. Neonatal Care Requirement IV III II (i)

Resuscitation Provision must be made for resuscitation of infants immediately after birth.

Resuscitation capabilities should include assisted ventilation with blended oxygen administered by bag or T-piece resuscitator with mask or endotracheal tube, chest compression, and appropriate intravascular therapy. Refer to the most recent edition of the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Program Guidelines for a complete list of resuscitation equipment and supplies.

E E E

(ii) Transport from Delivery Room to the NICU Transport to a NICU requires a capacity for uninterrupted support. An appropriately equipped pre-warmed transport incubator, with blended oxygen, should be used for this purpose.

E E E

(iii)

Transitional Care Recurrent observation of the neonate should be performed by personnel who can identify and respond to the early manifestations of neonatal disorders.

E E E

(iv) Care of Sick Neonates (I) The care of moderately and severely ill infants entails the following essentials:

Continuous cardiorespiratory monitoring.

E E E

Serial blood gas determinations and non-invasive blood gas monitoring.

E E E

Periodic blood pressure determinations (intra-arterial when necessary).

E E E

Portable diagnostic imaging for bedside interpretation. E E E Availability of electrocardiograms and echocardiograms with rapid interpretation.

E E Laboratory Services: Clinical laboratory services must be available to fully support clinical neonatal functions.

E E E

Fluid and electrolyte management and administration of blood and blood components.

E E E

Phototherapy.

E Phototherapy and exchange transfusion.

E E Administration of parenteral nutrition through peripheral or central vessels.

E E Provision of appropriate enteral nutrition and lactation support.

E E E

(v)

Mechanical Ventilatory Support (I)

Unit must be qualified to provide mechanical ventilatory support. The essential qualifications are as follows:

Continuous in-house presence of personnel experienced in airway management, endotracheal intubation, and diagnosis and treatment of air leak syndromes.

E E E

A staff of nurses (R.N.) and respiratory therapists (R.T.) who are specifically educated in the management of neonatal respiratory disorders.

E E E

Blood gas determinations and other data essential to treatment must be available 24 hours a day, 7 days a week.

E E E

NICUs should be able to provide a full range of respiratory support, including sustained conventional and/or high frequency ventilation and inhaled nitric oxide.

E E (vi)

Diagnostic Imaging Perform advanced imaging, with interpretation on an urgent basis, including CT, MRI, and echocardiography.

E E (vii)

Transfusion Services Transfusion services must be maintained at all times.

E E E

An appropriately trained technician should be available in-house 24 hours a day, 7 days a week.

E E E

All blood components must be obtainable on an emergency basis from within the facility.

E All blood components must be obtainable on an emergency basis, either on the premises or by pre-arrangement with another facility.

E E 4. Ancillary Services Requirement IV III II (i)

Laboratory Services:

Clinical laboratory services must be available to fully support clinical neonatal functions.

E E E

(I)

Laboratory capabilities should include but not be limited to the following:

Routine Availability Clotting factors E E E Serum total protein E E E Serum total protein E E E Serum albumin E E E Serum IgM E E E Serum triglycerides (for parenteral nutrition)

E E E

Metabolic screen E E E Liver function tests E E E Serologic test for syphilis E E E Serology for hepatitis E E E Screening for HIV E E E TORCH titers E E E Viral cultures E E E II.

Available 24 Hours – 7 Days a Week Hematocrit E E E Hemoglobin E E E Complete blood count E E E Reticulocyte count E E E Blood typing: major groups and Rh E E E Cross match E E E Minor blood group antibody screen E E E Coombs’ test E E E Prothrombin time E E E Partial thromboplastin time E E E Platelet count E E E Fibrinogen concentration E E E Serum sodium, potassium, chloride E E E Serum calcium E E E Serum phosphorus E E E Serum magnesium E E E Serum blood glucose E E E Therapeutic drug levels E E E Serum bilirubin, total and direct E E E Blood gases/Ph E E E Blood urea nitrogen E E E Serum creatinine E E E Serum/urine osmolality’s E E E Urinalysis E E E Cerebrospinal fluid: cells, chemistry E E E Bacterial cultures and sensitivities E E E C-reactive protein (CRP)

E E E

Gram stain E E E Toxicology E E E Group B strep screening E E E 5. Consultation and Transfer Requirement IV III II (i)

Neonatal Transport:

The facility that operates a transport service is required to maintain equipment and a trained team of personnel for the transport of newborn patients.

The team and equipment must be available at all times. The facility is responsible for transport of referred infants with its own equipment, or alternatively, with equipment from a commercial source.

E E E

The facility that operates a transport service should originate a protocol that describes procedures, staffing patterns, and equipment for the transport of referred infants. The protocol should conform to the most recent edition of the Tennessee Perinatal Care System Guidelines for Transportation, published by the Tennessee Department of Health.

E E E

The facility that operates a transport service is required to maintain records of its activities. (See the most recent edition of the Tennessee Perinatal Care System Guidelines for Transportation.)

E E E

The Level II facility should maintain an active relationship with a Level III or Level IV facility in the region for consultation and transfer. Protocols for transport should conform to the most recent edition of the Tennessee Perinatal Care System Guidelines for Transportation, published by the Tennessee Department of Health.

E Neonatal Consultation and Transport: When the severity of an illness requires a level of care that exceeds the capacity of the Level II facility, the infant should be transferred to a Level III or Level IV institution capable of providing required care.

Transfer of these infants should be provided after consultation with the receiving Level III or Level IV unit. Refer to the most recent edition of the Tennessee Perinatal Care System Guidelines for Transportation, published by the Tennessee Department of Health, for more information.

E 6. Maintenance of Data Requirement IV III II (i)

Maintenance of Data and Assessment of Quality Measures (I)

The following items represent the minimum information that should be in medical records maintained at all facilities:

Name, gender, hospital medical record number E E E Date of birth E E E Birthweight E E E Gestational age E E E Apgar scores E E E Maternal complications (test results relevant to neonatal care; maternal illness potentially affecting the fetus; history of illicit substance use or any other known socially highrisk circumstances; complications of pregnancy associated with abnormal fetal growth, fetal anomalies, or abnormal results from tests of fetal well-being; information regarding labor and delivery; and situations in which lactation may be compromised)

E E E

Discharge diagnoses E E E Special care administered (specify)

E E E

Documentation of newborn metabolic, hearing and critical congenital heart disease (CCHD) screens, and immunizations and medications given E E E Bilirubin screen (according to American Academy of Pediatrics guidelines)

E E E

Disposition -Discharged home -Transferred to a higher level of care/Receiving hospital/Transport service -Expired E E E (II) A systematic ongoing compilation of data should be maintained to reflect the care of sick patients, in addition to the listing of minimal data that is specified for Level I, Level II, and Level III facilities. All Level III & IV programs should participate in a state or national continuous quality initiative that includes ongoing data collection and review for benchmarking and evaluation of outcomes. Examples of continuous quality initiatives available in Tennessee are those provided by TIPQC and THA.

E E E

Personnel Qualifications and Functions Requirement IV III II (i)

Physicians (I)

Director The director of the newborn intensive care unit must be a full-time, board-certified pediatrician with subspecialty certification in neonatal-perinatal medicine. The director is responsible for maintaining practice guidelines and, in cooperation with nursing and hospital administration, is responsible for developing the operating budget; evaluating and purchasing equipment; planning, developing, and coordinating in-hospital and outreach educational programs; and participating in the evaluation of perinatal care.

E E In a Level II (UNIT), a board-certified pediatrician with subspecialty certification in neonatal-perinatal medicine should be chief of the neonatal care service. The chief should assure that appropriate trained and adequate staff are available at all times E (II)

Neonatologists The attending physician for neonates must be fellowship-trained and boardcertified or eligible to take the board certification exam in neonatal-perinatal medicine.

E E The co-directors of perinatal services should coordinate the hospital’s perinatal care services and, in conjunction with other medical, anesthesia, nursing, respiratory therapy, and hospital administration staff, develop policies concerning staffing, procedures, equipment, and supplies. The medical directors of obstetrics and neonatology are responsible for setting the hospital’s standard of perinatal care by working together to incorporate evidence-based practice patterns and nationally recognized care standards.

E (III)

Pediatricians A board-certified neonatologist must have primary and ultimate responsibility for infants who receive intensive care. Board-certified pediatricians, whose qualifications and appointments have been approved by the appropriate hospital committee, can care for infants who need more than routine care as long as they are under the supervision of a neonatologist.

E E (IV)

In-House Coverage In-house physician consultation and coverage should be provided 24 hours a day, 7 days a week by a board-certified neonatologist or a board-certified neonatal nurse practitioner. However, when in-house coverage does not include a board-certified neonatologist, he/she must be on-call and available to be on-site within 30 minutes of request.

E E (V)

Deliveries Deliveries of high-risk fetuses should be attended by an obstetrician and at least two other persons qualified in neonatal resuscitation whose only responsibility is the neonate. With multiple gestations, each newborn should have his or her own dedicated team of care providers who are capable of performing neonatal resuscitation according to the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Program guidelines.

E E E

Every delivery should be attended by at least one person whose primary responsibility is for the newborn and who is capable of performing neonatal resuscitation according to the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Program guidelines. Either that person or someone else who is immediately available should have the skills required to perform a complete resuscitation, including endotracheal intubation and administration of medications.

E E E

(VI)

Anesthesiologists Pediatric anesthesia services should be directed by a board-certified anesthesiologist who has a special interest and an expertise in pediatric anesthesia.

E E (VII)

Radiologists A radiologist must be available on-call at all times.

E E (VIII)

Sub-Specialty Consultants Should have pediatric surgical sub-specialists on call and readily available for consultation and continuous patient management.

E Should be available on-site or at a closely related institution by prearranged consultative agreement, ideally in close geographic proximity.

E Pediatric medical subspecialists E E Pediatric surgical specialists E E Pediatric anesthesiologists E E Pediatric ophthalmologists E E (ii)

Nurses (I) The Nurse Manager Of the Level IV NICU should have completed education according to the most recent edition of the Tennessee Perinatal Care System Educational Objectives for Nurses, Level IV, Neonatal, published by the Tennessee Department of Health. A baccalaureate degree is required.

E Of the Level III NICU should have completed education according to the most recent edition of the Tennessee Perinatal Care System Educational Objectives for Nurses, Level III, Neonatal, published by the Tennessee Department of Health. A baccalaureate degree is required.

E The nurse manager (R.N.) is responsible for all nursing activities in the nurseries of Level II facilities. The nurse manager in a hospital with a Level II ICU must complete the Level II neonatal courses prescribed for staff nurses in the most recent edition of the Tennessee Perinatal Care System Educational Objectives for Nurses, Level II, published by the Tennessee Department of Health.

E (II)

Staff Nurses (R.N.)

Must have received courses as outlined in the most recent edition of the Tennessee Perinatal Care System Educational Objectives for Nurses, Level IV, for neonatal nurses, published by the Tennessee Department of Health. Nurses should maintain institutional unit-specific competencies. In addition, all nurses should be current NRP and S.T.A.B.L.E. providers.

E Must have received courses as outlined in the most recent edition of the Tennessee Perinatal Care System Educational Objectives for Nurses, Level III, for neonatal nurses, published by the Tennessee Department of Health. Nurses should maintain institutional unit-specific competencies. In addition, all nurses should be current NRP and S.T.A.B.L.E. providers.

E Must be skilled in the observation and treatment of sick infants. For Level II facilities, they must complete the Level II neonatal course for nurses outlined in the most recent edition of the Tennessee Perinatal Care System Educational Objectives for Nurses, published by the Tennessee Department of Health. Nurses should maintain institutional unit-specific competencies. In addition, all nurses should be current NRP and S.T.A.B.L.E. providers.

E (III)

Nurse Educator Should have at least one neonatal nurse on its full-time staff who is responsible for staff education. This nurse should either be masters’ prepared or actively pursuing an advanced degree.

E E (IV)

Recommended Registered Nurse (R.N.)/Patient Ratios for Newborn Care (Association of Women’s Health, Obstetric, and Neonatal Nurses Guidelines for Professional Registered Nurse Staffing for Perinatal Units, 2010): 1:5–6 Newborns requiring only routine care E 1:3–4 Newborns requiring continuing care E 1:2–3 Newborns requiring intermediate care E E E 1:1–2 Newborns requiring intensive care E E E 1:1 Newborns requiring multisystem support E E E 1 or more :1 Unstable newborns requiring complex critical care E E E (iii)

Social Workers The services of social workers should be made available by the hospital 24 hours a day, 7 days a week. These services should be provided by a staff that is qualified in perinatal social work. This requires that social workers be educated according to the most recent edition of the Tennessee Perinatal Care System Educational Objectives in Medicine for Perinatal Social Workers, published by the Tennessee Department of Health.

E E (iv)

Case Manager/Discharge Coordinator Personnel experienced in dealing with discharge planning and education, followup and referral, and home care planning should be available to neonatal intensive care unit staff members and families.

E E E

Personnel experienced in dealing with perinatal issues, discharge planning and education, follow-up and referral, home care planning, and bereavement support should be available to intermediate and intensive care unit staff members and families.

E E E

(v)

Respiratory Therapists Respiratory therapists who can provide supplemental oxygen, assisted ventilation and continuous positive pressure ventilation (including high flow nasal cannula) of neonates with cardiopulmonary disease should be continuously available on-site to provide ongoing care as well as to address emergencies.

E Dedicated respiratory therapists who can provide the assisted ventilation of neonates with cardiopulmonary disease must be available. The NICU’s respiratory therapy director must be a registered respiratory therapist (R.R.T.).

E E (vi)

Dietitian/Lactation Consultant The staff must include at least one dietitian who has special training in perinatal nutrition and can plan diets that meet the special needs of high-risk neonates.

Availability of lactation consultants 7 days a week is recommended to assist with complex breastfeeding issues. 1.6 fulltime equivalent lactation consultants are recommended for every 1,000 births based on annual birth volume in Level II perinatal facilities (Association of Women’s Health, Obstetric, and Neonatal Nurses Guidelines for Professional Registered Nurse Staffing for Perinatal Units, 2010).

E The staff must include at least one dietitian who is knowledgeable in the management of parenteral and enteral nutrition of low birthweight and other highrisk infants. Availability of lactation consultants 7 days a week is recommended to assist with complex breastfeeding issues. 1.9 fulltime equivalent lactation consultants are recommended for every 1,000 births based on annual birth volume in Level III (also applies to Level IV) perinatal facilities (Association of Women’s Health, Obstetric, and Neonatal Nurses Guidelines for Professional Registered Nurse Staffing for Perinatal Units, 2010).

E E (vii)

Pharmacist A registered pharmacist with expertise in compounding and dispensing medications, including total parenteral nutrition (TPN) for neonates must be available 24 hours a day, 7 days a week.

E A registered pharmacist with expertise in compounding and dispensing medications for neonates must be included on staff. Registered pharmacists with expertise in dispensing neonatal medications, including total parenteral nutrition (TPN), must be available 24 hours a day, 7 days a week.

E E (viii)

Occupational Therapist/Physical Therapist/Speech Therapist At least one occupational therapist or physical therapist and one speech therapist with neonatal expertise must be included on staff. These disciplines will work collaboratively with the medical and nursing staffs to provide developmentally appropriate care.

E E (ix)

Neonatal Follow-Up Services Neonatal intensive care unit graduates who are considered high risk and those with birthweights <1500 grams should be enrolled in an organized follow-up program that tracks and records medical and neurodevelopmental outcomes to allow later analysis.

E E 8. Space and Equipment for Level II Facilities Requirement IV III II (i)

Physical Facilities and Equipment Physical facilities and equipment should meet criteria published in the latest edition of the Guidelines for Perinatal Care, jointly published by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.

E Equipment of a Level III or IV NICU should be adequate for the care of moderately and severely ill infants in accordance with contemporary standards. The quantities of all items of equipment should be sufficient to support the management of the maximum number of infants that are anticipated at times of peak census loads.

An inhouse Bioengineering Department should have an active program for preventive maintenance and rapid repair.

E E (ii)

Equipment Necessary for NICU Units A platform scale, preferably with metric indicators.

E E E

A controlled source of continuous and/or intermittent suction.

E E E

Incubators and/or radiant warmers for adequate thermal support.

E E E

Equipment for determination of blood glucose at the bedside.

E E E

Ability to provide intensive phototherapy.

E E E

A device for the external measurement of blood pressure from the infant’s arm or thigh.

E E E

Oxygen flow meters, tubing, binasal cannulas for short-term administration of oxygen.

E E E

An oxygen blending device, and warming nebulizer for short-term administration of oxygen.

E E E

An oxygen analyzer that displays the ambient concentration of oxygen.

E E E

A newborn pulse oximeter for non-invasive blood oxygen monitoring.

E E E

An infusion pump that can deliver appropriate volumes of continuous fluids and/or medications for newborns.

E E E

A fully equipped neonatal resuscitation cart.

E E E

Positive pressure ventilation equipment and masks; endotracheal tubes in all the appropriate sizes for neonates.

E E E

A laryngoscope with premature and infant size blades.

E E E

A CO detector.

E E E

Laryngeal mask airway (LMA, size 1)

E E E

A servo-controlled incubator or heated open bed for each infant who requires a controlled thermal environment.

E E E

Cardiorespiratory monitors that include pressure and waveform monitoring.

E E E

Oxygen analyzers, blenders, heaters, and humidifiers sufficient for anticipated census.

E E E

Modes of respiratory support: binasal cannulas, conventional mechanical ventilator, mechanism to deliver nasal CPAP.

E E E

A bag or T-piece resuscitator and mask for each infant.

E E E

An adequate supply of endotracheal tubes and other intubation supplies and LMA.

E E E

A device for viewing x-rays in the infant area.

E E E

The NICU must have a NICU Director who is responsible for the following:

(i) All NICU administrative functions;

(ii) Creation of policies and procedures regarding NICU care;

(iii) Ensure NICU staff are properly credentialed through the general hospital’s medical staff credentialing process; and (iv) Any other requirements in 0720-14-.07(16)(a).

The NICU must have a Nurse Manager who is responsible for all NICU nursing functions.

(d) Quality Initiative Program Participation- Each licensed NICU shall annually participate in a neo-natal quality initiative program approved by the Commission.

Approval of Quality Initiative Programs- Each program seeking approval by the Commission shall submit the following in writing:

(i) Curriculum Vitae of each presenter or program leader.

(ii) Copies of programmatic material to be used during the program.

(iii) Information concerning the neonatal subject to be covered by the program, as well as the anticipated length of the program.

(iv) Information on how annual participation and/or completion shall be documented by the program, which shall include a blank copy of any certificate to be used.

The Commission shall maintain a list of approved Quality Initiative Programs, as informed by the Perinatal Advisory Committee.
Each licensed NICU must maintain, and make readily available for inspection by Commission staff, participation or completion certificates for the preceding three (3) years.
If no Quality Initiative Program has been approved by the Commission for any calendar year, this requirement shall be automatically waived.

(17) PET Services (a) If a hospital provides PET services, the following licensing requirements apply:

Must become accredited within two years of licensure per machine per diagnostic type.
Must adhere to all federal and state regulations, as well as the Nuclear Regulatory Commission requirements.
A facility who provides MRI services and/or PET services shall file with the commission an annual report no later than thirty (30) days following the end of each state fiscal year that details the mix of payers by percentage of cases for the prior calendar year, charity care, Medicare, and Medicaid.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-3-511, 68-11-202, 68-11-204, 68-11-209, 68-57-101, 68-57- 102, 68-57-104, and 68-57-105.
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Amendment filed April 17, 2000; effective July 1, 2000. Amendment filed June 12, 2003; effective August 26, 2003. Amendment filed July 27, 2005; effective October 10, 2005. Amendment filed February 23, 2006; effective May 9, 2006. Amendment filed February 23, 2007; effective May 9, 2007. Amendment filed February 22, 2010; effective May 23, 2010. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed February 25, 2025; effective May 26, 2025. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.08 BUILDING STANDARDS

(1) A hospital shall construct, arrange, and maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of the patients are assured.

(2) After the applicant has submitted an application and licensure fees, the applicant must submit the building construction plans to the Commission. All facilities shall conform to the current edition of the following applicable codes as approved by the Commission: International Building Code (excluding Chapters 1 and 11) including referenced International Fuel Gas Code, International Mechanical Code, and International Plumbing Code; National Fire Protection Association (NFPA) NFPA 101 Life Safety Code excluding referenced NFPA 5000; Guidelines for Design and Construction of Health Care Facilities (FGI) including referenced Codes and Standards; U.S. Public Health Service Food Code; and Americans with Disabilities Act (ADA) Standards for Accessible Design. When referring to height, area or construction type, the International Building Code shall prevail. Where there are conflicts between requirements in local codes, the above listed codes, regulations and provisions of this chapter, the most stringent requirements shall apply.

(3) The codes in effect at the time of submittal of plans and specifications, as defined by these rules, shall be the codes to be used throughout the project.

(4) A licensed contractor shall perform all new construction and renovations to hospitals, other than minor alterations not affecting fire and life safety or functional issues, in accordance with the specific requirements of these regulations governing new construction in hospitals, including the submission of phased construction plans and the final drawings and the specifications to each.

(5) No new hospital shall be constructed, nor shall major alterations be made to an existing hospital without prior written approval of the Commission, and unless in accordance with plans and specifications approved in advance by the Commission. Before any new hospital is licensed or before any alteration or expansion of a licensed hospital can be approved, the applicant must furnish two (2) complete sets of plans and specifications to the Commission, together with fees and other information as required. Plans and specifications for new construction and major renovations, other than minor alterations not affecting fire and life safety or functional issues, shall be prepared by or under the direction of a licensed architect and/or a licensed engineer and in accordance with the rules of the Board of Architectural and Engineering Examiners.

(6) Final working drawings and specifications shall be accurately dimensioned and include all necessary explanatory notes, schedules, and legends. The working drawings and specifications shall be complete and adequate for contract purposes.

(7) Detailed plans shall be drawn to a scale of at least one-eighth inch equals one foot (1/8” = 1’), and shall show the general arrangement of the building, the intended purpose and the fixed equipment in each room, with such additional information as the Commission may require.

An architect or engineer licensed to practice in the State of Tennessee shall prepare the plans the Commission requires.

(a) The project architect or engineer shall forward two (2) sets of plans to the Commission for review. After receipt of approval of phased construction plans, the owner may proceed with site grading and foundation work prior to receipt of approval of final plans and specifications with the owner’s understanding that such work is at the owner’s own risk and without assurance that final approval of final plans and specifications shall be granted. The project architect or engineer shall submit final plans and specifications for review and approval. The commission must grant final approval before the project proceeds beyond foundation work.

(b) Review of plans does not eliminate responsibility of owner and/or architect to comply with all rules and regulations.

(8) Specifications shall supplement all drawings. They shall describe the characteristics of all materials, products and devices, unless fully described and indicated on the drawings.

Specification copies should be bound in an 8½ x 11 inch folder.

(9) Drawings and specifications shall be prepared for each of the following branches of work:

Architectural, Structural, Mechanical, Electrical and Sprinkler.

(10) Architectural drawings shall include where applicable:

(a) Plot plan(s) showing property lines, finish grade, location of existing and proposed structures, roadways, walks, utilities and parking areas;

(b) Floor plan(s) showing scale drawings of typical and special rooms, indicating all fixed and movable equipment and major items of furniture;

(c) Separate life safety plans showing the compartment(s), all means of egress and exit markings, exits and travel distances, dimensions of compartments and calculation and tabulation of exit units. All fire and smoke walls must be identified;

(d) The elevation of each facade;

(e) The typical sections throughout the building;

(f) The schedule of finishes;

(g) The schedule of doors and windows;

(h) Roof plans;

(i) Details and dimensions of elevator shaft(s), car platform(s), doors, pit(s), equipment in the machine room, and the rates of car travel must be indicated for elevators; and (j) Code analysis.

(11) Structural drawings shall include where applicable:

(a) Plans of foundations, floors, roofs and intermediate levels which show a complete design with sizes, sections and the relative location of the various members;

(b) Schedules of beams, girders and columns; and (c) Design live load values for wind, roof, floor, stairs, guard, handrails, and seismic.

(12) Mechanical drawings shall include where applicable:

(a) Specifications which show the complete heating, ventilating, fire protection, medical gas systems and air conditioning systems;

(b) Water supply, sewerage and HVAC piping systems;

(d) Heating, ventilating, HVAC piping, medical gas systems and air conditioning systems with all related piping and auxiliaries to provide a satisfactory installation;

(e) Water supply, sewage and drainage with all lines, risers, catch basins, manholes and cleanouts clearly indicated as to location, size, capacities, etc., and location and dimensions of septic tank and disposal field; and (f) Color coding to show clearly supply, return and exhaust systems.

(13) Electrical drawings shall include where applicable:

(a) A seal, certifying that all electrical work and equipment is in compliance with all applicable codes and that all materials are currently listed by recognized testing laboratories;

(b) All electrical wiring, outlets, riser diagrams, switches, special electrical connections, electrical service entrance with service switches, service feeders and characteristics of the light and power current, and transformers when located within the building;

(d) Color coding to show all items on emergency power;

(e) Circuit breakers that are properly labeled; and (f) Ground-Fault Circuit Interrupters (GFCI) that are required in all wet areas, such as kitchens, laundries, janitor closets, bath and toilet rooms, etc, and within six (6) feet of any lavatory.

(14) The electrical drawings shall not include knob and tube wiring, shall not include electrical cords that have splices, and shall not show that the electrical system is overloaded.

(15) In all new facilities or renovations to existing electrical systems, the installation must be approved by an inspector or agency authorized by the State Fire Marshal.

(16) Sprinkler drawings shall include where applicable:

(a) Shop drawings, hydraulic calculations, and manufacturer cut sheets;

(b) Site plan showing elevation of fire hydrant to building, test hydrant, and flow data (data from within a 12-month period); and (c) Show “Point of Service” where water is used exclusively for fire protection purposes.

(17) The licensed contractor shall not install a system of water supply, plumbing, sewage, garbage or refuse disposal nor materially alter or extend any existing system until the architect or engineer submits complete plans and specifications for the installation, alteration or extension, to the Commission demonstrating that all applicable codes have been met and the Commission has granted necessary approval.

(a) Before the hospital is used, Tennessee Department of Environment and Conservation shall approve the water supply system.

(b) Sewage shall be discharged into a municipal system or approved package system where available; otherwise, the sewage shall be treated and disposed of in a manner of operation approved by the Department of Environment and Conservation and shall comply with existing codes, ordinances and regulations which are enforced by cities, counties or other areas of local political jurisdiction.

(c) Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times. Hot water at shower, bathing and hand washing facilities shall be between 105°F and 115°F.

(18) It shall be demonstrated through the submission of plans and specifications that in each hospital:

(a) A negative air pressure shall be maintained in the soiled utility area, toilet room, janitor’s closet, dishwashing and other such soiled spaces, and a positive air pressure shall be maintained in all clean areas including, but not limited to, clean linen rooms and clean utility rooms;

(b) Rooms and areas containing radiation producing machines or radioactive material must have primary and/or secondary barriers to assure compliance with Regulations for Protection Against Radiation and security for materials. Radiation material shall be required to be stored and security must be provided in accordance with federal and state regulations to prevent exposure of the material to theft or tampering.

(19) When constructing new facilities or during major renovations to the operating suites, the hospital shall ensure that male and female physicians and staff have equitable proportional locker facilities including equal equipment, and similar amenities, with equal access to uniforms. Existing hospitals shall strive to have equitable male and female facilities. If physical changes are required, the additional areas shall maintain the flow and divisions in the sterile environments.

(20) The Commission shall acknowledge that it has reviewed plans and specifications in writing with copies sent to the project architect, the project engineer, the owner, the manager or other executive of the institution. The Commission may modify the distribution of such review at its discretion.

(21) In the event submitted materials do not appear to satisfactorily comply with 0720-14-.08(2), the Commission shall furnish a letter to the party submitting the plans which shall list the particular items in question and request further explanation and/or confirmation of necessary modifications.

(22) The licensed contractor shall execute all construction in accordance with the approved plans and specifications.

(23) If construction begins within one hundred eighty (180) days of the date of Commission approval, the Commission’s written notification of satisfactory review constitutes compliance with 0720-14-.08(2). This approval shall in no way permit and/or authorize any omission or deviation from the requirements of any restrictions, laws, regulations, ordinances, codes or rules of any responsible agency.

(24) Prior to final inspection a CD Rom disc, in TIF or PDF format, of the final approved plans including all shop drawings, sprinkler, calculations, hood and duct, addenda, specifications, etc., shall be submitted to the Commission.

(25) The Commission requires the following alarms that shall be monitored twenty-four (24) hours per day:

(a) Fire alarms;

(b) Generators (if applicable); and (c) Medical gas alarms (if applicable).

(26) Each hospital shall ensure that an emergency keyed lock box is installed next to each bank of functioning elevators located on the main level. Such lock boxes shall be permanently mounted seventy-two inches (72”) from the floor to the center of the box, be operable by a universal key no matter where such box is located, and shall contain only fire service keys and drop keys to the appropriate elevators.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-216, and 68- 11-261.
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Amendment filed February 18, 2003; effective May 4, 2003. Repeal and new rule filed September 6, 2005; effective November 20, 2005. Amendment filed February 23, 2007; effective May 9, 2007. Repeal and new rule filed December 20, 2011; effective March 19, 2012. Amendment filed January 21, 2016; effective April 20, 2016. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.09 LIFE SAFETY

(1) Any hospital which complies with the required applicable building and fire safety regulations at the time the Commission adopts new codes or regulations will, so long as such compliance is maintained (either with or without waivers of specific provisions), be considered to be in compliance with the requirements of the new codes or regulations.

(2) The hospital shall provide fire protection by the elimination of fire hazards, by the installation of necessary fire fighting equipment and by the adoption of a written fire control plan. Fire drills shall be held at least quarterly for each work shift for hospital personnel in each separate patient-occupied hospital building. There shall be a written report documenting the evaluation of each drill and the action recommended or taken for any deficiencies found.

Records which document and evaluate these drills must be maintained for at least three (3) years. All fires which result in a response by the local fire department shall be reported to the Commission within seven (7) days. The report shall contain sufficient information to ascertain the nature and location of the fire, its probable cause and any injuries incurred by any person or persons as a result of the fire. Initial reports by the facility may omit the name(s) of patient(s) and parties involved, however, should the Commission find the identities of such persons to be necessary to an investigation, the facility shall provide such information.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-216.
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Amendments filed September 6, 2005; effective November 20, 2005. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.10 INFECTIOUS WASTE AND HAZARDOUS WASTE

(1) Each hospital must develop, maintain and implement written policies and procedures for the definition and handling of its infectious and hazardous wastes. These policies and procedures must comply with the standards of this section and all other applicable state and federal regulations.

(2) The following waste shall be considered to be infectious waste:

(a) Waste contaminated by patients who are isolated due to communicable disease, as provided in the U.S. Centers for Disease Control “Guidelines for Isolation Precautions in Hospitals”;

(b) Cultures and stocks of infectious agents including specimen cultures collected from medical and pathological laboratories, cultures and stocks of infectious agents from research and industrial laboratories, waste from the production of biologicals, discarded live and attenuated vaccines, culture dishes and devices used to transfer, inoculate, and mix cultures;

(d) Pathological waste, such as tissues, organs, body parts, and body fluids that are removed during surgery and autopsy;

(e) All discarded sharps (e.g., hypodermic needles, syringes, pasteur pipettes, broken glass, scalpel blades) used in patient care or which have come into contact with infectious agents during use in medical, research, or industrial laboratories;

(f) Contaminated carcasses, body parts, and bedding of animals that were exposed to pathogens in research, in the production of biologicals, or in the in vivo testing of pharmaceuticals; and (g) Other waste determined to be infectious by the facility in its written policy.

(3) Infectious and hazardous waste must be segregated from other waste at the point of generation (i.e., the point at which the material becomes a waste) within the facility.

(4) Waste must be packaged in a manner that will protect waste handlers and the public from possible injury and disease that may result from exposure to the waste. Such packaging must provide for containment of the waste from the point of generation up to the point of storage, proper treatment or disposal. Packaging must be selected and utilized for the type of waste the package will contain, how the waste will be treated and disposed, and how it will be handled and transported or stored prior to treatment and disposal.

(a) Contaminated sharps must be directly placed in leakproof, rigid, and puncture-resistant containers which must then be tightly sealed;

(b) Whether disposable or reusable, all containers, bags, and boxes used for containment and disposal of infectious waste must be conspicuously identified. Packages containing infectious waste which pose additional hazards (e.g., chemical, radiological) must also be conspicuously identified to clearly indicate those additional hazards;

(c) Reusable containers for infectious waste must be thoroughly disinfected each time they are emptied, unless the surfaces of the containers have been completely protected from contamination by disposable fluid resistant liners or other devices removed with the waste; and (d) Opaque packaging must be used for pathological waste.

(5) After packaging, waste must be handled and transported by methods ensuring containment and preserving the integrity of the packaging, including the use of secondary containment where necessary.

(a) Infectious waste must not be compacted or ground (i.e., in a mechanical grinder) prior to treatment, except that pathological waste may be ground prior to disposal; and (b) Plastic bags of infectious waste must be transported by hand.

(a) Waste must be stored in a manner and location which affords protection from animals, precipitation, wind, and direct sunlight, does not present a safety hazard, does not provide a breeding place or food source for insects or rodents and does not create a nuisance.

(b) Pathological waste must be promptly treated, disposed of, or placed into refrigerated storage.

(7) In the event of spills, ruptured packaging, or other incidents where there is a loss of containment of waste, the facility must ensure that proper actions are immediately taken to:

(a) Isolate the area from the public and all except essential personnel;

(b) To the extent practicable, repackage all spilled waste and contaminated debris in accordance with the requirements of paragraph (6) of this section;

(c) Sanitize all contaminated equipment and surfaces appropriately. Written policies and procedure must specify how this will be done; and (d) Complete incident report and maintain copy on file.

(8) Except as provided otherwise in this section a facility must treat or dispose of infectious waste by one or more of the methods specified in this part.

(a) A facility may treat infectious waste in an on-site sterilization or disinfection device, or in an incinerator or a steam sterilizer, which has been designed, constructed, operated and maintained so that infectious waste treated in such a device are rendered noninfectious and is, if applicable, authorized for that purpose pursuant to current rules of the Department of Environment and Conservation. A valid permit or other written evidence of having complied with the Tennessee Air Pollution Control Regulations shall be available for review, if required. Each sterilizing or disinfection cycle must contain appropriate indicators to assure conditions were met for proper sterilization or disinfection of materials included in the cycle, and records kept. Proper operation of such devices must be verified at least monthly, and records of these monthly checks shall be available for review. Waste that contains toxic chemicals that would be volatilized by steam must not be treated in steam sterilizers. Infectious waste that has been rendered to a carbonized or mineralized ash shall be deemed non-infectious.

Unless otherwise hazardous and subject to the hazardous waste management requirements of the current rules of the Department of Environment and Conservation, such ash shall be disposable as a (non-hazardous) solid waste under current rules of the Department of Environment and Conservation.

(b) The facility may discharge liquid or semi-liquid infectious waste to the collection sewerage system of a wastewater treatment facility which is subject to a permit pursuant to T.C.A. §§ 69-3-101, et seq., provided that such discharge is in accordance with any applicable terms of that permit and/or any applicable municipal sewer use requirements.

(c) Any health care facility accepting waste from another state must promptly notify the Department of Environment and Conservation, county, and city public health agencies, and must strictly comply with all applicable local, state and federal regulations.

(9) The facility may have waste transported off-site for storage, treatment, or disposal. Such arrangements must be detailed in a written contract, available for review. If such off-site location is located within Tennessee, the facility must ensure that it has all necessary state and local approvals, and such approvals shall be available for review. If the off-site location is within another state, the facility must notify in writing all public health agencies with jurisdiction that the location is being used for management of the facility’s waste. Waste shipped off-site must be packaged in accordance with applicable federal and state requirements. Waste transported to a sanitary landfill in this state must meet the requirements of current rules of the Department of Environment and Conservation.

(10) Human anatomical remains which are transferred to a mortician for cremation or burial shall be exempt from the requirements of this subparagraph. Any other human limbs and recognizable organs must be incinerated or discharged (following grinding) to the sewer.

(11) All garbage, trash and other non-infectious waste shall be stored, transported, and disposed of in a manner that must not permit the transmission of disease, create a nuisance, provide a breeding place for insects and rodents, or constitute a safety hazard. All containers for waste shall be water tight, constructed of easily cleanable material and shall be kept on elevated platforms.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-216.
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-14-.11 RECORDS AND REPORTS

(1) A report listing all births, deaths and reportable fetal deaths which have occurred in the hospital shall be filed with the local registrar in the county where the institution is located or as otherwise directed by the State Registrar. The report shall be filed on the third (3rd) day of the month after the month in which the event occurred on a form or in a format prescribed by the State Registrar. If no birth, death or reportable fetal death occurred in the hospital, the report should be filed to indicate that fact.

(2) A Certificate of Live Birth shall be prepared for each live birth which occurred in the hospital or en route thereto on a form or in a format prescribed by the State Registrar and submitted to the State Registrar within ten (10) days of the birth.

(3) Immediately before or after the birth of a child to an unmarried woman in the facility, an authorized representative of the facility shall provide the mother, and if present, the biological father:

(a) Written information concerning the benefits, rights and responsibilities of establishing paternity for the child, as provided to the hospital by the Tennessee Department of Human Services;

(b) An Acknowledgment of Paternity Form provided by the Tennessee Department of Health; and (c) The opportunity to complete and submit to the hospital the Acknowledgment Form. The original, signed Acknowledgment of Paternity Form shall be submitted with the original birth certificate as directed by the State Registrar. A duplicate original Acknowledgment of Paternity Form shall be filed with the juvenile court of the county where the mother resides. Copies of the Acknowledgment Form shall be provided to the mother and the father of the child.

(4) A report of fetal death shall be completed by the hospital for each dead fetus delivered where the fetus weighs three hundred fifty (350) grams or more, or in the absence of weight, is of twenty (20) completed weeks of gestation or more. The report shall be in a form or format approved by the State Registrar and shall be submitted to the Tennessee Department of Health’s Office of Vital Records within ten (10) days of the delivery.

(5) Hospitals shall submit their Joint Annual Report data within one hundred and fifty (150) days after the end of each hospital’s fiscal year and within one hundred and five (105) days after closure or a change in ownership. Hospitals shall also submit to the Tennessee Department of Health, at the same time the hospital sends the signed paper copy of the report, a notarized statement from the hospital’s chief financial officer stating that the financial data reported on the Joint Annual Report is consistent with the audited financials for the hospital for that reporting year. The notarized statement shall also be attested to by the chief executive officer of the submitting hospital.

(6) Hospitals that fail to file their joint annual report timely or that file a joint annual report that does not include all of the required data elements or includes data that does not pass the Commission’s edits shall receive a deficiency from the Commission. Within ten (10) calendar days, the hospital shall be required to return a plan of correction indicating: how the deficiency will be corrected; the date upon which each deficiency will be corrected; what measures or systemic changes will be put in place to ensure that the deficient practice does not recur; and how the corrective action will be monitored to ensure the deficient practice does not recur. Either failure to submit a plan of correction in a timely manner or a finding by the Commission that the plan of correction is unacceptable shall subject the hospital’s license to possible disciplinary action.

(7) The hospital shall report each case of communicable disease to the local county health officer in the manner provided by existing regulations. Repeated failure to report communicable diseases shall be cause for a revocation of a hospital license.

(8) The hospital shall report all incidents of abuse, neglect, and misappropriation to the Commission in accordance with T.C.A. § 68-11-211.

(9) The hospital shall report the following incidents to the Commission in accordance with T.C.A. § 68-11-211.

(a) Strike by staff at the facility;

(b) External disasters impacting the facility;

(c) Disruption of any service vital to the continued safe operation of the hospital or to the health and safety of its patients and personnel; and (d) Fires at the hospital that disrupt the provision of patient care services or cause harm to the patients or staff, or that are reported by the facility to any entity, including but not limited to a fire department charged with preventing fires.

(10) The hospital shall report information contained in the medical records of patients who have cancer or pre-cancerous or tumorous diseases as provided by existing regulations. These reports shall be sent to the Cancer Reporting System of the Tennessee Department of Health on a quarterly schedule no later than six (6) months after the date of the diagnosis or treatment.

(11) The hospital shall report, at least quarterly to the Commission, claims data on the UB-04 form or its successor for all discharges from the facility.

(12) The hospital shall report to the Commission information regarding treatment of traumatic brain injuries. The report must be submitted on a form provided by the Commission and must include the following information:

(a) Name, age, and residence of the injured person; and (b) Other information as requested by the Commission which is currently available and collected by computer in the medical records department of the treating hospital.

(13) The hospital shall retain legible copies of the following records and reports in the facility in a single file for thirty-six (36) months following their issuance and shall be made available for inspection during normal business hours to any patient who requests to view them:

(a) Local fire safety inspections;

(b) Local building code inspections, if any;

(d) Commission licensure and fire safety inspections and surveys;

(e) Commission quality assurance surveys, including follow-up visits, and certification inspections, if any;

(f) Federal Health Care Financing Administration surveys and inspections, if any;

(g) Orders of the Commission, if any;

(h) Comptroller of the Treasury’s audit reports and finding, if any; and (i) Maintenance records of all safety equipment.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-3-102, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11- 209, 68-11-210, 68-11-211, 68-11-213, and 68-11-310.
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed May 24, 2004; effective August 7, 2004. Amendment filed September 6, 2005; effective November 20, 2005. Amendment filed February 23, 2007; effective May 9, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.12 PATIENT RIGHTS

(1) Each patient has at least the following rights:

(a) To privacy in treatment and personal care;

(b) To be free from mental and physical abuse. Should this right be violated, the facility must notify the Commission within five (5) working days. The Tennessee Department of Human Services, Adult Protection Services shall be notified immediately as required in T.C.A. § 71-6-103;

(c) To refuse treatment. The patient must be informed of the consequences of that decision, the refusal and its reason must be reported to the physician and documented in the medical record;

(e) To have their records kept confidential and private. Written consent by the patient must be obtained prior to release of information except to persons authorized by law. If the patient lacks capacity, written consent is required from the patient’s health care decision-maker. The hospital must have policies to govern access and duplication of the patient’s record;

(f) To have access to a phone number to call if there are questions or complaints about care;

(g) To have appropriate assessment and management of pain; and (h) To be involved in the decision-making of all aspects of their care.

(2) Each patient has a right to self-determination, which encompasses the right to make choices regarding life-sustaining treatment (including resuscitative services). This right of selfdetermination may be effectuated by an advance directive.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-216.
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendments filed September 6, 2005; effective November 20, 2005. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.13 POLICIES AND PROCEDURES FOR HEALTH CARE DECISION-MAKING

(1) Pursuant to this rule, each hospital shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a patient who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from individual patients. An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.

(2) An adult or emancipated minor may execute an advance directive for health care. The advance directive may authorize an agent to make any health care decision the patient could have made while having capacity, or may limit the power of the agent, and may include individual instructions. The effect of an advance directive that makes no limitation on the agent’s authority shall be to authorize the agent to make any health care decision the patient could have made while having capacity.

(3) The advance directive shall be in writing, signed by the patient, and shall either be notarized or witnessed by two (2) witnesses. Both witnesses shall be competent adults, and neither of them may be the agent. At least one (1) of the witnesses shall be a person who is not related to the patient by blood, marriage, or adoption and would not be entitled to any portion of the estate of the patient upon the death of the patient. The advance directive shall contain a clause that attests that the witnesses comply with the requirements of this paragraph.

(4) Unless otherwise specified in an advance directive, the authority of an agent becomes effective only upon a determination that the patient lacks capacity, and ceases to be effective upon a determination that the patient has recovered capacity.

(5) A facility may use any advanced directive form that meets the requirements of the Tennessee Health Care Decisions Act or has been developed and issued by the Commission.

(6) A determination that a patient lacks or has recovered capacity, or that another condition exists that affects an individual instruction or the authority of an agent shall be made by the designated physician, who is authorized to consult with such other persons as he or she may deem appropriate.

(7) An agent shall make a health care decision in accordance with the patient’s individual instructions, if any, and other wishes to the extent known to the agent. Otherwise, the agent shall make the decision in accordance with the patient’s best interest. In determining the patient’s best interest, the agent shall consider the patient’s personal values to the extent known.

(8) An advance directive may include the individual’s nomination of a court-appointed guardian.

(9) A health care facility shall honor an advance directive that is executed outside of this state by a nonresident of this state at the time of execution if that advance directive is in compliance with the laws of Tennessee or the state of the patient’s residence.

(10) No health care provider or institution shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care.

(11) Any living will, durable power of attorney for health care, or other instrument signed by the individual, complying with the terms of Tennessee Code Annotated, Title 32, Chapter 11, and a durable power of attorney for health care complying with the terms of Tennessee Code Annotated, Title 34, Chapter 6, Part 2, shall be given effect and interpreted in accord with those respective acts. Any advance directive that does not evidence an intent to be given effect under those acts but that complies with these regulations may be treated as an advance directive under these regulations.

(12) A patient having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.

(13) A patient having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke.

(14) A decree of annulment, divorce, dissolution of marriage, or legal separation revokes a previous designation of a spouse as an agent unless otherwise specified in the decree or in an advance directive.

(15) An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.

(16) Surrogates.

(a) An adult or emancipated minor may designate any individual to act as surrogate by personally informing the supervising health care provider. The designation may be oral or written.

(b) A surrogate may make a health care decision for a patient who is an adult or emancipated minor if and only if:

The patient has been determined by the designated physician to lack capacity, and 2. No agent or guardian has been appointed, or 3. The agent or guardian is not reasonably available.

(c) In the case of a patient who lacks capacity, the patient’s surrogate shall be identified by the supervising health care provider and documented in the current clinical record of the facility at which the patient is receiving health care.

(d) The patient’s surrogate shall be an adult who has exhibited special care and concern for the patient, who is familiar with the patient’s personal values, who is reasonably available, and who is willing to serve.

(e) Consideration may be, but need not be, given in order of descending preference for service as a surrogate to:

The patient’s spouse, unless legally separated;
The patient’s adult child;
The patient’s parent;
The patient’s adult sibling;
Any other adult relative of the patient; or 6. Any other adult who satisfies the requirements of 0720-14-.13(16)(d).

(f) No person who is the subject of a protective order or other court order that directs that person to avoid contact with the patient shall be eligible to serve as the patient’s surrogate.

(g) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:

Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the patient or in accordance with the patient’s best interests;
The proposed surrogate’s regular contact with the patient prior to and during the incapacitating illness;
The proposed surrogate’s demonstrated care and concern;
The proposed surrogate’s availability to visit the patient during his or her illness; and 5. The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.

(h) If the patient lacks capacity and none of the individuals eligible to act as a surrogate under 0720-14-.13(16)(c) through 0720-14-.13(16)(g) is reasonably available, the designated physician may make health care decisions for the patient after the designated physician either:

Consults with and obtains the recommendations of a facility’s ethics mechanism or standing committee in the facility that evaluates health care issues; or 2. Obtains concurrence from a second physician who is not directly involved in the patient’s health care, does not serve in a capacity of decision-making, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.

(i) In the event of a challenge, there shall be a rebuttable presumption that the selection of the surrogate was valid. Any person who challenges the selection shall have the burden of proving the invalidity of that selection.

(j) A surrogate shall make a health care decision in accordance with the patient’s individual instructions, if any, and other wishes to the extent known to the surrogate.

Otherwise, the surrogate shall make the decision in accordance with the surrogate’s determination of the patient’s best interest. In determining the patient’s best interest, the surrogate shall consider the patient’s personal values to the extent known to the surrogate.

(k) A surrogate who has not been designated by the patient may make all health care decisions for the patient that the patient could make on the patient’s own behalf, except that artificial nutrition and hydration may be withheld or withdrawn for a patient upon a decision of the surrogate only when the designated physician and a second independent physician certify in the patient’s current clinical records that the provision or continuation of artificial nutrition or hydration is merely prolonging the act of dying and the patient is highly unlikely to regain capacity to make medical decisions.

(l) Except as provided in 0720-14-.13(16)(m):

Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution nor an employee of an operator of a health care institution may be designated as a surrogate; and 2. A health care provider or employee of a health care provider may not act as a surrogate if the health care provider becomes the patient’s treating health care provider.

(m) An employee of the treating health care provider or an employee of an operator of a health care institution may be designated as a surrogate if:

The employee so designated is a relative of the patient by blood, marriage, or adoption; and 2. The other requirements of this section are satisfied.

(n) A health care provider may require an individual claiming the right to act as surrogate for a patient to provide written documentation stating facts and circumstances reasonably sufficient to establish the claimed authority.

(17) Guardian.

(a) A guardian shall comply with the patient’s individual instructions and may not revoke the patient’s advance directive absent a court order to the contrary.

(b) Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.

(c) A health care provider may require an individual claiming the right to act as guardian for a patient to provide written documentation stating facts and circumstances reasonably sufficient to establish the claimed authority.

(18) A designated physician who makes or is informed of a determination that a patient lacks or has recovered capacity, or that another condition exists which affects an individual instruction or the authority of an agent, guardian, or surrogate, shall promptly record the determination in the patient’s current clinical record and communicate the determination to the patient, if possible, and to any person then authorized to make health care decisions for the patient.

(19) Except as provided in 0720-14-.13(20) through 0720-14-.13(22), a health care provider or institution providing care to a patient shall:

(a) Comply with an individual instruction of the patient and with a reasonable interpretation of that instruction made by a person then authorized to make health care decisions for the patient; and (b) Comply with a health care decision for the patient made by a person then authorized to make health care decisions for the patient to the same extent as if the decision had been made by the patient while having capacity.

(20) A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.

(21) A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:

(a) Contrary to a policy of the institution which is based on reasons of conscience, and (b) The policy was timely communicated to the patient or to a person then authorized to make health care decisions for the patient.

(22) A health care provider or institution may decline to comply with an individual instruction or health care decision that requires medically inappropriate health care or health care contrary to generally accepted health care standards applicable to the health care provider or institution.

(23) A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 0720-14-.13(20) through 0720-14-.13(22) shall:

(a) Promptly so inform the patient, if possible, and any person then authorized to make health care decisions for the patient;

(b) Provide continuing care to the patient until a transfer can be effected or until the determination has been made that transfer cannot be effected;

(c) Unless the patient or person then authorized to make health care decisions for the patient refuses assistance, immediately make all reasonable efforts to assist in the transfer of the patient to another health care provider or institution that is willing to comply with the instruction or decision; and (d) If a transfer cannot be effected, the health care provider or institution shall not be compelled to comply.

(24) Unless otherwise specified in an advance directive, a person then authorized to make health care decisions for a patient has the same rights as the patient to request, receive, examine, copy, and consent to the disclosure of medical or any other health care information.

(25) A health care provider or institution acting in good faith and in accordance with generally accepted health care standards applicable to the health care provider or institution is not subject to civil or criminal liability or to discipline for unprofessional conduct for:

(a) Complying with a health care decision of a person apparently having authority to make a health care decision for a patient, including a decision to withhold or withdraw health care;

(b) Declining to comply with a health care decision of a person based on a belief that the person then lacked authority; or (c) Complying with an advance directive and assuming that the directive was valid when made and had not been revoked or terminated.

(26) An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.

(27) A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for such identification made in good faith.

(28) A copy of a written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.

(29) The withholding or withdrawal of medical care from a patient in accordance with the provisions of the Tennessee Health Care Decisions Act shall not, for any purpose, constitute a suicide, euthanasia, homicide, mercy killing, or assisted suicide.

(30) Physician Orders for Scope of Treatment (POST).

(a) Physician Orders for Scope of Treatment (POST) may be issued by a physician for a patient with whom the physician has a bona fide physician-patient relationship, but only:

With the informed consent of the patient;
If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or 3. If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available, if the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

(b) A POST may be issued by a physician assistant, nurse practitioner or clinical nurse specialist for a patient with whom such physician assistant, nurse practitioner or clinical nurse specialist has a bona fide physician assistant-patient or nurse-patient relationship, but only if:

No physician, who has a bona fide physician-patient relationship with the patient, is present and available for discussion with the patient (or if the patient is a minor or is otherwise incapable of making an informed decision, with the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act);
Such authority to issue is contained in the physician assistant’s, nurse practitioner’s or clinical nurse specialist’s protocols;
Either:

(i) The patient is a resident of a nursing home licensed under Title 68 or an ICF/MR facility licensed under Title 33 and is in the process of being discharged from the nursing home or transferred to another facility at the time the POST is being issued; or (ii) The patient is a hospital patient and is in the process of being discharged from the hospital or transferred to another facility at the time the POST is being issued; and 4. Either:

(i) With the informed consent of the patient;

(ii) If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or (iii) If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available and such authority to issue is contained in the physician assistant, nurse practitioner or clinical nurse specialist’s protocols and the physician assistant or nurse determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

(c) If the patient is an adult who is capable of making an informed decision, the patient’s expression of the desire to be resuscitated in the event of cardiac or respiratory arrest shall revoke any contrary order in the POST. If the patient is a minor or is otherwise incapable of making an informed decision, the expression of the desire that the patient be resuscitated by the person authorized to consent on the patient’s behalf shall revoke any contrary order in the POST. Nothing in this section shall be construed to require cardiopulmonary resuscitation of a patient for whom the physician or physician assistant or nurse practitioner or clinical nurse specialist determines cardiopulmonary resuscitation is not medically appropriate.

(d) A POST issued in accordance with this section shall remain valid and in effect until revoked. In accordance with this rule and applicable regulations, qualified emergency medical services personnel; and licensed health care practitioners in any facility, program, or organization operated or licensed by the Commission, the Department of Mental Health and Substance Abuse Services, or the Department of Disability and Aging, or operated, licensed, or owned by another state agency, shall follow a POST that is available to such persons in a form approved by the Commission.

(e) Nothing in these rules shall authorize the withholding of other medical interventions, such as medications, positioning, wound care, oxygen, suction, treatment of airway obstruction or other therapies deemed necessary to provide comfort care or alleviate pain.

(f) If a person has a do-not-resuscitate order in effect at the time of such person’s discharge from a health care facility, the facility shall complete a POST prior to discharge. If a person with a POST is transferred from one health care facility to another health care facility, the health care facility initiating the transfer shall communicate the existence of the POST to qualified emergency medical service personnel and to the receiving facility prior to the transfer. The transferring facility shall provide a copy of the POST that accompanies the patient in transport to the receiving health care facility. Upon admission, the receiving facility shall make the POST a part of the patient’s record.

(g) These rules shall not prevent, prohibit, or limit a physician from using a written order, other than a POST, not to resuscitate a patient in the event of cardiac or respiratory arrest in accordance with accepted medical practices. This action shall have no application to any do-not-resuscitate order that is not a POST, as defined in these rules.

(h) Valid do-not-resuscitate orders or emergency medical services do-not-resuscitate orders issued before July 1, 2004, pursuant to then-current law, shall remain valid and shall be given effect as provided in these rules.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-211, 68-11- 224, and 68-11-1801 through 68-11-1816.
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Amendment filed April 28, 2003; effective July 12, 2003. Repeal and new rule filed September 6, 2005; effective November 20, 2005. Amendment filed February 7, 2007; effective April 23, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed January 8, 2026; effective April 8, 2026.

Tenn. Comp. R. & Regs. 0720-14-.14 DISASTER PREPAREDNESS

(1) Emergency Electrical Power.

(a) All hospitals must have one or more on-site electrical generators which are capable of providing emergency electrical power to at least all life sustaining equipment and life sustaining resources such as: ventilators; blood banks, biological refrigerators, safety switches for boilers, safety lighting for corridors and stairwells and other essential equipment.

(b) Connections shall be through a switch which shall automatically transfer the circuits to the emergency power source in case of power failure. (It is recognized that some equipment may not sustain automatic transfer and provisions will have to be made to manually change these items from a non-emergency powered outlet to an emergency powered outlet or other power source).

(c) The emergency power system shall have a minimum of twenty-four (24) hours of either propane, natural gas, gasoline or diesel fuel. The quantity shall be based on its expected or known connected load consumption during power interruptions. In addition, the hospital shall have a written contract with an area fuel distributor which guarantees first priority service for re-fills during power interruptions.

(d) The emergency power system shall be inspected weekly and exercised and under actual load and operating temperature conditions for at least thirty (30) minutes, once each month. Records shall be maintained for all inspections and tests and kept on file for a minimum of three (3) years.

(2) Physical Facility and Community Emergency Plans.

(a) Physical Facility (Internal Situations).

Every hospital shall have a current internal emergency plan, or plans, that provides for fires, bomb threats, severe weather, utility service failures, plus any local high-risk situations such as floods, earthquakes, toxic fumes and chemical spills.
The plan(s) must include provisions for the relocation of persons within the building and/or either partial or full building evacuation. Plans that provide for the relocation of patients to other health care facilities must have written agreements for emergency transfers. Their agreements may be mutual, i.e. providing for transfers either way.
Copies of the plan(s), either complete or outlines, including specific emergency telephone numbers related to that type of disaster, shall be available to all staff.

Provisions that have security implications may be omitted from the outline versions. Familiarization information shall be included in employee orientation sessions and more detailed instructions must be included in continuing education programs. Records of orientation and education programs must be maintained for at least three (3) years.

Drills of the disaster preparedness plan shall be conducted at least once a year.

The risk focus may vary by type of drill. Drills are for the purpose of educating staff, resource determination, testing personal safety provisions and communications with other facilities and community agencies. Records which document and evaluate these drills must be maintained for at least three (3) years.

As soon as possible, real situations that result in a response by local authorities must be documented. This includes a critique of the activation of the plan. Actual documented situations that had education and training value may be substituted for a drill.

(b) Community Emergency (Mass Casualty).

Every hospital, unless exempted due to its limited scope of clinical services, shall have a plan that provides for the reception and treatment, within its capabilities, of medical emergencies resulting from a disaster within its usual service area.

The plan should consider the probability of the types of disasters which might occur, both natural and “man-made.”

The plan must provide for additional staffing, medical supplies, blood and other resources which would probably be needed. The plan must also include for the deferral of elective admission patients and also for the early transfer or discharge of some current patients if it appears that the number of casualties will exceed available staffed beds.
Copies of the plan(s), either complete or outlines, including specific emergency telephone numbers related to that type of disaster, shall be available to staff who would be assigned non-routine duties during these types of emergencies.

Familiarization information shall be included in employee orientation sessions and more detailed instruction must be included in continuing education programs. Records of orientation and education must be maintained for at least three (3) years.

At least one drill shall be conducted each year for the purpose of educating staff, resource determination, and communications with other facilities and community agencies. Records which document and evaluate these drills must be maintained for at least three (3) years.
As soon as possible, actual community emergency situations that result in the treatment of more than twenty (20) patients, or fifteen percent (15%) of the licensed bed capacity, whichever is less, must be documented. Actual situations that had education and training value may be substituted for a drill. This includes documented actual plan activation during community emergencies, even if no patients are received.

All hospitals shall establish and maintain communications with the county Emergency Management Agency. This includes the provision of the information and procedures that are needed for the local comprehensive emergency plan.

The hospitals shall cooperate, to the extent possible, in area disaster drills and local emergency situations.

Each hospital shall conduct both the physical facility and community emergency drills as required in these regulations, even if the local Emergency Management Agency is unable to participate.
A file of documents demonstrating communications and cooperation with the local agency must be maintained.

History

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed March 18, 2000; effective May 30, 2000. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.

Tenn. Comp. R. & Regs. 0720-14-.15 APPENDIX I

(1) Physician Orders for Scope of Treatment (POST) Form.

A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED

Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”)

This is a Physician Order Sheet based on the medical conditions and wishes of the person identified at right (“patient” ). Any section not Patient’s Last Name First Name/Middle Initial completed indicates full treatment for that section. When need occurs, first follow these orders, then contact physician.

Date of Birth

Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Generally avoid the intensive care unit. Treatment Plan: Basic medical treatments.  Full Treatment. In addition to care described in Comfort Measures Only and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including in the intensive care unit.

Other Instructions:

Section C Check One ARTIFICIALLY ADMINISTERED NUTRITION. Oral fluids & nutrition must be offered if feasible.  No artificial nutrition by tube.  Defined trial period of artificial nutrition by tube.  Long-term artificial nutrition by tube.

Other Instructions:

Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify)

The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other)

Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge)

MD/NP/CNS/PA Phone Number:

Signature of Patient, Parent of Minor, or Guardian/Health Care Representative Preferences have been expressed to a physician and/or health care professional. It can be reviewed and updated at any time if your preferences change. If you are unable to make your own health care decisions, the orders should reflect your preferences as best understood by your surrogate.

Name (print) Signature Relationship (write “self” if patient)

Agent/Surrogate Relationship Phone Number Health Care Professional Preparing Form Preparer Title Phone Number Date Prepared HIPAA PERMITS DISCLOSURE OF POST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY Directions for Health Care Professionals Completing POST Must be completed by a health care professional based on patient preferences, patient best interest, and medical indications.

To be valid, POST must be signed by a physician or, at discharge or transfer from a hospital or long term care facility, by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA). Verbal orders are acceptable with follow-up signature by physician in accordance with facility/community policy.

Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel.

Photocopies/faxes of signed POST forms are legal and valid.

Using POST Any incomplete section of POST implies full treatment for that section.

No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.”

Oral fluids and nutrition must always be offered if medically feasible.

When comfort cannot be achieved in the current setting, the person, including someone with “Comfort Measures Only,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).

IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”

A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.

Reviewing POST This POST should be reviewed if:

(1) The patient is transferred from one care setting or care level to another, or (2) There is a substantial change in the patient’s health status, or (3) The patient’s treatment preferences change.

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.

HIPAA PERMITS DISCLOSURE OF POST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY

(2) Advance Directive for Health Care Form.

ADVANCE DIRECTIVE FOR HEALTH CARE*

Instructions: Parts 1 and 2 may be used together or independently. Please mark out/void any unused part(s).

Part 5, Block A or Block B must be completed for all uses.

(Tennessee)

I, ____________________________________, hereby give these advance instructions on how I want to be treated by my doctors and other health care providers when I can no longer make those treatment decisions myself.

Part I Agent: I want the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my agent must follow my instructions below:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

Alternate Agent: If the person named above is unable or unwilling to make health care decisions for me, I appoint as alternate the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my agent must follow my instructions below:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.

When Effective (mark one):  I give my agent permission to make health care decisions for me at any time, even if I have capacity to make decisions for myself.  I do not give such permission (this form applies only when I no longer have capacity).

Part 2 Indicate Your Wishes for Quality of Life: By marking “yes” below, I have indicated conditions I would be willing to live with if given adequate comfort care and pain management. By marking “no” below, I have indicated conditions I would not be willing to live with (that to me would create an unacceptable quality of life).   Yes No Permanent Unconscious Condition: I become totally unaware of people or surroundings with little chance of ever waking up from the coma.   Yes No Permanent Confusion: I become unable to remember, understand, or make decisions. I do not recognize loved ones or cannot have a clear conversation with them.   Yes No Dependent in All Activities of Daily Living: I am no longer able to talk or communicate clearly or move by myself. I depend on others for feeding, bathing, dressing, and walking. Rehabilitation or any other restorative treatment will not help.   Yes No End-Stage Illnesses: I have an illness that has reached its final stages in spite of full treatment.

Examples: Widespread cancer that no longer responds to treatment; chronic and/or damaged heart and lungs, where oxygen is needed most of the time and activities are limited due to the feeling of suffocation.

Indicate Your Wishes for Treatment: If my quality of life becomes unacceptable to me (as indicated by one or more of the conditions marked “no” above) and my condition is irreversible (that is, it will not improve), I direct that medically appropriate treatment be provided as follows. By marking “yes” below, I have indicated treatment I want. By marking “no” below, I have indicated treatment I do not want.   Yes No CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it has stopped. Usually this involves electric shock, chest compressions, and breathing assistance.   Yes No Life Support/Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys, and other organs to continue to work.   Yes No Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a new condition but will not help the main illness.   Yes No Tube feeding/IV fluids: Use of tubes to deliver food and water to a patient’s stomach or use of IV fluids into a vein, which would include artificially delivered nutrition and hydration.

Part 3 Other instructions, such as hospice care, burial arrangements, etc.:

(Attach additional pages if necessary)

Part 4 Organ donation: Upon my death, I wish to make the following anatomical gift for purposes of transplantation, research, and/or education (mark one):  Any organ/tissue  My entire body  Only the following organs/tissues:  No organ/tissue donation SIGNATURE

Part 5 Your signature must either be witnessed by two competent adults (“Block A”) or by a notary public (“Block B”).

Signature: _______________________________________ Date: ____________________ (Patient)

Block A Neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.

Witnesses:

I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form.

Signature of witness number 1 2. I am a competent adult who is not named as the agent or alternate. I am not related to the patient by blood, marriage, or adoption and I would not be entitled to any portion of the patient’s estate upon his or her death under any existing will or codicil or by operation of law. I witnessed the patient’s signature on this form.

Signature of witness number 2 Block B You may choose to have your signature witnessed by a notary public instead of the witnesses described in Block A.

STATE OF TENNESSEE

COUNTY OF

I am a Notary Public in and for the State and County named above. The person who signed this instrument is personally known to me (or proved to me on the basis of satisfactory evidence) to be the person who signed as the “patient.” The patient personally appeared before me and signed above or acknowledged the signature above as his or her own. I declare under penalty of perjury that the patient appears to be of sound mind and under no duress, fraud, or undue influence.

My commission expires:

Signature of Notary Public WHAT TO DO WITH THIS ADVANCE DIRECTIVE: (1) provide a copy to your physician(s); (2) keep a copy in your personal files where it is accessible to others; (3) tell your closest relatives and friends what is in the document; and (4) provide a copy to the person(s) you named as your health care agent. * This form replaces the old forms for durable power of attorney for health care, living will, appointment of agent, and advance care plan, and eliminates the need for any of those documents.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1805.
Administrative History: Original rule filed February 16, 2007; effective May 2, 2007. Repeal and new rule filed August 28, 2012; effective November 26, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed February 8, 2017; effective May 9, 2017. Transferred from chapter 1200-08-01 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-15 Standards for Prescribed Child Care Centers (Transferred from 1200-08-02)

Tenn. Comp. R. & Regs. 0720-15-.01 DEFINITIONS

(1) Abuse. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) Administrator. The individual designated by the licensee or the governing body to be the person responsible for the day to day supervision and operation of the PCCC and may be either the licensee or the nursing director.

(3) Adult. An individual who has capacity and is at least 18 years of age.

(5) Agent. An individual designated in an advance directive for health care to make a health care decision for the individual granting the power.

(6) Board. The Tennessee Board for Licensing Health Care Facilities.

(7) Capacity. An individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. These regulations do not affect the right of a patient to make health care decisions while having the capacity to do so. A patient shall be presumed to have capacity to make a Amendments filed December 18, 2025; effective March 18, 2026.health care decision, to give or revoke an advance directive, and to designate or disqualify a surrogate. Any person who challenges the capacity of a patient shall have the burden of proving lack of capacity.

(8) Cardiopulmonary Resuscitation (CPR). The administering of any means or device to restore or support cardiopulmonary function in a child, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilators or respirations, defibrillation, the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a child where cardiac or respiratory arrest has occurred or is believed to be imminent.

(9) Certified Master Social Worker. A person currently certified as such by the Tennessee Board of Social Worker Certification and Licensure.

(10) Certified Nurse Practitioner. A person who is licensed as a registered nurse and has further been issued a certificate of fitness to prescribe and/or issue drugs by the Tennessee Board of Nursing.

(11) Certified Respiratory Technician. A person currently licensed as such by the Tennessee Board of Respiratory Care.

(12) Child or Children. A person or persons under 18 years of age.

(13) Child Care. The provision of supervision, protection, and meeting, at a minimum, the basic needs of a child for three (3) or more hours a day, but less than twenty-four (24) hours a day.

(14) Clinical Fellow. A Speech Language Pathologist who is in the process of obtaining his or her paid professional experience, as defined by a Communications Disorders and Sciences Board-approved accreditation agency, before being qualified for licensure.

(15) Commissioner. The Commissioner of the Tennessee Department of Health or his or her authorized representative.

(16) Dentist. A person currently licensed as such by the Tennessee Board of Dentistry.

(17) Department. The Tennessee Department of Health.

(18) Designated Physician. A physician designated by an individual or the individual’s agent, guardian, or surrogate, to have primary responsibility for the individual’s health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes such responsibility.

(19) Developmentally Appropriate. As defined by the National Association for the Education of Young Children, developmentally appropriate practice is the use of child development knowledge to identify the range of appropriate behaviors, activities and materials for a specific age group. This knowledge is used in conjunction with understanding about an individual child’s growth patterns, strengths, interests, and experiences to design the most appropriate learning environment. Developmentally appropriate curriculum provides for all areas of a child’s development: physical, emotional, social, and cognitive through an integrated approach.

(20) Dietitian. A person currently licensed as such by the Tennessee Board of Dietitian/Nutritionist Examiners.

(21) Do-Not-Resuscitate Order (DNR). A written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(22) Electronic Signature. The authentication of a health record document or documentation in an electronic form achieved through electronic entry of an exclusively assigned, unique identification code entered by the author of the documentation.

(23) Emancipated Minor. Any minor who is or has been married or has by court order or otherwise been freed from the care, custody and control of the minor’s parents.

(24) Emergency. Any situation or condition which presents an imminent danger of death or serious physical or mental harm to children.

(25) Emergency Responder. A paid or volunteer firefighter, law enforcement officer, or other public safety official or volunteer acting within the scope of his or her proper function under law or rendering emergency care at the scene of an emergency.

(26) Functional Assessment. An evaluation of the child’s abilities and needs related to self care, communication skills, social skills, motor skills, pre-academic areas, play with toys/objects, growth and development appropriate for age.

(27) Group. A specific number of children comprising an age range, assigned to specific staff in an assigned space, which is divided from the space of other groups by a recognizable barrier to define limits and to reduce distractions.

(28) Guardian. A judicially appointed guardian or conservator having authority to make a health care decision for an individual.

(29) Hazardous Waste. Materials whose handling, use, storage, and disposal are governed by local, state, or federal regulations.

(30) Health Care. Any care, treatment, service or procedure to maintain, diagnose, treat, or otherwise affect an individual’s physical or mental condition, and includes medical care as defined in T.C.A. § 32-11-103(5).

(31) Health Care Decision. Consent, refusal of consent or withdrawal of consent to health care.

(32) Health Care Decision-Maker. In the case of an individual who lacks capacity, the individual’s health care decision-maker is one of the following: the individual’s health care agent as specified in an advance directive, the individual’s court-appointed guardian or conservator with health care decision-making authority, the individual’s surrogate as determined pursuant to Rule 0720-15-.12 or T.C.A. § 33-3-220, the designated physician pursuant to these rules or in the case of a minor child, the person having custody or legal guardianship.

(33) Health Care Institution. A health care institution as defined in T.C.A. § 68-11-1602.

(34) Health Care Provider. A person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care in the ordinary course of business of practice of a profession.

(35) High School Diploma. As used in the context of staff qualifications, refers to a document recognizing graduation from a legally approved institution, public or private, based on the issuing state’s required number of academic credits, including passing a GED test. As used in this Chapter, a certificate or statement of attendance or similar document, or correspondence or video courses, do not qualify as a high school diploma.

(36) Holding Out to the Public. Advertising or soliciting the public through the use of personal, telephone, mail or other forms of communication to provide information about services provided by the facility.

(37) Individual Instruction. An individual’s direction concerning a health care decision for the individual.

(38) Infant. A child who is six (6) weeks through fifteen (15) months of age.

(39) Infectious Waste. Solid or liquid wastes which contain pathogens with sufficient virulence and quantity such that exposure to the waste by a susceptible host could result in an infectious disease.

(40) Licensee. The person or entity to whom the license is issued. The licensee is held responsible for compliance with all rules and regulations.

(41) Licensed Clinical Social Worker. A person currently licensed as such by the Tennessee Board of Social Workers.

(42) Licensed Practical Nurse. A person currently licensed as such by Tennessee Board of Nursing.

(43) Medical Emergency. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the child’s health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part, which includes labor when delivery is imminent, when there is inadequate time to effect safe transfer to a hospital prior to delivery, or when a transfer may pose a threat to the health and safety of the child or the unborn child.

(44) Medical Record. Medical histories, records, reports, summaries, diagnoses, prognoses, records of treatment and medication ordered and given, entries, x-rays, radiology interpretations, and other written electronics, or graphic data prepared, kept, made or maintained in a facility that pertains to confinement or services rendered to patients admitted or receiving care.

(45) Medically Inappropriate Treatment. Resuscitation efforts that cannot be expected either to restore cardiac or respiratory function to the patient or other medical or surgical treatments to achieve the expressed goals of the informed patient. In the case of the incompetent patient, the patient’s representative expresses the goals of the patient.

(46) Mid-Level Practitioner. A certified nurse practitioner or a licensed physician assistant.

(47) Misappropriation of Patient/Resident Property. The deliberate misplacement, exploitation or wrongful, temporary or permanent use of an individual’s belongings or money without the individual’s consent.

(48) Neglect. The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; however, the withholding of authorization for or provision of medical care to any terminally ill person who has executed an irrevocable living will in accordance with the Tennessee Right to Natural Death Law, or other applicable state law, if the provision of such medical care would conflict with the terms of the living will, shall not be deemed “neglect” for purposes of these rules.

(49) N.F.P.A. The National Fire Protection Association.

(50) Nursing Director. A licensed registered nurse providing continuous supervision of PCCC services and managing the operations of the facility.

(51) Occupational Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(52) Occupational Therapy Assistant. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(53) Optometrist. A person currently licensed as such by the Tennessee Board of Optometry.

(54) Parent. A biological, legal or adoptive parent, guardian, or a legal or physical custodian who has primary responsibility for a child.

(55) Person. An individual, corporation, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency, or instrumentality, or any other legal or commercial entity.

(56) Personally Informing. A communication by any effective means from the patient directly to a health care provider.

(57) Pharmacist. A person currently licensed as such by the Tennessee Board of Pharmacy.

(58) Physical Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(59) Physical Therapy Assistant. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(60) Physician. An individual authorized to practice medicine or osteopathy under Tennessee Code Annotated, Title 63, Chapters 6 or 9.

(61) Physician Assistant. A person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(62) Physician Orders for Scope of Treatment or POST. Written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(63) Plan of Care. The comprehensive plan for implementation of medical, nursing, psychosocial, developmental, and educational therapies to be provided upon admission and shall include necessary equipment to meet the child’s need, and the plan will be revised to include recommended changes in the therapeutic plans. The disposition to be followed in the event of emergency situations will be specified in the Plan of Care.

(64) Podiatrist. A person currently licensed as such by the Tennessee Board of Registration in Podiatry.

(65) Power of Attorney for Health Care. The designation of an agent to make health care decisions for the individual granting the power under T.C.A. Title 34, Chapter 6, Part 2.

(66) Prescribed Child Care Center (PCCC). A nonresidential child care, health care/child care center providing physician prescribed services and appropriate developmental services for six (6) or more children who are medically and/or technology dependent and require continuous nursing intervention. Child care for purposes of this section means the provision of supervision, protection, and meeting the basic needs of children, who are not related to the primary caregivers, for three (3) or more hours a day, but less than twenty-four (24) hours a day. As part of the continuum of care for medically dependent children, the center provides a triad of medically necessary services: skilled nursing care, developmental programming, and parental training. Prescribed child care (PCCC) provides a less restrictive alternative to hospitalization and reduces the isolation often experienced by the homebound, medically dependent child and family. The purpose of prescribed childcare is health care, but does not exclude other services.

(67) Psychologist. A person currently licensed as such by the Tennessee Board of Examiners in Psychology.

(68) Qualified Emergency Medical Service Personnel. Includes, but shall not be limited to, emergency medical technicians, paramedics, or other emergency services personnel, providers, or entities acting within the usual course of their professions, and other emergency responders.

(69) Reasonably Available. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the child’s health care needs. Such availability shall include, but not be limited to, availability by telephone.

(70) Registered Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(71) Registered Respiratory Therapist. A person currently licensed as such by the Tennessee Board of Respiratory Care.

(72) Shall or Must. Compliance is mandatory.

(73) Social Worker. A person who has at least a bachelor’s degree in Social Work or related field, and preferably, two (2) years medical social work or other community based work experience.

(74) Speech Language Pathologist. As defined in T.C.A. § 63-17-103, a person currently licensed as such by the Tennessee Board of Communications Disorders and Sciences.

(75) State. A state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States.

(76) Supervising Health Care Provider. The designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual’s health care.

(77) Surrogate. An individual, other than a patient’s agent or guardian, authorized to make a health care decision for the patient.

(78) Toddler. A child who is sixteen (16) months through thirty (30) months of age.

(79) Treating Health Care Provider. A health care provider who at the time is directly or indirectly involved in providing health care to the child.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11- 211, 68-11-216, 68-11-224, and 68-11-1802.
Administrative History: Original rule certified June 7, 1974. Amendment filed July 3, 1984; effective August 1, 1984. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Amendment filed April 1, 1992; effective May 16, 1992. Amendment filed January 6, 1995; effective March 22, 1995. Repeal filed March 18, 2000; effective May 30, 2000. New rule filed June 13, 2002; effective August 27, 2002. Amendment filed May 16, 2006; effective July 30, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendment filed September 15, 2015; effective December 14, 2015. Transferred from chapter 1200-08-02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-15-.02 LICENSING PROCEDURES

(2) In order to make application for a license:

(a) The applicant shall submit an application on a form prepared by the department.

(b) Each applicant for a license, with the exception of the U.S. Government, the State of Tennessee or local government, shall pay an annual license fee in the amount of one thousand four hundred and four dollars ($1,404.00). The fee must be submitted with the initial application or renewal application and is not refundable.

(c) The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the department. No child shall be admitted to the PCCC until a license has been issued. Applicants shall not hold themselves out to the public as being a PCCC until the license has been issued. A license shall not be issued until the facility is in substantial compliance with these rules and regulations including submission of all information required by T.C.A. § 68-11- 206(a)(1), or as later amended, and of all information required by the Commissioner.

(d) The applicant must prove the ability to meet the financial needs of the facility.

(f) The applicant shall allow the prescribed child care center to be inspected by a Department surveyor. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action to the Board that must be accepted by the Board.

Once the deficiencies have been corrected, then the Board shall consider the application for licensure.

(3) A proposed change of ownership, including a change in a controlling interest, must be reported to the department a minimum of thirty (30) days prior to the change. A new application and fee must be received by the department before the license may be issued.

(a) For the purposes of licensing, the licensee of a PCCC has the ultimate responsibility for the operation of the facility, including the final authority to make or control operational decisions and legal responsibility for the business management. A change of ownership occurs whenever this ultimate legal authority for the responsibility of the PCCC operation is transferred.

(b) A change of ownership occurs whenever there is a change in the legal structure by which the PCCC is owned and operated.

Transfer of the facility’s legal title;
Lease of the facility’s operations;
Dissolution of any partnership that owns, or owns a controlling interest in, the facility;
One partnership is replaced by another through the removal, addition or substitution of a partner;
Removal of the general partners or general partner, if the facility is owned by a limited partnership;
Merger of a facility owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are cancelled;
The consolidation of a corporate facility owner with one or more corporations; or, 8. Transfer between levels of government.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors or board of trustees;
Two (2) or more corporations merge and the originally licensed corporation survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government; or, 5. Corporate stock transfers or sales, even when a controlling interest.

(e) Management agreements are generally not changes of ownership if the owner continues to retain ultimate authority for the operation of the facility. However, if the ultimate authority is surrendered and transferred from the owner to a new manager, then a change of ownership has occurred.

(f) Sale/lease-back agreements shall not be treated as changes in ownership if the lease involves the facility’s entire real and personal property and if the identity of the leasee, who shall continue the operation, retains the exact same legal form as the former owner.

(4) Renewal.

(a) In order to renew a license, each prescribed child care center shall submit to periodic inspections by Department surveyors for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action and shall remedy the deficiencies. In addition, each licensee shall submit a renewal form approved by the board and applicable renewal fee prior to the expiration date of the license.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late; provided that the late penalty shall not exceed twice the renewal fee.

A completed application for licensure; and 2. The license fee provided in Rule 0720-15-.02(2)(b).

(d) Upon reapplication, the licensee shall submit to an inspection of the facility by Department of Health surveyors.

(5) All PCCCs may maintain certification as a Community Health Clinic (see Chapter 1200-13- 02, Tennessee Department of Health) and as a Comprehensive Outpatient Rehabilitation Facility (see 42 U.S.C. 1395x(cc) of the Social Security Act and Subpart B of 42 Code of Federal Regulations [CFR] Part 485).

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-206(a)(5) [effective January 1, 2009], 68-11-207, 68-11-209, 68-11-209(a)(1), 68-11-210, 68-11-216, and Chapter 846 of the Public Acts of 2008, § 1.
Administrative History: Original rule certified June 7, 1974. Amendment filed July 3, 1984; effective August 1, 1984. Repeal and new rule filed May, 22, 1986; effective July 21, 1986. Amendment filed October 22, 1987; effective December 6, 1987. Amendment filed April 1, 1992; effective May 16, 1992. Amendment filed November 3, 1992; effective December 18, 1992. Amendment filed March 7, 1994; effective May 21, 1994. Amendment filed December 30, 1994; effective March 18, 1995. Amendment filed June 13, 1997; effective August 27, 1997. Repeal filed March 18, 2000; effective May 30, 2000. New rule filed June 13, 2002; effective August 27, 2002. Amendment filed January 19, 2007; effective April 4, 2007. Public necessity rules filed April 29, 2009; effective through October 11, 2009. Emergency rules filed October 9, 2009; effective through April 7, 2010. Amendments filed September 24, 2009; effective December 23, 2009. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed March 26, 2019; effective June 24, 2019. Transferred from chapter 1200-08-02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-15-.03 DISCIPLINARY PROCEDURES

(1) The board may suspend or revoke a license for:

(a) Violation of federal or state statues;

(b) Violation of the rules as set forth in this chapter;

(d) Conduct or practice found by the board to be detrimental to the health, safety, or welfare of the children in the PCCC; and (e) Failure to renew license.

(2) The board may consider all factors which it deems relevant, including but not limited to the following when determining sanctions:

(a) The degree of sanctions necessary to ensure immediate and continued compliance;

(b) The character and degree of impact of the violation on the health, safety and welfare of the children in the PCCC;

(c) The conduct of the PCCC in taking all feasible steps or procedures necessary or appropriate to comply or correct the violations; and (d) Any prior violations by the PCCC of statutes, regulations or orders of the board.

(3) When a PCCC is found by the department to have committed a violation of this chapter, the department will issue to the facility a statement of deficiencies. Within ten (10) days of the receipt of the deficiencies, the PCCC must return a plan of correction indicating the following:

(a) How the deficiency will be corrected;

(b) The date upon which each deficiency will be corrected;

(4) Either failure to submit a plan of correction in a timely manner or a finding by the department that the plan of correction is unacceptable shall subject the PCCC license to possible disciplinary action.

(5) The department may assess a civil penalty not to exceed one thousand dollars ($1,000) against any person or entity operating a prescribed child care facility without the license required by this chapter or in violation of any other statute or regulation promulgated hereunder. Each day of operation is a separate offense.

(a) The board is authorized to conduct contested cases regarding appeals of the penalties assessed pursuant to this subsection.

(6) Any licensee or applicant for a license, aggrieved by decision or action of the department or board, pursuant to this chapter, may request a hearing before the board. The proceedings and judicial review of the board’s decision shall be in accordance with the Uniform Procedures Act, T.C.A. §§ 4-5-101, et seq.

(7) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to Rule

Tenn. Comp. R. & Regs. 0720-15-.04 ADMINISTRATION

(1) The licensee or governing body of the PCCC shall ensure the following:

(a) The facility complies with all applicable federal, state, and local laws, ordinances, rules and regulations;

(b) The facility is administered and operated in accordance with written policies and procedures;

(c) The general direction over the facility and the establishment of policies governing the operation of the facility and the welfare of the children served;

(d) That an administrator be designated for the operation of the facility who may be the licensee, or the nursing director.

(2) A current written policies and procedures manual shall be maintained. The manual must include the following elements:

(a) An organizational chart or a statement which clearly shows or describes the lines of

authority between the governing body, the administrator, the nursing director, and the staff;

(b) A description of facility services provided by the licensee. The description shall include at a minimum the hours of operation and admission and discharge criteria;

(d) A schedule of fees, if any, currently charged to the parent for all services provided by the licensee;

(3) The PCCC must have an effective governing body legally responsible for the conduct of the PCCC. If a PCCC does not have an organized governing body, the persons legally responsible for the conduct of the PCCC must carry out the functions specified in this

chapter.

(4) When licensure is applicable for a particular job, the number and renewal number of the current license must be maintained in personnel. 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.

(5) 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. A PCCC that violates a required policy also violates the rule and regulation establishing the requirement.

(6) No PCCC 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, or the Comptroller of the State Treasury. A PCCC 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.

(7) Personnel.

(a) All PCCC’s as defined in § 68-11-201 shall initiate a criminal background check on any person who is employed by or who wishes to volunteer in a capacity which involves providing direct care to a child, prior to or within seven (7) days of employment or provision of services. Any person who applies for employment in a position or who wishes to volunteer in a capacity which involves providing direct care to a child in such a facility shall consent to:

Provide past work and personal references to be checked by the PCCC; and/or 2. Agree to the release of any and all information and investigative records to the PCCC or its agent, or to any agency that contracts with the State of Tennessee necessary for the purpose of verifying whether the individual has been convicted of a felony in the State of Tennessee; and/or 3. Supply a fingerprint sample and submit to a criminal history records check to be conducted by the Tennessee Bureau of Investigation, other law enforcement agency, or any legally authorized entity; and/or 4. Release any information required for a criminal background investigation by a professional background screening organization or criminal background check service or registry.
Any cost incurred by the Tennessee Bureau of Investigation, professional background screening organization, law enforcement agency or other legally authorized entity, in conducting such investigations of such applicants or volunteers may be paid by the PCCC, or any agency that contracts with the State of Tennessee requesting such investigation and information, or the individual who seeks employment or is employed or volunteers. Payments of such costs to the Tennessee Bureau of Investigation are to be made in accordance with the provisions of Tennessee Code Annotated, § 38-6-103 and § 38-6-109.
A PCCC which declines to employ or terminates a person based upon information provided to the facility under this section shall be immune from suit by or on behalf of that person for the termination of or the refusal to employ that person.

(b) A personnel record for each staff member of a facility shall include an application for employment and a record of any disciplinary action taken.

(d) A job description shall be maintained which includes the employment requirements and the job responsibilities for each facility staff position.

(e) A personnel record shall be maintained which verifies that each employee meets the respective employment requirements for the staff position held, including annual verification of basic skills and annual evaluation of personnel performance. This evaluation shall be in writing. There shall be documentation to verify that the employee has reviewed the evaluation and has had an opportunity to comment on it.

(f) Training and development activities which are appropriate in assisting the staff in meeting the needs of the children being served shall be provided for each staff member including STD/HIV education and child abuse education. The provision of such activities shall be evidenced by documentation in the facility’s records.

(g) Training and development activities which are appropriate in assisting volunteers (if volunteers are used by the facility) in implementing their assigned duties shall be provided for each volunteer. The provision of such activities shall be evidenced by documentation in the facility’s records.

(h) Direct-services staff members shall be competent persons aged eighteen (18) years of age or older.

(i) All new employees, including volunteers, who have routine contact with children shall have a current tuberculosis test prior to employment. (See Appendix C)

(j) Employees shall have a tuberculin skin test annually.

(k) Employee records shall include date and type of tuberculin skin test used and date of tuberculin skin test results, date and results of chest x-ray, and any drug treatment for tuberculosis.

(8) Responsibility for Staff (a) The licensee of the PCCC is responsible for selecting individuals of suitable character to work with children.

(b) All PCCC facilities shall have a minimum full-time equivalent staff of one registered nurse. Thereafter, the ratio of staff to children shall be maintained at a ratio of one staff person for every three (3) children.

(d) A licensed health care professional at the center shall be designated to be in charge in the absence of the administrator.

(e) Exclusions for certain activities and crimes:

No person shall be employed, work as a caregiver, or have access to or contact with children in the child care program:

(i) Who is known to the child care center’s management as a perpetrator of child abuse or child sexual abuse; or (ii) Who is identified to the child care center’s management by the Department of Children’s Services as a validated or indicated perpetrator of abuse of a child; or (iii) Who is currently charged with, has been convicted of, or pled guilty in any manner to a crime involving a child; or (iv) Who has pled guilty to any lesser offense derived from an original offense involving a child; or (v) Who is currently charged with, has been convicted of, or who has pled guilty in any manner to a crime of violence against another person, or who has pled guilty to any lesser offense derived from a crime of violence against another person; or (vi) Who is currently charged with, who has been convicted of, or who has pled guilty in any manner to, or who has pled guilty to any lesser offense derived from, any offense involving the manufacture, sale, distribution, or possession of any drug; and (vii) Who is associated in providing care or ancillary services in any manner within a child care program; or (viii) Who is a family member or other person residing at the child care center’s facility or adjacent residence; or (ix) Who has unrestricted access to children in the facility.

An employee or volunteer who has been identified by the Department as having neglected a child based on an investigation conducted by the Department of Children’s Services pursuant to a report of harm, and who has not been criminally charged or convicted or pled guilty as stated above, shall be supervised by another adult while providing care for children.
Exceptions may be granted on a case-by-case basis by the Department in its sole discretion to persons subject to items 1.(iii), (iv), and (v) in situations where the person is charged with, has pled guilty to, or has been convicted of a crime involving accidental or negligent acts rising to the level of a criminal charge.

Exceptions are granted subject to the availability of documentation necessary to make a determination. The criteria which will be considered include, but are not limited to:

(i) The act did not rise above the level of criminally negligent homicide or vehicular homicide and did not include the use of drugs or alcohol;

(ii) The act was isolated and was not consistent with the person’s usual character;

(iii) The circumstances were not related to the provision of child care;

(iv) The circumstances do not reflect the inability to provide child care by the affected person in any manner inconsistent with these rules.

(f) The behavior of staff shall reflect knowledge and understanding of the special needs, growth, and developmental patterns of young children and understanding of appropriate activities, as reflected in staff’s performance evaluations.

(9) 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;

Postings of (a) and (b) shall be on a sign no smaller than eleven inches (11”) in width and seventeen inches (17”) in height.

(10) “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.

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

History

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, 68-11-234, 68-11-268, and 71-6-121.
Administrative History: Original rule filed June 13, 2002; effective August 27, 2002. Amendment filed April 17, 2007; effective July 1, 2007. Amendment filed July 18, 2007; effective October 1, 2007. Amendment filed February 22, 2010; effective May 23, 2010. Transferred from chapter 1200-08-02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-15-.05 ADMISSIONS, DISCHARGES, AND TRANSFERS

(1) The intake and assessment process shall include the following:

(a) The information to be obtained on all children or referrals for admission;

(b) The procedures for accepting referrals from outside agencies or organizations;

(d) Any prospective child data to be recorded during the intake process; and (e) The procedures to be followed when a child or a referral is found eligible for admission.

(2) Admission of Children and Communication with Parents (a) Infants and children considered for admission to the PCCC facility shall be those with complex medical conditions requiring continual care, including, but not limited to:

Supplemental oxygen;
Ventilator dependence;
Cystic fibrosis;
Apnea; and 5. Spinal cord injury and malignancy.

(b) The child shall not present significant risk to the health and safety of other children or personnel that cannot be eliminated by a modification of policies, practices, or procedures, or by the provision of auxiliary aids or services.

(c) The child shall be medically stabilized, require skilled nursing care, and/or other interventions, and be appropriate for outpatient care.

(d) Prior to placement, pre-admission planning conferences shall be held for the purpose of developing a plan of care.

(e) The plan of care shall be developed under the direction of the PCCC nursing director and shall specify the treatment plan needed to accommodate the medical, nursing, psychological, and developmental needs of the child and family. The educational needs of the child shall be coordinated with appropriate local public school system personnel.

Specific goals for care shall be identified. Plans for achieving the goals shall be determined and a schedule for evaluation of progress will be established.

(f) The plan shall be signed by the authorized representative of the PCCC, physician, and parent(s). Copies of the plan shall be given to the parent(s) and the PCCC staff.

(g) A consent form, outlining the purpose of a PCCC facility, family responsibilities, authorized treatment, and emergency disposition plans shall be signed by the parent(s) and witnessed prior to admission to the PCCC facility. The original consent form shall be retained by the facility. The parent(s) shall be provided a copy of the consent form.

(h) At the time of admission, written policies and procedures of the PCCC shall be provided to parents or other applicants. Policies shall include criteria for dismissal of children. A copy of PCCC policies and procedures shall be given to the parent and documentation of receipt filed in the child’s record.

(i) A pre-enrollment visit to the center by the parent shall be documented.

(j) Upon enrollment of a child, the parent shall receive a summary of the Department’s licensing requirements and receipt of the summary shall be documented by the parent’s signature.

(k) Each PCCC shall develop a plan for regular and ongoing communication with parents.

This plan shall include communication concerning curriculum, changes in personnel, or planned changes affecting children’s routine care. Documentation shall be maintained for the most recent quarter.

(l) During normal operating hours, parents shall be permitted access to their children, and ready access to all areas of the PCCC shall be granted Department representatives and inspection authorities (i.e., fire safety, sanitation, and health).

(m) Parents shall be informed in advance of the child’s removal from the premises except in cases of emergencies or pursuant to investigative procedures conducted pursuant to the child abuse laws.

(n) Children shall not be in care for more than sixteen hours in a twenty-four hour period except in special circumstances (e.g., acute illness of or injury to parents, natural disaster, unusual work hours). Individual plans for extended care shall be maintained, with documentation, signed by parent and administrator, retained on file.

(o) Part-time children shall be counted in the ratio and group and shall have required records on file before they are cared for.

(p) Any infant or child not meeting the criteria set out in 0720-15-.05(2)(a)–(c) shall be discharged from the PCCC.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed June 13, 2002; effective August 27, 2002. Transferred from chapter 1200-08- 02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-15-.06 BASIC SERVICES

(1) Nursing Services.

(a) The PCCC must have an organized nursing service that provides twenty-four (24) hour nursing services furnished or supervised by a registered nurse. A registered nurse must be on the premises at all times during business hours.

(b) The PCCC must have a well-organized service with a plan of administrative authority and delineation of responsibilities for child care. The nursing director must be a licensed registered nurse who is responsible for the operation of the nursing service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for the PCCC.

(c) The nursing service must have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all children as needed. There must be supervisory and staff personnel for each department or unit of the PCCC to ensure, when needed, the immediate availability of a registered nurse.

(d) There must be a procedure to ensure that nursing personnel for whom licensure is required have valid and current licenses.

(e) A registered nurse must assess, supervise and evaluate the nursing care for each child.

(f) The PCCC must ensure that an appropriate individualized plan of care is prepared for each child.

(g) A registered nurse must assign the nursing care of each child to other nursing personnel in accordance with the child’s needs and the specialized qualifications and competence of the nursing staff available. All nursing personnel shall have specialized training and a program in-service and continuing education commensurate with the duties and responsibilities of the individual. All training shall be documented for each individual so employed, along with documentation of annual competency skills.

Orientation of any new personnel must be conducted within the first two weeks of employment.

(h) Non-employee licensed nurses who are working in the PCCC must adhere to the policies and procedures of the facility. The nursing director must provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing service. Annual competency and skill documentation must be demonstrated on these individuals just as on employees, if they perform clinical activities.

(i) All drugs, devices and related materials must be administered by, or under the supervision of, nursing or other personnel in accordance with federal and state laws and regulations, including applicable licensing requirements.

(j) All orders for drugs, devices and related materials must be in writing and signed by the practitioner or practitioners responsible for the care of the child. Electronic and computer-generated records and signature entries are acceptable. When telephone or oral orders must be used, they must be:

Accepted only by personnel that are authorized to do so by policies and procedures, consistent with federal and state law; and 2. Signed or initialed by the prescribing practitioner according to policy.

(k) Intravenous medications must be administrated in accordance with state law and approved policies and procedures.

(l) There must be a procedure for reporting adverse drug reactions and errors in administration of drugs.

(2) Physician Services.

(a) Policies and procedures concerning services provided by the PCCC shall be available to the children’s primary care physicians as requested.

(b) If children with mental, physical or other impairments or with a medical disorder are enrolled, and special care is needed, a physician’s statement shall identify the condition and give the appropriate care professional special instructions for the child’s care.

(d) Consultation with a physician shall occur at least annually to review medical care provided within the PCCC and shall include, but not be limited to:

Evaluate the delivery of emergency and medical care when the child’s primary physician or his/her designated alternative is unavailable;
Review reports of accidents or unusual incidents occurring on the premises, identifying hazards to health and safety and recommending corrective action to the administrator;
Review performance improvement, infection control and safety action plans for appropriate actions;
Monitor the health status of facility personnel to ensure that no health conditions exist which would adversely affect children; and 5. Advise and provide consultation on matters regarding medical care, standards of care, surveillance and infection control.

(3) Educational Services.

(a) The PCCC will provide parent(s) education services by including them in care related conferences and teaching them how to perform necessary therapies and how to meet the developmental and psychological needs of their child at home.

(b) Monthly educational development programs shall be conducted and documented.

These programs shall be provided to:

Develop collaborative relationships between health professionals and parent(s).
Increase understanding and coping with the effects of childhood illness, and shall cover a variety of topics including:

(i) Issues of death and dying;

(ii) Awareness of services available;

(iii) Fostering of advocacy skills;

(iv) Impact of illness on child development; and (v) Parenting an ill child.

Develop case management skills to assist the family in setting priorities and planning and implementing the child’s care at home.
Develop a comprehensive Plan of Care to include the medical, nutritional, developmental and psychosocial needs of medically/technologically dependent children, including training in the implementation of new technology.
Prepare for management of emergency medical situations.

(c) A comprehensive orientation to acquaint the parent(s) with the philosophy and services of the PCCC shall be provided at the time of the child’s placement in the PCCC.

(d) Activities shall be used for the children based on developmentally appropriate educational practices.

(e) To the extent that children are physically able to participate, a daily program shall provide opportunities for learning, self-expression, and participation in a variety of creative activities such as art, music, literature, dramatic play, science and health.

(f) Indoor physical activities, requiring children to use both large and small muscles, shall be provided for children of each age group who are physically able to participate.

(g) Activities for infants/toddlers shall provide experience for the development of language, gross motor, fine motor, social/personal, cognitive, and self-help skills. Examples of such activities include music, dramatic play, story-time, free activity periods, outdoor play, and the opportunity to explore many materials, situations, and roles.

(h) Because of the importance of language development and communication skills to infants and toddlers, they shall be talked to, listened to, read to and sung to, in addition to other language experience activities, including but not limited to, finger plays, patty cake, and flannel board activities.

(4) Nutritional Services.

(a) The PCCC must have an organized dietary service that is directed and staffed by adequate qualified personnel. A facility may contract with an outside food management company if the company has a dietitian who serves the facility on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this paragraph and provides for consultant liaison with the facility staff for recommendations on dietetic policies affecting the children’s treatment. If an outside contract is utilized for management of its dietary services, the facility shall designate a full-time employee to be responsible for the overall management of the services.

(b) The PCCC must designate a person, either directly or by contractual agreement, to serve as the food and dietetic services director with responsibility for the daily management of the dietary services. The food and dietetic services director shall be:

A qualified dietitian; or, 2. A graduate of a dietetic technician or dietetic assistant training program, correspondence or classroom, approved by the American Dietetic Association; or, 3. An individual who has successfully completed in-person or online coursework that provided ninety (90) or more hours of classroom instruction in food service supervision. If the course has not been completed, this person shall be enrolled in a course and making satisfactory progress for completion within the time limit specified by the course requirement; or, 4. An individual who is a certified dietary manager (CDM), or certified food protection professional (CFPP); or, 5. A current or former member of the U.S. military who has graduated from an approved military dietary manager training program.

(c) There must be a qualified dietitian, full-time, part-time, or on a consultant basis, who is responsible for the development and implementation of a nutrition care process to meet the needs of health maintenance, disease prevention and, when necessary, medical nutrition therapy to treat an illness, injury or condition. Medical nutrition therapy includes assessment of the nutritional status of the child and treatment through diet therapy, counseling and/or use of specialized nutrition supplements.

(d) Menus must meet the needs of the children.

Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the children and must be prepared and served as prescribed.
Special diets shall be prepared and served as ordered.
Nutritional needs must be met in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the children.
A current therapeutic diet manual approved by the dietitian and nursing director must be readily available to all nursing and food service personnel.

(e) Educational programs, including orientation, on-the-job training, inservice education, and continuing education, shall be offered to dietetic services personnel on a regular

basis. Programs shall include instruction in the use of equipment, personal hygiene, proper inspection, and the handling, preparing and serving of food.

(f) A minimum of three (3) meals in each twenty-four (24) hour period shall be served. A supplemental night meal shall be served if more than fourteen (14) hours lapse between supper and breakfast. Additional nourishment shall be provided to children with special dietary needs. A minimum of three (3) days supply of food shall be on hand.

(g) Menus shall be prepared at least one week in advance. A dietitian shall be consulted to help write and plan the menus. If any change in the actual food served is necessary, the change shall be made on the menu to designate the foods actually served to the children. Menus of food served shall be kept on file for a thirty (30) day period.

(h) The dietician or designee shall have a conference, dated on the medical record with each child and/or family within two (2) weeks of admission to discuss the diet plan indicated by the physician. The child’s dietary preferences shall be recorded and utilized in planning his/her daily menu.

(i) Food shall be protected from dust, flies, rodents, unnecessary handling, droplet infection, overhead leakage and other sources of contamination whether in storage or while being prepared and served and/or transported through hallways.

(j) Perishable food shall not be allowed to stand at room temperature except during necessary periods of preparation or serving. Prepared foods shall be kept hot (140°F or above) or cold (45°F or less). Appropriate equipment for temperature maintenance, such as hot and cold serving units or insulated containers, shall be used.

(k) Food shall not be forced on or withheld from children. Food shall not be used as a reward, nor shall food be used or withheld as punishment.

(l) Specific feeding instructions given by parents shall be in writing. If staff feel instructions to be inappropriate or in conflict with established policy or the therapeutic diet prescribed by the practitioner, staff shall initiate discussion with the parent to resolve the conflict.

(m) New foods shall be introduced to infants and toddlers; foods shall be introduced one at a time over a five-to-seven day period with parental approval.

(n) The feeding schedule for infants shall be in accordance with the child’s need rather than according to the hour. (Infants fed breast milk may require more frequent feedings than formula-fed babies.)

(o) Parents and caregivers shall work together when weaning an infant to insure consistency in the weaning process. Weaning shall be delayed until after an infant adjusts to group care.

(p) Children shall not be permitted to carry a bottle with them throughout the day.

(q) All formulas and food brought from home shall be labeled with child’s name. Milk shall be placed immediately in the refrigerator. Once milk has been warmed, it shall not be rewarmed or returned to the refrigerator. For optimum digestion, formula is to be served at body temperature.

(r) Frozen breast milk shall be dated when expressed. Bottled breast milk shall not be heated in a microwave oven. To prevent scalding, extreme caution shall be taken when a microwave oven is used to heat food.

(s) Previously opened baby food jars shall be not accepted in the PCCC.

(t) Infants shall be held while being fed if they are unable to sit in a high chair, an infant seat, or at the table. Bottles shall not be propped. A child shall not be given a bottle while lying flat.

(u) When children are capable of using a high chair, they shall be allowed to do so and to experiment with food, with feeding themselves, and to eat with fingers or spoon.

Children shall not be left unattended while eating.

(v) Dishwashing machines shall be used according to manufacturer specifications.

(w) All dishes, glassware and utensils used in the preparation and serving of food and drink shall be cleaned and sanitized after each use.

(x) The cleaning and sanitizing of handwashed dishes shall be accomplished by using a three-compartment sink according to the current “U.S. Public Health Services Sanitation Manual”:

(y) The kitchen shall contain sufficient refrigeration equipment and space for the storage of perishable foods.

(z) All refrigerators and freezers shall have thermometers. Refrigerators shall be kept at a temperature not to exceed 45°F. Freezers shall be kept at a temperature not to exceed 0°F.

(aa) Written policies and procedures shall be followed concerning the scope of food services in accordance with the current edition of the “U.S. Public Health Service Recommended Ordinance and Code Regulating Eating and Drinking Establishments,” and the current “U.S. Public Health Service Sanitation Manual” should be used as a guide to food sanitation.

(5) Pharmaceutical Services.

(a) The PCCC shall have pharmaceutical services that meet the needs of the children and are in accordance with the Tennessee Board of Pharmacy statutes and rules. The administrator is responsible for developing policies and procedures that minimize drug errors.

(b) All internal and external medications and preparations intended for human use shall be stored separately. They shall be properly stored in medicine compartments, including cabinets on wheels, or drug rooms. Such cabinets or drug rooms shall be kept securely locked when not in use, and the key must be in the possession of the supervising nurse or other authorized persons. Poisons or external medications shall not be stored in the same compartment and shall be labeled as such.

(c) Schedule II drugs must be stored behind two (2) separately locked doors at all times and accessible only to persons in charge of administering medication.

(d) Every PCCC shall comply with all state and federal regulations governing Schedule II drugs.

(e) A notation shall be made in a Schedule II drug book and in the child’s medical chart each time a Schedule II drug is given. The notation shall include the name of each child receiving the drug, name of the drug, the dosage given, the method of administration, the date and time given and the name of the physician prescribing the drug.

(f) All oral orders shall be immediately recorded, designated as such and signed by the person receiving them and countersigned by the physician within ten (10) days.

(g) All orders for drugs, devices and related materials must be in writing and signed by the practitioner or practitioners responsible for the care of the child. Electronic and computer-generated records and signature entries are acceptable. When telephone or oral orders must be used, they shall be:

Accepted only by personnel that are authorized to do so by policies and procedures, consistent with federal and state law; and, 2. Signed or initialed by the prescribing practitioner according to policy.

(h) Medications not specifically limited as to time or number of doses when ordered are controlled by automatic stop orders or other methods in accordance with written policies. No Schedule II drug shall be given or continued beyond seventy-two (72) hours without a written order by the physician.

(i) Medication administration records (MAR) shall be maintained for each child. Each dose shall be properly recorded in the medical record after it has been administered.

(j) Preparation of doses for more than one scheduled administration time shall not be permitted.

(k) Medication shall be administered only by licensed medical or nursing personnel or other licensed health professionals acting within the scope of their licenses.

(l) Unless the unit dose package system is used, individual prescriptions of drugs shall be kept in the original container with the original label intact showing the name of the child, the drug, the physician, the prescription number and the date dispensed.

(m) Legend drugs shall be dispensed by a licensed pharmacist.

(n) Any unused portions of prescriptions shall be turned over to the parent(s) or only on discharge. A notation of drugs released shall be entered into the medical record. All unused prescriptions not taken by the parent and left at the PCCC must be destroyed on the premises and recorded by a pharmacist. Such record shall be kept in the PCCC.

(6) Rehabilitation Services.

(a) Physical therapy, occupational therapy and speech therapy shall be provided directly or through contractual agreement by individuals who meet the qualifications specified by PCCC policy and consistent with state law.

(b) Speech therapy services shall be provided only by or under supervision of a qualified speech language pathologist in good standing, or by a person qualified as a Clinical Fellow subject to Tennessee Board of Communications Disorders and Sciences Rule

Tenn. Comp. R. & Regs. 0720-15-.07 BUILDING STANDARDS

(1) A PCCC shall construct, arrange, and maintain the condition of the physical plant and the overall facility environment in such a manner that the safety and well-being of the occupants are assured.

(2) After the applicant has submitted an application and licensure fees, the applicant must submit the building construction plans to the department. All facilities shall conform to the current edition of the following applicable codes as approved by the Board for Licensing Health Care Facilities: International Building Code (excluding Chapters 1 and 11) including referenced International Fuel Gas Code, International Mechanical Code, and International Plumbing Code; National Fire Protection Association (NFPA) NFPA 101 Life Safety Code excluding referenced NFPA 5000; Guidelines for Design and Construction of Health Care Facilities (FGI) including referenced Codes and Standards; U.S. Public Health Service Food Code; and Americans with Disabilities Act (ADA) Standards for Accessible Design. When referring to height, area or construction type, the International Building Code shall prevail. Where there are conflicts between requirements in local codes, the above listed codes, regulations and provisions of this chapter, the most stringent requirements shall apply.

(3) The codes in effect at the time of submittal of plans and specifications, as defined by these rules, shall be the codes to be used throughout the project.

(4) The licensed contractor shall perform all new construction and renovations to PCCCs, other than minor alterations not affecting fire and life safety or functional issues, in accordance with the specific requirements of these regulations governing new construction in PCCCs, including the submission of phased construction plans and the final drawings and the specifications to each.

(5) No new PCCC shall be constructed, nor shall major alterations be made to an existing PCCC without prior written approval of the department, and unless in accordance with plans and specifications approved in advance by the department. Before any new PCCC is licensed or before any alteration or expansion of a licensed PCCC can be approved, the applicant must furnish two (2) complete sets of plans and specifications to the department, together with fees and other information as required. Plans and specifications for new construction and major renovations, other than minor alterations not affecting fire and life safety or functional issues, shall be prepared by or under the direction of a licensed architect and/or a licensed engineer and in accordance with the rules of the Board of Architectural and Engineering Examiners.

(6) Final working drawings and specifications shall be accurately dimensioned and include all necessary explanatory notes, schedules and legends. The working drawings and specifications shall be complete and adequate for contract purposes.

(a) The project architect or engineer shall forward two (2) sets of plans to the appropriate

section of the department for review. After receipt of approval of phased construction plans, the owner may proceed with site grading and foundation work prior to receipt of approval of final plans and specifications with the owner’s understanding that such work is at the owner’s own risk and without assurance that final approval of final plans and specifications shall be granted. The project architect or engineer shall submit final plans and specifications for review and approval. The department must grant final approval before the project proceeds beyond foundation work.

(b) Review of plans does not eliminate responsibility of owner and/or architect to comply with all rules and regulations.

(8) Specifications shall supplement all drawings. They shall describe the characteristics of all materials, products and devices, unless fully described and indicated on the drawings.

Specification copies should be bound in an 8½ x 11 inch folder.

(9) Drawings and specifications shall be prepared for each of the following branches of work:

Architectural, Structural, Mechanical, Electrical and Sprinkler.

(10) Architectural drawings shall include where applicable:

(a) Plot plan(s) showing property lines, finish grade, location of existing and proposed structures, roadways, walks, utilities and parking areas;

(b) Floor plan(s) showing scale drawings of typical and special rooms, indicating all fixed and movable equipment and major items of furniture;

(d) The elevation of each facade;

(e) The typical sections throughout the building;

(f) The schedule of finishes;

(g) The schedule of doors and windows;

(h) Roof plans;

(i) Details and dimensions of elevator shaft(s), car platform(s), doors, pit(s), equipment in the machine room, and the rates of car travel must be indicated for elevators; and (j) Code analysis.

(11) Structural drawings shall include where applicable:

(a) Plans of foundations, floors, roofs and intermediate levels which show a complete design with sizes, sections and the relative location of the various members;

(b) Schedules of beams, girders and columns; and (c) Design live load values for wind, roof, floor, stairs, guard, handrails, and seismic.

(12) Mechanical drawings shall include where applicable:

(a) Specifications which show the complete heating, ventilating, fire protection, medical gas systems and air conditioning systems;

(b) Water supply, sewerage and HVAC piping systems;

(d) Heating, ventilating, HVAC piping, medical gas systems and air conditioning systems with all related piping and auxiliaries to provide a satisfactory installation;

(13) Electrical drawings shall include where applicable:

(a) A seal, certifying that all electrical work and equipment is in compliance with all applicable codes and that all materials are currently listed by recognized testing laboratories;

(d) Color coding to show all items on emergency power;

(14) The electrical drawings shall not include knob and tube wiring, shall not include electrical cords that have splices, and shall not show that the electrical system is overloaded.

(15) In all new facilities or renovations to existing electrical systems, the installation must be approved by an inspector or agency authorized by the State Fire Marshal.

(16) Sprinkler drawings shall include where applicable:

(a) Shop drawings, hydraulic calculations, and manufacturer cut sheets;

(17) The licensed contractor shall not install a system of water supply, plumbing, sewage, garbage or refuse disposal nor materially alter or extend any existing system until the architect or engineer submits complete plans and specifications for the installation, alteration or extension, to the department demonstrating that all applicable codes have been met and the department has granted necessary approval.

(a) Before the PCCC is used, Tennessee Department of Environment and Conservation shall approve the water supply system.

(18) It shall be demonstrated though the submission of plans and specifications that in each PCCC a negative air pressure shall be maintained in the soiled utility area, toilet room, janitor’s closet, dishwashing and other such soiled spaces, and a positive air pressure shall be maintained in all clean areas including, but not limited to, clean linen rooms and clean utility rooms.

(19) The department shall acknowledge that it has reviewed plans and specifications in writing with copies sent to the project architect, the project engineer, the owner, the manager or other executive of the institution. The department may modify the distribution of such review at its discretion.

(20) In the event submitted materials do not appear to satisfactorily comply with 0720-15-.07(2), the department shall furnish a letter to the party submitting the plans which shall list the particular items in question and request further explanation and/or confirmation of necessary modifications.

(21) The licensed contractor shall execute all construction in accordance with the approved plans and specifications.

(22) If construction begins within one hundred eighty (180) days of the date of department approval, the department’s written notification of satisfactory review constitutes compliance with 0720-15-.07(2). This approval shall in no way permit and/or authorize any omission or deviation from the requirements of any restrictions, laws, regulations, ordinances, codes or rules of any responsible agency.

(23) Prior to final inspection, a CD Rom disc, in TIF or PDF format, of the final approved plans including all shop drawings, sprinkler, calculations, hood and duct, addenda, specifications, etc., shall be submitted to the department.

(24) The department requires the following alarms that shall be monitored twenty-four (24) hours per day:

(a) Fire alarms;

(b) Generators (if applicable); and (c) Medical gas alarms (if applicable).

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed June 13, 2002; effective August 27, 2002. Amendment filed February 18, 2003; effective May 4, 2003. Amendment filed June 21, 2007; effective September 4, 2007. Repeal and new rule filed December 20, 2011; effective March 19, 2012. Amendment filed January 21, 2016; effective April 20, 2016. Transferred from chapter 1200-08-02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-15-.08 LIFE SAFETY

(1) Any prescribed child care center which complies with the required applicable building and fire safety regulations at the time the board adopts new codes or regulations will, so long as such compliance is maintained (either with or without waivers of specific provisions), be considered to be in compliance with the requirements of the new codes or regulations.

(2) The prescribed child care center shall provide fire protection by the elimination of fire hazards, by the installation of necessary fire fighting equipment and by the adoption of a written fire control plan. All fires which result in a response by the local fire department shall be reported to the department within seven (7) days. The report shall contain sufficient information to ascertain the nature and location of the fire, its probable cause and any injuries incurred by any person or persons as a result of the fire. Records which document and evaluate these incidents must be maintained for at least three (3) years.

(3) The prescribed child care center shall have a written emergency plan to document instructions to staff, upon employment, and clients, upon enrollment, in fire evacuation procedures. The plan shall include actions to be taken in inclement weather and internal and external emergencies. Evacuation plans shall be posted in prominent areas such as reception areas, near door in class rooms, etc. and shall designate meeting places outside the building in event of emergencies.

(4) Corridor doors shall not have louvers.

(5) Battery powered emergency lighting shall be installed in corridors, common areas and in stair ways.

(6) Corridors shall be lighted at all times, to a minimum of one foot candle.

(7) Corridors and exit doors shall be kept clear of equipment, furniture and other obstacles at all times. There shall be a clear passage at all times from the exit doors to a safe area.

(8) Corridors in multi-storied buildings shall have two exits remote from each other. At least one exit shall be directly to the outside.

(9) Storage beneath any stair is prohibited.

(10) Combustible finishes and furnishings shall not be used.

(11) Open flame and portable space heaters shall not be permitted in the facility. Cooking appliances other than microwave ovens shall not be allowed in the facility.

(12) All heaters shall be guarded and spaced to prevent ignition of combustible material and accidental burns. The guard shall not have a surface temperature greater than 120°F.

(13) Fireplaces and/or fireplace inserts may be used only if provided with guards or screens which are secured in place. Fireplaces and chimneys shall be inspected and cleaned annually and verified documentation shall be maintained.

(14) All electrical equipment shall be maintained in good repair and in safe operating condition.

(15) Electrical cords shall not be run under rugs or carpets.

(16) The electrical systems shall not be overloaded. Power strips must be equipped with circuit breakers. Extension cords shall not be used.

(17) Fire extinguishers, complying with NFPA 10, shall be provided and mounted to comply with NFPA 10. An extinguisher in the kitchen area shall be a minimum of 2-A:10 B:C and an extinguisher with a rating of 20-A shall be adjacent to every hazardous area. The minimum travel distance shall not exceed fifty (50) feet between the extinguishers.

(18) Smoking and smoking materials shall be permitted only in designated areas. Ashtrays must be provided wherever smoking is permitted. The facility shall have written policies and procedures for smoking within the facility which shall designate a room or rooms to be used exclusively for staff and visitors who smoke. The designated smoking room or rooms shall not be the dining room or activity room.

(19) Trash and other combustible waste shall not be allowed to accumulate within and around the facility and shall be stored in appropriate containers with tight-fitting lids. Trash containers shall be UL approved.

(20) All safety equipment shall be maintained in good repair and in a safe operating condition.

(21) Janitorial supplies shall not be stored in the kitchen, food storage area, dining area or child accessible areas.

(22) Emergency telephone numbers must be posted near a telephone accessible to the children.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed June 13, 2002; effective August 27, 2002. Amendment filed May 16, 2006; effective July 30, 2006. Amendment filed June 21, 2007; effective September 4, 2007. Transferred from chapter 1200-08-02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-202, 68-11-204, 68-11- 206, 68-11-207, 68-11-208, 68-11-209, and 68-11-213.
Administrative History: Original rule certified June 7, 1974. Amendment filed July 3, 1984; effective August 1, 1984. Repeal filed May 22, 1986; effective July 21, 1986. New rule filed June 13, 2002; effective August 27, 2002. Amendment filed March 1, 2007; effective May 15, 2007. Transferred from chapter 1200-08-02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1370-01-.10 .

(c) A licensed physical therapist shall be in charge of the physical therapy service and a licensed occupational therapist shall be in charge of the occupational therapy service.

(d) Direct contact shall exist between the child and the therapist for those children that require treatment ordered by a physician.

(e) If ordered by a physician, the physical therapist and the occupational therapist shall provide treatment and training designed to preserve and improve abilities for independent functions, such as: range of motion, strength, tolerance, coordination and activities of daily living.

(f) Therapy services shall be coordinated with the nursing service and made a part of the child’s treatment plan.

(g) Sufficient staff shall be made available to provide the service ordered.

(7) Psychologist/Social Work Services.

(a) Social services and psychological services must be available to the children, the child’s family and other persons significant to the child, in order to facilitate adjustment of these individuals to the impact of the child’s illness and to promote maximum benefits from the health care services provided.

(b) Social work services shall include psychosocial assessment, counseling, coordination of discharge planning, community liaison services, financial assistance and consultation.

(c) Psychological services shall include psychoanalysis, psychotherapy, psychological testing, psychoeducational evaluation therapy remediation and consultation.

(d) A child’s social history shall be obtained within two (2) weeks of admission and shall be appropriately maintained.

(e) Social work services shall be provided by a qualified social worker.

(f) Facilities for social work services shall be readily accessible and shall permit privacy for interviews and counseling.

(8) Respiratory Care Services (Optional).

(a) If the PCCC provides respiratory care services, the PCCC must meet the needs of the patients in accordance with acceptable standards of practice.

(b) The organization of the respiratory care services must be appropriate to the scope and complexity of the services offered.

(c) There must be adequate numbers of licensed respiratory therapists, respiratory technicians, and other personnel to provide the ordered services.

(d) Services must be delivered in accordance with physician directives.

(e) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing.

(9) Infection Control.

(a) The PCCC must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.

(b) The administrator shall assure that an infection control program, including members of the multidisciplinary staff such as nursing and administrative staff, develop guidelines and techniques for the prevention, surveillance, control and reporting of facility infections. Duties of the program shall include the establishment of:

Written infection control policies;
Techniques and systems for identifying, reporting, investigating and controlling infections in the facility;
Written procedures governing the use of aseptic techniques and procedures in the facility;
Written procedures concerning food handling, laundry practices, disposal of environmental and human wastes, traffic control and visiting rules, sources of air pollution, and routine culturing of autoclaves and sterilizers;
A log of incidents related to infectious and communicable diseases;
Formal provisions to educate and orient all appropriate personnel in the practice of aseptic techniques such as handwashing, proper grooming, masking, dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of equipment and supplies; and, 7. Continuing education for all facility personnel on the cause, effect, transmission, prevention, and elimination of infections.

(c) The administrator must ensure that the facility-wide performance improvement program and training programs address problems identified by the infection control program and must be responsible for the implementation of successful corrective action plans in affected problem areas.

(d) Parents of every child enrolled shall be notified immediately if one of the following communicable diseases has been introduced into the child care center: hepatitis A, foodborne outbreaks (food poisoning) salmonella, shigella, measles, mumps, rubella, pertussis, polio, haemophilus influenza type B, meningococcal meningitis. The PCCC shall report the occurrence of the above diseases to the local health department.

(e) Impetigo and diagnosed strep shall be treated appropriately for 24 hours prior to readmission to the center. Children having scabies or lice shall have proof of treatment to be readmitted. The PCCC shall provide care and/or isolation for a child with a contagious condition only if written instructions of a licensed physician or certified health care provider are obtained first.

(f) The PCCC shall develop policies and procedures for testing a child’s blood for the presence of the hepatitis B virus and the HIV virus in the event that an employee of the facility, a student studying at the facility, or other health care provider rendering services at the facility is exposed to a child’s blood or other body fluid. The testing shall be performed at no charge to the child and the test results shall be confidential.

(g) The facility and its employees shall adopt and utilize standard or universal precautions of the Centers for Disease Control (CDC) for preventing transmission of infections, HIV, and communicable diseases.

(h) All PCCCs shall adopt appropriate policies regarding the testing of children and staff for HIV and any other identified causative agent of acquired immune deficiency syndrome.

(i) Precautions shall be taken to prevent the contamination of sterile supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents. Decontamination and preparation areas shall be separated.

(j) Space and facilities for housekeeping equipment and supplies shall be provided in each service area. Storage for bulk supplies and equipment shall be located away from child care areas. The building shall be kept in good repair, clean, sanitary and safe at all times.

(10) Performance Improvement.

(a) The PCCC must ensure that there is an effective, facility-wide performance improvement program to evaluate child care and performance of the organization.

(b) The performance improvement program must be ongoing and have a written plan of implementation which assures that:

All organized services related to child care, including services furnished by a contractor, are evaluated;
Nosocomial infections and medication therapy are evaluated; and, 3. All services performed in the facility are evaluated as to the appropriateness of diagnosis and treatment.

(c) The PCCC must have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically related needs of its children.

(d) The facility must develop and implement plans for improvement to address deficiencies identified by the performance improvement program and must document the outcome of the remedial action.

(e) Performance improvement program records shall be disclosable to the Department to demonstrate compliance with this section.

(f) Good faith attempts by the performance improvement program committee to identify and correct deficiencies will not be used as a basis for sanctions.

(11) Transportation Services (If Provided).

(a) If a PCCC provides transportation, its management shall recognize its full responsibility for the child between home and facility and on field trips. On field trips or when transporting children between home and the facility, staff shall maintain an accurate list of children being transported and shall take roll frequently. The driver or accompanying staff member shall assure that every child is received by a parent or other designated person. The owner of the vehicle shall carry adequate liability insurance.

(b) Parents shall be notified of each field trip and notification documented.

Regular scheduled inspections shall be documented. Documentation of regular maintenance shall be kept on file in the facility. (See Appendix A)

(d) The driver shall comply with the health requirements as specified in Appendix C of these rules.

(e) On field trips off premises, at least two (2) adults shall be in the vehicle, in addition to the driver.

(f) Children shall always be attended by a licensed nurse while in a vehicle.

(g) The number of infants and other non-ambulatory children transported by one licensed nurse shall be limited to six. A second licensed nurse shall be in the vehicle supervising the children when seven or more children are being transported.

(h) Transportation provided by the PCCC or under PCCC auspices shall comply with state law.

(i) All children and the driver shall be secured in individual passenger restraint devices at all times during the transportation by the PCCC or under PCCC auspices. Exception:

Children four (4) years of age and older transported by a school bus or public transportation are not required to be restrained because these vehicles are not required to be equipped with restraint devices.

(j) No child shall be allowed to ride on the floor of a vehicle, and no child shall be placed with another child in the same restraint device.

(k) Drivers of any vehicle used to transport children shall have a proper license and endorsement required for the transportation of the number of passengers transported and the vehicle size and weight as required in Chapter 50 of Title 55 of the Tennessee Code Annotated.

(l) A vehicle used to transport children shall have fire extinguishers, emergency reflective triangles, a first aid kit and a blood-borne pathogenic clean-up kit, and an adult familiar with the use of this equipment on board. Emergency exiting procedures shall be practiced by all staff responsible for transporting children on a regular basis.

(m) Storage of firearms is prohibited in vehicles used to transport children.

(n) A minimum of ten (10) inches seat space per child is required in a vehicle transporting children.

(o) Children shall not spend more than ninety (90) minutes traveling one way.

(12) Recreational Services.

(a) The PCCC shall provide opportunities for recreational activities appropriate to the needs, interests, and ages of the children being served.

(b) Equipment Needs for Children:

General (i) All indoor and outdoor equipment shall be well made and safe. There shall be no dangerous angles, no sharp edges, splinters, or nails sticking out, no open S-hooks or pinch points within children’s reach.

(ii) Damaged equipment shall be repaired or removed from the room or playground immediately.

(iii) Equipment shall be kept clean by washing frequently with soap and water.

(iv) There shall be developmentally appropriate equipment and furnishings for each age group in attendance.

(v) Material and equipment shall be provided to meet the needs of all the children enrolled.

(vi) Individual lockers, separate hooks and shelves or other containers (placed at children’s reaching level for mobile children) shall be provided for each child’s belongings.

Indoor Play Equipment (i) Pieces of equipment, such as television sets, bookcases and appliances, shall be secured or supported so that they will not fall or tip over.

(ii) Indoor equipment, materials, and toys shall be available to:

(I) Meet active and quiet play needs of all children enrolled;

(II) Provide a variety of developmentally appropriate activities so that each child has at least three choices during play time; and (III) Adequately provide for all the activities required in other sections of this rule.

(iii) Toys, educational and play materials shall be organized and displayed within children’s reach so that, if physically able, they can select and return items independently.

(iv) Teaching aids that are small or that have small parts that can be inhaled or swallowed shall be inaccessible to infants and toddlers.

Outdoor Play Equipment (Optional)

(i) All outdoor play equipment shall be sufficient in amount and variety so that children can take part in many kinds of play each day.

(ii) The Consumer Products Safety Commission’s “Handbook on Public Playground Safety” or similar authority shall be used for guidance on playground construction and maintenance.

(iii) All outdoor play equipment shall be placed to avoid injury. Fall zones shall extend at least four (4) feet and preferably six (6) feet away from the perimeter of equipment and away from retainer structures, fences, and other equipment and out of children’s traffic paths.

(iv) Resilient surfacing material shall cover fall zones at a recognized acceptable depth. (See Appendix B)

(v) Supports for climbers, swings, and other heavy equipment that could cause injury if toppled shall be securely anchored to the ground, even if the equipment is designed to be portable.

(13) Environmental Services.

(a) Environmental services shall be provided to assure the clean and sanitary condition of the PCCC and to provide a safe and hygienic environment for children and staff.

Cleaning shall be accomplished in accordance with the infection control rules and regulations herein and PCCC policy; and (b) There shall be verification of regular continuing education and competency for basic housekeeping principles.

(c) Each facility shall have routine cleaning of articles and surfaces such as furniture, floors, walls, ceilings, supplies, exhaust, grills and lighting fixtures.

(d) Sufficient and proper cleaning supplies and equipment shall be available to housekeeping staff. Cleaning supplies, toxic substances and equipment shall be secured at all times to prevent access by children. Toxic substances shall not be left unattended when not secured.

(e) A closet for janitorial supplies shall be provided.

(f) Storage for bulk supplies and equipment shall be located away from child care areas.

Storage shall not be allowed in the outmost shipping carton.

(g) The building shall be kept in good repair, clean, sanitary and safe at all times.

(14) Infection Control. A Prescribed Child Care Center shall have an annual influenza vaccination program which shall include at least:

(a) The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Prescribed Child Care Center will encourage all staff and independent practitioners to obtain an influenza vaccination;

(b) A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider);

Flu vaccination, 2. Non-vaccine control measures, and 3. The diagnosis, transmission, and potential impact of influenza;

(d) An annual evaluation of the influenza vaccination program and reasons for nonparticipation; and (e) A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee.

(15) Laundry Services.

(a) Laundry services shall:

Provide space for storage of clean linen within nursing units and for bulk storage within clean areas of the PCCC; and 2. Provide carts, bags or other acceptable containers appropriately marked to identify those used for soiled linen and those used for clean linen to prevent dual utilization of the equipment and cross contamination.

(b) The PCCC shall name an individual who is responsible for laundry service. This individual shall be responsible for:

Establishing a laundry service, either within the PCCC or by contract, that provides the facility with sufficient clean, sanitary linen at all times;
Knowing and enforcing infection control rules and regulations for the laundry service;
Assuring the collection, packaging, transportation and storage of soiled, contaminated, and clean linen is in accordance with all applicable infection control rules and procedures; and, 4. Assuring that a contract laundry service complies with all applicable infection control rules and procedures.

History

Authority: §§ 4-5-202, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-216, and 68-11- 222.
Administrative History: Original rule filed June 13, 2002; effective August 27, 2002. Amendment filed December 16, 2013; effective March 16, 2014. Amendment filed September 15, 2015; effective December 14, 2015. Amendments filed July 18, 2016; effective October 16, 2016. Transferred from chapter 1200-08-02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-15-.09 INFECTIOUS AND HAZARDOUS WASTE

(1) Each PCCC must develop, maintain and implement written policies and procedures for the definition and handling of its infectious and hazardous wastes. These policies and procedures must comply with the standards of this section and all other applicable state and federal regulations.

(2) Waste must be packaged in a manner that will protect waste handlers and the public from possible injury and disease that may result from exposure to the waste. Such packaging must provide for containment of the waste from the point of generation up to the point of proper treatment or disposal. Packaging must be selected and utilized for the type of waste the package will contain, how the waste will be treated and disposed of, and how it will be handled and transported prior to treatment and disposal.

(3) After packaging, waste must be handled and transported by methods ensuring containment and preserving the integrity of the packaging, including the use of secondary containment where necessary.

(4) Waste must be stored in a manner and location which afford protection from animals precipitation, wind, and direct sunlight, do not present a safety hazard, do not provide a breeding place or food source for insects or rodents and do not create a nuisance.

(5) In the event of spills, or other incidents where there is a loss of containment of waste, the facility must ensure that proper actions are immediately taken to:

(a) Isolate the area;

(b) Repackage all spilled waste and contaminated debris in accordance with the requirements of paragraph (4) of this rule; and (c) Sanitize all contaminated equipment and surfaces appropriately.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed June 13, 2002; effective August 27, 2002. Transferred from chapter 1200-08- 02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-15-.10 RECORDS AND REPORTS

(1) Children’s Records.

(a) The following records shall be maintained at the PCCC and made available to the Department upon request. Each child shall have a record containing the following information:

A current information form which includes the child’s name, date of birth, name of parent(s), child and parent’s home address, parent’s business address, phone numbers, work hours, social history, and the name and address (home and business or school) of a responsible person to contact in an emergency if parent(s) cannot be located promptly;
Name, address and telephone number of a physician to call in case of an emergency;
Written consent of parent(s) regarding emergency medical care;
A transportation plan, including to whom the child will be released, and a clear policy concerning the release of the child(ren) to anyone whose behavior may place the child(ren) in immediate risk;
Comprehensive protocol for care specifying the goals for care and methods for goal achievement and time frame for reviewing and revising the plan;
A consent for treatment form signed by parent and PCCC representative;
A medical history for the child, including notations from visits to health care providers;
Before a preschool child older than eight weeks is accepted for care, he/she shall have proof of being age-appropriately immunized according to the current schedule authorized by the Tennessee Department of Health. (Children six through eight weeks of age may be enrolled before immunizations are begun.)
If a child has any known allergies, they shall be indicated in the child’s health record. Foreign-born children must also present evidence of tuberculosis screening. (See Appendix C)
A copy of each infant/toddler’s or preschool child’s health history and immunization record, signed or stamped by a certified health care provider, shall be on file in the prescribed child care center and available to the appropriate staff. The health record shall be returned to the parent upon request when the child leaves the center.
Exceptions to requirements 8. and 10. of this section may be made only if:

(i) The child’s physician or the health department provides a signed and dated statement, giving a medical reason why the child should not be given a specified immunization; or (ii) The child’s parent provides a signed written statement that such immunizations conflict with his/her religious tenets and practices.

Before an infant or toddler is accepted for care, the parent shall have proof of the child’s physical examination within three months prior to admission, signed or stamped by a physician or health care provider. Each infant/toddler shall have on file an official health record of the first medical checkup and health history.
Other requirements as set forth in Appendix C shall apply.
Flow chart of treatments administered;
Concise, accurate information and initialed case notes reflecting progress toward plan goal achievement or reasons for lack of progress;
Documentation of nutritional management and special diets, as appropriate;
Documentation of physical, occupational, speech and/or other special therapies;
Daily attendance records for each child;
Written permission for field trips away from the premises; and 20. The same records shall be kept on infants/toddlers as on other children in the PCCC. In addition, each infant’s/toddler’s and any other non-verbal child’s daily activities, including time and amount of feeding, time and amount of medication given, vital signs taken, elimination, times of diaper changes, sleep patterns, and developmental progress shall be recorded and shared with the parent(s) daily.

(b) A child’s records shall be kept for one year following the child’s leaving the PCCC. (The health record shall be returned upon request when the child leaves the facility.)

(2) The PCCC shall report all incidents of abuse, neglect, and misappropriation to the Department of Health in accordance with T.C.A. § 68-11-211.

(3) The PCCC shall report the following incidents to the Department of Health in accordance with T.C.A. § 68-11-211.

(a) Strike by staff at the facility;

(b) External disasters impacting the facility;

(c) Disruption of any service vital to the continued safe operation of the PCCC or to the health and safety of its patients and personnel; and (d) Fires at the PCCC that disrupt the provision of patient care services or cause harm to the patients or staff, or that are reported by the facility to any entity, including but not limited to a fire department charged with preventing fires.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-211.
Administrative History: Original rule filed June 13, 2002; effective August 27, 2002. Amendment filed Janaury 3, 2012; effective April 2, 2012. Transferred from chapter 1200-08-02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-15-.11 CHILD, PARENT OR RESPONSIBLE PARTY’S RIGHTS

(1) The PCCC shall demonstrate respect and support for each child’s rights. The facility insures each child receives professional and humanistic services in a manner that protects their fundamental human, civil, constitutional and statutory rights.

Policies and procedures shall be developed, approved, and maintained to ensure consistent application and communication throughout the organization.

(a) The following rights of children and parents shall apply whenever appropriate:

Impartial access to treatment or accommodations that are available or medically indicated regardless of race, creed, sex, national origin, or sources of payment for care.
Considerate, respectful care at all times and under all circumstances, with recognition of his/her personal dignity, values and beliefs.
Identity and professional status of individuals providing services to the child and to know who is primarily responsible for the child’s care or treatment.
Expectation of reasonable safety insofar as family practices and environment are concerned.
Confidentiality of child’s records.
Ability to voice complaints regarding care without fear of discrimination or compromising their child’s future care.
The parent may direct a determination which encompasses the right to make choices regarding life sustaining treatment, including resuscitative services.
Information about fee schedules and payment policies.
Environment conducive to personal and informational privacy.

(b) Children shall not be abused, neglected, or administered corporal punishment.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed June 13, 2002; effective August 27, 2002. Transferred from chapter 1200-08- 02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-15-.12 POLICIES AND PROCEDURES FOR HEALTH CARE DECISION-MAKING

(1) Pursuant to this rule, each prescribed child care center shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a child who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from individual children. An adult or emancipated minor may give an individual instruction. The instruction may be oral or written.

The instruction may be limited to take effect only if a specified condition arises.

(3) The advance directive shall be in writing, signed by the patient, and shall either be notarized or witnessed by two (2) witnesses. Both witnesses shall be competent adults, and neither of them may be the agent. At least one (1) of the witnesses shall be a person who is not related to the child by blood, marriage, or adoption and would not be entitled to any portion of the estate of the child upon the death of the child. The advance directive shall contain a clause that attests that the witnesses comply with the requirements of this paragraph.

(5) A facility may use any advanced directive form that meets the requirements of the Tennessee Health Care Decisions Act or has been developed and issued by the Board for Licensing Health Care Facilities.

(8) An advance directive may include the individual’s nomination of a court-appointed guardian.

(10) No health care provider or institution shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care.

(12) A patient having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.

(13) A patient having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke.

(15) An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.

(16) Surrogates.

(a) An adult or emancipated minor may designate any individual to act as surrogate by personally informing the supervising health care provider. The designation may be oral or written.

(b) A surrogate may make a health care decision for a patient who is an adult or emancipated minor if and only if:

The patient has been determined by the designated physician to lack capacity, and 2. No agent or guardian has been appointed, or 3. The agent or guardian is not reasonably available.

(e) Consideration may be, but need not be, given in order of descending preference for service as a surrogate to:

The patient’s spouse, unless legally separated;
The patient’s adult child;
The patient’s parent;
The patient’s adult sibling;
Any other adult relative of the patient; or 6. Any other adult who satisfies the requirements of 0720-15-.12(16)(d).

(f) No person who is the subject of a protective order or other court order that directs that person to avoid contact with the patient shall be eligible to serve as the patient’s surrogate.

(g) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:

Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the patient or in accordance with the patient’s best interests;
The proposed surrogate’s regular contact with the patient prior to and during the incapacitating illness;
The proposed surrogate’s demonstrated care and concern;
The proposed surrogate’s availability to visit the patient during his or her illness; and 5. The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.

(h) If the child lacks capacity and none of the individuals eligible to act as a surrogate under 0720-15-.12(16)(c) through 0720-15-.12(16)(g) is reasonably available, the designated physician may make health care decisions for the child after the designated physician either:

Consults with and obtains the recommendations of a facility’s ethics mechanism or standing committee in the facility that evaluates health care issues; or 2. Obtains concurrence from a second physician who is not directly involved in the child’s health care, does not serve in a capacity of decision-making, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.

(j) A surrogate shall make a health care decision in accordance with the patient’s individual instructions, if any, and other wishes to the extent known to the surrogate.

(l) Except as provided in 0720-15-.12(16)(m):

Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution nor an employee of an operator of a health care institution may be designated as a surrogate; and 2. A health care provider or employee of a health care provider may not act as a surrogate if the health care provider becomes the patient’s treating health care provider.

(m) An employee of the treating health care provider or an employee of an operator of a health care institution may be designated as a surrogate if:

The employee so designated is a relative of the patient by blood, marriage, or adoption; and 2. The other requirements of this section are satisfied.

(17) Guardian.

(a) A guardian shall comply with the patient’s individual instructions and may not revoke the patient’s advance directive absent a court order to the contrary.

(b) Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.

(19) Except as provided in 0720-15-.12(20) through 0720-15-.12(22), a health care provider or institution providing care to a patient shall:

(20) A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.

(21) A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:

(23) A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 0720-15-.12(20) through 0720-15-.12(22) shall:

(a) Promptly so inform the patient, if possible, and any person then authorized to make health care decisions for the patient;

(b) Provide continuing care to the patient until a transfer can be effected or until the determination has been made that transfer cannot be effected;

(a) Complying with a health care decision of a person apparently having authority to make a health care decision for a patient, including a decision to withhold or withdraw health care;

(26) An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.

(27) A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for such identification made in good faith.

(28) A copy of a written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.

(30) Physician Orders for Scope of Treatment (POST).

(a) Physician Orders for Scope of Treatment (POST) may be issued by a physician for a patient with whom the physician has a bona fide physician-patient relationship, but only:

With the informed consent of the patient;
If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or 3. If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available, if the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

No physician, who has a bona fide physician-patient relationship with the patient, is present and available for discussion with the patient (or if the patient is a minor or is otherwise incapable of making an informed decision, with the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act);
Such authority to issue is contained in the physician assistant’s, nurse practitioner’s or clinical nurse specialist’s protocols;
Either:

(i) With the informed consent of the patient;

(d) A POST issued in accordance with this section shall remain valid and in effect until revoked. In accordance with this rule and applicable regulations, qualified emergency medical services personnel; and licensed health care practitioners in any facility, program, or organization operated or licensed by the Board for Licensing Health Care Facilities, the Department of Mental Health and Substance Abuse Services, or the Department of Intellectual and Developmental Disabilities, or operated, licensed, or owned by another state agency, shall follow a POST that is available to such persons in a form approved by the Board for Licensing Health Care Facilities.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-224, and 68- 11-1801 through 68-11-1815.
Administrative History: Original rule filed June 13, 2002; effective August 27, 2002. Repeal and new rule filed May 16, 2006; effective July 30, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200-08-02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-15-.13 DISASTER PREPAREDNESS

(1) The administrator of every PCCC shall have in effect and available for all supervisory personnel and staff, written copies of the following required disaster plans, for the protection of all persons in the event of fire and other emergencies for evacuation to areas of refuge and/or evacuation from the building. A detailed log with staff’s signatures of training received shall be maintained. All employees shall be trained annually as required in the following plans and shall be kept informed with respect to their duties under the plans. A copy of the plans shall be readily available at all times in the telephone operator’s position or at the security center. Each of the following plans shall be exercised annually prior to the month listed in each plan:

(a) Fire Safety Procedures Plan (to be exercised at any time during the year) shall include:

Minor fires;
Major fires;
Fighting the fire;
Evacuation procedures; and, 5. Staff functions by department and job assignment.

(b) Tornado/Severe Weather Procedures Plan shall include:

Staff duties by department and job assignment; and, 2. Evacuation procedures.

Staff duties;
Search team, searching the premises;
Notification of authorities;
Location of suspicious objects; and, 5. Evacuation procedures.

(d) Floods Procedures Plans, if applicable, shall include:

Staff duties;
Evacuation procedures; and 3. Safety procedures following the flood.

(e) Severe Cold Weather and Severe Hot Weather Procedures Plans shall include:

Staff duties;
Equipment failures;
Insufficient HVAC on emergency power;
Evacuation procedures; and 5. Emergency food service.

(f) Earthquake Disaster Procedures Plan shall include:

Staff duties;
Evacuation procedures;
Safety procedures; and, 4. Emergency services;

(2) Emergency Planning with Local Government Authorities.

(a) All PCCC shall establish and maintain communications with the county Emergency Management Agency. This includes the provision of the information and procedures that are needed for the local comprehensive emergency plan. The prescribed childcare centers shall cooperate, to the extent possible, in area disaster drills and local emergency situations.

(b) Each PCCC shall conduct both the physical facility and community emergency drills as required in these regulations, even if the local Emergency Management Agency is unable to participate.

Appendix A Vehicle Safety Check Preventive Maintenance Check List Vehicle No. Facility Use one column per day; write date in shaded area. Check each item (T) if OK, (0) if item needs attention, and (x) if deficiency is corrected. Note any defects and/or corrections at the bottom of sheet. In addition, defects are to be reported to your supervisor.

Exterior  Date  Checked Tires Turn Signals Body (cleanliness)

Head Lights Mirrors Wipers Body (dents)

Interior  Brakes Steering Safety Equipment Dash Gauges Seat Belts Cleanliness Body (dents)

Under Hood  Oil Coolant Transmission Fluid W/W Fluid Belts/Hoses Brake Fluid Amount of Gas Added Mileage Driver Initials Defects/Maintenance Performed:

Remarks:

Appendix B Playground Surfacing (1) Playground Surface Materials (a) A variety of surfaces on the playground provides flexibility and visual interest as well as enjoyment and learning experiences for children. Various play activities require or are facilitated by different surfaces. For example, concrete, asphalt, or hard-packed dirt are better than grass or sand for trike riding and hopscotch; while sand, pebbles, dirt or other “fluid” material are necessary for manipulative activities such as digging or pouring.

(b) Climbers, swings and other equipment which can take a child’s feet off the ground are in a “fall zone.” A fall of even six (6)” can cause injury to a small child. The fall-zone area under and around equipment where children might fall and be injured shall be covered with impact-absorbing materials which will effectively cushion the fall of a child.

According to the Consumer Product Safety Commission (which is mentioned in these standards for additional guidance), falls from equipment onto a hard surface account for 60% to 70% of playground related injuries, and injuries from falls are responsible for over half of all deaths of children after infancy.

(c) Tricycles and other children’s vehicles are not included in this fall-zone rule, although consideration should be given to placing tricycle tracks within a resilient area and/or providing helmets.

(d) Before the variety of materials is examined, another hazard should be considered. In landscaping a play area for children, make certain no poisonous plants, bushes, or grasses are used. The Department has a list of plants to avoid, or consult with your local Poison Control Center if in doubt. (A nursery may not be reliable since nurseries are not accustomed to that question.)

(e) Whether loose-fill material or a “unitary” covering is chosen as a resilient surface, it should extend far enough to cover the fall zone, or at least 4 feet and preferably six (6) feet from all sides or perimeters of equipment where children could fall or be propelled (e.g., from arc of swing or exit end of slide).

(f) Some surface materials are listed below, with advantages and disadvantages of each given, along with acceptable depth requirements. The range of depths is based on height of equipment in fall zone: the taller the equipment, the more resiliency needed.

(Sources for this information are the Consumer Product Safety Commission’s 1992 “Handbook for Public Playground Safety” and “Caring for Our Children,” American Public Health Association/American Academy of Pediatrics [1992]). Administrators are advised to follow guidelines in one of these publications for construction, renovation and maintenance of playgrounds and playground equipment.) Other materials are not precluded; if another material is chosen, use the suggested depth for a similar material (e.g., if cocoa mulch is chosen, use the greatest depth given for wood mulch).

(2) Natural/Loose-Fill Materials Note: Most are not easily accessible to wheel chairs.

(a) Grass: Provides color and soft appearance to play area, esthetically pleasing. High maintenance. Wears off in high-traffic areas, leaving mud or hard-packed dirt; therefore, unacceptable as a resilient surface under climbers and swings.

(b) Coarse sand: Dries fairly quickly (if good drainage system), good for manipulative activities (pouring, sifting, moving), is easily raked. (Sand play area must be apart from sand area around equipment. Sand play area must be covered when not in use and cleaned occasionally.) Depth: 6” min./Eqt. ht: 5 ft.; 12” min./Eqt. ht.: 6 ft. Moderate to high maintenance required because of need to rake when displaced and to clean occasionally. Can cause small cuts and possible eye injury if thrown. CPSC Handbook makes distinction among fine, medium, and coarse.

(c) Pea gravel: Drains well, can be played on immediately after rain, suitable for manipulative activities (in protected area away from equipment). Medium size is best (small size can be lodged in ears and noses, large size could cause injury if thrown and is difficult to walk on.) Scatters easily, not recommended for slopes. Depth: 6” to 12” depending on height of equipment. Low maintenance. Must be raked when displaced.

Use caution when selecting; must be smooth “river rock.”

(d) Rubber mulch: A newer product (untested as of this printing). Provides acceptable resiliency at 6” depth, drains well. Some types leave black marks or dust on skin and clothing. Some objection to heat generated by the sun and its combustibility. Low maintenance. Must be raked when displaced.

(e) Sawdust: Inexpensive and drains well when new. High maintenance, requiring a large amount for acceptable resiliency because it scatters easily and must be raked often; must be replaced often because of deterioration. Untested.

(f) Wood chips: Drain fairly well. Better drainage provided if placed over sand/dirt combination (perhaps with gravel/dirt layered system). Easily scattered, requiring occasional raking. Depth: 6” to 12” depending on height of equipment. Check for splintering. Rots, needing replacement. Moderate maintenance.

(g) Wood mulch: See wood chips for drainage information. Packs down, requiring raking.

Less abrasive than sand. Depth: 6” to 12”, depending on height of equipment. Rots, needing replacement on at least annual basis. Moderate to high maintenance.

(3) Unitary Products These are of solid construction, usually rubber or rubber composition over foam mats or tiles, or they may be “poured.” The CPSC “Handbook for Public Playground Safety” (1992 ed.) reads:

“Unitary materials are available from a number of different manufacturers many of whom have a range of materials with differing shock absorbing properties. Persons wishing to install a unitary material as a playground surface should request test data from the manufacturer that should identify the Critical Height of the desired material. In addition, site requirements should be obtained from the manufacturer because some unitary materials require installation over a hard surface while for others this is not required.”

Their advantages are their low or no maintenance feature, consistent shock absorbency, wheelchair accessibility, and good footing. The primary disadvantage is the initial high cost; however, most are guaranteed for 5 years but may last longer. Some need to be installed by a professional--some on concrete, some on a level dirt/sand surface. (For more information, see CPSC Handbook.)

Artificial turf should not be used on playgrounds because of its lack of conformity to CPSC standards and because it causes carpet-type burns on falls.

Appendix C Immunization and TB Requirements In addition to the rules in Section 0720-15-.10, these rules are also required of prescribed child care centers.

(1) Immunization Rules (a) Age-appropriate immunization against the following diseases is required for every child nine (9) weeks of age and above: diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, haemophilus influenza type B, and hepatitis B (and such vaccines and medications as deemed appropriate by the Department of Health in the event of a disease outbreak).

(b) Records of children shall state whether immunizations required for care are complete, and if not complete, when future immunizations will be given. If immunizations are not continued on time by the parent, the child shall not remain in care. If a child has any known allergies, they shall be indicated in the child’s health record. Foreign-born children shall also present evidence of tuberculosis screening.

(2) Requirements for Tuberculosis Screening of Child Care Populations PCCCs that provide care for periods of less than twenty-four (24) hours per day shall comply with the following health regulations relating to tuberculosis control:

(a) Staff 1. It is preferable that staff be screened for tuberculosis within 90 days prior to employment. However, if the situation dictates immediate hire, the staff person shall be screened for signs and symptoms of TB and obtain a mantoux tuberculin skin test no later than two (2) weeks after employment.

In immediate hire situations, a TB Screening Inventory shall be completed on the staff person (see attached form entitled “Child Care Staff: Tuberculosis Screening Inventory). If the results of the screening inventory are negative, the staff person may begin work while awaiting the outcome of the mantoux tuberculin skin test. If the results of the screening inventory indicate the likelihood of a positive TB infection, the applicant shall be evaluated by a physician prior to beginning employment. This evaluation may include a chest x-ray and if necessary, other specific tests. If the results of the mantoux tuberculin skin test are positive, the employee shall be evaluated by a physician prior to continuing employment. Persons requiring an evaluation by a physician shall provide documentation indicating that they are free of infectious tuberculosis.
Prospective or current staff who are known to have positive tuberculosis reaction shall receive a chest x-ray to rule out infectious tuberculosis. No x-ray is required for persons with documentation of completed preventive therapy. Screening for signs and symptoms of TB shall occur periodically.

(b) Children 1. Foreign-born All foreign-born children shall present evidence of tuberculin skin test performed in the United States at any time after twelve (12) months of age. Any child with a positive tuberculin skin test shall be referred to a physician for evaluation. After the initial evaluation, future periodic screening is not required unless the child develops persistent pulmonary symptoms or there is contact with tuberculosis.

Native-born Special screening of children born in the United States is not required unless there is a history of contact to tuberculosis or there are symptoms and/or physical findings suggestive of tuberculosis. If symptoms are present, the child shall be evaluated by a physician. Such children shall provide documentation indicating that they are free of infectious tuberculosis.

Child Care Staff Tuberculosis Screening Inventory Note: This inventory is not a self-evaluation. This form is to be completed by PCCC administrative personnel.

Name:______________________________ Status: (circle one:) Applicant Employee Any child care applicant/employee with the following symptoms should be evaluated promptly for TB: _____ persistent cough (i.e., a cough lasting three weeks or more), especially in the presence of other signs or symptoms compatible with active TB such as: _______ weight loss _______ night sweats _______ bloody sputum _______ anorexia _______ fever If the above symptoms are indicated, the individual should not begin or continue employment until a diagnosis of TB has been excluded or until the person is on therapy and a determination has been made that the individual is noninfectious.

Inventory Results: _____ indicated - medical confirmation of noninfectious status required _____ not indicated - no further action necessary Signature:____________________________ Date Completed:_______________________ Medical Confirmation: _____ confirmation of noninfectious status received Signature:____________________________ Date Received:________________________

History

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed June 13, 2002; effective August 27, 2002. Transferred from chapter 1200-08-02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.

Tenn. Comp. R. & Regs. 0720-15-.14 APPENDIX I

Appendix I (1) Physician Orders for Scope of Treatment (POST) Form.

(This space intentionally left blank)

A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED

Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”)

This is a Physician Order Sheet based on the medical conditions and wishes of the person identified at right (“patient” ). Any section not completed indicates full treatment for that section. When need occurs, first follow these orders, then contact physician.

Patient’s Last Name First Name/Middle Initial Date of Birth

Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Other Instructions:

Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify)

The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other)

Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge)

MD/NP/CNS/PA Phone Number:

Name (print) Signature Relationship (write “self” if patient)

To be valid, POST must be signed by a physician or, at discharge or transfer from a hospital or long term care facility, by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA). Verbal orders are acceptable with followup signature by physician in accordance with facility/community policy.

Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel.

Photocopies/faxes of signed POST forms are legal and valid.

Using POST Any incomplete section of POST implies full treatment for that section.

No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.”

Oral fluids and nutrition must always be offered if medically feasible.

IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”

A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.

Reviewing POST This POST should be reviewed if:

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.

(2) Advance Directive for Health Care Form.

ADVANCE DIRECTIVE FOR HEALTH CARE*

(Tennessee)

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.

Part 5, Block A or Block B must be completed for all uses. assistance.   Yes No Life Support/Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys, and other organs to continue to work.   Yes No Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a new condition but will not help the main illness.   Yes No Tube feeding/IV fluids: Use of tubes to deliver food and water to a patient’s stomach or use of IV fluids into a vein, which would include artificially delivered nutrition and hydration.

Part 3 Other instructions, such as hospice care, burial arrangements, etc.:

(Attach additional pages if necessary)

Part 5 Your signature must either be witnessed by two competent adults (“Block A”) or by a notary public (“Block B”).

Signature: _______________________________________ Date: ____________________ (Patient)

Block A Neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.

Witnesses:

I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form.

Signature of witness number 2 Block B You may choose to have your signature witnessed by a notary public instead of the witnesses described in Block A.

STATE OF TENNESSEE

COUNTY OF

My commission expires:

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1805.
Administrative History: Original rule filed February 16, 2007; effective May 2, 2007. Repeal and new rule filed August 28, 2012; effective November 26, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed February 8, 2017; effective May 9, 2017. Transferred from chapter 1200-08- 02 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-16 Administration (Transferred from 1200-08-03)

Tenn. Comp. R. & Regs. 0720-16-.01 MANAGEMENT

(1) through (14) Repealed.

(15) Management Provisions Applicable Only to Critical Access Hospitals.

(a) The facility shall enter into agreements with one or more hospitals participating in the Medicare/Medicaid programs to provide services which the Critical Access Hospital is unable to provide.

(b) When there are no inpatients, the facility is not required to be staffed by licensed medical professionals, but must maintain a receptionist or other staff person on duty to provide emergency communications access. The hospital shall provide an effective system to ensure that a physician or a mid-level practitioner with training and experience in emergency care is on call and immediately available by telephone or radio and available on site within thirty (30) minutes, twenty-four (24) hours a day.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-209, 68-11-202, 68-11-203, and 68-11-209.
Administrative History: Original rule certified June 7, 1974. Amendment filed April 3, 1974; effective May 3, 1974. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Amendment filed October 22, 1987; effective December 6, 1987. Amendment filed July 28, 1988; effective September 11, 1988. Amendment filed June 29, 1994; effective September 12, 1994. Amendment filed June 13, 1997; effective August 27, 1997. Amendment filed November 30, 1999; effective February 6, 2000. Amendment filed March 18, 2000; effective May 30, 2000. Transferred from chapter 1200-08-03 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-16-.02 MEDICAL STAFF

(1) through (6) Repealed.

(7) (a) through (c) Repealed (d) Critical Access Hospital.

Every patient may be under the care of a physician or under the care of a practitioner supervised by a physician.
Whenever a patient is admitted to the facility by a practitioner, the supervising physician shall be notified of that fact, by phone or otherwise, and within 24 hours the supervising physician shall examine the patient or before discharge if discharged within 24-hours, and a plan of care be placed in the patient’s chart, unless the patient is transferred to a higher level of care within 24-hours.
A physician, a practitioner or a registered nurse shall be on duty and physically available in the facility when there are inpatients.
A physician on staff shall:

(i) Provide medical direction to the facility’s health care activities and consultation for non-physician health care providers.

(ii) In conjunction with the practitioner staff members, participate in developing, executing, and periodically reviewing the facility’s written policies and the services provided to patients.

(iii) Review and sign the records of each patient admitted and treated by a practitioner no later than fifteen (15) days after the patient’s discharge from the facility.

(iv) Provide health care services to the patients in the facility, whenever needed and/or requested.

(v) Prepare guidelines for the medical management of health problems, including conditions requiring medical consultation and/or patient referral.

(vi) At intervals no more than two (2) weeks apart, be physically present in the facility for a sufficient time to provide medical direction, medical care services, and staff consultation as required.

(vii) When not physically present in the facility, either be available through direct telecommunication for consultation and assistance with medical emergencies and patient referral, or ensure that another physician is available for this purpose.

(viii) The physical site visit for a given two week period is not required if, during that period, no inpatients have been treated in the facility.

A practitioner on staff shall:

(i) Participate in the development, execution, and periodic review of the guidelines and written policies governing treatment in the facility.

(ii) Participate with a physician in a review of each patient’s health records.

(iii) Provide health care services to patients according to the facility’s policies.

(iv) Arrange for or refer patients to needed services that are not provided at the facility.

(v) Assure that adequate patient health records are maintained and transferred as necessary when a patient is referred.

History

Authority: T.C.A. §§ 4-5-202, 4-5-209, 68-11-201, et seq., 68-11-202, 68-11-203, 68-11-209, and 68-11- 303.
Administrative History: Original rule certified June 7, 1974. Amendment filed November 30, 1984; effective December 30, 1984. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Amendment filed January 30, 1989; effective March 16, 1989. Amendment filed April 1, 1992; effective May 16, 1992. Amendment filed December 4, 1992; effective January 19, 1993. Amendment filed November 30, 1999; effective February 6, 2000. Amendment filed March 18, 2000; effective May 30, 2000. Transferred from chapter 1200-08-03 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-16-.03 REPEALED

History

Authority: T.C.A. § 68-11-209.
Administrative History: Original rule certified June 7, 1974. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Repeal filed March 18, 2000; effective May 30, 2000. Transferred from chapter 1200-08-03 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-16-.04 REPEALED

History

Authority: T.C.A. §§ 68-11-202(a) and 68-11-209.
Administrative History: Original rule certified June 7, 1974. Amendment filed November 30, 1984; effective December 30, 1984. Repeal filed May 22, 1986; effective June 21, 1986. Transferred from chapter 1200-08-03 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-16-.05 REPEALED

History

Authority: T.C.A. §§ 68-11-202(a) and 68-11-209.
Administrative History: Original rule certified June 7, 1974. Amendment filed April 3, 1974; effective May 3, 1974. Amendment filed November 30, 1984; effective December 30, 1984. Repeal filed May 22, 1986; effective June 21, 1986. Transferred from chapter 1200-08-03 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-16-.06 REPEALED

History

Authority: T.C.A. § 53-1310.
Administrative History: Original rule certified June 7, 1984. Repeal filed May 22, 1986; effective June 21, 1986. Transferred from chapter 1200-08-03 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-17 Patient Services (Transferred from 1200-08-04)

Tenn. Comp. R. & Regs. 0720-17-.01 REPEALED

History

Authority: T.C.A. §§ 4-5-202, 68-11-201, et seq., 68-11-209, and 68-11-303.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Amendment filed December 4, 1992; effective January 19, 1993. Repeal filed March 18, 2000; effective May 30, 2000. Transferred from chapter 1200-08-04 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-17-.02 REPEALED

History

Authority: T.C.A. §§ 68-11-202 and 68-11-209.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Repeal filed March 18, 2000; effective May 30, 2000. Transferred from chapter 1200-08-04 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-17-.03 SPECIALIZED DEPARTMENT SERVICES

(1) Repealed.

(2) Laboratory.

(a) Organization. The laboratory shall be licensed in accordance with the Tennessee Medical Laboratory Act. All technical laboratory staff shall be licensed in accordance with the Tennessee Medical Laboratory Act and shall be qualified by education, training and experience for the type of service rendered. The laboratory shall be CLIA certified.

(b) through (e) Repealed.

(f) The Critical Access Hospital, at a minimum, shall provide basic laboratory services essential to the immediate diagnosis and treatment of patients, including:

Chemical examinations of urine stick or tablet methods, or both (including urine ketoses);
Microscopic examinations of urine sediment;
Hemoglobin or hematocrit;
Blood sugar;
Gram stain;
Examination of stool specimens for occult blood;
Pregnancy test;
Primary culturing for transmittal to a CLIA certified laboratory;
Sediment rate; and, 10. CBC.

History

Authority: T.C.A. §§ 4-5-202, 4-5-209, 68-11-201, 68-11-202, 68-11-203, 68-11-209, and 68-11-303.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Amendment filed October 22, 1987; effective December 6, 1987. Amendment filed December 4, 1992; effective January 19, 1993. Amendment filed November 30, 1999; effective February 6, 2000. Amendment filed March 18, 2000; effective May 30, 2000. Transferred from chapter 1200-08-04 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-17-.04 REPEALED

History

Authority: T.C.A. § 68-11-209.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed May 22, 1986; effective June 21, 1986. Repeal filed March 18, 2000; effective May 30, 2000. Transferred from chapter 1200-08-04 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-17-.05 REPEALED

History

Authority: T.C.A. §§ 4-5-201, 4-5-202, 68-11-201, 68-11-202, 68-11-203, 68-11-204, 68-11-206, 68-11- 207, 68-11-209, 68-11-210, 68-11-213, 68-11-214, and 68-11-224.
Administrative History: Original rule filed June 22, 1992; effective August 6, 1992. Repeal filed March 18, 2000; effective May 30, 2000. Transferred from chapter 1200-08-04 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-17-.06 THROUGH 0720-17-.12 REPEALED

History

Authority: T.C.A. § 53-1310.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1984. Repeal filed May 22, 1986; effective June 21, 1986. Transferred from chapter 1200-08-04 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-18 Standards for Nursing Homes (Transferred from 1200-08-06)

Tenn. Comp. R. & Regs. 0720-18-.01 DEFINITIONS

(1) Abuse. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) Administrator. A person currently licensed as such by the Tennessee Board of Examiners for Nursing Home Administrators.

(3) Adult. An individual who has capacity and is at least 18 years of age.

(5) Agent. An individual designated in an advance directive for health care to make a health care decision for the individual granting the power.

(6) Board. The Tennessee Board for Licensing Health Care Facilities.

(7) Capacity. An individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. These regulations do not affect the right of a resident to make health care decisions while having the capacity to do so. A resident shall be presumed to have capacity to make a health care decision, to give or revoke an advance directive, and to designate or disqualify a surrogate.

Any person who challenges the capacity of a resident shall have the burden of proving lack of capacity.

(8) Cardiopulmonary Resuscitation (CPR). The administering of any means or device to restore or support cardiopulmonary functions in a resident, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilations or respirations, defibrillation, the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a resident where cardiac or respiratory arrest has occurred or is believed to be imminent.

(9) Certified Nurse Aide or Certified Nursing Assistant. An individual who has successfully completed an approved nursing assistant training program and is registered with the department.

(10) Clinical Fellow. A Speech Language Pathologist who is in the process of obtaining his or her paid professional experience, as defined by a Communications Disorders and Sciences Board-approved accreditation agency, before being qualified for licensure.

(11) Commissioner. The Commissioner of the Tennessee Department of Health or his or her authorized representative.

(12) Competent. A resident who has capacity.

(13) Department. The Tennessee Department of Health.

(14) Designated Physician. A physician designated by an individual or the individual’s agent, guardian, or surrogate, to have primary responsibility for the individual’s health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes such responsibility.

(15) Dietitian. A person currently licensed as such by the Tennessee Board of Dietitian/Nutritionist Examiners. Persons exempt from licensure shall be registered with the American Dietetics Association pursuant to T.C.A. § 63-25-104.

(16) Director of Nursing (DON). A Registered Nurse employed full-time in a nursing home who satisfies the responsibilities set forth in this chapter.

(17) Do-Not-Resuscitate Order (DNR). A written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(18) Emancipated Minor. Any minor who is or has been married or has by court order or otherwise been freed from the care, custody and control of the minor’s parents.

(19) Emergency Responder. A paid or volunteer firefighter, law enforcement officer, or other public safety official or volunteer acting within the scope of his or her proper function under law or rendering emergency care at the scene of an emergency.

(20) Guardian. A judicially appointed guardian or conservator having authority to make a health care decision for an individual.

(21) Hazardous Waste. Materials whose handling, use, storage, and disposal are governed by local, state or federal regulations.

(22) Health Care. Any care, treatment, service or procedure to maintain, diagnose, treat, or otherwise affect an individual’s physical or mental condition, and includes medical care as defined in T.C.A. § 32-11-103(5).

(23) Health Care Decision. Consent, refusal of consent or withdrawal of consent to health care.

(24) Health Care Decision-Maker. In the case of a resident who lacks capacity, the resident’s health care decision-maker is one of the following: the resident’s health care agent as specified in an advance directive, the resident’s court-appointed guardian or conservator with health care decision-making authority, the resident’s surrogate as determined pursuant to

Rule 0720-18-.13 or T.C.A. § 33-3-220, the designated physician pursuant to these rules or in the case of a minor child, the person having custody or legal guardianship.

(25) Health Care Institution. A health care institution as defined in T.C.A. § 68-11-1602.

(26) Health Care Provider. A person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care in the ordinary course of business or practice of a profession.

(27) Hospital. Any institution, place, building or agency represented and held out to the general public as ready, willing and able to furnish care, accommodations, facilities and equipment for the use, in connection with the services of a physician or dentist, of one (1) or more nonrelated persons who may be suffering from deformity, injury or disease or from any other condition for which nursing, medical or surgical services would be appropriate for care, diagnosis or treatment.

(28) Hospitalization. The reception and care of any person for a continuous period longer than twenty-four (24) hours, for the purpose of giving advice, diagnosis, nursing service or treatment bearing on the physical health of such person, and maternity care involving labor and delivery for any period of time.

(29) Incompetent. A resident who has been adjudicated incompetent by a court of competent jurisdiction and has not been restored to legal capacity.

(30) Individual Instruction. An individual’s direction concerning a health care decision for the individual.

(31) Infectious Waste. Solid or liquid wastes which contain pathogens with sufficient virulence and quantity such that exposure to the waste by a susceptible host could result in an infectious disease.

(32) Involuntary Transfer. The movement of a resident between nursing homes, without the consent of the resident, the resident’s legal guardian, next of kin or representative.

(33) Licensed Practical Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(34) Licensee. The person or entity to whom the license is issued. The licensee is held responsible for compliance with all rules and regulations.

(35) Life Threatening or Serious Injury. Injury requiring the patient to undergo significant additional diagnostic or treatment measures.

(36) Medical Director. A licensed physician employed by the nursing home to be responsible for medical care in the facility.

(37) Medical Emergency. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the resident’s health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

(38) Medical Equipment. Equipment used for the diagnosis, treatment and monitoring of patients, including, but not limited to, oxygen care equipment and oxygen delivery systems, enteral and parenteral feeding pumps, and intravenous pumps.

(39) Medical Record. Medical histories, records, reports, summaries, diagnoses, prognoses, records of treatment and medication ordered and given, entries, x-rays, radiology interpretations and other written, electronic, or graphic data prepared, kept, made or maintained in a facility that pertains to confinement or services rendered to residents.

(40) Medically Inappropriate Treatment. Resuscitation efforts that cannot be expected either to restore cardiac or respiratory function to the resident or other medical or surgical treatments to achieve the expressed goals of the informed resident. In the case of the incompetent resident, the resident’s representative expresses the goals of the resident.

(41) Misappropriation of Patient/Resident Property. The deliberate misplacement, exploitation or wrongful, temporary or permanent use of an individual’s belongings or money without the individual’s consent.

(42) Neglect. The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; however, the withholding of authorization for or provision of medical care to any terminally ill person who has executed an irrevocable living will in accordance with the Tennessee Right to Natural Death Law, or other applicable state law, if the provision of such medical care would conflict with the terms of the living will, shall not be deemed “neglect” for purposes of these rules.

(43) NFPA. The National Fire Protection Association.

(44) Nurse Aide or Nursing Assistant Training Program. A specialized program approved by the Department to provide classroom instruction and supervised clinical experience for individuals who wish to be employed as Nurse Aides or Nursing Assistants.

(45) Nursing Personnel. Licensed nurses and certified nurse aides who provide nursing care.

(46) Occupational Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(47) Person. An individual, corporation, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency, or instrumentality, or any other legal or commercial entity.

(48) Personally Informing. A communication by any effective means from the resident directly to a health care provider.

(49) Pharmacist. A person currently licensed as such by the Tennessee Board of Pharmacy.

(50) Physical Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(51) Physician Assistant. A person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(52) Physician Orders for Scope of Treatment or POST. Written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(53) Physician. An individual authorized to practice medicine or osteopathy under Tennessee Code Annotated, Title 63, Chapters 6 or 9.

(54) Podiatrist. A person currently licensed as such by the Tennessee Board of Registration in Podiatry.

(55) Power of Attorney for Health Care. The designation of an agent to make health care decisions for the individual granting the power under T.C.A. Title 34, Chapter 6, Part 2.

(56) Program Coordinator. A registered nurse who possesses a minimum of two years nursing experience with at least one year in long term care and is responsible for ensuring that the requirements of the Nurse Aide Training Program are met.

(57) Qualified Emergency Medical Service Personnel. Includes, but shall not be limited to, emergency medical technicians, paramedics, or other emergency services personnel, providers, or entities acting within the usual course of their professions, and other emergency responders.

(58) Reasonably Available. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the resident’s health care needs. Such availability shall include, but not be limited to, availability by telephone.

(59) Registered Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(60) Resident/Patient. Includes but is not limited to any person who is suffering from an illness or injury and who is in need of nursing care.

(61) Secured Unit. A facility or distinct part of a facility where residents are intentionally denied egress by any means.

(62) Shall or Must. Compliance is mandatory.

(63) Social Worker. In a facility with more than 120 beds a qualified social worker is an individual with:

(a) A bachelor’s degree in social work or a bachelor’s degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology; and, (b) One year of supervised social work experience in a health care setting working directly with individuals.

(64) Speech Language Pathologist. As defined in T.C.A. § 63-17-103, a person currently licensed as such by the Tennessee Board of Communications Disorders and Sciences.

(65) State. A state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States.

(66) Student. A person currently enrolled in a course of study that is approved by the appropriate licensing board.

(67) Supervising Health Care Provider. The designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual’s health care.

(68) Surrogate. An individual, other than a resident’s agent or guardian, authorized to make a health care decision for the resident.

(69) Survey. An on-site examination by the department to determine the quality of care and/or services provided.

(70) Transfer. The movement of a resident between nursing homes at the direction of a physician or other qualified medical personnel when a physician is not readily available. The term does not include movement of a resident who leaves the facility against medical advice. The term does not apply to the commitment and movement of mentally ill and mentally retarded persons, the discharge or release of a resident no longer in need of nursing home care, or a nursing home’s refusal, after an appropriate medical screening, to render any medical care on the grounds that the person does not have a medical need for nursing home care.

(71) Treating Health Care Provider. A health care provider who at the time is directly or indirectly involved in providing health care to the resident.

(72) Treating Physician. The physician selected by or assigned to the resident and who has the primary responsibility for the treatment and care of the resident. Where more than one physician shares such responsibility, any such physician may be deemed to be the “treating physician.”

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11- 207, 68-11-209, 68-11-210, 68-11-211, 68-11-213, 68-11-224, 68-11-234, 68-11-1802, and 71-6-121.
Administrative History: Original rule filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed April 10, 2000; effective June 24, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed April 28, 2003; effective July 12, 2003. Amendments filed September 21, 2005; effective December 5, 2005. Amendment filed February 7, 2007; effective April 23, 2007. Amendment filed July 18, 2007; effective October 1, 2007. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendment filed September 15, 2015; effective December 14, 2015. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.02 LICENSING PROCEDURES

(1) No person, partnership, association, corporation, or state, county or local government unit, or any division, department, board or agency thereof, shall establish, conduct, operate, or maintain in the State of Tennessee any nursing home without having a license. A license shall be issued only to the applicant named and only for the premises listed in the application for licensure. Satellite facilities shall be prohibited. Licenses are not transferable or assignable and shall expire and become invalid annually on the anniversary date of their original issuance. The license shall be conspicuously posted in the nursing home.

(2) In order to make application for a license:

(a) The applicant shall submit an application on a form provided by the department along with a copy of the Certificate of Need (CON) issued by the Tennessee Health Services and Development Agency (HSDA). Any condition placed on the CON will also be placed on the license.

(b) Each applicant for a license shall pay an annual license fee based on the number of nursing home beds. The fee must be submitted with the application and is not refundable.

(c) The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the department.

Residents shall not be admitted to the nursing home until a license has been issued.

Applicants shall not hold themselves out to the public as being a nursing home until the license has been issued. A license shall not be issued until the facility is in substantial compliance with these rules, including submission of all information required by T.C.A. § 68-11-206(1) or as later amended, and all information required by the Commissioner.

(d) The applicant shall not use subterfuge or other evasive means to obtain a license, such as filing for a license through a second party when an individual has been denied a license or has had a license disciplined or has attempted to avoid inspection and review process.

(e) The applicant shall allow the nursing home to be inspected by a Department surveyor.

In the event that deficiencies are noted, the applicant shall submit a plan of corrective action to the Board that must be accepted by the Board. Once the deficiencies have been corrected, then the Board shall consider the application for licensure.

(a) For the purpose of licensing, the licensee of a nursing home has the ultimate responsibility for the operation of the facility, including the final authority to make or control operational decisions and legal responsibility for the business management. A change of ownership occurs whenever this ultimate legal authority for the responsibility of the nursing home’s operation is transferred.

(b) A change of ownership occurs whenever there is a change in the legal structure by which the nursing home is owned and operated.

Transfer of the facility’s legal title;
Lease of the facility’s operations;
Dissolution of any partnership that owns, or owns a controlling interest in, the facility.
One partnership is replaced by another through the removal, addition or substitution of a partner;
Removal of the general partner or general partners, if the facility is owned by a limited partnership;
Merger of a facility owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are canceled;
The consolidation of a corporate facility owner with one or more corporations; or, 8. Transfers between levels of government.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors or board of trustees;
Two (2) or more corporations merge and the originally-licensed corporation survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government; or, 5. Corporate stock transfers or sales, even when a controlling interest.

(4) Each nursing home, except those operated by the U.S. Government or the State of Tennessee, making application for license under this chapter shall pay annually to the department a fee based on the number of nursing home beds, as follows:

(a) Less than 25 beds $ 1,040.00 (b) 25 to 49 beds, inclusive $ 1,300.00 (c) 50 to 74 beds, inclusive $ 1,560.00 (d) 75 to 99 beds, inclusive $ 1,820.00 (e) 100 to 124 beds, inclusive $ 2,080.00 (f) 125 to 149 beds, inclusive $ 2,340.00 (g) 150 to 174 beds, inclusive $ 2,600.00 (h) 175 to 199 beds, inclusive $ 2,860.00 For nursing homes of two hundred (200) beds or more the fee shall be two thousand eight hundred and sixty dollars ($2,860.00) plus two hundred dollars ($200.00) for each twenty-five (25) beds or fraction thereof in excess of one hundred ninety-nine (199) beds. The fee shall be submitted with the application or renewal and is not refundable. When additional beds are licensed, the licensing procedures for new facilities must be followed and the difference between the fee previously paid and the fee for the new bed capacity, if any, must be paid.

(5) Renewal.

(a) In order to renew a license, each nursing home shall submit to periodic inspections by Department surveyors for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action and shall remedy the deficiencies. In addition, each licensee shall submit a renewal form approved by the board and applicable renewal fee prior to the expiration date of the license.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late; provided that the late penalty shall not exceed twice the renewal fee.

A completed application for licensure;
The license fee provided in Rule 0720-18-.02(4); and 3. Any other information required by the Health Services and Development Agency.

(d) Upon reapplication, the licensee shall submit to an inspection of the facility by Department of Health surveyors.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-206(a)(5) [effective January 1, 2009], 68-11-209, 68-11-209(a)(1), 68-11-210, and 68-11-216 and Chapter 846 of the Public Acts of 2008, § 1.
Administrative History: Original rules filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Amendment filed March 13, 1986; effective April 12, 1986. Amendment filed December 30, 1986; effective February 13, 1987. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed November 19, 2003; effective February 2, 2004. Amendment filed September 21, 2005; effective December 5, 2005. Amendment filed January 19, 2007; effective April 4, 2007. Public necessity rules filed April 29, 2009; effective through October 11, 2009. Emergency rules filed October 9, 2009; effective through April 7, 2010. Amendments filed September 24, 2009; effective December 23, 2009. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed March 21, 2018; to have been effective June 19, 2018. However, on May 24, 2018, the Government Operations Committee filed a 5-day stay; new effective date June 24, 2018. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.03 DISCIPLINARY PROCEDURES

(1) The board may suspend or revoke a license for:

(a) Violation of federal statutes or rules;

(b) Violation of state statutes or the rules as set forth in this chapter;

(d) Conduct or practice found by the board to be detrimental to the health, safety, or welfare of the residents of the nursing home; and, (e) Failure to renew the license.

(2) The board may consider all factors which it deems relevant, including but not limited to the following, when determining sanctions:

(a) The degree of sanctions necessary to ensure immediate and continued compliance;

(b) The character and degree of impact of the violation on the health, safety and welfare of the residents in the facility;

(c) The conduct of the facility in taking all feasible steps or procedures necessary or appropriate to comply or correct the violation; and, (d) Any prior violations by the facility of statutes, rules or orders of the Commissioner or the board.

(3) The Board shall have the authority to place a facility on probation. To be considered for probation, a facility must have had at least two (2) separate substantiated complaint investigation surveys within six (6) months, where each survey had at least one deficiency cited at the level of substandard quality of care or immediate jeopardy, as those terms are defined at 42 CFR 488.301. None of the surveys can have been initiated by an unusual event or incident self reported by the facility.

(a) If a facility meets the criteria for probation, the board may hold a hearing at its next regularly scheduled meeting to determine if the facility should be placed on probation.

Prior to initiating such a hearing, the board shall provide notice to the facility detailing what specific non-compliance the board had identified that the facility must respond to at the probation hearing.

(b) Prior to imposing probation, the board may consider and address in its findings all factors which it deems relevant, including, but not limited to, the following:

What degree of sanctions is necessary to ensure immediate and continued compliance; and 2. Whether the non-compliance was an unintentional error or omission, or was not fully within the control of the facility; and 3. Whether the nursing home recognized the non-compliance and took steps to correct the identified issues, including whether the facility notified the department of the non-compliance either voluntarily or as required by state law or regulations; and 4. The character and degree of impact of the non-compliance on the health, safety and welfare of the patient or patients in the facility; and 5. The conduct of the facility in taking all feasible steps or procedures necessary or appropriate to comply or correct the non-compliance; and 6. The facility’s prior history of compliance or non-compliance.

(4) If the Board places a facility on probation, the facility shall detail in a plan of correction those specific actions, which when followed, will correct the non-compliance identified by the board.

(5) During the period of probation, the facility must make reports on a schedule determined by the board. These reports must demonstrate and explain to the board how the facility is implementing the actions identified in its plan of correction. In making such reports, the board shall not require the facility to disclose any information protected as privileged and confidential under any state or federal law or regulation.

(6) The Board is authorized at any time during the probation to remove the probational status of the facility’s license, based upon information presented to it showing that the conditions identified by the board have been corrected and are reasonably likely to remain corrected.

(7) The Board must rescind the probational status of the facility if it determines that the facility has complied with its plan of correction as submitted and approved by the board, unless the facility has additional non-compliance that warrants an additional term of probation as defined in T.C.A. § 68-11-207(e)(1).

(8) A single period of probation for a facility shall not extend beyond twelve (12) months. If the board determines during or at the end of the probation that the facility is not taking steps to correct non-compliance or otherwise not responding in good faith pursuant to the plan of correction, the board may take any additional action as authorized by law.

(9) The hearing to place a facility on probation and judicial review of the board’s decision shall be in accordance with the Uniform Administrative Procedures Act.

(10) When a nursing home is found by the department to have committed a violation of this

chapter, the department will issue to the facility a statement of deficiencies. Within ten (10) days of the receipt of the statement of deficiencies, the facility must return a plan of correction indicating the following:

(a) How the deficiency will be corrected;

(b) The date upon which each deficiency will be corrected;

(c) What measures or systemic changes will be put in place to ensure that the deficient practice does not recur; and, (d) How the corrective action will be monitored to ensure that the deficient practice does not recur.

(11) Either failure to submit a plan of correction in a timely manner or a finding by the department that the plan of correction is unacceptable shall subject the nursing home’s license to possible disciplinary action.

(12) Whenever the Commissioner exercises the authority to suspend the admission of any new resident(s) to the nursing home because of detrimental conditions, as provided by T.C.A. § 68-11-207(b), the nursing home shall post a copy of the Commissioner’s order upon the public entrance doors of the facility and prominently display it there for so long as it remains effective. During the suspension of admissions, the nursing home shall inform any person who inquires about the admission of a new resident of the provisions of the order and make a copy of the order available.

(13) Any licensee or applicant for a license, aggrieved by a decision or action of the department or board, pursuant to this chapter, may request a hearing before the board. The proceedings and judicial review of the board’s decision shall be in accordance with the Uniform Administrative Procedures Act, T.C.A. §§ 4-5-101, et seq.

(14) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to Rule

Tenn. Comp. R. & Regs. 0720-18-.04 ADMINISTRATION

(1) The nursing home shall have a full-time (working at least 32 hours per week) administrator licensed in Tennessee, who shall not function as the director of nursing. Any change of administrators shall be reported in writing to the department within fifteen (15) days. The administrator shall designate in writing an individual to act in his/her absence in order to provide the nursing home with administrative direction at all times. The administrator shall assure the provision of appropriate fiscal resources and personnel required to meet the needs of the residents.

(2) The hospital administrator may serve as the administrator of a hospital-based nursing home provided that he/she is a Tennessee licensed nursing home administrator, the facilities are located on the same campus, and the surveys do not reflect substandard care.

(3) Any agreement to manage a nursing home must be reported in writing to the department within fifteen (15) days of its implementation.

(4) Upon the unexpected loss of the facility administrator, the facility shall proceed according to the following provisions:

(a) The term “unexpected loss” means the absence of a nursing home administrator due to serious illness or incapacity, unplanned hospitalization, death, resignation with less than thirty (30) days notice or unplanned termination.

(b) The facility must notify the department within twenty-four (24) hours after notice of the unexpected loss of the administrator. Notification to the department shall identify an individual to be responsible for administration of the facility for the immediate future not to exceed thirty (30) days. This responsible individual need not be licensed as an administrator and may be the facility’s director of nursing.

(c) Within seven (7) days of notice of the unexpected loss, the facility must request a waiver of the appropriate regulations from the board.

(d) On or before the expiration of thirty (30) days after notice of the unexpected loss, the facility shall appoint a temporary administrator to serve until either a permanent administrator is employed or the request for a waiver is considered by the board, whichever occurs first. The temporary administrator shall be any of the following:

A full-time administrator licensed in Tennessee or any other state;
One (1) or more part-time administrators licensed in Tennessee. Part-time shall not be less than twenty (20) hours per week; or, 3. A full-time candidate for licensure as a Tennessee administrator who has completed the required training and the application process. Such candidate shall be scheduled for the next licensure exam and is eligible for the continued administrator role only with the successful completion of that exam.

(e) The procedures set forth above shall be followed until the next regularly scheduled meeting of the board in which the board considers the facility’s application for a waiver.

After reviewing the circumstances, the board may grant, refuse or condition a waiver as necessary to protect the health, safety and welfare of the residents in the facility.

(f) Any facility which follows these procedures shall not be subject to a civil penalty for absence of an administrator at any time preceding the board’s consideration of the facility’s request for a waiver.

(5) The facility shall make reasonable efforts to safeguard personal property and promptly investigate complaints of such loss. A record shall be prepared of all clothing, personal possessions and money brought by the resident to the nursing home at the time of admission. The record shall be filled out in duplicate. One copy of the record shall be given to the resident or the resident’s representative and the original shall be maintained in the nursing home record. This record shall be updated as additional personal property is brought to the facility.

(6) The facility shall maintain a surety bond on all resident funds held in trust. Such surety bonds shall be sufficient to cover the amount of such funds. The surety bond shall be an agreement between the company issuing the bond and the nursing home and shall remain in the possession of the nursing home.

(7) If the facility holds resident funds, such funds shall be kept in an account separate from the facility’s funds. Resident funds shall not be used by the facility. The facility shall maintain and allow each resident access to a written record of all financial arrangements and transactions involving the individual resident’s funds. The facility shall provide each resident or his/her representative with a written itemized statement at least quarterly of all financial transactions involving the resident’s funds.

(8) Within thirty (30) days of a resident’s death, the facility shall provide an accounting of the resident’s funds held by the facility and an inventory of the resident’s personal property held by the facility to the resident’s executor, administrator or other person authorized by law to receive the decedent’s property. The facility shall obtain a signed receipt from any person to whom the decedent’s property is transferred.

(9) Upon the sale of the facility, the seller shall provide written verification that all the resident’s funds and property have been transferred and shall obtain a signed receipt from the new owner. Upon receipt, the buyer shall provide, to the residents, an accounting of funds and property held on their behalf.

(10) When licensure is applicable for a particular job, verification 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.

Documentation that references were verified shall be on file. Documentation that all appropriate abuse registries have been checked shall be on file. Adequate medical screenings to exclude communicable disease shall be required of each employee.

(11) Prior to employment, all nursing homes shall complete a criminal background check on any person who will be in a position which involves providing direct care to a resident or patient.

(a) Any person who applies for employment in a position which involves providing direct patient care to a resident in such a facility shall consent to:

Provide past work and personal references to be checked by the nursing home; and/or 2. Agree to release and use of any and all information and investigative records necessary for the purpose of verifying whether the individual has been convicted of a criminal offense in the state of Tennessee, to either the nursing home or its agent, to any agency that contracts with the state of Tennessee, to any law enforcement agency, or to any other legally authorized entity; and/or 3. Supply a fingerprint sample and submit to a state criminal history records check to be conducted by the Tennessee Bureau of Investigations, or a state and federal criminal history records check to be conducted by the Tennessee Bureau of Investigation and the Federal Bureau of Investigation; and/or 4. Release any information required for a criminal background investigation by a professional background screening organization or criminal background check service or registry.

(b) A nursing home shall not disclose criminal background check information obtained to a person who is not involved in evaluating a person’s employment, except as required or permitted by state or federal law.

(c) Any costs incurred by the Tennessee Bureau of Investigation, professional background screening organization, law enforcement agency, or other legally authorized entity, in conducting such investigations of such applicants may be paid by the nursing home, or any agency that contracts with the state of Tennessee requesting such investigation and information, or the individual who seeks employment or is employed. Payment of such costs to the Tennessee Bureau of Investigation are to be made in accordance with T.C.A. §§ 38-6-103 and 38-6-109. The costs of conducting criminal background checks shall be an allowable cost under the state Medicaid program, if paid for by the nursing home.

(d) Criminal background checks are also required by any organization, company, or agency that provides or arranges for the supply of direct care staff to any nursing home licensed in the state of Tennessee. Such company, organization, or agency shall be responsible for initiating a criminal background check on any person hired by that entity for the purpose of working in a nursing home, and shall be required to report the results of the criminal background check to any facility in which the organization arranges the employee to work, upon request by a facility.

(e) A nursing home that declines to employ or terminates a person based upon criminal background information provided to the facility shall be immune from suit by or on behalf of that person for the termination of or the refusal to employ that person.

(12) 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. A nursing home which violates a required policy also violates the rule establishing the requirement.

(13) Policies and procedures shall be consistent with professionally recognized standards of practice.

(14) No nursing home 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, the long term care ombudsman, the Comptroller of the State Treasury, or any government agency. A nursing home 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) Each nursing home shall adopt safety policies for the protection of residents from accident and injury.

(16) Each nursing home shall post whether they have liability insurance, the identity of their primary insurance carrier, and if self-insured, the corporate entity responsible for payment of any claims. It shall be posted on a sign no smaller than eleven inches (11”) in width and seventeen inches (17”) in height and displayed at the main public entrance.

(17) Documentation pertaining to the payment agreement between the nursing home and the resident shall be completed prior to admission. A copy of the documentation shall be given to the resident and the original shall be maintained in the nursing home records.

(18) The nursing home shall ensure a framework for addressing issues related to care at the end of life.

(19) The nursing home shall provide a process that assesses pain in all patients. There shall be an appropriate and effective pain management program.

(20) The nursing home shall carry out the following functions, all of which shall be documented in a written medical equipment management plan:

(a) Develop and maintain a current itemized inventory of medical equipment used in the facility, that is owned or leased by the operator of the facility;

(b) Develop and maintain a schedule for the maintenance, inspection and testing of medical equipment according to manufacturers’ recommendations or other generally accepted standards. The schedule shall include the date and time such maintenance, inspection and testing was actually performed, and the name of the individual who performed such tasks; and (c) Ensure maintenance, inspection and testing were conducted by facility personnel adequately trained in such procedures or by a contractor qualified to perform such procedures.

(21) All health care facilities licensed pursuant to T.C.A. §§ 68-11-201, et seq. shall post on a sign no smaller than eight and one-half inches (8½”) in width and eleven inches (11”) in height the following in the main public entrance:

(a) 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.

(22) “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.

(23) Residents of the facility are exempt from the smoking prohibition. The resident smoking practices shall be governed by the policies and procedures established by the facility. Smoke from such areas shall not infiltrate into the areas where smoking is prohibited.

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

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-17-1803, 39-17-1804, 39-17-1805, 68-11-202, 68-11-204, 68- 11-206, 68-11-209, 68-11-225, 68-11-254, 68-11-256, 68-11-257, 68-11-268, 68-11-906, and 71-6-121.
Administrative History: Original rule filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Amendment filed May 24, 1985; effective June 23, 1985. Amendment filed March 13, 1986; effective April 12, 1986. Amendment filed October 22, 1987; effective December 6, 1987. Amendment filed May 10, 1990; effective June 24, 1990. Amendment filed March 9, 1992; effective April 23, 1992. Amendment filed March 10, 1995; effective May 24, 1995. Amendment filed June 13, 1997; effective August 27, 1997. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendment filed May 24, 2004; effective August 7, 2004. 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. pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.05 ADMISSIONS, DISCHARGES, AND TRANSFERS

(1) Every person admitted for care or treatment shall be under the supervision of a physician who holds a license in good standing to practice in Tennessee. The name of the resident’s attending physician shall be recorded in the resident’s medical record. The nursing home shall not admit the following types of residents:

(a) Persons who pose a clearly documented danger to themselves or to other residents in the nursing home.

(b) Children under fourteen (14) years of age, except when the department has approved the admission of a specific child.

(c) Persons for whom the nursing home is not capable of providing the care ordered by the attending physician. Documentation of the reason(s) for refusal of the admission shall be maintained.

(2) A diagnosis must be entered in the admission records of the nursing home for every person admitted for care or treatment.

(3) Prior to the admission of a resident to a nursing home or prior to the execution of a contract for the care of a resident in a nursing home (whichever occurs first), each nursing home shall disclose in writing to the resident or to the resident’s guardian, conservator or representative, if any, whether the facility has liability insurance and the identity of the primary insurance carrier. If the facility is self-insured, their statement shall reflect that fact and indicate the corporate entity responsible for payment of any claims.

(4) Any residential facility licensed by the board of licensing health care facilities shall upon admission provide to each resident the division of adult protective services’ statewide toll-free number: 888-277-8366.

(5) Facilities utilizing secured units must be able to provide survey staff with twelve (12) months of the following performance information specific to the secured unit and its residents:

(a) Documentation that each secured resident has been evaluated by an interdisciplinary team consisting of at least a physician, a social worker, a registered nurse, and a family member (or patient care advocate) prior to admittance to the unit;

(b) Ongoing and up-to-date documentation of quarterly review by each resident’s interdisciplinary team as to the appropriateness of placement in the secured unit;

(d) A current listing of all unusual incidents and/or complications on the unit;

(e) An up-to-date staffing pattern and staff ratios for the unit is recorded on a daily basis.

The staffing pattern must ensure that there is a minimum of one (1) attendant, awake, on duty, and physically located on the unit twenty-four (24) hours per day, seven (7) days per week at all times;

(f) A formulated calendar of daily group activities scheduled including a resident attendance record for the previous three (3) months;

(g) An up-to-date listing of any incidences of decubitus and/or nosocomial infections, including resident identifiers; and, (h) Documentation showing that 100% of the staff working on the unit receives and has received annual in-service training which shall include, but not be limited to the following subject areas:

Basic facts about the causes, progression and management of Alzheimer’s Disease and related disorders;
Dealing with dysfunctional behavior and catastrophic reactions in the residents;
Identifying and alleviating safety risks to the resident;
Providing assistance in the activities of daily living for the resident; and, 5. Communicating with families and other persons interested in the resident.

(7) Any admission in excess of the licensed bed capacity is prohibited except when an emergency admission is directed by the department.

(8) No resident shall be discharged without a written order from the attending physician or through other legal processes and timely notification of next of kin and/or sponsor or authorized representative, if any. Each nursing home shall establish a policy for handling patients who wish to leave against medical advice.

(9) When a resident is discharged, a brief description of the significant findings and events of the resident’s stay in the nursing home, the condition on discharge and the recommendation and arrangement for future care, if any, shall be provided.

(10) No resident shall be transferred without a written order from the attending physician or through other legal processes and timely notification of next of kin and/or sponsor or authorized representative, if any.

(11) When a resident is transferred, a summary of treatment given at the nursing home, condition of the resident at time of transfer and date and place to which he is transferred shall be entered in the record. If the transfer is due to an emergency, this information will be recorded within forty-eight (48) hours, otherwise, it will precede the transfer of the resident.

(12) When a resident is transferred, a copy of the clinical summary shall, with consent of the resident, be sent to the nursing home that will continue the care of the resident.

(13) Where an involuntary transfer is proposed, in addition to any other relevant factors, the following factors shall be taken into account:

(a) The traumatic effect on the resident.

(b) The proximity of the proposed nursing home to the present nursing home and to the family and friends of the resident.

(d) Compliance by the proposed nursing home with all applicable federal and state regulations.

(14) When the attending physician has ordered a resident transferred or discharged, but the resident or a representative of the resident opposes the action, the nursing home shall counsel with the resident, the next of kin, sponsor and representative, if any, in an attempt to resolve the dispute and shall not transfer the resident until such counseling has been provided. No involuntary transfer or discharge shall be made until the nursing home has first informed the department and the area long-term care ombudsman. Unless a disaster occurs on the premises or the attending physician orders the transfer as a medical emergency (due to the resident’s immediate need for a higher level of care) no involuntary transfer or discharge shall be made until five (5) business days after these agencies have been notified, unless they each earlier declare that they have no intention of intervening.

(15) Except when the Board has revoked or suspended the license, a nursing home which intends to close, cease doing business, or reduce its licensed bed capacity by ten percent (10%) or more shall notify both the department and the area long-term care ombudsman at the earliest moment of the decision, but not later than thirty (30) days before the action is to be implemented. The facility shall establish a protocol, subject to the department’s approval, for the transfer or discharge of the residents. Should the nursing home violate the provisions of this paragraph, the department shall request the Attorney General of the State of Tennessee to intervene to protect the residents, as is provided by T.C.A. § 68-11-213(a).

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11- 257, and 71-6-121.
Administrative History: Original rule filed March 27; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed April 10, 2000; effective June 24, 2000. Amendment filed February 23, 2007; effective May 9, 2007. Amendment filed April 17, 2007; effective July 1, 2007. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.06 BASIC SERVICES

(1) Performance Improvement.

(a) The nursing home must ensure that there is an effective, facility-wide performance improvement program to evaluate resident care and performance of the organization.

(b) The performance improvement program must be ongoing and have a written plan of implementation which assures that:

All organized services related to resident care, including services furnished by a contractor, are evaluated;
Nosocomial infections and medication therapy are evaluated;
All services performed in the facility are evaluated as to the appropriateness of diagnosis and treatment; and 4. The facility shall develop and implement a system for measuring improvements in adherence to the hand hygiene program and influenza vaccination program.

(c) The nursing home must have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically related needs of its residents.

(d) The facility must develop and implement plans for improvement to address deficiencies identified by the performance improvement program and must document the outcome of the remedial action.

(e) Performance improvement program records are not disclosable, except when such disclosure is required to demonstrate compliance with this section.

(f) Good faith attempts by the performance improvement program committee to identify and correct deficiencies will not be used as a basis for sanctions.

(2) Physician Services.

(a) Policies and procedures concerning services provided by the nursing home shall be available for the admitting physicians.

(b) Residents shall be aided in receiving dental care as deemed necessary.

(d) The Medical Director shall be responsible for the medical care in the nursing home.

The Medical Director shall:

Delineate the responsibilities of and communicate with attending physicians to ensure that each resident receives medical care;
Ensure the delivery of emergency and medical care when the resident’s attending physician or his/her designated alternate is unavailable;
Review reports of all accidents or unusual incidents occurring on the premises, identifying hazards to health and safety and recommending corrective action to the administrator;
Make periodic visits to the nursing home to evaluate the existing conditions and make recommendations for improvements;
Review and take appropriate action on reports from the Director of Nursing regarding significant clinical developments;
Monitor the health status of nursing home personnel to ensure that no health conditions exist which would adversely affect residents; and, 7. Advise and provide consultation on matters regarding medical care, standards of care, surveillance and infection control.

(3) Infection Control.

(a) The nursing home must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.

(b) The physical environment shall be maintained in such a manner to assure the safety and well being of the residents.

Any condition on the nursing home site conducive to the harboring or breeding of insects, rodents or other vermin shall be prohibited. Chemical substances of a poisonous nature used to control or eliminate vermin shall be properly identified.

Such substances shall not be stored with or near food or medications.

Cats, dogs or other animals shall not be allowed in any part of the facility except for specially trained animals for the handicapped and except as addressed by facility policy for pet therapy programs. The facility shall designate in its policies and procedures those areas where animals will be excluded. The areas designated shall be determined based upon an assessment of the facility performed by medically trained personnel.
Telephones shall be readily accessible and at least one (1) shall be equipped with sound amplification and shall be accessible to wheelchair residents.
Equipment and supplies for physical examination and emergency treatment of residents shall be available.
A bed complete with mattress and pillow shall be provided. In addition, resident units shall be provided with at least one chair, a bedside table, an over bed tray and adequate storage space for toilet articles, clothing and personal belongings.
Individual wash cloths, towels and bed linens must be provided for each resident.

Linen shall not be interchanged from resident to resident until it has been properly laundered.

Bath basin water service, emesis basin, bedpan and urinal shall be individually provided.
Water pitchers, glasses, thermometers, emesis basins, douche apparatus, enema apparatus, urinals, mouthwash cups, bedpans and similar items of equipment coming into intimate contact with residents shall be disinfected or sterilized after each use unless individual equipment for each is provided and then sterilized or disinfected between residents and as often as necessary to maintain them in a clean and sanitary condition. Single use, resident disposable items are acceptable but shall not be reused.
The facility shall have written policies and procedures governing care of residents during the failure of the air conditioning, heating or ventilation system, including plans for hypothermia and hyperthermia. When the temperature of any resident area falls below 65°F or exceeds 85°F, or is reasonably expected to do so, the facility shall be alerted to the potential danger, and the department shall be notified.

(c) The administrator shall assure that an infection control program including members of the medical staff, nursing staff and administrative staff develop guidelines and techniques for the prevention, surveillance, control and reporting of facility infections.

Duties of the program shall include the establishment of:

Written infection control policies;
Techniques and systems for identifying, reporting, investigating and controlling infections in the facility;
Written procedures governing the use of aseptic techniques and procedures in the facility;
Written procedures concerning food handling, laundry practices, disposal of environmental and resident wastes, traffic control and visiting rules, sources of air pollution, and routine culturing of autoclaves and sterilizers;
A log of incidents related to infectious and communicable diseases;
Formal provisions to educate and orient all appropriate personnel in the practice of aseptic techniques such as handwashing, proper grooming, masking, dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of resident care equipment and supplies; and, 7. Continuing education for all facility personnel on the cause, effect, transmission, prevention, and elimination of infections.

(d) The administrator, the medical staff and director of nursing services must ensure that the facility-wide performance improvement program and training programs address problems identified by the infection control program and must be responsible for the implementation of successful corrective action plans in affected problem areas.

(e) The facility shall develop policies and procedures for testing a resident’s blood for the presence of the hepatitis B virus and the HIV virus in the event that an employee of the facility, a student studying at the facility, or other health care provider rendering services at the facility is exposed to a resident’s blood or other body fluid. The testing shall be performed at no charge to the resident, and the test results shall be confidential.

(f) The facility and its employees shall adopt and utilize standard precautions (per CDC) for preventing transmission of infections, HIV, and communicable diseases, including adherence to a hand hygiene program which shall include:

Use of alcohol-based hand rubs or use of non-antimicrobial or antimicrobial soap and water before and after each patient contact if hands are not visibly soiled;
Use of gloves during each patient contact with blood or where other potentially infectious materials, mucous membranes, and non-intact skin could occur and gloves changed before and after each patient contact;
Use of either a non-antimicrobial soap and water or an antimicrobial soap and water for visibly soiled hands; and 4. Health care worker education programs which may include:

(i) Types of patient care activities that can result in hand contamination;

(ii) Advantages and disadvantages of various methods used to clean hands;

(g) All nursing homes shall adopt appropriate policies regarding the testing of residents and staff for HIV and any other identified causative agent of acquired immune deficiency syndrome.

(h) The facility shall document evidence of annual vaccination against influenza for each resident, in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control most recent to the time of the vaccine. Influenza vaccination is medically contraindicated or the resident has refused the vaccine. Influenza vaccination for all residents accepting the vaccine shall be completed by November 30 of each year or within ten (10) days of the vaccine becoming available. Residents admitted after this date during the flu season and up to February 1, shall as medically appropriate, receive influenza vaccination prior to or on admission unless refused by the resident.

The facility shall document evidence of vaccination against pneumococcal disease for all residents who are 65 years of age or older, in accordance with the recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control at the time of vaccination, unless such vaccination is medically contraindicated or the resident has refused offer of the vaccine. The facility shall provide or arrange the pneumococcal vaccination of residents who have not received this immunization prior to or on admission unless the resident refuses offer of the vaccine.

(i) A nursing home shall have an annual influenza vaccination program which shall include at least:

The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The nursing home will encourage all staff and independent practitioners to obtain an influenza vaccination;
A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider);
Education of all employees about the following:

(i) Flu vaccination, (ii) Non-vaccine control measures, and (iii) The diagnosis, transmission, and potential impact of influenza;

An annual evaluation of the influenza vaccination program and reasons for nonparticipation; and 5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee.

(j) Precautions shall be taken to prevent the contamination of sterile supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents. Decontamination and preparation areas shall be separated.

(k) Space and facilities for housekeeping equipment and supply storage shall be provided in each service area. Storage for bulk supplies and equipment shall be located away from patient care areas. The building shall be kept in good repair, clean, sanitary and safe at all times.

(l) The facility shall appoint a housekeeping supervisor who shall be responsible for:

Organizing and coordinating the facility’s housekeeping service;
Acquiring and storing sufficient housekeeping supplies and equipment for facility maintenance; and, 3. Assuring the clean and sanitary condition of the facility to provide a safe and hygienic environment for residents and staff. Cleaning shall be accomplished in accordance with the infection control rules herein and facility policy.

(m) Laundry facilities located in the nursing home shall:

Be equipped with an area for receiving, processing, storing and distributing clean linen;
Be located in an area that does not require transportation for storage of soiled or contaminated linen through food preparation, storage or dining areas;
Provide space for storage of clean linen within nursing units and for bulk storage within clean areas of the facility; and, 4. Provide carts, bags or other acceptable containers appropriately marked to identify those used for soiled linen and those used for clean linen to prevent dual utilization of the equipment and cross contamination.

(n) The facility shall name an individual who is responsible for laundry service. This individual shall be responsible for:

Establishing a laundry service, either within the nursing home or by contract, that provides the facility with sufficient clean, sanitary linen at all times;
Knowing and enforcing infection control rules and regulations for the laundry service;
Assuring the collection, packaging, transportation and storage of soiled, contaminated, and clean linen is in accordance with all applicable infection control rules and procedures; and, 4. Assuring that a contract laundry service complies with all applicable infection control rules and procedures.

(4) Nursing Services.

(a) Each nursing home must have an organized nursing service that provides twenty-four (24) hour nursing services furnished or supervised by a registered nurse. Each home shall have a licensed practical nurse or registered nurse on duty at all times and at least two (2) nursing personnel on duty each shift.

(b) The facility must have a well-organized nursing service with a plan of administrative

authority and delineation of responsibilities for resident care. The Director of Nursing (DON) must be a licensed registered nurse who has no current disciplinary actions against his/her license. The DON is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the facility.

Develop, maintain and periodically update:

(i) Nursing service objectives and standards of practice;

(ii) Nursing service policy and procedure manuals;

(iii) Written job descriptions for each level of nursing personnel;

(iv) Methods for coordination of nursing service with other resident services; and, (v) Mechanisms for monitoring quality of nursing care, including the periodic review of medical records.

Participate in selecting prospective residents in terms of the nursing services they need and nursing competencies available.
Make daily rounds to see residents.
Notify the resident’s physician when medically indicated.
Review each resident’s medications periodically and notify the physician where changes are indicated.
Supervise the administration of medications.
Supervise assignments of the nursing staff for the direct care of all residents.
Plan, develop and conduct monthly in-service education programs for nursing personnel and other employees of the nursing home where indicated. An organized orientation program shall be developed and implemented for all nursing personnel.
Supervise and coordinate the feeding of all residents who need assistance.
Coordinate the dietary requirements of residents with the staff responsible for the dietary service.
Coordinate housekeeping personnel.
Assure that discharge planning is initiated in a timely manner.
Assure that residents, along with their necessary medical information, are transferred or referred to appropriate facilities, agencies or outpatient services, as needed, for follow-up or ancillary care.

(d) The nursing service must have adequate numbers of licensed registered nurses, licensed practical nurses, and certified nurse aides to provide nursing care to all residents as needed. Nursing homes shall provide a minimum of two (2) hours of direct care to each resident every day including 0.4 hours of licensed nursing personnel time.

There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the availability of a licensed nurse for bedside care of any resident.

(e) A registered nurse must supervise and evaluate the nursing care for each resident.

(f) The facility must ensure that an appropriate individualized plan of care is prepared for each resident with input from appropriate disciplines, the resident and/or the resident’s family or the resident’s representative.

(g) A registered nurse must assign the nursing care of each resident to other nursing personnel in accordance with the resident’s needs and the specialized qualifications and competence of the nursing staff available.

(h) Non-employee licensed nurses who are working in the nursing home must adhere to the policies and procedures of the facility. The director of the nursing service must provide for the adequate supervision and evaluation of the clinical activities of nonemployee nursing personnel which occur within the responsibility of the nursing service.

(j) There must be a facility procedure for reporting adverse drug reactions and errors in administration of drugs.

(k) When non-employees are utilized as sitters or attendants, they shall be under the

authority of the nursing service and their duties shall be set forth clearly in written nursing service policies.

(l) Each resident shall be given proper personal attention and care of skin, feet, nails and oral hygiene in addition to the specific professional nursing care as ordered by the resident’s physician.

(m) Medications, treatments, and diet shall be carried out as prescribed to safeguard the resident, to minimize discomfort and to attain the physician’s objective.

(n) Residents shall have baths or showers at least two (2) times each week, or more often if requested by the resident.

(o) Body position of residents in bed or chair bound shall be changed at least every two (2) hours, day and night, while maintaining good body alignment. Proper skin care shall be provided for bony prominences and weight bearing parts to prevent discomfort and the development of pressure areas, unless contraindicated by physician’s orders.

(p) Residents who are incontinent shall have partial baths each time the bed or bed clothing has been wet or soiled. The soiled or wet bed linen and the bed clothing shall be replaced with clean, dry linen and clothing immediately after being soiled.

(q) Residents shall have shampoos, haircuts and shaves as needed, or desired.

(r) Rehabilitation measures such as assisting patients with range of motion, prescribed exercises and bowel and bladder retraining programs shall be carried out according to the individual needs and abilities of the resident.

(s) Residents shall be active and out of bed except when contraindicated by written physician’s orders.

(t) Residents shall be encouraged to achieve independence in activities of daily living, self-care, and ambulation as a part of daily care.

(u) Residents shall have clean clothing as needed and shall be kept free from odor.

(v) Residents’ weights shall be taken and recorded at least monthly unless contraindicated by a physician’s order.

(w) Physical restraints shall be checked every thirty (30) minutes and released every two (2) hours so the resident may be exercised and offered toilet access.

(x) Restraints may be applied or administered to residents only on the signed order of a physician. The signed physician’s order must be for a specified and limited period of time and must document the necessity of the restraint. There shall be no standing orders for restraints.

(y) When a resident’s safety or safety of others is in jeopardy, the nurse in charge shall use his/her judgment to use physical restraints if a physician’s order cannot be immediately obtained. A written order must be obtained as soon as possible.

(z) Locked restraints are prohibited.

(aa) Assistance with eating shall be given to the resident as needed in order for the resident to receive the diet for good health care.

(bb) Abnormal food intake will be evaluated and recorded.

(cc) A registered nurse may make the actual determination and pronouncement of death under the following circumstances:

The deceased was a resident of a nursing home;
The death was anticipated, and the attending physician or nursing home medical director has agreed in writing to sign the death certificate. Such agreement by the attending physician or nursing home medical director must be present with the deceased at the place of death;
The nurse is licensed by the state; and, 4. The nurse is employed by the nursing home in which the deceased resided.

(5) Medical Records.

(a) The nursing home shall comply with the Tennessee Medical Records Act, T.C.A. §§ 68-11-301, et seq.

(b) The nursing home must maintain a medical record for each resident. Medical records must be accurate, promptly completed, properly filed and retained, and accessible. The facility must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

(c) All medical records, in either written, electronic, graphic or otherwise acceptable form, must be retained in their original or legally reproduced form for a minimum period of at least ten (10) years after which such records may be destroyed. However, in cases of residents under mental disability or minority, their complete facility records shall be retained for the period of minority or known mental disability, plus one (1) year, or ten (10) years following the discharge of the resident, whichever is longer. Records destruction shall be accomplished by burning, shredding or other effective method in keeping with the confidential nature of the contents. The destruction of records must be made in the ordinary course of business, must be documented and in accordance with the facility’s policies and procedures, and no record may be destroyed on an individual

basis.

(d) When a nursing home closes with no plans of reopening, an authorized representative of the facility may request final storage or disposition of the facility’s medical records by the department. Upon transfer to the department, the facility relinquishes all control over final storage of the records and the files shall become property of the State of Tennessee.

(e) The nursing home must have a system of coding and indexing medical records. The system must allow for timely retrieval by diagnosis and procedure.

(f) The nursing home must have a procedure for ensuring the confidentiality of resident records. Information from or copies of records may be released only to authorized individuals, and the facility must ensure that unauthorized individuals cannot gain access to or alter resident records. Original medical records must be released by the facility only in accordance with federal and state laws, court orders or subpoenas.

(g) The medical record must contain information to justify admission, support the diagnosis, and describe the resident’s progress and response to medications and services.

(h) All entries must be legible, complete, dated and authenticated according to facility policy.

(i) All records must document the following:

Evidence of a physical examination, including a health history, performed no more than thirty (30) days prior to admission or within forty-eight (48) hours following admission;
Admitting diagnosis;
A dietary history as part of each resident’s admission record;
Results of all consultative evaluations of the resident and appropriate findings by clinical and other staff involved in the care of the resident;
Documentation of complications, facility acquired infections, and unfavorable reactions to drugs;
Properly executed informed consent forms for procedures and treatments specified by facility policy, or by federal or state law if applicable, as requiring written resident consent;
All practitioners’ orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the resident’s condition;
Discharge summary with disposition of case and plan for follow-up care; and, 9. Final diagnosis with completion of medical records within thirty (30) days following discharge.

(j) Electronic and computer-generated records and signature entries are acceptable.

(6) Pharmaceutical Services.

(a) The nursing home shall have pharmaceutical services that meet the needs of the residents and are in accordance with the Tennessee Board of Pharmacy statutes and rules. The medical staff is responsible for developing policies and procedures that minimize drug errors.

(c) Schedule II drugs must be stored behind two (2) separately locked doors at all times and accessible only to persons in charge of administering medication.

(d) Every nursing home shall comply with all state and federal regulations governing Schedule II drugs.

(e) A notation shall be made in a Schedule II drug book and in the resident’s nursing notes each time a Schedule II drug is given. The notation shall include the name of the resident receiving the drug, name of the drug, the dosage given, the method of administration, the date and time given and the name of the physician prescribing the drug.

(f) All oral orders shall be immediately recorded, designated as such and signed by the person receiving them and countersigned by the physician within ten (10) days.

(g) All orders for drugs, devices and related materials must be in writing and signed by the practitioner or practitioners responsible for the care of the resident. Electronic and computer-generated records and signature entries are acceptable. When telephone or oral orders must be used, they shall be:

Accepted only by personnel that are authorized to do so by the medical staff policies and procedures, consistent with federal and state law; and, 2. Signed or initialed by the prescribing practitioner according to nursing home policy.

(i) Medication administration records (MAR) shall be checked against the physician’s orders. Each dose shall be properly recorded in the clinical record after it has been administered.

(j) Preparation of doses for more than one scheduled administration time shall not be permitted.

(k) Medication shall be administered only by licensed medical or licensed nursing personnel or other licensed health professionals acting within the scope of their licenses.

(l) Unless the unit dose package system is used, individual prescriptions of drugs shall be kept in the original container with the original label intact showing the name of the resident, the drug, the physician, the prescription number and the date dispensed.

(m) Legend drugs shall be dispensed by a licensed pharmacist.

(n) Nursing homes may participate in drug donation repository programs as defined in Title 63, Chapter 10 and may use such programs for drug disposal services. The facility’s participation in a drug donation repository program shall be outlined in the facility’s policies and procedures.

(o) Alternatively, if a nursing home declines to participate in the drug donation repository program or in the case of drugs not acceptable under the program, any unused portions of prescription drugs shall be turned over to the resident only on a written order by the physician. If not turned over to the resident, such unused drugs left in a nursing home must be destroyed on the premises by a licensed nurse and a witness.

The facility’s policies and procedures shall outline person(s) who may serve as a witness and methodology. The facility’s policies and procedures must be in compliance with applicable DEA regulations.

(7) Radiology Services. The nursing home must maintain or have available diagnostic radiologic services according to the needs of the residents. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.

(8) Laboratory Services. The nursing home must maintain or have available, either directly or through a contractual agreement, adequate laboratory services to meet the needs of the residents. The nursing home must ensure that all laboratory services provided to its residents are performed in a facility licensed in accordance with the Tennessee Medical Laboratory Act (TMLA). All technical laboratory staff shall be licensed in accordance with the TMLA and shall be qualified by education, training and experience for the type of services rendered.

(9) Food and Dietetic Services.

(a) The nursing home must have organized dietary services that are directed and staffed by adequate qualified personnel. A facility may contract with an outside food management company if the company has a dietitian who serves the facility on a fulltime, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this paragraph and provides for constant liaison with the facility medical staff for recommendations on dietetic policies affecting resident treatment. If an outside contract is utilized for management of its dietary services, the facility shall designate a full-time employee to be responsible for the overall management of the services.

(b) The nursing home must designate a person, either directly or by contractual agreement, to serve as the food and dietetic services director with responsibility for the daily management of the dietary services. The food and dietetic services director shall be:

A qualified dietitian; or, 2. A graduate of a dietetic technician or dietetic assistant training program, correspondence or classroom, approved by the American Dietetic Association; or, 3. An individual who has successfully completed in-person or online coursework that provided ninety (90) or more hours of classroom instruction in food service supervision. If the course has not been completed, this person shall be enrolled in a course and making satisfactory progress for completion within the time limit specified by the course requirement; or, 4. An individual who is a certified dietary manager (CDM), or certified food protection professional (CFPP); or, 5. A current or former member of the U.S. military who has graduated from an approved military dietary manager training program.

(c) There must be a qualified dietitian, full-time, part-time, or on a consultant basis, who is responsible for the development and implementation of a nutrition care process to meet the needs of residents for health maintenance, disease prevention and, when necessary, medical nutrition therapy to treat an illness, injury or condition. Medical nutrition therapy includes assessment of the nutritional status of the resident and treatment through diet therapy, counseling and/or use of specialized nutrition supplements.

(d) Menus must meet the needs of the residents.

Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the residents and must be prepared and served as prescribed.
Special diets shall be prepared and served as ordered.
Nutritional needs must be met in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the residents.
A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel.

(e) Education programs, including orientation, on-the-job training, inservice education, and continuing education shall be offered to dietetic services personnel on a regular basis.

Programs shall include instruction in the use of equipment, personal hygiene, proper inspection, and the handling, preparing and serving of food.

(f) A minimum of three (3) meals in each twenty-four (24) hour period shall be served. A supplemental night meal shall be served if more than fourteen (14) hours lapse between supper and breakfast. Additional nourishments shall be provided to patients with special dietary needs. A minimum of three (3) days supply of food shall be on hand.

(g) Menus shall be prepared at least one week in advance. A dietitian shall be consulted to help write and plan the menus. If any change in the actual food served is necessary, the change shall be made on the menu to designate the foods actually served to the residents. Menus of food served shall be kept on file for a thirty (30) day period.

(h) The dietitian or designee shall have a conference, dated on the medical chart, with each resident and/or family within two (2) weeks of admission to discuss the diet plan indicated by the physician. The resident’s dietary preferences shall be recorded and utilized in planning his/her daily menu.

(k) All nursing homes shall have commercial automatic dishwashers approved by the National Sanitation Foundation. Dishwashing machines shall be used according to manufacturer specifications.

(l) All dishes, glassware and utensils used in the preparation and serving of food and drink shall be cleaned and sanitized after each use.

(m) The cleaning and sanitizing of handwashed dishes shall be accomplished by using a three-compartment sink according to the current “U.S. Public Health Service Sanitation Manual.”

(n) The kitchen shall contain sufficient refrigeration equipment and space for the storage of perishable foods.

(o) All refrigerators and freezers shall have thermometers. Refrigerators shall be kept at a temperature not to exceed 45°F. Freezers shall be kept at a temperature not to exceed 0°F.

(p) Written policies and procedures shall be followed concerning the scope of food services in accordance with the current edition of the “U.S. Public Health Service Recommended Ordinance and Code Regulating Eating and Drinking Establishments” and the current “U.S. Public Health Service Sanitation Manual” should be used as a guide to food sanitation.

(10) Social Work Services.

(a) Social services must be available to the resident, the resident’s family and other persons significant to the resident, in order to facilitate adjustment of these individuals to the impact of illness and to promote maximum benefits from the health care services provided.

(b) Social work services shall include psychosocial assessment, counseling, coordination of discharge planning, community liaison services, financial assistance and consultation.

(c) A resident’s social history shall be obtained within two (2) weeks of admission and shall be appropriately maintained.

(d) Social work services shall be provided by a qualified social worker.

(e) Facilities for social work services shall be readily accessible and shall permit privacy for interviews and counseling.

(11) Physical, Occupational and Speech Therapy Services.

Tenn. Comp. R. & Regs. 0720-18-.07 SPECIAL SERVICES: ALZHEIMER’S UNITS

Structurally distinct parts of a nursing home may be designated as special care units for ambulatory residents with dementia or Alzheimer’s Disease and related disorders. Such units shall be designed to encourage self-sufficiency, independence and decision-making skills, and may admit residents only after the unit is found to be in compliance with licensure standards and upon final approval by the department. Units which hold themselves out to the public as providing specialized Alzheimer’s services shall comply with the provisions of T.C.A. § 68-11- 1404 and shall be in compliance with the following minimum standards:

(1) In order to be admitted to the special care unit:

(a) A diagnosis of dementia must be made by a physician. The specific etiology causing the dementia shall be identified to the best level of certainty prior to admission to the special care unit; and, (b) The need for admission must be determined by an interdisciplinary team consisting at least of a physician experienced in the management of residents with Alzheimer’s Disease and related disorders, a social worker, a registered nurse and a relative of the resident or a resident care advocate.

(2) Special care units shall be separated from the remaining portion of the nursing home by a locked door and must have extraordinary and acceptable fire safety features and policies which ensure the well being and protection of the residents.

(3) The residents must have direct access to a secured, therapeutic outdoor area. This outdoor area shall be designed and maintained to facilitate emergency evacuation.

(4) There must be limited access to the designated unit so that visitors and staff do not pass through the unit to get to other areas of the nursing home.

(5) Each unit must contain a designated dining/activity area which shall accommodate 100% seating for residents.

(6) Corridors or open spaces shall be designed to facilitate ambulation and activity, and shall have an unobstructed view from the central working or nurses’ station.

(7) Drinking facilities shall be provided in the central working area or nurses’ station and in the primary activities areas. Glass front refrigerators may be used.

(8) The unit shall be designed, equipped and maintained to promote positive resident response through the use of:

(a) Reduced-glare lighting, wall and floor coverings, and materials and decorations conducive to appropriate sensory and visual stimulation; and, (b) Meaningful wandering space shall be provided that encourages physical exercise and ensures that residents will not become frustrated upon reaching dead-ends.

(9) The designated units shall provide a minimum of 3.5 hours of direct care to each resident every day including .75 hours of licensed nursing personnel time. Direct care shall not be limited to nursing personnel time and may include direct care provided by dietary employees, social workers, administrator, therapists and other care givers, including volunteers.

(10) In addition to the classroom instruction required in the nurse aide training program, each nurse aide assigned to the unit shall have forty (40) hours of classroom instruction which shall include but not be limited to the following subject areas:

(a) Basic facts about the causes, progression and management of Alzheimer’s Disease and related disorders;

(b) Dealing with dysfunctional behavior and catastrophic reactions in the resident;

(d) Providing assistance in the activities of daily living for the resident; and, (e) Communicating with families and other persons interested in the resident.

(11) Each resident shall have a treatment plan developed, periodically reviewed and implemented by an interdisciplinary treatment team consisting at least of a physician experienced in the management of residents with Alzheimer’s Disease and related disorders, a registered nurse, a social worker, an activity coordinator and a relative of the resident or a resident care advocate.

(12) A protocol for identifying and alleviating job related stress among staff on the special care unit must be developed and carried out.

(13) The staff of the unit shall organize a support group for families of residents which meets at least quarterly for the purpose of:

(a) Providing ongoing education for families;

(b) Permitting families to give advice about the operation of the unit;

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-1404.
Administrative History: Original rule filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.08 BUILDING STANDARDS

(1) A nursing home shall construct, arrange, and maintain the condition of the physical plant and the overall nursing home environment in such a manner that the safety and well-being of the residents are assured.

(3) The codes in effect at the time of submittal of plans and specifications, as defined by these rules, shall be the codes to be used throughout the project.

(4) The licensed contractor shall perform all new construction and renovations to nursing homes, other than minor alterations not affecting fire and life safety or functional issues, in accordance with the specific requirements of these regulations governing new construction in nursing homes, including the submission of phased construction plans and the final drawings and the specifications to each.

(5) No new nursing home shall be constructed, nor shall major alterations be made to an existing nursing home without prior written approval of the department, and unless in accordance with plans and specifications approved in advance by the department. Before any new nursing home is licensed or before any alteration or expansion of a licensed nursing home can be approved, the applicant must furnish two (2) complete sets of plans and specifications to the department, together with fees and other information as required. Plans and specifications for new construction and major renovations, other than minor alterations not affecting fire and life safety or functional issues, shall be prepared by or under the direction of a licensed architect and/or a licensed engineer and in accordance with the rules of the Board of Architectural and Engineering Examiners.

(a) The project architect or engineer shall forward two (2) sets of plans to the appropriate

(b) Review of plans does not eliminate responsibility of owner and/or architect to comply with all rules and regulations.

(8) Specifications shall supplement all drawings. They shall describe the characteristics of all materials, products and devices, unless fully described and indicated on the drawings.

Specification copies should be bound in an 8½ x 11 inch folder.

(9) Drawings and specifications shall be prepared for each of the following branches of work:

Architectural, Structural, Mechanical, Electrical and Sprinkler.

(10) Architectural drawings shall include where applicable:

(a) Plot plan(s) showing property lines, finish grade, location of existing and proposed structures, roadways, walks, utilities and parking areas;

(b) Floor plan(s) showing scale drawings of typical and special rooms, indicating all fixed and movable equipment and major items of furniture;

(d) The elevation of each facade;

(e) The typical sections throughout the building;

(f) The schedule of finishes;

(g) The schedule of doors and windows;

(h) Roof plans;

(i) Details and dimensions of elevator shaft(s), car platform(s), doors, pit(s), equipment in the machine room, and the rates of car travel must be indicated for elevators; and (j) Code analysis.

(11) Structural drawings shall include where applicable:

(a) Plans of foundations, floors, roofs and intermediate levels which show a complete design with sizes, sections and the relative location of the various members;

(b) Schedules of beams, girders and columns; and (c) Design live load values for wind, roof, floor, stairs, guard, handrails, and seismic.

(12) Mechanical drawings shall include where applicable:

(a) Specifications which show the complete heating, ventilating, fire protection, medical gas systems and air conditioning systems;

(b) Water supply, sewerage and HVAC piping systems;

(d) Heating, ventilating, HVAC piping, medical gas systems and air conditioning systems with all related piping and auxiliaries to provide a satisfactory installation;

(13) Electrical drawings shall include where applicable:

(a) A seal, certifying that all electrical work and equipment is in compliance with all applicable codes and that all materials are currently listed by recognized testing laboratories;

(d) Color coding to show all items on emergency power;

(14) The electrical drawings shall not include knob and tube wiring, shall not include electrical cords that have splices, and shall not show that the electrical system is overloaded.

(15) In all new facilities or renovations to existing electrical systems, the installation must be approved by an inspector or agency authorized by the State Fire Marshal.

(16) Sprinkler drawings shall include where applicable:

(a) Shop drawings, hydraulic calculations, and manufacturer cut sheets;

(17) The licensed contractor shall not install a system of water supply, plumbing, sewage, garbage or refuse disposal nor materially alter or extend any existing system until the architect or engineer submits complete plans and specifications for the installation, alteration or extension to the department demonstrating that all applicable codes have been met and the department has granted necessary approval.

(a) Before the nursing home is used, Tennessee Department of Environment and Conservation shall approve the water supply system.

(18) It shall be demonstrated through the submission of plans and specifications that in each nursing home a negative air pressure shall be maintained in the soiled utility area, toilet room, janitor’s closet, dishwashing and other such soiled spaces, and a positive air pressure shall be maintained in all clean areas including, but not limited to, clean linen rooms and clean utility rooms.

(20) In the event submitted materials do not appear to satisfactorily comply with 0720-18-.08(2), the department shall furnish a letter to the party submitting the plans which shall list the particular items in question and request further explanation and/or confirmation of necessary modifications.

(21) The licensed contractor shall execute all construction in accordance with the approved plans and specifications.

(22) If construction begins within one hundred eighty (180) days of the date of department approval, the department’s written notification of satisfactory review constitutes compliance with 0720-18-.08(2). This approval shall in no way permit and/or authorize any omission or deviation from the requirements of any restrictions, laws, regulations, ordinances, codes or rules of any responsible agency.

(24) The department requires the following alarms that shall be monitored twenty-four (24) hours per day:

(a) Fire alarms;

(b) Generators (if applicable); and (c) Medical gas alarms (if applicable).

(25) Each nursing home shall ensure that an emergency keyed lock box is installed next to each bank of functioning elevators located on the main level. Such lock boxes shall be permanently mounted seventy-two inches (72”) from the floor to the center of the box, be operable by a universal key no matter where such box is located, and shall contain only fire service keys and drop keys to the appropriate elevators.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-57, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68- 11-261.
Administrative History: Original rule filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Amendment filed July 3, 1984; effective August 1, 1984. Amendment filed March 13, 1986; effective April 12, 1986. Amendment filed October 22, 1987; effective December 6, 1987. Amendment filed February 11, 1992; effective March 27, 1992. Amendment filed January 6, 1995; effective March 22, 1995. Amendment filed June 13, 1997; effective August 27, 1997. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed February 18, 2003; effective May 4, 2003. Repeal and new rule filed September 21, 2005; effective December 5, 2005. Amendment filed February 23, 2007; effective May 9, 2007. Repeal and new rule filed December 20, 2011; effective March 19, 2012. Amendment filed January 21, 2016; effective April 20, 2016. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.09 LIFE SAFETY

(1) Any nursing home which complies with the required applicable building and fire safety regulations at the time the board adopts new codes or regulations will, so long as such compliance is maintained (either with or without waivers of specific provisions), be considered to be in compliance with the requirements of the new codes or regulations.

(2) The nursing home shall provide fire protection by the elimination of fire hazards, by the installation of necessary fire fighting equipment and by the adoption of a written fire control plan. Fire drills shall be held at least quarterly for each work shift for nursing home personnel in each separate patient-occupied nursing home building. There shall be a written report documenting the evaluation of each drill and the action recommended or taken for any deficiencies found. Records which document and evaluate these drills must be maintained for at least three (3) years. All fires which result in a response by the local fire department shall be reported to the department within seven (7) days. The report shall contain sufficient information to ascertain the nature and location of the fire, its probable cause and any injuries incurred by any person or persons as a result of the fire. Initial reports by the facility may omit the name(s) of resident(s) and parties involved, however, should the department find the identities of such persons to be necessary to an investigation, the facility shall provide such information.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Repeal and new rule filed September 21, 2005; effective December 5, 2005. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-202, 68-11-204, and 68-11-206 through 68-11-209.
Administrative History: Original rule filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Amendment filed March 13, 1986; effective April 12, 1986. Amendment filed December 30, 1986; effective February 13, 1987. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed May 24, 2004; August 7, pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1370-01-.10 .

(c) A licensed physical therapist shall be in charge of the physical therapy service and a licensed occupational therapist shall be in charge of the occupational therapy service.

(d) Direct contact shall exist between the resident and the therapist for those residents that require treatment ordered by a physician.

(e) The physical therapist and occupational therapist, pursuant to a physician order, shall provide treatment and training designed to preserve and improve abilities for independent functions, such as: range of motion, strength, tolerance, coordination and activities of daily living.

(f) Therapy services shall be coordinated with the nursing service and made a part of the resident care plan.

(g) Sufficient staff shall be made available to provide the service offered.

(12) Ventilator Services. A nursing home that provides ventilator services shall meet or exceed the following minimum standards by:

(a) Ensuring a licensed respiratory care practitioner as defined by Tennessee Code Annotated Section 63-27-102(7), shall be physically present at the facility twenty four (24) hours per day, seven (7) days per week to provide:

Ventilator care;
Administration of medical gases;
Administration of aerosol medications; and 4. Diagnostic testing and monitoring of life support systems;

(b) Ensuring that an appropriate, individualized plan of care is prepared for each patient requiring ventilator services. The plan of care shall be developed with input and participation from a pulmonologist or a physician with experience in ventilator care;

(c) Ensuring that admissions criteria is established to ensure the medical stability of ventilator-dependent patients prior to transfer from an acute care setting;

(d) Ensuring that Arterial Blood Gas (ABG) is readily available in order to document the patient’s acid base status and/or End Tidal Carbon Dioxide (etCOs) and whether continuous pulse oximetry measurements should be performed in lieu of ABG studies;

(e) Ensuring that an audible, redundant external alarm system is located outside of each ventilator-dependent patient’s room for the purpose of alerting caregivers of patient disconnection, ventilator disconnection or ventilator failure;

(f) Ensuring that the nursing home is equipped with emergency suction equipment and an adequate number of Ambu bags for manual ventilation;

(g) Ensuring that ventilator equipment is connected to electrical outlets connected to backup generator power;

(h) Ensuring that ventilators are equipped with battery back-up systems;

(i) Ensuring that the nursing home is equipped to employ the use of current ventilator technology consistent with meeting patients’ needs for mobility and comfort; and (j) Ensuring that a back-up ventilator is available at all times.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-3-511, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11- 207, 68-11-209, 68-11-216, 68-11-240, 68-11-241, and 68-11-801.
Administrative History: Original rule filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Amendment filed March 13, 1986; effective April 12, 1986. Amendment filed January 29, 1991; effective March 15, 1991. Amendment filed December 29, 1992; effective February 15, 1993. Amendment filed June 15, 1993; effective July 30, 1993. Amendment filed April 17, 1996; effective July 1, 1996. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed January 31, 2000; effective April 15, 2000. Amendment filed March 29, 2000; effective June 12, 2000. Amendment filed September 13, 2002; effective November 27, 2002. Amendment filed September 4, 2003; effective November 18, 2003. Amendment filed September 21, 2005; effective December 5, 2005. Amendment filed July 18, 2007; effective October 1, 2007. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed December 16, 2013; effective March 16, 2014. Amendment filed September 15, 2015; effective December 14, 2015. Amendments filed July 18, 2016; effective October 16, 2016. Emergency rule filed February 28, 2018; effective through August 27, 2018. Amendments filed April 19, 2018; effective July 18, 2018. Emergency rules filed May 29, 2020; effective through November 25, 2020. Emergency rules expired effective November 26, 2020, and the rules reverted to their previous statuses. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.10 INFECTIOUS AND HAZARDOUS WASTE

(1) Each nursing home must develop, maintain and implement written policies and procedures for the definition and handling of its infectious and hazardous wastes. These policies and procedures must comply with the standards of this section and all other applicable state and federal regulations.

(2) The following waste shall be considered to be infectious waste:

(a) Waste contaminated by residents who are isolated due to communicable disease, as provided in the U.S. Centers for Disease Control “Guidelines for Isolation Precautions in Hospitals”;

(d) All discarded sharps (e.g., hypodermic needles, syringes, pasteur pipettes, broken glass, scalpel blades) used in resident care or which have come into contact with infectious agents during use in medical, research, or industrial laboratories; or, (e) Other waste determined to be infectious by the facility in its written policy.

(3) Infectious and hazardous waste must be segregated from other waste at the point of generation, i.e., the point at which the material becomes a waste within the facility.

(4) Waste must be packaged in a manner that will protect waste handlers and the public from possible injury and disease that may result from exposure to the waste. Such packaging must provide for containment of the waste from the point of generation up to the point of proper treatment or disposal. Packaging must be selected and utilized for the type of waste the package will contain, how the waste will be treated and disposed, and how it will be handled and transported prior to treatment and disposal.

(a) Contaminated sharps must be directly placed in leakproof, rigid, and puncture-resistant containers which must then be tightly sealed.

(c) Reusable containers for infectious waste must be thoroughly sanitized each time they are emptied, unless the surfaces of the containers have been completely protected from contamination by disposable liners or other devices removed with the waste.

(d) Opaque packaging must be used for pathological waste.

(5) After packaging, waste must be handled and transported by methods ensuring containment and preserving the integrity of the packaging, including the use of secondary containment where necessary.

(a) Infectious waste must not be compacted or ground (i.e., in a mechanical grinder) prior to treatment, except that pathological waste may be ground prior to disposal.

(b) Plastic bags of infectious waste must be transported by hand.

(6) Waste must be stored in a manner which preserves the integrity of the packaging, inhibits rapid microbial growth and putrefaction, and minimizes the potential of exposure or access by unknowing persons. Waste must be stored in a manner and location which affords protection from animals, precipitation, wind, and direct sunlight, does not present a safety hazard, does not provide a breeding place or food source for insects or rodents and does not create a nuisance.

(7) In the event of spills, ruptured packaging, or other incidents where there is a loss of containment of waste, the facility must ensure that proper actions are immediately taken to:

(a) Isolate the area from the public and all except essential personnel;

(b) To the extent practicable, repackage all spilled waste and contaminated debris in accordance with the requirements of this rule;

(c) Sanitize all contaminated equipment and surfaces appropriately. Written policies and procedures must specify how this will be done; and, (d) Complete an incident report and maintain a copy on file.

(8) Except as provided otherwise in this rule, a facility must treat or dispose of infectious waste by one or more of the methods specified in this paragraph.

(a) A facility may treat infectious waste in an on-site sterilization or disinfection device, or in an incinerator or a steam sterilizer, which has been designed, constructed, operated and maintained so that infectious waste treated in such a device is rendered noninfectious and is, if applicable, authorized for that purpose pursuant to current rules of the Department of Environment and Conservation. A valid permit or other written evidence of having complied with the Tennessee Air Pollution Control Regulations shall be available for review, if required. Each sterilizing or disinfection cycle must contain appropriate indicators to assure conditions were met for proper sterilization or disinfection of materials included in the cycle, and records kept. Proper operation of such devices must be verified at least monthly, and records of these monthly checks shall be available for review. Waste that contains toxic chemicals that would be volatilized by steam must not be treated in steam sterilizers. Infectious waste that has been rendered to carbonized or mineralized ash shall be deemed non-infectious.

Unless otherwise hazardous and subject to the hazardous waste management requirements of the current rules of the Department of Environment and Conservation, such ash shall be disposable as a non-hazardous solid waste under current rules of the Department of Environment and Conservation.

(9) The facility may have waste transported off-site for storage, treatment, or disposal. Such arrangements must be detailed in a written contract, available for review. If such off-site location is in Tennessee, the facility must ensure that it has all necessary state and local approvals, and such approvals shall be available for review. If the off-site location is in another state, the facility must notify in writing all public health agencies with jurisdiction that the location is being used for management of the facility’s waste. Waste shipped off-site must be packaged in accordance with applicable federal and state requirements. Waste transported to a sanitary landfill in this state must meet the requirements of current rules of the Department of Environment and Conservation.

(10) All garbage, trash and other non-infectious waste shall be stored and disposed of in a manner that shall not permit the transmission of disease, create a nuisance, provide a breeding place for insects and rodents, or constitute a safety hazard. All containers for waste shall be water tight, constructed of easily cleanable material and shall be kept on elevated platforms.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Amendment filed July 3, 1984; effective August 1, 1984. Amendment filed March 13, 1986; effective April 12, 1986. Amendment filed October 22, 1987; effective December 6, 1987. Amendment filed February 11, 1992; effective March 27, 1992. Amendment filed January 6, 1995; effective March 22, 1995. Amendment filed June 13, 1997; effective August 27, 1997. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.11 RECORDS AND REPORTS

(1) The nursing home shall report each case of communicable disease to the local county health officer in the manner provided by existing regulations. Failure to report a communicable disease may result in disciplinary action, including revocation of the facility’s license.

(2) The nursing home shall report all incidents of abuse, neglect, and misappropriation to the Department of Health in accordance with T.C.A. § 68-11-211.

(3) The nursing home shall report the following incidents to the Department of Health in accordance with T.C.A. § 68-11-211.

(a) Strike by staff at the facility;

(b) External disasters impacting the facility;

(c) Disruption of any service vital to the continued safe operation of the nursing home or to the health and safety of its patients and personnel; and (d) Fires at the nursing home that disrupt the provision of patient care services or cause harm to the patients or staff, or that are reported by the facility to any entity, including but not limited to a fire department charged with preventing fires.

(4) The nursing home shall retain legible copies of the following records and reports for thirty-six months following their issuance. They shall be maintained in a single file and shall be made available for inspection during normal business hours to any person who requests to view them:

(a) Local fire safety inspections;

(b) Local building code inspections, if any;

(d) Department licensure and fire safety inspections and surveys;

(e) Federal Health Care Financing Administration surveys and inspections, if any;

(f) Orders of the Commissioner or Board, if any;

(g) Comptroller of the Treasury’s audit reports and findings, if any; and, (h) Maintenance records of all safety and patient care equipment.

Routine maintenance shall be administered according to the manufacturer’s recommended maintenance for the above equipment.
Ensure that facility staff or contract personnel are appropriately trained to conduct safety and patient care equipment inspections.

(5) A yearly statistical report, the “Joint Annual Report of Nursing Homes,” shall be submitted to the Department. The forms are mailed to each nursing home by the Department each year.

The forms shall be completed and returned to the Department as requested.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11-209, 68-11- 210, 68-11-211, 68-11-213, and 68-11-804.
Administrative History: Original rule filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Amendment filed March 13, 1986; effective April 12, 1986. Amendment filed December 29, 1993; effective February 15, 1993. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed September 4, 2003; effective November 18, 2003. Amendment filed April 17, 2007; effective July 1, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.12 RESIDENT RIGHTS

(1) The nursing home shall establish and implement written policies and procedures setting forth the rights of residents for the protection and preservation of dignity, individuality and, to the extent medically feasible, independence. Residents and their families or other representatives shall be fully informed and documentation shall be maintained in the resident’s file of the following rights:

(a) To privacy in treatment and personal care;

(b) To privacy, if married, for visits by his/her spouse;

(d) To be different, in order to promote social, religious and psychological well being;

(e) To privately talk and/or meet with and see anyone;

(f) To send and receive mail promptly and unopened;

(g) To be free from mental and physical abuse. Should this right be violated, the facility must notify the department within five (5) working days. The Tennessee Department of Human Services, Adult Protective Services shall be notified immediately as required in T.C.A. § 71-6-103;

(h) To be free from chemical and physical restraints;

(i) To meet with members of and take part in activities of social, commercial, religious and community groups. The administrator may refuse access to the facility to any person if that person’s presence would be injurious to the health and safety of a resident or staff, or would threaten the security of the property of the resident, staff or facility;

(j) To form and attend resident council meetings. The facility shall provide space for meetings and reasonable assistance to the council when requested;

(k) To retain and use personal clothing and possessions as space permits;

(l) To be free from being required by the facility to work or perform services;

(m) To be fully informed by a physician of his/her health and medical condition. The facility shall give the resident and family the opportunity to participate in planning the resident’s care and medical treatment;

(n) To refuse treatment. The resident must be informed of the consequences of that decision. The refusal and its reason must be reported to the physician and documented in the medical record;

(o) To refuse experimental treatment and drugs. The resident’s or health care decisionmaker’s written consent for participation in research must be obtained and retained in his or her medical record;

(p) To have their records kept confidential and private. Written consent by the resident must be obtained prior to release of information except to persons authorized by law. If the resident lacks capacity, written consent is required from the resident’s health care decision-maker. The nursing home must have policies to govern access and duplication of the resident’s record;

(q) To manage personal financial affairs. Any request by the resident for assistance must be in writing. A request for any additional person to have access to a resident’s funds must also be in writing;

(r) To be told in writing before or at the time of admission about the services available in the facility and about any extra charges, charges for services not covered under Medicare or Medicaid, or not included in the facility’s bill;

(s) To be free from discrimination because of the exercise of the right to speak and voice complaints;

(t) To exercise his/her own independent judgment by executing any documents, including admission forms;

(u) To have a free choice of providers of medical services, such as physician and pharmacy. However, medications must be supplied in packaging consistent with the medication system of the nursing home;

(v) To be free from involuntary transfer or discharge, except for these reasons:

Medical reasons;
His/her welfare or that of the other residents; or 3. Nonpayment, except as prohibited by the Medicaid program;

(w) To voice grievances and complaints, and to recommend changes in policies and services to the facility staff or outside representatives of the resident’s choice. The facility shall establish a grievance procedure and fully inform all residents and family members or other representatives of the procedure;

(x) To have appropriate assessment and management of pain; and (y) To be involved in the decision making of all aspects of their care.

(2) The rights set forth in this section may be abridged, restricted, limited or amended only as follows:

(a) When medically contraindicated;

(b) When necessary to protect and preserve the rights of other residents in the facility; or (c) When contradicted by the explicit provisions of another rule of the board.

(3) Any reduction in residents’ rights based upon medical consideration or the rights of other residents must be explicit, reasonable, appropriate to the justification, and the least restrictive response feasible. They may be time-limited, shall be explained to the resident, and must be documented in the individual resident’s record by reciting the limitation’s reason and scope.

Medical contraindications shall be supported by a physician’s order. At least once each month, the administrator and the director of nursing shall review the restriction’s justification and scope before removing it, amending it, or renewing it. The names of any residents in the facility whose rights have been restricted under the provisions of this rule shall be maintained on a separate list which shall be available for inspection by the department and by the area long-term care ombudsman.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-901, and 68- 11-902.
Administrative History: Original rule filed March 27, 1975; effective April 25, 1975. Repeal and new rule filed July 14, 1983; effective August 15, 1983. Amendment filed May 24, 2985; effective June 23, 1985. Amendment filed March 13, 1986; effective April 12, 1986. Amendment filed October 22, 1987; effective December 6, 1987. Amendment filed May 10, 1990; effective June 24, 1990. Amendment filed March 9, 1992; effective April 23, 1992. Amendment filed March 10, 1995; effective May 24, 1995. Amendment filed June 13, 1997; effective August 27, 1997. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendment filed September 21, 2005; effective December 5, 2005. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.13 POLICIES AND PROCEDURES FOR HEALTH CARE DECISION-MAKING

(1) Pursuant to this rule, each nursing home shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a resident who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from individual residents. An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.

(2) An adult or emancipated minor may execute an advance directive for health care. The advance directive may authorize an agent to make any health care decision the resident could have made while having capacity, or may limit the power of the agent, and may include individual instructions. The effect of an advance directive that makes no limitation on the agent’s authority shall be to authorize the agent to make any health care decision the resident could have made while having capacity.

(3) The advance directive shall be in writing, signed by the resident, and shall either be notarized or witnessed by two (2) witnesses. Both witnesses shall be competent adults, and neither of them may be the agent. At least one (1) of the witnesses shall be a person who is not related to the resident by blood, marriage, or adoption and would not be entitled to any portion of the estate of the resident upon the death of the resident. The advance directive shall contain a clause that attests that the witnesses comply with the requirements of this paragraph.

(4) Unless otherwise specified in an advance directive, the authority of an agent becomes effective only upon a determination that the resident lacks capacity, and ceases to be effective upon a determination that the resident has recovered capacity.

(6) A determination that a resident lacks or has recovered capacity, or that another condition exists that affects an individual instruction or the authority of an agent shall be made by the designated physician, who is authorized to consult with such other persons as he or she may deem appropriate.

(7) An agent shall make a health care decision in accordance with the resident’s individual instructions, if any, and other wishes to the extent known to the agent. Otherwise, the agent shall make the decision in accordance with the resident’s best interest. In determining the resident’s best interest, the agent shall consider the resident’s personal values to the extent known.

(8) An advance directive may include the individual’s nomination of a court-appointed guardian.

(10) No health care provider or institution shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care.

(12) A resident having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.

(13) A resident having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke.

(15) An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.

(16) Surrogates.

(a) An adult or emancipated minor may designate any individual to act as surrogate by personally informing the supervising health care provider. The designation may be oral or written.

(b) A surrogate may make a health care decision for a resident who is an adult or emancipated minor if and only if:

The resident has been determined by the designated physician to lack capacity, and 2. No agent or guardian has been appointed, or 3. The agent or guardian is not reasonably available.

(c) In the case of a resident who lacks capacity, the resident’s surrogate shall be identified by the supervising health care provider and documented in the current clinical record of the facility at which the resident is receiving health care.

(d) The resident’s surrogate shall be an adult who has exhibited special care and concern for the resident, who is familiar with the resident’s personal values, who is reasonably available, and who is willing to serve.

(e) Consideration may be, but need not be, given in order of descending preference for service as a surrogate to:

The resident’s spouse, unless legally separated;
The resident’s adult child;
The resident’s parent;
The resident’s adult sibling;
Any other adult relative of the resident; or 6. Any other adult who satisfies the requirements of 0720-18-.13(16)(d).

(f) No person who is the subject of a protective order or other court order that directs that person to avoid contact with the resident shall be eligible to serve as the resident’s surrogate.

(g) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:

Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the resident or in accordance with the resident’s best interests;
The proposed surrogate’s regular contact with the resident prior to and during the incapacitating illness;
The proposed surrogate’s demonstrated care and concern;
The proposed surrogate’s availability to visit the resident during his or her illness; and 5. The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.

(h) If the resident lacks capacity and none of the individuals eligible to act as a surrogate under 0720-18-.13(16)(c) through 0720-18-.13(16)(g) is reasonably available, the designated physician may make health care decisions for the resident after the designated physician either:

Consults with and obtains the recommendations of a facility’s ethics mechanism or standing committee in the facility that evaluates health care issues; or 2. Obtains concurrence from a second physician who is not directly involved in the resident’s health care, does not serve in a capacity of decision-making, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.

(j) A surrogate shall make a health care decision in accordance with the resident’s individual instructions, if any, and other wishes to the extent known to the surrogate.

Otherwise, the surrogate shall make the decision in accordance with the surrogate’s determination of the resident’s best interest. In determining the resident’s best interest, the surrogate shall consider the resident’s personal values to the extent known to the surrogate.

(k) A surrogate who has not been designated by the resident may make all health care decisions for the resident that the resident could make on the resident’s own behalf, except that artificial nutrition and hydration may be withheld or withdrawn for a resident upon a decision of the surrogate only when the designated physician and a second independent physician certify in the resident’s current clinical records that the provision or continuation of artificial nutrition or hydration is merely prolonging the act of dying and the resident is highly unlikely to regain capacity to make medical decisions.

(l) Except as provided in 0720-18-.13(16)(m):

Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution nor an employee of an operator of a health care institution may be designated as a surrogate; and 2. A health care provider or employee of a health care provider may not act as a surrogate if the health care provider becomes the resident’s treating health care provider.

(m) An employee of the treating health care provider or an employee of an operator of a health care institution may be designated as a surrogate if:

The employee so designated is a relative of the resident by blood, marriage, or adoption; and 2. The other requirements of this section are satisfied.

(n) A health care provider may require an individual claiming the right to act as surrogate for a resident to provide written documentation stating facts and circumstances reasonably sufficient to establish the claimed authority.

(17) Guardian.

(a) A guardian shall comply with the resident’s individual instructions and may not revoke the resident’s advance directive absent a court order to the contrary.

(b) Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.

(c) A health care provider may require an individual claiming the right to act as guardian for a resident to provide written documentation stating facts and circumstances reasonably sufficient to establish the claimed authority.

(18) A designated physician who makes or is informed of a determination that a resident lacks or has recovered capacity, or that another condition exists which affects an individual instruction or the authority of an agent, guardian, or surrogate, shall promptly record the determination in the resident’s current clinical record and communicate the determination to the resident, if possible, and to any person then authorized to make health care decisions for the resident.

(19) Except as provided in 0720-18-.13(20) through 0720-18-.13(22), a health care provider or institution providing care to a resident shall:

(a) Comply with an individual instruction of the resident and with a reasonable interpretation of that instruction made by a person then authorized to make health care decisions for the resident; and (b) Comply with a health care decision for the resident made by a person then authorized to make health care decisions for the resident to the same extent as if the decision had been made by the resident while having capacity.

(20) A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.

(21) A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:

(a) Contrary to a policy of the institution which is based on reasons of conscience, and (b) The policy was timely communicated to the resident or to a person then authorized to make health care decisions for the resident.

(23) A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 0720-18-.13(20) through 0720-18-.13(22) shall:

(a) Promptly so inform the resident, if possible, and any person then authorized to make health care decisions for the resident;

(b) Provide continuing care to the resident until a transfer can be effected or until the determination has been made that transfer cannot be effected;

(c) Unless the resident or person then authorized to make health care decisions for the resident refuses assistance, immediately make all reasonable efforts to assist in the transfer of the resident to another health care provider or institution that is willing to comply with the instruction or decision; and (d) If a transfer cannot be effected, the health care provider or institution shall not be compelled to comply.

(24) Unless otherwise specified in an advance directive, a person then authorized to make health care decisions for a resident has the same rights as the resident to request, receive, examine, copy, and consent to the disclosure of medical or any other health care information.

(a) Complying with a health care decision of a person apparently having authority to make a health care decision for a resident, including a decision to withhold or withdraw health care;

(26) An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.

(27) A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for such identification made in good faith.

(28) A copy of a written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.

(29) The withholding or withdrawal of medical care from a resident in accordance with the provisions of the Tennessee Health Care Decisions Act shall not, for any purpose, constitute a suicide, euthanasia, homicide, mercy killing, or assisted suicide.

(30) Physician Orders for Scope of Treatment (POST).

(a) Physician Orders for Scope of Treatment (POST) may be issued by a physician for a patient with whom the physician has a bona fide physician-patient relationship, but only:

With the informed consent of the patient;
If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or 3. If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available, if the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

No physician, who has a bona fide physician-patient relationship with the patient, is present and available for discussion with the patient (or if the patient is a minor or is otherwise incapable of making an informed decision, with the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act);
Such authority to issue is contained in the physician assistant’s, nurse practitioner’s or clinical nurse specialist’s protocols;
Either:

(i) With the informed consent of the patient;

(d) A POST issued in accordance with this section shall remain valid and in effect until revoked. In accordance with this rule and applicable regulations, qualified emergency medical services personnel; and licensed health care practitioners in any facility, program, or organization operated or licensed by the Board for Licensing Health Care Facilities, the Department of Mental Health and Substance Abuse Services, or the Department of Intellectual and Developmental Disabilities, or operated, licensed, or owned by another state agency, shall follow a POST that is available to such persons in a form approved by the Board for Licensing Health Care Facilities.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-224, and 68- 11-1801 through 68-11-1815.
Administrative History: Original rule filed June 22, 1992; effective August 6, 1992. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed April 28, 2003; effective July 12, 2003. Repeal and new rule filed September 21, 2005; effective December 5, 2005. Amendment filed February 7, 2007; effective April 23, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.14 DISASTER PREPAREDNESS

(1) Emergency Electrical Power.

(a) All nursing homes must have one or more on-site electrical generators which are capable of providing emergency electrical power to at least all life sustaining equipment and life sustaining resources such as: ventilators, blood banks, biological refrigerators, safety switches for boilers, safety lighting for corridors and stairwells, and other essential equipment.

(b) Connections shall be through a switch which shall automatically transfer the circuits to the emergency power source in case of power failure. It is recognized that some equipment may not sustain automatic transfer and provisions will have to be made to manually change these items from a non-emergency powered outlet to an emergency powered outlet or other power source. All emergency power transfer switches shall be labeled as such. Switches affecting heat, ventilation, and all systems shall be labeled.

(c) The emergency power system shall have a minimum of twenty four (24) hours of either propane, gasoline or diesel fuel. The quantity shall be based on its expected or known connected load consumption during power interruptions. In addition, the nursing home shall have a written contract with an area fuel distributor which guarantees first priority service for re-fills during power interruptions.

(d) The emergency power system (generator) shall be inspected weekly and exercised under actual load and operating temperature conditions for at least thirty (30) minutes, once each month, including automatic and manual transfer of equipment. The generator shall be exercised by trained facility staff who are familiar with the systems operation. Instructions for the operation of the systems and the manual transfer of emergency power shall be maintained with the facility’s disaster preparedness plan and shall be separately identified in the plan. Records shall be maintained for all weekly inspections and monthly tests and be kept on file for a minimum of three (3) years.

(2) Physical Facility and Community Emergency Plans.

(a) Physical Facility (Internal Situations).

Every nursing home shall have a current internal emergency plan, or plans, that provides for fires, bomb threats, severe weather, utility service failures, plus any local high risk situations such as floods, earthquakes, toxic fumes and chemical spills. The plan should consider the probability of the types of disasters which might occur, both natural and “man-made.”
The plan(s) must include provisions for the relocation of persons within the building and/or either partial or full building evacuation. Facilities which do not have sufficient emergency generator capacity to provide a place of refuge for residents during severe hot or cold weather emergencies shall specifically establish an emergency plan to assure a common area (dining room, hallway, or day rooms) is heated or cooled sufficiently to sustain residents during an emergency. This can be accomplished through several approaches including the installation of a transfer switch at the facility to which an emergency generator may be connected to operate a HVAC system for the place of refuge, or transportation of a generator to the facility and direct connection from the generator to emergency portable heating or cooling units. The plan must be coordinated with local emergency management agencies that provide emergency generators or heating or cooling units; and facilities are encouraged to enter into private agreements with local generator suppliers, rental agencies or other reliable sources of emergency power. Plans that provide for the relocation of residents to other health care facilities must have written agreements for emergency transfers. The agreements may be mutual, i.e. providing for transfers either way.
Copies of the plan(s), either complete or outlines, including specific emergency telephone numbers related to that type of disaster, shall be available to all staff.

A copy shall be readily available at all times in the telephone operator’s position or at the security center. Provisions that have security implications may be omitted from the outline versions. Familiarization information shall be included in employee orientation sessions and more detailed instructions must be included in continuing education programs. Records of orientation and education programs must be maintained for at least three (3) years.

The plan must provide for additional staffing, medical supplies, blood and other resources which would probably be needed.
Each of the following disaster preparedness plans shall be conducted annually prior to the month listed in the plan. Drills are for the purpose of educating staff, resource determination, testing personnel safety provisions and communications with other facilities and community agencies. Records which document and evaluate these drills must be maintained for at least three (3) years.

(i) Fire Safety Procedures Plan, to be exercised at any time during the year, shall include:

(I) Minor fires;

(II) Major fires;

(III) Fighting the fire;

(IV) Evacuation procedures;

(V) Staff functions by department and job assignment; and, (VI) Fire drill schedules (fire drills shall be held at least quarterly on each work shift).

(ii) External disaster procedures plan (for tornado, flood, earthquake), to be exercised prior to March, shall include:

(I) Staff duties by department and job assignment; and, (II) Evacuation procedures.

(iii) Bomb Threat Procedures Plan, to be exercised at any time during the year:

(I) Staff duties by department and job assignment; and, (II) Search team, searching the premises.

The nursing home shall develop and periodically review with all employees a prearranged plan for the orderly evacuation of all residents in case of a fire, internal disaster or other emergency. The plan of evacuation shall be posted throughout the home. Fire drills shall be held at least quarterly for each work shift for nursing home personnel in each separate patient-occupied nursing home building. There shall be a written report documenting the evaluation of each drill and the action recommended or taken for any deficiencies found. Records which document and evaluate these drills must be maintained for at least three (3) years.

(b) Community Emergency (Mass Casualty).

Every nursing home, unless exempted due to its limited scope of clinical services, shall have a plan that provides for the reception and treatment, within its capabilities, of medical emergencies resulting from a disaster within its usual service area. The plan should consider the probability of the types of disasters which might occur, both natural and “man-made.”
The plan must provide for additional staffing, medical supplies, blood and other resources which would probably be needed. The plan must also provide for the deferral of elective admission patients and also for the early transfer or discharge of some current patients if it appears that the number of casualties will exceed available staffed beds.
Copies of the plan(s), either complete or outlines, including specific emergency telephone numbers related to that type of disaster, shall be available to staff who would be assigned non-routine duties during these types of emergencies.

At least one drill shall be conducted each year for the purpose of educating staff, resource determination, and communications with other facilities and community agencies. Records which document and evaluate these drills must be maintained for at least three (3) years.
As soon as possible, actual community emergency situations that result in the treatment of more than twenty (20) patients, or fifteen percent (15%) of the licensed bed capacity, whichever is less, must be documented. Actual situations that had education and training value may be substituted for a drill. This includes documented actual plan activation during community emergencies, even if no patients are received.

All nursing homes shall establish and maintain communications with the county Emergency Management Agency. This includes the provision of the information and procedures that are needed for the local comprehensive emergency plan.

The nursing homes shall cooperate, to the extent possible, in area disaster drills and local emergency situations.

Each nursing home shall conduct both the physical facility and community emergency drills as required in these regulations, even if the local Emergency Management Agency is unable to participate.
A file of documents demonstrating communications and cooperation with the local agency must be maintained.

History

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Repeal and new rule filed January 31, 2000; effective April 15, 2000. Amendment filed September 21, 2005; effective December 5, 2005. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.

Tenn. Comp. R. & Regs. 0720-18-.15 NURSE AIDE TRAINING AND COMPETENCY EVALUATION

All nurse aide training programs must comply with the federal nurse aide training and competency regulations, promulgated pursuant to the Omnibus Budget Reconciliation Act of 1987, and with federal labor laws, including but not limited to minimum age requirements. Copies of these regulations may be obtained from the department.

(1) Testing service.

(a) The Department shall provide or contract for the provision of nurse aide testing services as follows:

Annual publication of testing schedules and sites.
Test sites shall be located so that no individual is required to drive farther than thirty (30) miles to reach a test site.
Scheduled tests shall be administered, except when no individual is scheduled to test at a particular test site.
The number of individuals passing and failing shall be published following each test.
The minimum passing grade for each test shall be seventy-five percent (75%) for the written or oral component. The performance demonstration portion of the test shall consist, at minimum, of five performance tasks, which shall be selected randomly for each registrant from a pool of skills evaluation tasks ranked according to degree of difficulty, with at least one task selected from each degree of difficulty. Registrants are required to pass a minimum of five (5) performance tasks.
Individuals who fail any portion of the test three (3) consecutive times shall repeat training prior to taking the test again.

(b) Applications to take the test shall be sent by the program coordinator to the appropriate testing agency postmarked no later than thirty (30) days prior to the test date. Requests for special testing needs shall be made to the testing agency at this time.

(c) The department shall provide the board with quarterly reports on the number of individuals passing and failing each test.

(d) A practical and written test will be developed to reflect that a trainee has acquired the minimum competency skills necessary to become a competent and qualified nurse aide. The Nurse Aide Advisory Committee, composed of twelve (12) members with at least three (3) members nominated by the Tennessee Health Care Association, will periodically review testing materials and set criteria for survey visits of the nurse aide programs.

(e) The test will be developed from a pool of questions, only a portion of which is to be used for grading purposes in any one test, not to exceed one hundred (100) questions.

A system must be developed which prevents the disclosure of the pool of questions and of the performance demonstration portion of the test.

(2) Training program.

(a) Requests for approval of a nurse aide training program shall be submitted to the department and shall include the following:

Name, address and telephone number of the facility, institution or agency offering the program;
The program coordinator’s name, address, license number and verification of a minimum of two (2) years nursing experience, at least one of which must be in the provision of long-term care facility services;
Statement of course objectives;
Description of course content specifying the number of hours to be spent in the classroom and in clinical settings; and, 5. In lieu of 3. and 4. above, the fact that the curriculum is previously departmentapproved.

(b) Notification of any change to any one of the above five (5) items or termination of the program must be submitted to the department within 30 days.

(c) Each training program shall have a pass rate on both written and performance exams of at least 70%. Annual reviews of Nurse Aide Training Programs shall include:

Letter of commendation for exceptional pass rate as evaluated by the department;
Letter of concern for programs having one year of test pass rates below 70%;
Request for plan of program improvement for programs with two consecutive years of test pass rates below 70%;
After the third year of consecutive test pass rates below seventy-percent (70%), the program shall be closed for no less than twenty-four (24) months. All students enrolled in the program shall be allowed to complete the course. Any program closed may appeal the closure to the Board pursuant to the Uniform Administrative Procedures Act compiled in Title 4, Chapter 5, Part 3.

(d) Each program coordinator shall be responsible for ensuring that the following requirements are met:

Course objectives are accomplished;
Only persons having appropriate skills and knowledge are selected to conduct any part of the training;
The provision of direct individual care to residents by a trainee is limited to appropriately supervised clinical experiences; a program instructor must be present or readily available on-site during all clinical training hours including direct patient care for the seventy-five (75) hour training program. All activities of daily living (ADL) skills, including but not limited to bathing, feeding, toileting, grooming, oral care, and perineal care, must be taught prior to student performing direct patient care;
The area used for training is well-lighted, well-ventilated and provides for privacy for instruction. Such requirements are not to exceed the requirements for physical space in a nursing facility;
Each trainee demonstrates competence in clinical skills and fundamental principles of resident care;
Records are kept to verify the participation and performance of each trainee in each phase of the training program. The satisfactory completion of the training program by each trainee shall be attested to on each trainee’s record;
Each trainee is issued a certificate of completion which includes at least the name of the program, the date of issuance, the trainee’s name and the signature of the program coordinator.
The program coordinator shall be responsible for the completion, signing and submission to the department of all required documentation.

(e) Student to teacher ratio must be as follows: 25:1 in classroom and 15:1 for direct patient care training.

(3) Nurse Aide Registry. A nursing home must not use any individual working in a facility as a nurse aide for more than four (4) months unless that individual’s name is included on the Nurse Aide Registry. A facility must not use on a temporary, per diem, leased or any basis other than permanent, any individual who does not meet the requirements of training and competency testing.

(a) The Nurse Aide Registry shall include:

The individual’s full name, including a maiden name and any other surnames used;
The individual’s last known home address;
The individual’s date of birth; and, 4. The date that the individual passed the competency test and the expiration date of the individual’s current registration.

(b) The name of any individual who has not performed nursing or nursing related services for a period of twenty-four (24) consecutive months shall be removed from the Nurse Aide Registry.

(4) Continued Competency. The facility must complete a performance review of each nurse aide employee at least once every 12 months and must provide regular in-service education based on the outcome of these reviews.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11-209, 68-11- 210, 68-11-211, 68-11-213, and 68-11-804 and Public Chapter 148 of 2021.
Administrative History: Original rule filed September 4, 2003; effective November 18, 2003. Amendment filed March 27, 2015; effective June 25, 2015. Emergency rule filed August 18, 2021; effective through February 14, 2022. Emergency rule expired effective February 15, 2022, and the rule reverted to its previous status. Transferred from chapter 1200-08-06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-18-.16 APPENDIX I

(1) Physician Orders for Scope of Treatment (POST) Form.

(This space intentionally left blank)

A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED

Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”)

This is a Physician Order Sheet based on the medical conditions and wishes of the person identified at right (“patient”).

Any section not completed indicates full treatment for that section. When need occurs, first follow these orders, then contact physician.

Patient’s Last Name First Name/Middle Initial Date of Birth

Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Other Instructions:

Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify)

The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other)

Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge)

MD/NP/CNS/PA Phone Number:

Name (print) Signature Relationship (write “self” if patient)

Verbal orders are acceptable with follow-up signature by physician in accordance with facility/community policy.

Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel.

Photocopies/faxes of signed POST forms are legal and valid.

Using POST Any incomplete section of POST implies full treatment for that section.

No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.”

Oral fluids and nutrition must always be offered if medically feasible.

IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”

A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.

Reviewing POST This POST should be reviewed if:

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.

(2) Advance Directive for Health Care Form.

ADVANCE DIRECTIVE FOR HEALTH CARE*

(Tennessee)

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.

Instructions: Parts 1 and 2 may be used together or independently. Please mark out/void any unused part(s).

Part 5, Block A or Block B must be completed for all uses.   Yes No CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it has stopped. Usually this involves electric shock, chest compressions, and breathing assistance.   Yes No Life Support/Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys, and other organs to continue to work.   Yes No Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a new condition but will not help the main illness.   Yes No Tube feeding/IV fluids: Use of tubes to deliver food and water to a patient’s stomach or use of IV fluids into a vein, which would include artificially delivered nutrition and hydration.

Part 3 Other instructions, such as hospice care, burial arrangements, etc.:

(Attach additional pages if necessary)

Part 5 Your signature must either be witnessed by two competent adults (“Block A”) or by a notary public (“Block B”).

Signature: _______________________________________ Date: ____________________ (Patient)

Block A Neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.

Witnesses:

I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form.

Signature of witness number 2 Block B You may choose to have your signature witnessed by a notary public instead of the witnesses described in Block A.

STATE OF TENNESSEE

COUNTY OF

My commission expires:

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1805.
Administrative History: Original rule filed February 16, 2007; effective May 2, 2007. Repeal and new rule filed August 28, 2012; effective November 26, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed February 8, 2017; effective May 9, 2017. Transferred from chapter 1200-08- 06 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-19 Residential Home for Aged Quality Enabling Program (Transferred from 1200-08-07)

Tenn. Comp. R. & Regs. 0720-19-.01 PURPOSE

It is the intent of this rule to improve the quality of care and of service in Tennessee’s Residential Homes for the Aged through the mechanism of distributing certain designated and limited state funds. This rule is now jointly promulgated by the Tennessee Board for Licensing Health Care Facilities and Tennessee Department of Health to implement the provisions of Chapter 927 of the Public Acts of 1986.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 12-4-320 (Public Acts of 1986, Chapter 927), 53-1310, and 68-11- 209.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed January 13, 1987; effective February 27, 1987. Amendment filed August 23, 2006; effective November 6, 2006. Transferred from chapter 1200-08-07 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-19-.02 PARTICIPATION OF RESIDENTS

An eligible program participant must meet all of the following requirements, both at the time of application and during continued participation:

(1) (a) Has a total income, from all sources, which does not exceed six hundred dollars ($600.00) per month;

(b) Is a beneficiary or recipient of payments under the Social Security Act;

(d) Satisfies the standards for lawful admission to a residential home for the aged and with no medical problems that would require that the resident be transferred to a higher level of care.

History

Authority: T.C.A. §§ 4-5-201, 12-4-320, and 68-11-209.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed January 13, 1987; effective February 27, 1987. Amendment filed April 1, 1992; effective May 16, 1992. Transferred from chapter 1200-08-07 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-19-.03 PARTICIPATION OF PROVIDERS

(1) To be eligible to participate in this program, a residential home for the aged must meet all of the following requirements, both at the time of application and during continued participation:

(a) Be currently licensed by the Board as a residential home for the aged;

(b) Be located in counties specified in T.C.A. § 12-4-320;

(c) Have been free, for 1 year, of any disciplinary sanction ordered by either the Commissioner or the Board (such as a suspension of admissions, a probated license, or a license subject to special conditions);

(d) Be in compliance with Title VI of the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973;

(e) Be free of current deficiencies which endanger or restrict the rights of a resident;

(f) Provide the Department with such data and information as is necessary to evaluate the effectiveness of the program to include a quarterly report which describes how the expenditures improve the Quality of Care and Services in Tennessee Residential Homes for the Aged. These expenditures must be for services on care above what the regulations require as mandatory.

(g) Have the operator or responsible attendant participate in all Department or Board sponsored training programs which are made available without charge;

(h) Accept the eligible resident’s income and the State’s reimbursement as payment in full for the residential home’s services and neither accept any payment for its services from any other person on behalf of the resident, nor attempt to hold any other person as responsible or liable for the cost of these services.

History

Authority: T.C.A. §§ 4-5-201, et seq., 4-5-202, 4-5-204, 12-4-320 (Public Acts of 1986, Chapter 927), and 68-11-209.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed January 13, 1987; effective February 27, 1987. Amendment filed June 20, 1988; effective September 28, 1988. Amendment filed December 4, 1992; effective January 19, 1993. pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-19-.04 APPLICATION TO PARTICIPATE

(1) (a) The Department will take appropriate steps to notify eligible providers and potentiallyeligible persons of the availability of this program of the requirements to participate and of the process to make an application.

(b) All applications shall be made upon forms provided by the Department. Completed applications shall be submitted to the Department for review. Failure to submit a completed application within forty-five (45) days of the applications being mailed out by the Department will result in the applicant being denied participation in the program for the current fiscal year. A decision on the application will be made within thirty (30) days of its receipt.

(d) Current residents of a residential home for the aged which has been approved to participate, or which has a pending application should apply through a representative of the home for the aged.

(e) Potential residents may apply themselves, through another, or through a representative of a home for the aged, but should also identify an approved provider who is willing to admit them as a resident.

(f) Reimbursement will not be made until both the residential home for the aged and the resident have been approved for participation.

History

Authority: T.C.A. §§ 4-5-202, 12-4-320 (Public Acts of 1986, Chapter 927), and 68-11-209.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed January 13, 1987; effective February 27, 1987. Amendment filed June 19, 1995; effective September 2, 1995. Transferred from chapter 1200-08-07 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-19-.05 REIMBURSEMENT

(1) (a) The Department shall reimburse an approved and participating residential home for the aged for each day of care and services given to an approved and participating resident as permitted by allocated funding.

(b) The Department will reimburse a participating home the current amount as defined in T.C.A. § 12-4-320(b) of thirteen dollars ($13.00) per eligible resident day, not to exceed the maximum allowable percentage rate based on the allotted contract amount for the current fiscal year.

(c) Claims for reimbursement shall be submitted quarterly to the Department on forms approved by the Department. The authorized representative of the Residential Home for the Aged shall certify the participant’s continued eligibility for services during the previous quarter, attesting that the representative has personally examined documents demonstrating that continued eligibility. In order to be reimbursed, all claims must be submitted no later that fifteen (15) days from the last full day upon which the service was rendered, except for claims occurring before the effective date and implementation of these regulations.

(d) The Department may recoup or recover funds paid to any provider for services rendered to an ineligible recipient, or if the provider has accepted prohibited payments from any other individual on behalf of the resident.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 12-4-320 (Public Acts of 1986, Chapter 927), and 68-11-209.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed January 13, 1987; effective February 27, 1987. Amendment filed June 20, 1988; effective September 28, 1988. Amendment filed April 1, 1992; effective May 16, 1992. Amendment filed December 4, 1992; effective January 19, 1993. Amendment filed June 19, 1995; effective September 2, 1995. Amendment filed August 23, 2006; effective November 6, 2006. Transferred from chapter 1200-08-07 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-19-.06 TERMINATION FROM PARTICIPATION

(1) A participating provider or a participating resident may be terminated from this program for any of the following reasons:

(a) The termination of the program after thirty (30) days’ notice to all person and homes who are then participating;

(b) A resident no longer meets the requirements for participation, set forth in 0720-19-.02, or a provider no longer meets the requirements for participation, set forth in 0720-19- .03;

(c) An order of the Commissioner or the Board imposes discipline upon a provider, in which case the participating resident may continue to benefit from reimbursement for a period not to exceed thirty (30) days immediately after the entry of the order of discipline. During this period, the eligible resident may seek admission to another approved residence, not so disqualified;

(d) A provider has lost his license, in which case the participating resident’s reimbursement ends on the day of the loss;

(e) Failure to comply with any of the provisions of these rules; or (f) False or erroneous certification or claim of a resident’s period of residence or eligibility, including concealing income.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 12-4-320 (Public Acts of 1986, Chapter 927), 53-1310, and 68-11- 209.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed January 13, 1987; effective February 27, 1987. Amendment filed August 23, 2006; effective November 6, 2006. Transferred from chapter 1200-08-07 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-19-.07 HEARINGS

(1) If any applicant or owner of a Residential Home for the Aged is dissatisfied with any decision made by the Department or by the Board he has the right to appeal that decision and request a hearing.

(2) All such hearings shall be conducted before the Chairman of the Board for Licensing Health Care Facilities, who is now designated by both the Board and the Department to hear such cases and to enter a final judgment in such matters. All such hearings shall be conducted as provided in the Uniform Administrative Procedures Act, Tennessee Code Annotated, Title 4,

chapter 5, part 3.

(3) The decision of the Chairman of the Board may be appealed to the Chancery Court, as provided in T.C.A. § 4-5-322.

(4) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to rule

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-201, 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 12-4-320 (Public Acts of 1986, Chapter 927), 68-11-208, and 68-11-209.
Administrative History: Original rule filed June 7, 1974; effective July 7, 1974. Repeal and new rule filed January 13, 1987; effective February 27, 1987. Amendment filed April 1, 1992; effective May 16, 1992. Amendment filed March 1, 2007; effective May 15, 2007. Transferred from chapter 1200-08-07 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-20 Standards for Ambulatory Surgical Treatment Centers (Transferred from 1200-08-10)

Tenn. Comp. R. & Regs. 0720-20-.01 DEFINITIONS

(1) Abuse. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) Acceptable Plan of Correction. The Licensing Division approves an Ambulatory Surgical Treatment Center’s plan to correct deficiencies identified during an on-site survey conducted by the Survey Division or its designated representative. The plan of correction shall be a written document and shall provide, but not limited to, the following information:

(a) How the deficiency will be corrected.

(b) Who will be responsible for correcting the deficiency.

(d) How the facility will prevent the same deficiency from re-occurring.

(3) Accredited Record Technician (ART). A person currently accredited as such by the American Medical Records Association.

(4) Adult. An individual who has capacity and is at least 18 years of age.

(5) Advance Directive. An individual instruction or a written statement relating to the subsequent provision of health care for the individual, including, but not limited to, a living will or a durable power of attorney for health care.

(6) Agent. An individual designated in an advance directive for health care to make a health care decision for the individual granting the power.

(7) Ambulatory Surgical Treatment Center (ASTC). Any institution, place or building devoted primarily to the maintenance and operation of a facility for the performance of surgical procedures. Such facilities shall not provide beds or other accommodations for the stay of a patient to exceed twelve (12) hours duration, provided that the length of stay may be extended for an additional twelve (12) hours in the event such stay is deemed necessary by the attending physician, the facility Medical Director, or the anesthesiologist for observation or recovery, but in no event shall the length of stay exceed twenty-four (24) hours. Individual patients shall be discharged in an ambulatory condition without danger to the continued wellbeing of the patients or shall be transferred to a hospital. Excluded from this definition are the private physicians’ and dentists’ office practices. For the purposes of this rule, those medical and dental offices, facilities, and other settings at which surgical procedures exclusively are performed are ASTC’s and not private office practices.

ASTC’s must comply with the following for purposes of these regulations:

(a) Surgical procedures performed must be limited to those procedures which are commonly performed on an inpatient basis in hospitals but may safely be performed in an ASTC;

(b) If anesthesia is required for a surgical procedure, it must be local, regional or general anesthesia and routinely be four (4) hours or less in duration;

(c) Surgical procedures that generally result in extensive blood loss, require major or prolonged invasion of body cavities, or are considered emergency or life-threatening in nature may not be performed.

(8) Board. The Tennessee Board for Licensing Health Care Facilities.

(9) Cancer Treatment and Radiation Clinic. A facility in which the only procedures performed are diagnostic and therapeutic radiology, chemotherapy and related services.

(10) Capacity. An individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. These regulations do not affect the right of a patient to make health care decisions while having the capacity to do so. A patient shall be presumed to have capacity to make a health care decision, to give or revoke an advance directive, and to designate or disqualify a surrogate.

Any person who challenges the capacity of a patient shall have the burden of proving lack of capacity.

(11) Cardiopulmonary Resuscitation (CPR). The administering of any means or device to support cardiopulmonary functions in a patient, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilators or respirators, defibrillation, the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a patient where cardiac or respiratory arrest has occurred or is believed to be imminent.

(12) Certified Registered Nurse Anesthetist. A registered nurse currently licensed by the Tennessee Board of Nursing who is currently certified as such by the American Association of Nurse Anesthetists.

(13) Clinical Laboratory Improvement Act (CLIA). The federal law requiring that clinical laboratories be approved by the U.S. Department of Health and Human Services, Health Care Financing Administration.

(14) Collaborative Plan. The formal written plan between the mid-level practitioners and licensed physician.

(16) Commissioner. Commissioner of the Tennessee Department of Health or his or her authorized representative.

(17) Competent. A patient who has capacity.

(18) Dentist. A person currently licensed as such by the Tennessee Board of Dentistry.

(19) Department. The Tennessee Department of Health.

(20) Designated Physician. A physician designated by an individual or the individual’s agent, guardian, or surrogate, to have primary responsibility for the individual’s health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes such responsibility.

(21) Do-Not-Resuscitate Order (DNR). A written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(23) Emancipated Minor. Any minor who is or has been married or has by court order or otherwise been freed from the care, custody and control of the minor’s parents.

(24) Emergency Responder. A paid or volunteer firefighter, law enforcement officer, or other public safety official or volunteer acting within the scope of his or her proper function under law or rendering emergency care at the scene of an emergency.

(25) Gastrointestinal Endoscopy Clinic. A facility in which the only procedures performed are those related to the gastrointestinal tract and other endoscopic procedures. This excludes laparoscopy and limits entry to major body cavities by needle aspiration only.

(26) General Anesthesia. An induced state of unconsciousness accompanied by partial or complete loss of protective reflexes inducing the inability to continually maintain an airway independently and respond purposefully to physical stimulation or verbal command, and produced by a pharmacological or non-pharmacological method or a combination thereof.

(27) Graduate Registered Nurse Anesthetist. A registered nurse currently licensed in Tennessee who is a graduate of a nurse anesthesia educational program that is accredited by the American Association of Nurse Anesthetist’s Council on Accreditation of Nurse Anesthesia Educational Programs and awaiting initial certification examination results, provided that initial certification is accomplished within eighteen (18) months of completion of an accredited nurse anesthesia educational program.

(28) Guardian. A judicially appointed guardian or conservator having authority to make a health care decision for an individual.

(29) Hazardous Waste. Materials whose handling, use, storage and disposal are governed by local, state or federal regulations.

(31) Health Care Decision. Consent, refusal of consent or withdrawal of consent to health care.

(32) Health Care Decision-Maker. In the case of a patient who lacks capacity, the patient’s health care decision-maker is one of the following: the patient’s health care agent as specified in an advance directive, the patient’s court-appointed guardian or conservator with health care decision-making authority, the patient’s surrogate as determined pursuant to Rule 0720-20- .13 or T.C.A. § 33-3-220, the designated physician pursuant to these rules or in the case of a minor child, the person having custody or legal guardianship.

(33) Health Care Institution. A health care institution as defined in T.C.A. § 68-11-1602.

(35) Hospital. Any institution, place, building or agency represented and held out to the general public as ready, willing and able to furnish care, accommodations, facilities and equipment for the use, in connection with services of a physician or dentist, to one (1) or more non-related persons who may be suffering from deformity, injury or disease or from any other condition for which nursing, medical or surgical services would be appropriate for care, diagnosis or treatment.

(36) Incompetent. A patient who has been adjudicated incompetent by a court of competent jurisdiction and has not been restored to legal capacity.

(37) Individual Instruction. An individual’s direction concerning a health care decision for the individual.

(38) Infectious Waste. Solid or liquid wastes which contain pathogens with sufficient virulence and quantity such that exposure to the waste by a susceptible host could result in an infectious disease.

(39) Licensed Practical Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(40) Licensee. The person or entity to whom the license is issued. The licensee is held responsible for compliance with all applicable rules and regulations.

(41) Life Threatening or Serious Injury. Injury requiring the patient to undergo significant additional diagnostic or treatment measures.

(42) Medical Emergency. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

(43) Medical Record. Medical histories, records, reports, summaries, diagnoses, prognoses, records of treatment and medication ordered and given, entries, x-rays, radiology interpretations and other written electronics, or graphic data prepared, kept, made or maintained in a facility that pertains to confinement or services rendered to patients admitted or receiving care.

(44) Medical Staff. An organized body composed of individuals appointed by the ambulatory surgical treatment center governing board. All members of the medical staff shall be licensed to practice in Tennessee, with the exception of interns and residents.

(46) Mid-Level Practitioner. A registered nurse licensed in Tennessee who holds a master’s degree in a clinical nursing specialty, national certification through the ANCC or American Academy of Nurse Practitioners and holds a certificate of fitness to prescribe from the Tennessee Board of Nursing.

(49) N.F.P.A. National Fire Protection Association.

(50) Nurse Midwife. A person currently licensed by the Tennessee Board of Nursing as a registered nurse (R.N.) and qualified to deliver midwifery services or certified by the American College of Nurse-Midwives.

(51) Patient. Includes but is not limited to any person who is suffering from an acute or chronic illness or injury or who is crippled, convalescent or infirm, or who is in need of obstetrical, surgical, medical, nursing or supervisory care.

(52) PALS. Pediatric Advance Life Support.

(53) Person. An individual, corporation, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency, or instrumentality, or any other legal or commercial entity.

(54) Personally Informing. A communication by any effective means from the patient directly to a health care provider.

(55) Physician. An individual authorized to practice medicine or osteopathy under Tennessee Code Annotated, Title 63, Chapters 6 or 9.

(56) Physician Assistant. A person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(57) Physician Orders for Scope of Treatment or POST. Written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(58) Podiatrist. A person currently licensed as such by the Tennessee Board of Registration in Podiatry.

(59) Power of Attorney for Health Care. The designation of an agent to make health care decisions for the individual granting the power under T.C.A. Title 34, Chapter 6, Part 2.

(60) Qualified Emergency Medical Service Personnel. Includes, but shall not be limited to, emergency medical technicians, paramedics, or other emergency services personnel, providers, or entities acting within the usual course of their professions, and other emergency responders.

(61) Radiological Technologist. A person currently certified as such by the American Society of Radiological Technologists.

(62) Reasonably Available. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the patient’s health care needs. Such availability shall include, but not be limited to, availability by telephone.

(63) Registered Nurse (R.N.). A person currently licensed as such by the Tennessee Board of Nursing.

(64) Registered Record Administrator (RRA). A person currently registered as such by the American Medical Records Association.

(65) Shall or Must. Compliance is mandatory.

(66) State. A state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States.

(68) Surgical Procedure. A manual or operative method performed by a licensed medical practitioner to treat diseases, injuries, conditions and/or deformities. (As related to pregnancy termination, surgical procedure excludes, but is not limited to, PAP smear or vaginal examinations, ultrasounds, amniocentesis, intramuscular injections.)

(69) Surgical Technologist. A person who works under supervision to facilitate the safe and effective conduct of invasive surgical procedures. This individual is usually employed by a hospital, medical office, or surgical center and supervised during the surgical procedure according to institutional policy and procedure to assist in providing a safe operating room environment that maximizes patient safety by performing certain tasks including, but not limited to:

(a) Preparation of the operating room and the sterile field for surgical procedures by preparing sterile supplies, instruments, and equipment using sterile technique;

(70) Surrogate. An individual, other than a patient’s agent or guardian, authorized to make a health care decision for the patient.

(71) Transfer. The movement of a patient at the direction of a physician or other qualified medical personnel when a physician is not readily available but does not include such movement of a patient who leaves the facility against medical advice.

(72) Treating Health Care Provider. A health care provider who at the time is directly or indirectly involved in providing health care to the patient.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11- 211, 68-11-216, 68-11-224, 68-11-1802, 68-57-101, 68-57-102, and 68-57-105.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Amendment filed August 10, 1982; effective September 9, 1982. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Amendment filed March 12, 1993; effective April 26, 1993. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed April 28, 2003; effective July 12, 2003. Amendment filed June 16, 2003; effective August 30, 2003. Amendment filed May 20, 2004; effective August 3, 2004. Amendments filed September 9, 2005; effective November 23, 2005. Amendment filed February 23, 2006; effective May 9, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendment filed February 22, 2010; effective May 23, 2010. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.02 LICENSING PROCEDURES

(1) No person, partnership, association, corporation, or state, county or local government unit, or any division, department, board or agency thereof, shall establish, conduct, operate, or maintain in the State of Tennessee any ASTC without having a license. A license shall be issued only to the applicant named and only for the premises listed in the application for licensure. Licenses are not transferable or assignable and shall expire and become invalid annually on the anniversary date of their original issuance. The license shall be conspicuously posted in the ASTC.

(2) In order to make application for a license:

(a) The applicant shall submit an application on a form prepared by the department.

(b) Each applicant for a license shall pay an annual license fee in the amount of one thousand four hundred and four dollars ($1,404.00). The fee must be submitted with the application and is not refundable.

A license shall not be issued until the facility is in substantial compliance with these rules and regulations including submission of all information required by Tennessee Code Annotated § 68-11-206(l), or as later amended, and all information required by the Commissioner.

(d) The applicant must prove the ability to meet the financial needs of the facility.

(f) The applicant shall allow the ambulatory surgical treatment center to be inspected by a Department surveyor. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action to the Board that must be accepted by the Board.

Once the deficiencies have been corrected, then the Board shall consider the application for licensure.

(3) Each ASTC, when issued a license, shall be classified according to the type of services rendered or category of patients served. The ASTC shall confine its services to those described in its license and shall advertise only the services which it is licensed to perform.

The classification shall be listed on the license.

(4) A proposed change of ownership must be reported to the department a minimum of thirty (30) days prior to the change. A new application and fee must be received by the department before the license may be issued.

(a) For purposes of licensing, the licensee of an ASTC has the ultimate responsibility for the operation of the facility, including the final authority to make or control operational decisions and legal responsibility for the business management. A change of ownership occurs whenever this ultimate legal authority for the responsibility of ASTC operations is transferred.

(b) A change of ownership occurs whenever there is a change in the legal structure by which the facility is owned and operated and any ownership interest of the preceding or succeeding entity changes.

Transfer of the facility’s legal title;
Lease of the facility’s operation;
Dissolution of any partnership that owns, or owns a controlling interest in, the facility;
One partnership is replaced by another through the removal, addition or substitution of a partner;
Merger of a facility owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are canceled;
The consolidation of a corporate facility owner with one or more corporations; or, 7. Transfers between levels of government.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors or board of trustees;
Two (2) or more corporations merge and the originally licensed corporation survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government; or, 5. Corporate stock transfers or sales, even when a controlling interest.

(5) Renewal.

(a) In order to renew a license, each ambulatory surgical treatment center shall submit to periodic inspections by Department surveyors for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action and shall remedy the deficiencies. In addition, each licensee shall submit a renewal form approved by the board and applicable renewal fee prior to the expiration date of the license.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late; provided that the late penalty shall not exceed twice the renewal fee.

A completed application for licensure;
The license fee provided in Rule 0720-20-.02(2)(b); and 3. Any other information required by the Health Services and Development Agency.

(d) Upon reapplication, the licensee shall submit to an inspection of the facility by Department of Health surveyors.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206(a)(5), 68-11-206, 68-11-209, 68-11-209(a)(1), 68-11-210, 68-11-216, and Chapter 846 of the Public Acts of 2008, §1.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Amendment filed February 26, 1985; effective March 28, 1985. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed June 16, 2003; effective August 30, 2003. Amendment filed January 19, 2007; effective April 4, 2007. Amendment filed July 18, 2007; effective October 1, 2007. Public necessity rules filed April 29, 2009; effective through October 11, 2009. Emergency rules filed October 9, 2009; effective through April 7, 2010. Amendments filed September 24, 2009; effective December 23, 2009. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed March 21, 2018; to have been effective June 19, 2018. However, on May 24, 2018, the Government Operations Committee filed a 5-day stay; new effective date June 24, 2018. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.03 DISCIPLINARY PROCEDURES

(1) The board may suspend or revoke a license for:

(a) Violation of federal or state statutes;

(b) Violation of the rules as set forth in this chapter;

(d) Conduct or practice found by the board to be detrimental to the health, safety, or welfare of the patients of the ASTC; and (e) Failure to renew license.

(2) The board may consider all factors which it deems relevant, including but not limited to the following when determining sanctions:

(a) The degree of sanctions necessary to ensure immediate and continued compliance;

(b) The character and degree of impact of the violation on the health, safety and welfare of the patients in the facility;

(3) When an ambulatory surgical treatment center is found by the department to have committed a violation of this chapter, the department will issue to the facility a statement of deficiencies.

Within ten (10) days of the receipt of the statement of deficiencies the facility must return a policy of correction indicating the following:

(a) How the deficiency will be corrected;

(b) The date upon which each deficiency will be corrected;

(4) Either failure to submit a plan of correction in a timely manner or a finding by the department that the plan of correction is unacceptable shall subject the ambulatory surgical treatment center’s license to possible disciplinary action.

(5) Any licensee or applicant for a license, aggrieved by a decision or action of the department or board, pursuant to this chapter, may request a hearing before the board. The proceedings and judicial review of the board’s decision shall be in accordance with the Uniform Procedures Act, T.C.A. §§ 4-5-101 et seq.

(6) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to Rule

Tenn. Comp. R. & Regs. 0720-20-.04 ADMINISTRATION

(1) The ASTC must have an effective governing body legally responsible for the conduct of the ASTC. If an ASTC does not have an organized governing body, the persons legally responsible for the conduct of the ASTC must carry out the functions specified in this chapter.

(2) The governing body shall appoint a chief executive officer or administrator who is responsible for managing the ASTC. 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 ASTC with administrative direction at all times.

(3) The governing body, 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.

(4) The governing body shall assure that the ASTC has the financial resources to provide the services essential to the operation of the facility.

(5) Staffing shall be adequate to provide the services essential to the operation of the ASTC.

(6) The ambulatory surgical treatment center shall ensure a framework for addressing issues related to care at the end of life.

(7) The ambulatory surgical treatment center shall provide a process that assesses pain in all patients. There shall be an appropriate and effective pain management program.

(8) The ASTC shall perform only those surgical procedures which can be safely and effectively carried out on an outpatient basis.

(9) Each ASTC shall have at all times a designated Medical Director who shall be a licensed physician or dentist 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 ASTC 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 ASTC 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 ASTC 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 or therapy services are purchased from others, the governing body 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 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 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) Each ASTC shall specify the classification of services to be provided in the facility and list authorized surgical procedures.

(19) 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.

(20) Infection Control.

(a) The ASTC must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active performance improvement program for the prevention, control, and investigation of infections and communicable diseases.

(b) The physical environment of the ambulatory surgical treatment center shall be maintained in a safe, clean and sanitary manner.

Any condition on the ambulatory surgical treatment center site conducive to the harboring or breeding of insects, rodents or other vermin shall be prohibited.

Chemical substances of a poisonous nature used to control or eliminate vermin shall be properly identified. Such substances shall not be stored with or near food or medications.

Cats, dogs or other animals shall not be allowed in any part of the ambulatory surgical treatment center except for specially trained animals for the handicapped and except as addressed by ambulatory surgical treatment center policy for pet therapy programs. The ambulatory surgical treatment center shall designate in its policies and procedures those areas where animals will be excluded. The areas designated shall be determined based upon an assessment of the ambulatory surgical treatment center performed by medically trained personnel.
The layout of patient care areas of the ASTC, as well as the personal items offered to the patient, shall be outlined in the ASTC’s policy and be based on the type of procedure performed on the patient.
Bath basin water service, emesis basin, bedpan and urinal shall be individually provided.
Water pitchers, glasses, thermometers, emesis basins, douche apparatus, enema apparatus, urinals, mouthwash cups, bedpans and similar items of equipment coming into intimate contact with patients shall be disinfected or sterilized after each use unless individual equipment for each is provided and then sterilized or disinfected between patients and as often as necessary to maintain them in a clean and sanitary condition. Single use, patient disposable items are acceptable but shall not be reused.

(c) The chief executive officer or administrator shall assure that an infection control committee including members of the medical staff, nursing staff and administrative staff develops guidelines and techniques for the prevention, surveillance, control and reporting of facility infections. Duties of the committee shall include the establishment of:

Written infection control policies;
Techniques and systems for identifying, reporting, investigating and controlling infections in the facility;
Written procedures governing the use of aseptic techniques and procedures in all areas of the facility, including adoption of a standardized central venous catheter insertion process which shall contain these key components:

(i) Hand hygiene (as defined in 0720-20-.04(20)(g));

(ii) Maximal barrier precautions to include the use of sterile gowns, gloves, mask and hat, and large drape on patient;

(iii) Chlorhexidine skin antisepsis;

(iv) Optimal site selection;

(v) Daily review of line necessity; and (vi) Development and utilization of a procedure checklist;

Written procedures concerning food handling, laundry practices, disposal of environmental and patient wastes, traffic control and visiting rules in high risk areas, sources of air pollution, and routine culturing of autoclaves and sterilizers;
A log of incidents related to infectious and communicable diseases;
A method of control used in relation to the sterilization of supplies and water, and a written policy addressing reprocessing of sterile supplies;
Formal provisions to educate and orient all appropriate personnel in the practice of aseptic techniques such as handwashing and scrubbing practices, proper grooming, masking and dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of patient care equipment and supplies; and, 8. Continuing education provided for all facility personnel on the cause, effect, transmission, prevention, and elimination of infections, as evidenced by front line employees verbalizing understanding of basic techniques.

(d) The chief executive officer, the medical staff and the chief nursing officer must ensure that the facility-wide performance improvement program and training programs address problems identified by the infection control committee and must be responsible for the implementation of successful corrective action plans in affected problem areas.

(f) The facility shall have an annual influenza vaccination program which shall include at least:

The offer of influenza vaccination to all staff and independent practitioners or accept documented evidence of vaccination from another vaccine source or facility;
A signed declination statement on record from all who refuse the influenza vaccination for other than medical contraindications;
Education of all direct care personnel about the following:

(i) Flu vaccination, (ii) Non-vaccine control measures, and (iii) The diagnosis, transmission, and potential impact of influenza;

An annual evaluation of the influenza vaccination program and reasons for nonparticipation; and 5. The requirements to complete vaccinations or declination statements are suspended by the Medical Director in the event of a vaccine shortage.

(g) The facility and its employees shall adopt and utilize standard precautions (per CDC) for preventing transmission of infections, HIV, and communicable diseases, including adherence to a hand hygiene program which shall include:

Use of alcohol-based hand rubs or use of non-antimicrobial or antimicrobial soap and water before and after each patient contact if hands are not visibly soiled;
Use of gloves during each patient contact with blood or where other potentially infectious materials, mucous membranes, and non-intact skin could occur and gloves changed before and after each patient contact;
Use of either a non-antimicrobial soap and water or an antimicrobial soap and water for visibly soiled hands; and 4. Health care worker education programs which may include:

(i) Types of patient care activities that can result in hand contamination;

(ii) Advantages and disadvantages of various methods used to clean hands;

(h) All ASTC’s 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) Performance Improvement. The ASTC shall have a planned, systematic, organization-wide approach to process design and redesign, performance measurement, assessment and improvement which is approved by the designated medical staff committee of the facility, the owner and/or the governing body. This plan shall address and/or include, but is not limited to:

(a) Infection control, including post-operative surveillance;

(b) Complications arising after the patient was admitted;

(d) A system which identifies appropriate plans of action to correct identified quality deficiencies;

(e) Documentation that the above policies are being followed and that appropriate action is taken whenever indicated.

(f) The facility shall develop and implement a system for measuring improvements in adherence to the hand hygiene program, central venous catheter insertion process, and influenza vaccination program.

(22) The ASTC shall ensure a framework for addressing issues related to care at the end of life.

(23) The ASTC shall provide a process that assesses pain in all patients. There shall be an appropriate and effective pain management program.

(24) 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;

Postings of (a) and (b) shall be on a sign no smaller than eleven inches (11”) in width and seventeen inches (17”) in height.

(25) “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.

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

(27) Informed Consent.

(a) Any ambulatory surgical treatment center in which abortions, other than abortions necessary to prevent the death of the pregnant female, are performed shall conspicuously post a sign in a location defined below so as to be clearly visible to patients, which reads:

(b) The sign shall be printed in languages appropriate for the majority of clients of the facility with lettering that is legible and that is Arial font, at least 40-point bold-faced type.

(c) A facility in which abortions are performed that is an ambulatory surgical treatment center shall post the required sign in each patient waiting room and patient consultation room used by patients on whom abortions are performed.

(d) An ambulatory surgical treatment center shall be assessed a civil penalty by the board for licensing health care facilities of two thousand five hundred dollars ($2,500.00) for each day of violation in which:

The sign required above was not posted during business hours when patients or prospective patients are present; and 2. An abortion other than an abortion necessary to prevent the death of the pregnant female was performed in the ambulatory surgical treatment center.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-15-202, 39-17-1803, 39-17-1805, 68-11-201, 68-11-202, 68- 11-204, 68-11-206, 68-11-209, 68-11-216, 68-11-268, and 71-6-121.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Amendment filed September 10, 1991; effective October 25, 1991. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendment filed June 16, 2003; effective August 30, 2003. Amendment filed September 9, 2005; effective November 23, 2005. Amendment filed April 20, 2006; effective July 4, 2006. Amendment filed July 18, 2007; effective October 1, 2007. Amendment filed October 11, 2007; effective December 25, 2007. Amendment filed February 22, 2010; effective May 23, 2010. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.05 ADMISSIONS, DISCHARGES, AND TRANSFERS

(1) Every person admitted for care or treatment to any ASTC shall be under the supervision of a physician licensed to practice in Tennessee. The name, address and telephone number of the physician attending the patient shall be recorded in the patient’s medical record.

(2) The above does not preclude the admission of a patient to an ASTC by a dentist or podiatrist licensed to practice in Tennessee with the concurrence of a physician member of the medical staff.

(4) The facility shall ensure that no person on the grounds of race, color, national origin, or handicap, will be excluded from participation in, be denied benefits of, or otherwise subjected to discrimination in the provision of any care or service of the facility. The facility shall protect the civil rights of residents under the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

(5) For purposes of this chapter, the requirements for signature or countersignature by a physician, dentist, podiatrist or other person responsible for signing, countersigning or authenticating an entry may be satisfied by the electronic entry by such person of a unique code assigned exclusively to him or her, or by entry of other unique electronic or mechanical symbols, provided that such person has adopted same as his or her signature in accordance with established ASTC protocol or rules.

(6) Each ASTC must have a written transfer agreement with a local hospital.

(7) The ASTC shall develop a patient referral system both for referrals within the facility and other health care providers.

(8) The ASTC shall have available a plan for emergency transportation to a licensed local hospital.

(9) The facility must ensure continuity of care and provide an effective discharge planning process that applies to all patients. The facility’s discharge planning process, including discharge policies and procedures, must be specified in writing and must:

(a) Be developed and/or supervised by a registered nurse, social worker or other appropriately qualified personnel;

(b) Begin upon admission;

(c) Be provided when identified as a need by the patient, a person acting on the patient’s behalf, or by the physician; and (d) Include the likelihood of a patient’s capacity for self-care or the possibility of the patient returning to his or her pre-ambulatory surgical treatment center environment.

(10) A discharge plan is required on every patient, even if the discharge is to home.

(11) The facility must arrange for the initial implementation of the patient’s discharge plan and must reassess the patient’s discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan.

(12) As needed, the patient and family members or interested persons must be taught and/or counseled to prepare them for post-operative care.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-216.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed June 16, 2003; effective August 30, 2003. Transferred from chapter 1200-08- 10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.06 BASIC SERVICES

(1) Surgical Services.

(a) Facilities restricted in services they provide, e.g. those that restrict services to radiation therapy or use of local anesthetics only, may be exempted from all or part of the requirements of this rule pertaining to laboratory services, food and dietetic services, surgical services, and anesthesia services.

(b) If the facility provides surgical services, the services must be well-organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered, the services must be consistent in quality with inpatient care in accordance with the complexity of services offered.

(c) A hospital may choose to separately license a portion of the facility as an Ambulatory Surgical Treatment Center; the licensure fee for such is not required.

(d) The organization of the surgical services must be appropriate to the scope of the services offered.

(e) The operating rooms must be supervised by an experienced registered nurse or a doctor of medicine or osteopathy.

(f) An ASTC may use scrub nurses in its operating rooms. For the purposes of this rule, a “scrub nurse” is defined as a registered nurse or either a licensed practical nurse (L.P.N.) or a surgical technologist (operating room technician) supervised by a registered nurse who works directly with a surgeon within the sterile field, passing instruments, sponges, and other items needed during the procedure and who scrubs his or her hands and arms with special disinfecting soap and wears surgical gowns, caps, eyewear, and gloves, when appropriate.

(g) Qualified registered nurses may perform circulating duties in the operating room. In accordance with applicable state laws and approved medical staff policies and procedures, LPNs and surgical technologists may assist in circulatory duties under the supervision of a qualified registered nurse who is immediately available to respond to emergencies.

(h) Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner.

(i) Surgical services must be consistent with needs and resources. Policies covering surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care.

(j) The Health Facilities Commission shall publish an approved list of accredited surgical technology programs.

Surgical technologists must meet one (1) or more of the following:

(ii) Successfully completed an accredited surgical technologist program;

This section does not prohibit a person from performing surgical technology services if the person is acting within the scope of the person’s license, certification, registration, permit, or designation, or is a student or intern under the direct supervision of a healthcare provider.

(k) An ASTC can petition the director of health care facilities of the department for a waiver from the provisions of 0720-20-.06(1)(j) if they are unable to employ a sufficient number of surgical technologists who meet the requirements. The facility shall demonstrate to the director that a diligent and thorough effort has been made to employ surgical technologists who meet the requirements. The director shall refuse to grant a waiver upon finding that a diligent and thorough effort has not been made. A waiver shall exempt a facility from meeting the requirements for not more than nine (9) months.

Additional waivers may be granted, but all exemptions greater than twelve (12) months shall be approved by the Board for Licensing Health Care Facilities.

(l) Surgical technologists shall demonstrate continued competence in order to perform their professional duties in surgical technology. The employer shall maintain evidence of the continued competence of such individuals. Continued competence activities may include but are not limited to continuing education, in-service training, or certification renewal. Persons qualified to be employed as surgical technologists shall complete fifteen (15) hours of continuing education or contact hours annually. Current certification by the National Board of Surgical Technology and Surgical Assisting shall satisfy this requirement.

(m) There must be a complete history and physical work-up in the chart of every patient prior to surgery, except in emergencies. If the history has been dictated, but not yet recorded in the patient’s chart, there must be a statement to that effect and an admission note in the chart by the practitioner who admitted the patient.

(n) Properly executed informed consent, advance directive, if available, and organ donation forms, if available, must be in the patient’s chart before surgery, except in emergencies. The patient is not required to sign advance directive and organ donation forms.

(o) Adequate equipment and supplies must be available as determined by the governing body and the medical staff, and must meet the current acceptable standards of practice in the ASTC industry. In conjunction with their governing body and the medical staff, the facility shall develop policies and procedures specifying the types of emergency equipment that are appropriate for the facility’s patient population, and shall make the items immediately available at the ASTC to handle inter- or post-operative emergencies.

(p) At least one registered nurse shall be in the recovery area during the patient’s recovery period.

(q) The operating room register must be complete and up-to-date.

(r) An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon.

(s) The ASTC shall provide one or more surgical suites which shall be constructed, equipped, and maintained to assure the safety of patients and personnel.

(t) Surgical suites are required to meet the same standards as hospital operating rooms, including those using general anesthesia.

(u) The ASTC shall have separate areas for waiting rooms, recovery rooms, treatment and/or examining rooms.

(2) Anesthesiology Services. Anesthesia shall be administered by:

(a) A qualified anesthesiologist;

(b) A doctor of medicine or osteopathy (other than an anesthesiologist);

(d) A certified registered nurse anesthetist (CRNA); or (e) A graduate registered nurse anesthetist under the supervision of an anesthesiologist who is immediately available if needed.

(f) After the completion of anesthesia, patients shall be constantly attended by competent personnel until responsive and able to summon aid. Each center shall maintain a log of the inspections made prior to each day’s use of the anesthesia equipment. A record of all service and maintenance performed on all anesthesia machines, vaporizers and ventilators shall also be on file.

(g) When inhaled general anesthesia known to trigger malignant hyperthermia and/or succinylcholine are maintained in the facility, there shall be thirty-six (36) ampules of Dantrolene for injection onsite. This requirement applies to anesthesia agents, current or future, that are shown to cause malignant hyperthermia. If Dantrolene is administered, appropriate monitoring must be provided post-operatively.

(h) Written policies and procedures relative to the administration of anesthesia shall be developed and approved by the medical staff and governing body.

(i) Any patient receiving conscious sedation shall receive:

Continuous EKG monitoring;
Continuous oxygen saturations;
Serial BP monitoring at intervals no less than every 5 minutes; and 4. Supplemental oxygen therapy and immediately available:

(i) Ambubag;

(ii) Suction;

(iii) Endotracheal tube; and (iv) Crash cart.

(3) Medical Staff.

(a) The ASTC shall have a medical staff organized under written by-laws that are approved by the governing body. The medical staff of the ASTC shall define a mechanism to:

Assure that an optimal level of professional performance is maintained;
Appoint independent practitioners through a defined credentialing process;
Apply credentialing criteria uniformly;
Utilize the current license, relevant training and experience, current competence and the ability to perform requested privileges in the credentialing process; and 5. Provide for participation in required committees of the facility to ensure that quality medical care is provided to the patients.

(b) Each licensed independent practitioner shall provide care under the auspices of the facility in accordance with approved privileges.

(c) Clinical privileges shall be granted based on the practitioners’ qualifications and the services provided by the facility, and shall be reviewed and/or revised at least every two (2) years.

(4) Nursing Service. A licensed registered nurse (R.N.) shall be on duty at all times. Additional appropriately trained staff shall be provided as needed to ensure that the medical needs of the patients are fully met.

(a) The ASTC shall be organized under written policies and procedures relating to patient care, establishment of standards for nursing care and mechanisms for evaluating such care and nursing services.

(b) A qualified registered nurse designated by the administrator shall be responsible for coordinating and supervising all nursing services.

(c) There shall be a sufficient staffing pattern of registered nurses to provide quality nursing care to each surgical patient from admission through discharge. Additional staff shall be on duty and available to assist the professional staff to adequately handle routine and emergency patient needs.

(d) The ASTC shall establish written procedures for emergency services which will ensure that professional staff members who have been trained in emergency resuscitation procedures shall be on duty at all times when there is a patient in the ASTC and until the patient has been discharged.

(e) Nursing care policies and procedures shall be consistent with professionally recognized standards of nursing practice and shall be in accordance with the Nurse Practice Act of the State of Tennessee and the Association of Operating Room Nurses Standards of Practice.

(f) Staff development and training shall be provided to the nursing staff and other ancillary staff in order to maintain and improve knowledge and skills. The educational/training program shall be planned, documented and conducted on a continuing basis. There shall be at least appropriate training on equipment, safety concerns, infection control and emergency care on an annual basis.

(5) Pharmaceutical Services. The ASTC must provide drugs and biologicals in a safe and effective manner in accordance with accepted standards of practice. Such drugs and biologicals must be stored in a separate room or cabinet which shall be kept locked at all times.

(6) Ancillary Services. All ancillary or supportive health or medical services, including but not limited to, radiological, pharmaceutical, or medical laboratory services shall be provided in accordance with all applicable state and federal laws and regulations.

(7) Radiological Services. The ASTC shall provide within the facility, or through arrangement, diagnostic radiological services commensurate with the needs of the ambulatory surgical treatment center.

(a) If radiological services are provided by facility staff, the services shall be maintained free of hazards for patients and personnel.

(b) New installations of radiological equipment, and subsequent inspections for the identification of radiation hazards shall be made as specified in state and federal requirements.

(c) Personnel monitoring shall be maintained for each individual working in the area of radiation. Readings shall be on at least a monthly basis and reports kept on file and available for review.

Personnel - The ASTC shall have a radiologist either full-time or part-time on a consulting basis, both to supervise the service and to discharge professional radiological services.
The use of all radiological apparatus shall be limited to personnel designated as qualified by the radiologist; and use of fluoroscopes shall be limited to physicians.

(d) If provided under arrangement with an outside provider, the radiological services must be directed by a qualified radiologist and meet state and federal requirements.

(8) Laboratory Services.

(a) The ASTC shall provide on the premises or by written agreement with a laboratory licensed under T.C.A. § 68-29-105, a clinical laboratory to provide those services commensurate with the needs and services of the ASTC.

(b) Any patient terminating pregnancy in an ASTC shall have an Rh type, documented prior to the procedure, performed on her blood. In addition, she shall be given the opportunity to receive Rh immune globulin after an appropriate crossmatch procedure is performed within a licensed laboratory.

(9) Food and Dietetic Services. If a patient will be in the facility for more than four (4) hours postop, an appropriate diet shall be provided.

(10) Environmental Services.

(a) The facility shall provide a safe, accessible, effective and efficient environment of care consistent with its mission, service, law and regulation.

(b) The facility shall develop policies and procedures that address:

Safety;
Security;
Control of hazardous materials and waste;
Emergency preparedness;
Life safety;
Medical equipment; and, 7. Utility systems.

(c) Staff shall have been oriented to and educated about the environment of care and possess knowledge and skills to perform responsibilities under the environment of care policies and procedures.

(d) Utility systems, medical equipment, life safety elements, and safety elements of the environment of care shall be maintained, tested and inspected.

(e) Safety issues shall be addressed and resolved.

(f) Appropriate staff shall participate in implementing safety recommendations and monitoring their effectiveness.

(g) The building and grounds shall be suitable to services provided and patients served.

(11) Infection Control. An Ambulatory Surgical Treatment Center shall have an annual influenza vaccination program which shall include at least:

(a) The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Ambulatory Surgical Treatment Center will encourage all staff and independent practitioners to obtain an influenza vaccination;

(b) A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at https://www.tn.gov/content/dam/tn/health/documents/SampleIndividualFluForm.pdf);

Flu vaccination, 2. Non-vaccine control measures, and 3. The diagnosis, transmission, and potential impact of influenza;

(12) Medical Records.

(a) The ASTC shall comply with the Medical Records Act of 1974, T.C.A. §§ 68-11-301, et seq.

(b) A medical record shall be maintained for each person receiving medical care provided by the ASTC and shall include:

Patient identification;
Name of nearest relative or other responsible agent;
Identification of primary source of medical care;
Dates and times of visits;
Signed informed consent;
Pertinent medical history;
Diagnosis;
Physician examination report;
Anesthesia records of pertinent pre-operative and post-operative reports including pre-anesthesia evaluation, type of anesthesia, technique and dosage used;
Operative report;
Discharge summary, including instructions for self-care and instructions for obtaining post-operative emergency care;
Reports of all laboratory and diagnostic procedures along with tests performed and the results authenticated by the appropriate personnel; and, 13. X-ray reports.

(c) Medical records shall be current and confidential. Medical records and copies thereof shall be made available when requested by an authorized representative of the board or the department.

(13) Invasive Procedures.

(a) For purposes of interventional pain management, only a medical doctor, licensed pursuant to T.C.A. §§ 63-6-101 et seq., or an osteopathic physician, licensed pursuant to T.C.A. §§ 63-9-101 et seq., who meets the following qualifications will be permitted to perform invasive procedures of the spine, spinal cord, sympathetic nerves of the spine or block of major peripheral nerves of the spine.

Board certified through the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) or the American Board of Physician Specialties (ABPS)/American Association of Physician Specialists (AAPS) in one of the following medical specialties:

(i) Anesthesiology;

(ii) Neurological surgery, or neuromusculoskeletal medicine;

(iii) Orthopedic surgery;

(iv) Physical medicine and rehabilitation;

(v) Radiology; or (vi) Any other board certified physician who had completed an ABMS subspecialty board in pain medicine or completed an ACGME accredited pain fellowship;

A recent graduate in a medical specialty listed in part 1. not yet eligible to apply for ABMS, AOA, or ABPS/AAPS board certification; provided, there is a practice relationship with a medical doctor or an osteopathic physician who meets the requirements of part 1.;
A licensee who is not board certified in one of the specialties listed in part 1., but is board certified in a different ABMS, AOA, or ABPS/AAPS specialty and has completed a post-graduate training program in interventional pain management approved by the board;
A licensee who serves as a clinical instructor in pain medicine at an accredited Tennessee medical training program; or 5. A licensee who has an active pain management practice in a clinic accredited in outpatient interdisciplinary pain rehabilitation by the Commission on Accreditation of Rehabilitation Facilities or any successor organizations.
This subparagraph (13)(a) shall not apply to a medical doctor, licensed pursuant to T.C.A. §§ 63-6-101 et seq., or an osteopathic physician, licensed pursuant to T.C.A. §§ 63-9-101 et seq., in the placement of medical devices used in the treatment of conditions not primarily related to pain.

(b) An advanced practice nurse or physician assistant shall only perform invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves of the spine or block of major peripheral nerves of the spine under the direct supervision of a medical doctor or an osteopathic physician who meets the qualifications of Rule 0720- 20-.06(12)(a)1. or 3. Direct supervision is defined as being physically present in the center at the time the invasive procedure is performed.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11- 216, 68-57-101, 68-57-102, 68-57-104, and 68-57-105.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Amendment filed September 10, 1991; effective October 25, 1991. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed June 16, 2003; effective August 30, 2003. Amendment filed February 23, 2006; effective May 9, 2006. Amendment filed February 23, 2007; effective May 9, 2007. Amendment filed February 22, 2010; effective May 23, 2010. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed March 27, 2015; effective June 25, 2015. Amendment filed October 20, 2015; effective January 18, 2016. Amendments filed July 18, 2016; effective October 16, 2016. Amendments filed January 7, 2019; to have become effective April 7, 2019. However, the Government Operations Committee filed a 60-day stay of the effective date of the rules; new effective date June 6, 2019. Transferred from chapter 1200-08- 10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed February 25, 2025; effective May 26, 2025.

Tenn. Comp. R. & Regs. 0720-20-.07 RESERVED

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-209, and 68-57-105.
Administrative History: Original rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 4, 2000; effective June 4, 2000. Amendment filed June 16, 2003; effective August 30, 2003. Amendment filed January 3, 2012; effective April 2, 2012. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.08 BUILDING STANDARDS

(1) An ASTC shall construct, arrange, and maintain the condition of the physical plant and the overall ASTC environment in such a manner that the safety and well-being of the patients are assured.

(3) The codes in effect at the time of submittal of plans and specifications, as defined by these rules, shall be the codes to be used throughout the project.

(4) The licensed contractor shall perform all new construction and renovations to ASTCs, other than minor alterations not affecting fire and life safety or functional issues, in accordance with the specific requirements of these regulations governing new construction in ASTCs, including the submission of phased construction plans and the final drawings and the specifications to each.

(5) No new ASTC shall be constructed, nor shall major alterations be made to an existing ASTC without prior written approval of the department, and unless in accordance with plans and specifications approved in advance by the department. Before any new ASTC is licensed or before any alteration or expansion of a licensed ASTC can be approved, the applicant must furnish two (2) complete sets of plans and specifications to the department, together with fees and other information as required. Plans and specifications for new construction and major renovations, other than minor alterations not affecting fire and life safety or functional issues, shall be prepared by or under the direction of a licensed architect and/or a licensed engineer and in accordance with the rules of the Board of Architectural and Engineering Examiners.

(a) The project architect or engineer shall forward two (2) sets of plans to the appropriate

(b) Review of plans does not eliminate responsibility of owner and/or architect to comply with all rules and regulations.

(8) Specifications shall supplement all drawings. They shall describe the characteristics of all materials, products and devices, unless fully described and indicated on the drawings.

Specification copies should be bound in an 8½ x 11 inch folder.

(9) Drawings and specifications shall be prepared for each of the following branches of work:

Architectural, Structural, Mechanical, Electrical and Sprinkler.

(10) Architectural drawings shall include where applicable:

(a) Plot plan(s) showing property lines, finish grade, location of existing and proposed structures, roadways, walks, utilities and parking areas;

(b) Floor plan(s) showing scale drawings of typical and special rooms, indicating all fixed and movable equipment and major items of furniture;

(d) The elevation of each facade;

(e) The typical sections throughout the building;

(f) The schedule of finishes;

(g) The schedule of doors and windows;

(h) Roof plans;

(i) Details and dimensions of elevator shaft(s), car platform(s), doors, pit(s), equipment in the machine room, and the rates of car travel must be indicated for elevators; and (j) Code analysis.

(11) Structural drawings shall include where applicable:

(a) Plans of foundations, floors, roofs and intermediate levels which show a complete design with sizes, sections and the relative location of the various members;

(b) Schedules of beams, girders and columns; and (c) Design live load values for wind, roof, floor, stairs, guard, handrails, and seismic.

(12) Mechanical drawings shall include where applicable:

(a) Specifications which show the complete heating, ventilating, fire protection, medical gas systems and air conditioning systems;

(b) Water supply, sewerage and HVAC piping systems;

(d) Heating, ventilating, HVAC piping, medical gas systems and air conditioning systems with all related piping and auxiliaries to provide a satisfactory installation;

(13) Electrical drawings shall include where applicable:

(a) A seal, certifying that all electrical work and equipment is in compliance with all applicable codes and that all materials are currently listed by recognized testing laboratories;

(d) Color coding to show all items on emergency power;

(14) The electrical drawings shall not include knob and tube wiring, shall not include electrical cords that have splices, and shall not show that the electrical system is overloaded.

(15) In all new facilities or renovations to existing electrical systems, the installation must be approved by an inspector or agency authorized by the State Fire Marshal.

(16) Sprinkler drawings shall include where applicable:

(a) Shop drawings, hydraulic calculations, and manufacturer cut sheets;

(17) The licensed contractor shall not install a system of water supply, plumbing, sewage, garbage or refuse disposal nor materially alter or extend any existing system until the architect or engineer submits complete plans and specifications for the installation, alteration or extension to the department demonstrating that all applicable codes have been met and the department has granted necessary approval.

(a) Before the ASTC is used, Tennessee Department of Environment and Conservation shall approve the water supply system.

(18) It shall be demonstrated through the submission of plans and specifications that in each ASTC a negative air pressure shall be maintained in the soiled utility area, toilet room, janitor’s closet, dishwashing and other such soiled spaces, and a positive air pressure shall be maintained in all clean areas including, but not limited to, clean linen rooms and clean utility rooms.

(20) In the event submitted materials do not appear to satisfactorily comply with 0720-20-.08(2), the department shall furnish a letter to the party submitting the plans which shall list the particular items in question and request further explanation and/or confirmation of necessary modifications.

(21) The licensed contractor shall execute all construction in accordance with the approved plans and specifications.

(22) If construction begins within one hundred eighty (180) days of the date of department approval, the department’s written notification of satisfactory review constitutes compliance with 0720-20-.08(2). This approval shall in no way permit and/or authorize any omission or deviation from the requirements of any restrictions, laws, regulations, ordinances, codes or rules of any responsible agency.

(24) The department requires the following alarms that shall be monitored twenty-four (24) hours per day:

(a) Fire alarms;

(b) Generators (if applicable); and (c) Medical gas alarms (if applicable).

(25) With the submission of plans the facility shall specify the evacuation capabilities of the patients as defined in the National Fire Protection Code (NFPA). This declaration will determine the design and construction requirements of the facility.

(26) Each ASTC shall ensure that an emergency keyed lock box is installed next to each bank of functioning elevators located on the main level. Such lock boxes shall be permanently mounted seventy-two inches (72”) from the floor to the center of the box, be operable by a universal key no matter where such box is located, and shall contain only fire service keys and drop keys to the appropriate elevators.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-216, and 68- 11-261.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Amendment filed July 3, 1984; effective August 1, 1984. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 4, 2000; effective June 4, 2000. Amendment filed February 18, 2003; effective May 4, 2003. Amendment filed June 16, 2003; effective August 30, 2003. Repeal and new rule filed September 9, 2005; effective November 23, 2005. Amendment filed February 23, 2007; effective May 9, 2007. Repeal and new rule filed December 20, 2011; effective March 19, 2012. Amendment filed January 21, 2016; effective April 20, 2016. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-202, 68-11-204, 68-11- 206, 68-11-208, 68-11-209, and 68-11-216.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed March 1, 2007; effective May 15, 2007. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.09 LIFE SAFETY

(1) Any ambulatory surgical treatment center which complies with the required applicable building and fire safety regulations at the time the board adopts new codes or regulations will, so long as such compliance is maintained (either with or without waivers of specific provisions), be considered to be in compliance with the requirements of the new codes or regulations.

(2) The ambulatory surgical treatment center shall provide fire protection by the elimination of fire hazards, by the installation of necessary fire fighting equipment and by the adoption of a written fire control plan. All fires which result in a response by the local fire department shall be reported to the department within seven (7) days. The report shall contain sufficient information to ascertain the nature and location of the fire, its probable cause and any injuries incurred by any person or persons as a result of the fire. Initial reports by the facility may omit the name(s) of patient(s) and parties involved, however, should the department find the identities of such persons to be necessary to an investigation, the facility shall provide such information.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-216.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Amendment filed July 3, 1984; effective August 1, 1984. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed June 16, 2003; effective August 30, 2003. Repeal and new rule filed September 9, 2005; effective November 23, 2005. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.10 INFECTIOUS AND HAZARDOUS WASTE

(1) Each ambulatory surgical treatment center must develop, maintain and implement written policies and procedures for the definition and handling of its infectious and hazardous wastes, these policies and procedures must comply with the standards of this section and all other applicable state and federal regulations.

(2) The following waste shall be considered to be infectious waste:

(a) Waste contaminated by patients who are isolated due to communicable disease, as provided in the U.S. Centers for Disease Control “Guidelines for Isolation Precautions in Hospitals”;

(b) Cultures and stocks of infectious agents including specimen cultures collected from medical and pathological laboratories, cultures and stocks of infectious agents from research and industrial laboratories, wastes from the production of biologicals, discarded live and attenuated vaccines, and culture dishes and devices used to transfer, inoculate, and mix cultures;

(d) Pathological waste, such as tissues, organs, body parts, and body fluids that are removed during surgery and autopsy;

(e) All discarded sharps (including but not limited to, hypodermic needles, syringes, pasteur pipettes, broken glass, scalpel blades) used in patient care or which have come into contact with infectious agents during use in medical, research, or industrial laboratories;

(f) Contaminated carcasses, body parts, and bedding of animals that were exposed to pathogens in research, in the production of biologicals, or in the in vivo testing of pharmaceuticals;

(g) Other waste determined to be infectious by the facility in its written policy.

(3) Infectious and hazardous waste must be segregated from other waste at the point of generation (i.e., the point at which the material becomes a waste) within the facility.

(4) Waste must be packaged in a manner that will protect waste handlers and the public from possible injury and disease that may result from exposure to the waste. Such packaging must provide for containment of the waste from the point of generation up to the point of proper treatment or disposal. Packaging must be selected and utilized for the type of waste the package will contain, how the waste will be treated and disposed, and how it will be handled and transported, prior to treatment and disposal.

(a) Contaminated sharps must be directly placed in leakproof, rigid, and puncture-resistant containers which must then be tightly sealed;

(d) Opaque packaging must be used for pathological waste.

(5) After packaging, waste must be handled and transported by methods ensuring containment and preserving the integrity of the packaging, including the use of secondary containment where necessary.

(a) Waste must not be compacted or ground (i.e., in a mechanical grinder) prior to treatment, except that pathological waste may be ground prior to disposal;

(b) Plastic bags of infectious waste must be transported by hand.

(b) Pathological waste must be promptly treated, disposed of, or placed into refrigerated storage.

(7) In the event of spills, ruptured packaging, or other incidents where there is a loss of containment of waste, the facility must ensure that proper actions are immediately taken to:

(a) Isolate the area from the public and all except essential personnel;

(b) To the extent practicable, repackage all spilled waste and contaminated debris in accordance with the requirements of paragraph (6) of this section; and (c) Sanitize all contaminated equipment and surfaces appropriately. Written policies and procedure must specify how this will be done.

(d) Complete incident report and maintain copy on file.

(8) Except as provided otherwise in this section a facility must treat or dispose of infectious waste by one or more of the methods specified in this part.

(a) A facility may treat infectious waste in an on-site sterilization or disinfection device, or in an incinerator or a steam sterilizer, which has been designed, constructed, operated and maintained so that infectious wastes treated in such a device are rendered noninfectious and is, if applicable, authorized for that purpose pursuant to current rules of the Department of Environment and Conservation. A valid permit or other written evidence of having complied with the Tennessee Air Pollution Control Regulations shall be available for review, if required. Each sterilizing or disinfection cycle must contain appropriate indicators to assure conditions were met for proper sterilization or disinfection of materials included in the cycle, and records kept. Proper operation of such devices must be verified at least monthly, and records of these monthly checks shall be available for review. Waste that contains toxic chemicals that would be volatilized by steam must not be treated in steam sterilizers. Infectious waste that has been rendered to a carbonized or mineralized ash shall be deemed non-infectious.

(b) The facility may discharge liquid or semi-liquid infectious waste to the collection sewerage system of a wastewater treatment facility which is subject to a permit pursuant to T.C.A. §§ 69-3-101 et seq., provided that such discharge is in accordance with any applicable terms of that permit and/or any applicable municipal sewer use requirements.

(c) Any health care facility accepting waste from another state must promptly notify the Department of Environment and Conservation, county and city public health agencies, and must strictly comply with all applicable local, state and federal regulations.

(11) All garbage, trash and other non-infectious wastes shall be stored and disposed of in a manner that must not permit the transmission of disease, create a nuisance, provide a breeding place for insects and rodents, or constitute a safety hazard. All containers for waste shall be water tight, be constructed of easily cleanable material and be kept on elevated platforms.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-216.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Amendment filed July 3, 1984; effective August 1, 1984. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed June 16, 2003; effective August 30, 2003. Amendment filed September 9, 2005; effective November 23, 2005. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.11 RECORDS AND REPORTS

(1) The Joint Annual Report of Ambulatory Surgical Treatment Centers shall be filed with the department. The forms are furnished and mailed to each ASTC by the department each year and the forms must be completed and returned to the department as required.

(2) The facility shall report information contained in the medical records of patients who have cancer or pre-cancerous or tumorous diseases as provided by existing regulations. These reports shall be sent to the Cancer Reporting System of the department on a quarterly schedule no later than six (6) months after the date of the diagnosis or treatment.

(3) The ASTC shall report to the department each patient case of communicable disease detected in the center. Repeated failure to report communicable diseases shall be cause for revocation of an ASTC’s license. The ASTC shall monitor outbreaks of communicable diseases in the nearby geographical area of the facility and inform the ASTC staff of these outbreaks in order for the employees to contact their personal physician for consultation regarding their vaccination status.

(4) The ASTC shall report all incidents of abuse, neglect, and misappropriation to the Department of Health in accordance with T.C.A. § 68-11-211.

(5) The ASTC shall report the following incidents to the Department of Health in accordance with T.C.A. § 68-11-211.

(a) Strike by staff at the facility;

(b) External disasters impacting the facility;

(c) Disruption of any service vital to the continued safe operation of the ASTC or to the health and safety of its patients and personnel; and (d) Fires at the ASTC that disrupt the provision of patient care services or cause harm to the patients or staff, or that are reported by the facility to any entity, including but not limited to a fire department charged with preventing fires.

(6) The ASTC shall retain legible copies of the following records and reports which shall be retained in the facility, shall be maintained in a single file, and shall be made available for inspection during normal business hours to any patient who requests to view them for thirtysix (36) months following their issuance:

(a) Local fire safety inspections;

(b) Local building code inspections, if any;

(d) Department licensure and fire safety inspections and surveys;

(e) Department quality assurance surveys, including follow-up visits, and certification inspections, if any;

(f) Federal Health Care Financing Administration surveys and inspections, if any;

(g) Orders of the Commissioner or Board, if any;

(h) Comptroller of the Treasury’s audit reports and finding, if any; and, (i) Maintenance records of all safety equipment.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-1-1004, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11- 209, 68-11-210, 68-11-211, 68-11-213, and 68-11-216.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Amendment filed September 10, 1991; effective October 25, 1991. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendments filed January 3, 2012; effective April 2, 2012. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.12 PATIENT RIGHTS

(1) Each patient has at least the following rights:

(a) To privacy in treatment and personal care;

(b) To be free from mental and physical abuse. Should this right be violated, the facility must notify the department within five (5) business days and the Tennessee Department of Human Services, Adult Protective Services immediately as required by T.C.A. §§ 71-6-101 et seq;

(c) To refuse treatment. The patient must be informed of the consequences of that decision, the refusal and its reason must be reported to the physician and documented in the medical record;

(e) To have their records kept confidential and private. Written consent by the patient must be obtained prior to release of information except to persons authorized by law. If the patient lacks capacity, written consent is required from the patient’s health care decision-maker. The ambulatory surgical treatment center must have policies to govern access and duplication of the patient’s record;

(f) To have appropriate assessment and management of pain; and (g) To be involved in the decision-making of all aspects of their care.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-216.
Administrative History: Original rule filed July 22, 1977; effective August 22, 1977. Repeal and new rule filed June 30, 1992; effective August 14, 1992. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendment filed September 9, 2005; effective November 23, 2005. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.13 POLICIES AND PROCEDURES FOR HEALTH CARE DECISION-MAKING

(1) Pursuant to this rule, each ambulatory surgical treatment center shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a patient who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from individual patients. An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.

(8) An advance directive may include the individual’s nomination of a court-appointed guardian.

(10) No health care provider or institution shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care.

(12) A patient having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.

(13) A patient having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke.

(15) An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.

(16) Surrogates.

(a) An adult or emancipated minor may designate any individual to act as surrogate by personally informing the supervising health care provider. The designation may be oral or written.

(b) A surrogate may make a health care decision for a patient who is an adult or emancipated minor if and only if:

The patient has been determined by the designated physician to lack capacity, and 2. No agent or guardian has been appointed, or 3. The agent or guardian is not reasonably available.

(e) Consideration may be, but need not be, given in order of descending preference for service as a surrogate to:

The patient’s spouse, unless legally separated;
The patient’s adult child;
The patient’s parent;
The patient’s adult sibling;
Any other adult relative of the patient; or 6. Any other adult who satisfies the requirements of 0720-20-.13(16)(d).

(f) No person who is the subject of a protective order or other court order that directs that person to avoid contact with the patient shall be eligible to serve as the patient’s surrogate.

(g) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:

Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the patient or in accordance with the patient’s best interests;
The proposed surrogate’s regular contact with the patient prior to and during the incapacitating illness;
The proposed surrogate’s demonstrated care and concern;
The proposed surrogate’s availability to visit the patient during his or her illness; and 5. The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.

(h) If the patient lacks capacity and none of the individuals eligible to act as a surrogate under 0720-20-.13(16)(c) through 0720-20-.13(16)(g) is reasonably available, the designated physician may make health care decisions for the patient after the designated physician either:

Consults with and obtains the recommendations of a facility’s ethics mechanism or standing committee in the facility that evaluates health care issues; or 2. Obtains concurrence from a second physician who is not directly involved in the patient’s health care, does not serve in a capacity of decision-making, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.

(j) A surrogate shall make a health care decision in accordance with the patient’s individual instructions, if any, and other wishes to the extent known to the surrogate.

(l) Except as provided in 0720-20-.13(16)(m):

Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution nor an employee of an operator of a health care institution may be designated as a surrogate; and 2. A health care provider or employee of a health care provider may not act as a surrogate if the health care provider becomes the patient’s treating health care provider.

(m) An employee of the treating health care provider or an employee of an operator of a health care institution may be designated as a surrogate if:

The employee so designated is a relative of the patient by blood, marriage, or adoption; and 2. The other requirements of this section are satisfied.

(17) Guardian.

(a) A guardian shall comply with the patient’s individual instructions and may not revoke the patient’s advance directive absent a court order to the contrary.

(b) Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.

(19) Except as provided in 0720-20-.13(20) through 0720-20-.13(22), a health care provider or institution providing care to a patient shall:

(20) A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.

(21) A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:

(23) A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 0720-20-.13(20) through 0720-20-.13(22) shall:

(a) Promptly so inform the patient, if possible, and any person then authorized to make health care decisions for the patient;

(b) Provide continuing care to the patient until a transfer can be effected or until the determination has been made that transfer cannot be effected;

(a) Complying with a health care decision of a person apparently having authority to make a health care decision for a patient, including a decision to withhold or withdraw health care;

(26) An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.

(27) A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for such identification made in good faith.

(28) A copy of a written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.

(30) Physician Orders for Scope of Treatment (POST).

(a) Physician Orders for Scope of Treatment (POST) may be issued by a physician for a patient with whom the physician has a bona fide physician-patient relationship, but only:

With the informed consent of the patient;
If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or 3. If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available, if the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

No physician, who has a bona fide physician-patient relationship with the patient, is present and available for discussion with the patient (or if the patient is a minor or is otherwise incapable of making an informed decision, with the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act);
Such authority to issue is contained in the physician assistant’s, nurse practitioner’s or clinical nurse specialist’s protocols;
Either:

(i) The patient is a resident of a nursing home licensed under Ti tle 68 or an ICF/MR facility licensed under Title 33 and is in the process of being discharged from the nursing home or transferred to another facility at the time the POST is being issued; or (ii) The patient is a hospital patient and is in the process of being discharged from the hospital or transferred to another facility at the time the POST is being issued; and 4. Either:

(i) With the informed consent of the patient;

(d) A POST issued in accordance with this section shall remain valid and in effect until revoked. In accordance with this rule and applicable regulations, qualified emergency medical services personnel; and licensed health care practitioners in any facility, program, or organization operated or licensed by the Board for Licensing Health Care Facilities, the Department of Mental Health and Substance Abuse Services, or the Department of Intellectual and Developmental Disabilities, or operated, licensed, or owned by another state agency, shall follow a POST that is available to such persons in a form approved by the Board for Licensing Health Care Facilities.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-224, and 68- 11-1801 through 68-11-1815.
Administrative History: Original rule filed June 22, 1992; effective August 6, 1992. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed April 28, 2003; effective July 12, 2003. Repeal and new rule filed September 9, 2005; effective November 23, 2005. Amendment filed February 7, 2007; effective April 23, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-20-.14 DISASTER PREPAREDNESS

(1) The administration of every facility shall have in effect and available for all supervisory personnel and staff, written copies of the following required disaster plans for the protection of all persons in the event of fire and other emergencies for evacuation to areas of refuge and/or evacuation from the building. A detailed log with staff signatures of training received shall be maintained. All employees shall be trained annually as required in the following plans and shall be kept informed with respect to their duties under the plans. A copy of the plans and the specific emergency numbers related to that type of disaster shall be readily available at all times. Each of the following plans shall be exercised annually:

(a) Fire Safety Procedures Plan shall include:

Minor fires;
Major fires;
Fighting the fire;
Evacuation procedures;
Staff functions.

(b) Tornado/Severe Weather Procedures Plan shall include:

Staff duties;
Evacuation procedures.

Staff duties;
Evacuation procedures;
Safety procedures following the flood.

(d) Earthquake Disaster Procedures Plan:

Staff duties;
Evacuation procedures;
Safety procedures;
Emergency services.

(2) Emergency Planning with Local Government Authorities.

(a) All facilities shall establish and maintain communications with the county Emergency Management Agency. This includes the provision of the information and procedures that are needed for the local comprehensive emergency plan. The facility shall cooperate, to the extent possible, in area disaster drills and local emergency situations.

(b) Each facility shall conduct both the physical facility and community emergency drills as required in these regulations, even if the local Emergency Management Agency is unable to participate.

(3) The emergency power system shall:

(a) Use either propane, gasoline or diesel fuel. The generator shall be designed to meet the facility’s HVAC and essential needs and shall have a minimum of twenty-four (24) hours of fuel designed to operate at its rated load. The fuel quantity shall be based on its expected or known connected load consumption during power interruptions.

(b) Automatically transfer within ten (10) seconds in ASTC’s conducting invasive surgical procedures.

(c) Be inspected monthly and exercised at the actual load and operating temperature conditions and not on dual power for at least thirty (30) minutes each month, including automatic and manual transfer of equipment. A log shall be maintained for all inspections and tests and kept on file for a minimum of three (3) years. The facility shall have trained staff familiar with the generator’s operation.

(d) Emergency generators are not required if the facility does not utilize anesthesia that renders the patient incapable of self preservation. However, the facility shall have an emergency power source able to produce adequate power to run required equipment for a minimum of two (2) hours.

(4) Emergency electrical power connections shall be through a switch which shall automatically transfer the circuits to the emergency power source in case of power failure. (It is recognized that some equipment may not sustain automatic transfer and provisions will have to be made to manually change these items from a non-emergency powered outlet to an emergency powered outlet or other power source.)

(5) In the event of natural disaster or electrical power failure, no new surgical procedures shall be begun, and surgical procedures in progress shall be brought to conclusion as soon as possible.

History

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed November 22, 1996; effective August 27, 1997. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed June 16, 2003; effective August 30, 2003. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.

Tenn. Comp. R. & Regs. 0720-20-.15 APPENDIX I

(1) Physician Orders for Scope of Treatment (POST) Form.

A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED

Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”)

Patient’s Last Name This is a Physician Order Sheet based on the medical conditions and wishes of the person identified at right (“patient” ). Any section not completed indicates full treatment for that section. When need occurs, first follow these orders, then contact physician.

First Name/Middle Initial Date of Birth

Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Section B Check One Box Only MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.  Comfort Measures Only. Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.  Limited Additional Interventions. In addition to care described in Comfort Measures Only above, use medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. Treatment Plan: basic medical treatments.  Full Treatment. In addition to care described in Comfort Measures Only and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including in the intensive care unit.

Other Instructions:

Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify)

The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other)

Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge)

MD/NP/CNS/PA Phone Number:

Name (print) Signature Relationship (write “self” if patient)

Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel.

Photocopies/faxes of signed POST forms are legal and valid.

Using POST Any incomplete section of POST implies full treatment for that section.

No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.”

Oral fluids and nutrition must always be offered if medically feasible.

IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”

A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.

Reviewing POST This POST should be reviewed if:

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.

(2) Advance Directive for Health Care Form.

ADVANCE DIRECTIVE FOR HEALTH CARE*

(Tennessee)

Instructions: Parts 1 and 2 may be used together or independently. Please mark out/void any unused part(s).

Part 5, Block A or Block B must be completed for all uses.

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.

Indicate Your Wishes for Treatment: If my quality of life becomes unacceptable to me (as indicated by one or more of the conditions marked “no” above) and my condition is irreversible (that is, it will not improve), I direct that medically appropriate treatment be provided as follows. By marking “yes” below, I have indicated treatment I want. By marking “no” below, I have indicated treatment I do not want.   Yes No CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it has stopped. Usually this involves electric shock, chest compressions, and breathing assistance.   Yes No Life Support/Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys, and other organs to continue to work.   Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal Yes No with a new condition but will not help the main illness.   Yes No Tube feeding/IV fluids: Use of tubes to deliver food and water to a patient’s stomach or use of IV fluids into a vein, which would include artificially delivered nutrition and hydration.

Part 3 Other instructions, such as hospice care, burial arrangements, etc.:

(Attach additional pages if necessary)

Part 5 Your signature must either be witnessed by two competent adults (“Block A”) or by a notary public (“Block B”).

Signature: _______________________________________ Date: ____________________ (Patient)

Block A Neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.

Witnesses:

I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form.

Signature of witness number 2 Block B You may choose to have your signature witnessed by a notary public instead of the witnesses described in Block A.

STATE OF TENNESSEE

COUNTY OF

My commission expires:

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1805.
Administrative History: Original rule filed February 16, 2007; effective May 2, 2007. Repeal and new rule filed August 28, 2012; effective November 26, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed February 8, 2017; effective May 9, 2017. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-21 Standards for Homes for the Aged (Transferred from 1200-08-11)

Tenn. Comp. R. & Regs. 0720-21-.01 DEFINITIONS

(1) Abuse. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) Activities of Daily Living (ADL’s). Those personal functional activities which indicate an individual’s independence in eating, dressing, personal hygiene, bathing, toileting, and moving from one place to another.

(3) Adult. An individual who has capacity and is at least 18 years of age.

(5) Aged. A person who is fifty-five (55) years of age or older.

(6) Agent. An individual designated in an advance directive for health care to make a health care decision for the individual granting the power.

(7) Ambulatory Resident. A resident who is physically and mentally capable under emergency conditions of finding a way to safety without physical assistance from another person. An ambulatory resident may use a cane, wheelchair or other supportive device and may require verbal prompting.

(8) Board. The Tennessee Board for Licensing Health Care Facilities.

(9) Capacity. An individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. These regulations do not affect the right of a resident to make health care decisions while having the capacity to do so. A resident shall be presumed to have capacity to make a health care decision, to give or revoke an advance directive, and to designate or disqualify a surrogate.

Any person who challenges the capacity of a resident shall have the burden of proving lack of capacity.

(10) Cardiopulmonary Resuscitation (CPR). The administering of any means or device to restore or support cardiopulmonary function in a resident, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilators or respirations, defibrillation, the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a resident where cardiac or respiratory arrest has occurred or is believed to be imminent.

(11) Commissioner. The Commissioner of the Tennessee Department of Health or his or her authorized representative.

(12) Department. The Tennessee Department of Health.

(13) Designated Physician. A physician designated by an individual or the individual’s agent, guardian, or surrogate, to have primary responsibility for the individual’s health care or, in the absence of designation or if the designated physician is not reasonably available, a physician who undertakes such responsibility.

(14) Do-Not-Resuscitate Order (DNR). A written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(15) Emancipated Minor. Any minor who is or has been married or has by court order or otherwise been freed from the care, custody and control of the minor’s parents.

(16) Emergency. Any situation or condition which presents an imminent danger of death or serious physical or mental harm to residents.

(17) Emergency Responder. A paid or volunteer firefighter, law enforcement officer, or other public safety official or volunteer acting within the scope of his or her proper function under law or rendering emergency care at the scene of an emergency.

(18) Evacuation Capability. The ability to either evacuate the building or move to a point of safety.

(19) Guardian. A judicially appointed guardian of conservator having authority to make a health care decision.

(20) Hazardous Waste. Materials whose handling, use, storage, and disposal are governed by local, state, or federal regulations.

(21) Health Care. Any care, treatment, service or procedure to maintain, diagnose, treat, or otherwise affect an individual’s physical or mental condition, and includes medical care as defined in T.C.A. § 32-11-103(5).

(22) Health Care Decision. Consent, refusal or consent or withdrawal of consent to health care.

(23) Health Care Decision-Maker. In the case of a resident who lacks capacity, the resident’s health care decision-maker is one of the following: the resident’s health care agent as specified in an advance directive, the resident’s court-appointed guardian or conservator with healthcare decision-making authority, the resident’s surrogate as determined pursuant to

Rule 0720-21-.12 or T.C.A. § 33-3-220, the designated physician pursuant to these rules or in the case of a minor child, the person having custody or legal guardianship.

(24) Health Care Institution. A health care institution as defined in T.C.A. § 68-11-1602.

(25) Health Care Provider A person who si licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care in the ordinary course of business or practice of a profession.

(26) Holding Out to the Public. Advertising or soliciting the public through the use of personal, telephone, mail or other forms of communication to provide information about services provided by the facility.

(27) Home for the Aged. A home represented and held out to the general public as a home which accepts primarily aged persons for relatively permanent, domiciliary care with primarily being defined as 51% or more of the population of the home for the aged. It provides room, board and personal services to four (4) or more nonrelated persons. The term home includes any building or part thereof which provides services as defined in these rules.

(28) Home for the Aged Resident. A person who is ambulatory and who requires permanent, domiciliary care but who will be transferred to a licensed hospital, licensed nursing home or licensed assisted care living facility when health care services are needed which must be provided in such other facilities.

(29) Incompetent. A resident who has been adjudicated incompetent by a court of competent jurisdiction and has not been restored to legal capacity.

(30) Individual Instruction. An individual’s direction concerning a health care decision for the individual.

(32) Licensee. The person or entity to whom the license is issued. The licensee is held responsible for compliance with all rules and regulations.

(33) Life Threatening or Serious Injury. Injury requiring the patient to undergo significant additional diagnostic or treatment measures.

(34) Medically Inappropriate Treatment Resuscitation efforts that cannot be expected either to restore cardiac or respiratory function to the resident or other medical or surgical treatments to achieve the expressed goals of the informed resident. In the case of the incompetent resident, the resident’s representative expresses the goals of the resident.

(35) N.F.P.A. The National Fire Protection Association.

(36) Misappropriation of Patient/Resident Property. The deliberate misplacement, exploitation or wrongful, temporary or permanent use of an individual’s belongings or money without the individual’s consent.

(37) Neglect. The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; however, the withholding of authorization for or provision of medical care to any terminally ill person who has executed an irrevocable living will in accordance with the Tennessee Right to Natural Death Law, or other applicable state law, if the provision of such medical care would conflict with the terms of the living will, shall not be deemed “neglect” for purposes of these rules.

(38) Person. An individual, corporation, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency or instrumentality, or any other legal or commercial entity.

(39) Personal Services. Those services that are rendered to residents who need supervision or assistance in activities of daily living. Personal services must include protective care of the resident, responsibility for the safety of the resident when in the facility, daily awareness of the resident’s whereabouts and the ability and readiness to intervene if crises arise. Personal services do not include nursing or medical care.

(40) Personally Informing. A communication by any effective means from the resident directly to a health care provider.

(41) Physician Assistant. A person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(42) Physician Orders for Scope of Treatment or POST. Written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(43) Power of Attorney for Health Care. The designation of an agent to make health care decisions for the individual granting the power under T.C.A. Title 34, Chapter 6, Part 2.

(44) Qualified Emergency Medical Service Personnel. Includes, but shall not be limited to, emergency services personnel providers, or entities acting within the usual course of their professions, and other emergency responders.

(45) Reasonably Available. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the resident’s health care needs. Such availability shall include, but not limited to, availability by telephone.

(46) Responsible Attendant. The person designated by the licensee who remains awake to provide personal services to the residents. In the absence of the licensee, the responsible attendant is responsible for ensuring the home complies with all rules and regulations.

(47) Secured Unit. A facility or distinct part of a facility where the residents are intentionally denied egress by any means.

(48) Shall or Must. Compliance is mandatory.

(49) State. A state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States.

(50) Supervising Heath Care Provider. The designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual’s health care.

(51) Surrogate. An individual, other that a resident’s agent or guardian, authorized to make a health care decision for the resident.

(52) Treating Health Care Provider. A health care provider who at the time is directly or indirectly involved in providing health care to the resident.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11- 207, 68-11-209, 68-11-210, 68-11-211, 68-11-213, 68-11-216, 68-11-224, and 68-11-1802.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Amendment filed August 16, 1988; effective September 30, 1988. Amendment filed January 30, 1992; effective March 15, 1992. Amendment filed December 7, 1993; effective February 20, 1994. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed April 28, 2003; effective July 12, 2003. Amendment filed September 8, 2006; effective November 22, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendment filed February 23, 2007; effective May 9, 2007. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.02 LICENSING PROCEDURES

(2) In order to make application for a license:

(a) The applicant shall submit an application on a form prepared by the department.

(b) Each applicant for a license shall pay an annual license fee based on the number of beds as follows:

Less than 6 beds $ 390.00 2. 6 to 24 beds, inclusive $ 1,040.00 3. 25 to 49 beds, inclusive $ 1,300.00 4. 50 to 74 beds, inclusive $ 1,560.00 5. 75 to 99 beds, inclusive $ 1,820.00 6. 100 to 124 beds, inclusive $ 2,080.00 7. 125 to 149 beds, inclusive $ 2,340.00 8. 150 to 174 beds, inclusive $ 2,600.00 9. 175 to 199 beds, inclusive $ 2,860.00 For homes for the aged of two hundred (200) beds or more the fee shall be two thousand eight hundred and sixty dollars ($2,860.00) plus two hundred dollars ($200.00) for each twenty-five (25) beds or fraction thereof in excess of one hundred ninety-nine (199) beds. The fee shall be submitted with the application or renewal and is not refundable.

(c) The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the department.

Residents shall not be admitted to the home until a license has been issued. Applicants shall not hold themselves out to the public as being a home for the aged until the license has been issued. A license shall not be issued until the facility is in substantial compliance with these rules.

(d) The applicant must prove the ability to meet the financial needs of the facility.

(f) The applicant shall allow the residential home for the aged to be inspected by a Department surveyor. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action to the Board that must be accepted by the Board.

Once the deficiencies have been corrected, then the Board shall consider the application for licensure.

(a) For the purpose of licensing, the licensee of a home for the aged has the ultimate responsibility for the operation of the facility, including the final authority to make or control operational decisions and legal responsibility for the business management. A change of ownership occurs whenever this ultimate legal authority for the responsibility of the home’s operation is transferred.

(b) A change of ownership occurs whenever there is a change in the legal structure by which the home is owned and operated.

Transfer of the facility’s legal title;
Lease of the facility’s operations;
Dissolution of any partnership that owns, or owns a controlling interest in, the facility;
One partnership is replaced by another through the removal, addition or substitution of a partner;
Removal of the general partner or general partners, if the facility is owned by a limited partnership;
Merger of a facility owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are canceled;
The consolidation of a corporate facility owner with one or more corporations; or 8. Transfers between levels of government.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors or board of trustees;
Two (2) or more corporations merge and the originally-licensed corporation survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government; or 5. Corporate stock transfers or sales, even when a controlling interest.

(4) Renewal.

(a) In order to renew a license, each residential home for the aged shall submit to periodic inspections by Department surveyors for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action and shall remedy the deficiencies. In addition, each licensee shall submit a renewal form approved by the board and applicable renewal fee prior to the expiration date of the license.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late; provided that the late penalty shall not exceed twice the renewal feee.

A completed application for licensure; and 2. The license fee provided in Rule 0720-21-.02(2)(b).

(d) Upon reapplication, the licensee shall submit to an inspection of the facility by Department of Health surveyors.

(5) A license shall be issued only for the location designated and the licensee named in the application. If a home moves to a new location, a new license will be required before residents are admitted. A licensee who plans to relocate must contact the department to inspect the new building prior to relocation.

(6) Any admission in excess of the licensed bed capacity is prohibited.

(7) A separate license shall be required for each home for the aged when more than one home is operated under the same management or ownership.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-206(a)(5) [effective January 1, 2009], 68-11-209, 68-11-209(a)(1), 68-11-210, and 68-11-216 and Chapter 846 of the Public Acts of 2008, § 1.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Amendment filed August 16, 1988; effective September 30, 1988. Amendment filed January 30, 1992; effective March 15, 1992. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Amendment filed November 19, 2003; effective February 2, 2004. Amendment filed September 8, 2006; effective November 22, 2006. Amendment filed January 19, 2007; effective April 4, 2007. Public necessity rules filed April 29, 2009; effective through October 11, 2009. Emergency rules filed October 9, 2009; effective through April 7, 2010. Amendments filed September 24, 2009; effective December 23, 2009. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed March 21, 2018; to have been effective June 19, 2018. However, on May 24, 2018, the Government Operations Committee filed a 5-day stay; new effective date June 24, 2018. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.03 DISCIPLINARY PROCEDURES

(1) The board may suspend or revoke a license for:

(a) Violation of state statutes;

(b) Violation of the rules as set forth in this chapter;

(d) Conduct or practice found by the board to be detrimental to the health, safety, or welfare of the residents of the home; and (e) Failure to renew the license.

(2) The board may consider all factors which it deems relevant, including but not limited to the following, when determining sanctions:

(a) The degree of sanctions necessary to ensure immediate and continued compliance;

(b) The character and degree of impact of the violation on the health, safety and welfare of the residents in the home;

(c) The conduct of the home in taking all feasible steps or procedures necessary or appropriate to comply or correct the violation; and (d) Any prior violations by the home of statutes, rules or orders of the Commissioner or the board.

(3) Failure to timely submit an acceptable plan of correction shall subject the home’s license to possible disciplinary action.

(4) The Commissioner may suspend the admission of any new residents to the home, pending a prompt hearing before the board or an administrative law judge, when the conditions are or are likely to be detrimental to the health, safety or welfare of the residents.

(5) Whenever the Commissioner suspends the admission of any new residents to the home because of the detrimental conditions found, the home shall post a copy of the Commissioner’s Order upon the public entrance doors of the facility and prominently display it there for so long as it remains effective and until the Commissioner or the board removes the suspension and restores the facility’s ability to admit new residents. During the suspension, the home shall inform any person who inquires about the admission of a new resident of the provisions of the order and make a copy of the order available for the inquirer’s inspection.

(6) Following a contested case hearing, the board may find a facility’s license subject to suspension or revocation and may then immediately impose any sanction authorized by law.

(7) The board may recommend the appointment of one or more special monitors to serve such term and to be present in the home for such hours each week as the board finds necessary and appropriate, as specified in its order. The home shall reimburse the reasonable fees and expenses of any special monitor so appointed by the board.

(8) Any licensee or applicant for a license, aggrieved by a decision or action of the department or board, pursuant to this rule, may request a hearing before the board. The proceedings and judicial review of the board’s decision shall be in accordance with the Uniform Procedures Act, T.C.A. §§ 4-5-101, et seq.

(9) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to Rule

Tenn. Comp. R. & Regs. 0720-21-.04 ADMINISTRATION

(1) The licensee shall be at least eighteen (18) years of age, of reputable and responsible character, able to comply with these rules, and must maintain financial resources and income sufficient to provide for the needs of the residents, including their room, board and personal services.

(2) The licensee must designate in writing a capable and responsible person to act on administrative matters and to exercise all the powers and responsibilities of the licensee as set forth in this chapter in the absence of the licensee.

(3) Each home must have an administrator who shall be certified by the board, unless the administrator is currently licensed in Tennessee as a nursing home administrator pursuant to T.C.A. §§ 63-16-101, et seq.

(4) An applicant for certification as a home for the aged administrator shall meet the following requirements:

(a) Must be at least eighteen (18) years of age and a high school graduate or the holder of a general equivalency diploma.

(b) Must not have been convicted of a criminal offense involving the abuse or intentional neglect of an elderly or vulnerable individual.

(c) Must submit an application, on a form provided by the department, and a fee of one hundred eighty dollars ($180) prior to issuance or renewal of a certificate. All certificates shall expire biennially on June 30, thereafter.

(d) Biennial renewal of certification is required. The renewal application and fee of one hundred eighty dollars ($180) shall be submitted with written proof of attendance, during the period prior to renewal, of at least twenty-four (24) classroom hours of continuing education courses. The initial biennial re-certification expiration date of home for the aged administrator candidates who receive their initial administrator certification between the dates of January 1 and June 30 of any year will be extended to two (2) years plus the additional months remaining in the fiscal year. The extension applies only to the first biennial certification period for any such administrator and may only be applied when there are less than six (6) months remaining in the state fiscal year.

(e) Continuing education.

The twenty-four (24) classroom hours of required continuing education courses shall include instruction in the following:

(i) State rules and regulations for homes for the aged;

(ii) Health care management;

(iii) Nutrition and food service;

(iv) Financial management; and (v) Healthy lifestyles.

All educational courses must be approved by the board. Courses sponsored by the National Association of Residential Care Facilities and the National Association of Nursing Home Administrators are deemed approved by the board.
In order to obtain board approval for educational courses, a copy of the course curriculum must be submitted to the board for approval prior to attending the course.
Proof of administrator certification course attendance shall be submitted to the department upon completion of the course.

(5) Infection Control. A home for the aged shall have an annual influenza vaccination program which shall include at least:

(a) The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The home for the aged will encourage all staff and independent practitioners to obtain an influenza vaccination;

Flu vaccination, 2. Non-vaccine control measures, and 3. The diagnosis, transmission, and potential impact of influenza;

(6) Each home for the aged shall:

(a) Have an identified responsible attendant and a sufficient number of employees to meet the needs of the residents. The responsible attendant must be at least eighteen (18) years of age and able to comply with these rules.

(b) Have a responsible awake attendant on the premises at all times.

(c) Maintain documentation of the checks of the “Registry of Persons who have Abused or Intentionally Neglected Elderly or Vulnerable Individuals” prior to hiring any employee.

(d) Have a written statement of policies and procedures outlining the responsibilities of the licensee to the resident and any obligation of the resident to the facility.

(e) Post whether they have liability insurance, the identity of their primary insurance carrier, and if self-insured, the corporate entity responsible for payment of any claims. It shall be posted on a sign no smaller than eleven inches (11”) in width and seventeen inches (17”) in height and displayed at the main public entrance.

(f) Keep a written up-to-date log of all residents and produce the log for the local fire department in the event of an emergency.

(g) Maintain written policies and procedures informing the resident of his/her rights and how to register grievances and complaints.

(h) Not allow an owner, responsible attendant, employee or representative thereof to act as a court-appointed guardian, trustee, or conservator for any resident of the facility or any of such resident’s property or funds, except as provided by Rule 0720-21-.10.

(i) Cooperate in the department’s inspections including allowing entry at any hour and providing all required records.

(j) Develop and follow a written policy, plan, procedure, technique or system regarding a subject whenever these rules require that a licensee develop such a plan. A residential home which violates a required policy also violates the rule establishing the requirements.

(k) Not 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, Adult Protective Services, the Comptroller of the State Treasury or the Long Term Care Ombudsman Program. A home 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.

(l) Allow pets in the home only when they are not a nuisance or do not pose a health hazard.

(m) Comply with all local laws, rules or ordinances, and with this chapter.

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

(7) No occupant or employee who has a reportable communicable disease, as stipulated by the department, is permitted to reside or work in a home unless the home has a written protocol approved by the department.

(8) 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;

Postings of (a) and (b) shall be on a sign no smaller than eleven inches (11”) in width and seventeen inches (17”) in height.

(9) “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.

(10) Residents of the facility are exempt from the smoking prohibition. The resident smoking practices shall be governed by the policies and procedures established by the facility. Smoke from such areas shall not infiltrate into areas where smoking is prohibited.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-17-1803, 39-17-1804, 39-17-1805, 68-11-201, 68-11-202, 68- 11-204, 68-11-206, 68-11-207, 68-11-209, 68-11-213, 68-11-257, 68-11-268, and 71-6-121.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Amendment filed August 16, 1988; effective September 30, 1988. Repeal and new rule filed July 27, 2000; effective October 10, 2000. 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. Amendments filed July 18, 2016; effective October 16, 2016. Administrative correction made to URL on September 18, 2018. Emergency rules filed May 29, 2020; effective through November 25, 2020. Emergency rules expired effective November 26, 2020, and the rules reverted to their previous statuses. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.05 ADMISSIONS, DISCHARGES AND TRANSFERS

(1) Only residents whose needs can be met by the facility within its licensure category shall be admitted.

(2) Prior to the admission of a resident or prior to the execution of a contract for the care of a resident (whichever occurs first), each home for the aged shall disclose in writing to the resident or to the resident’s guardian, conservator or representative, if any, whether the facility has liability insurance and the identity of the primary insurance carrier. If the facility is self-insured, their statement shall reflect that fact and indicate the corporate entity responsible for payment of any claims.

(3) The home shall:

(a) Be able to identify at the time of admission and during continued stay those residents whose needs for services are consistent with these rules and those residents who should be transferred to a higher level of care.

(b) Have a written admission agreement that includes a procedure for handling the transfer or discharge of residents and that does not violate the residents’ rights under the law or these rules.

(d) Give a thirty (30) day notice to all residents before any changes in fees can be made.

(e) Ensure that residents see a physician for acute illness or injury and are transferred in accordance with any physician’s orders.

(f) The facility shall document evidence of annual vaccination against influenza for each resident, in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control most recent to the time of vaccine, unless such vaccination is medically contraindicated or the resident has refused the vaccine. Influenza vaccination for all residents accepting the vaccine shall be completed by November 30 of each year or within ten (10) days of the vaccine becoming available. Residents admitted after this date during the flu season and up to February 1, shall as medically appropriate, receive influenza vaccination prior to or on admission unless refused by the resident.

The facility shall document evidence of vaccination against pneumococcal disease for all residents who are sixty-five (65) years of age or older, in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control at the time of vaccination, unless such vaccination is medically contraindicated or the resident has refused offer of the vaccine. The facility shall provide or arrange the pneumococcal vaccination of residents who have not received this immunization prior to or on admission unless the resident refuses offer of the vaccine.

(g) Provide to the resident at the time of admission a copy of the Resident’s Rights for the resident’s review and signature. A signed copy must be provided to the resident at the time of admission.

(4) Individuals who require professional medical or nursing observation and/or care on a continual or daily basis shall not be admitted to or retained in the home, with the following exception: When an individual who resides in the facility develops a temporary illness, injury, or disability requiring short-term medical or nursing care, the individual may remain in the home if such care can be safely and appropriately given in that setting and is provided by licensed professionals.

(5) Individuals who are usually, typically or customarily incapable of self-administering medications or who require medications that are usually, typically or customarily not selfadministered shall not be admitted to or retained in the home unless provided by a home care organization or physician.

(6) Residents who require professional medical or nursing observation and/or care on a continual or daily basis or who require more technical medical or nursing care than the personnel and the home can lawfully offer on a short-term basis as described in paragraph (3), shall be transferred to a licensed hospital, nursing home or assisted care living facility.

(7) A home for the aged shall not admit or retain residents who pose a clearly documented danger to themselves or to other residents in the home. Persons in the early stages of Alzheimer’s Disease and related disorders may be admitted only after it has been determined by an interdisciplinary team that care can appropriately and safely be given in the facility. The interdisciplinary team must review such persons at least quarterly as to the appropriateness of placement in the facility. The interdisciplinary team shall consist of, at a minimum, a physician experienced in the treatment of Alzheimer’s Disease and related disorders, a social worker, a registered nurse, and a family member (or patient care advocate).

(8) Residents shall be capable of evacuating the home in accordance with Chapter 22 of the Life Safety Code. Residents who cannot evacuate within thirteen (13) minutes shall not be admitted or retained in the facility.

(9) The licensee shall not admit or retain a resident who requires physical or chemical restraint.

(10) Facilities utilizing secured units must be able to annually provide survey staff with twelve (12) months of the following performance information specific to the secured unit and its residents:

(a) Documentation that each secured resident has been evaluated by the interdisciplinary team prior to admittance to the unit;

(b) Ongoing and up-to-date documentation of quarterly review by each resident’s interdisciplinary team as to the appropriateness of placement in the secured unit;

(d) A current listing of all unusual incidents and/or complications on the unit;

(e) An up-to-date staffing pattern and staff ratios for the unit recorded on a daily basis. The staffing pattern must ensure that there is a minimum of one (1) attendant, awake, on duty and physically located on the unit twenty-four (24) hours per day, seven (7) days per week at all times;

(f) A formulated calendar of daily group activities scheduled including a resident attendance record for the previous three (3) months;

(g) An up-to-date listing of any incidences of decubitus and/or nosocomial infections, including resident identifiers; and (h) Documentation showing that 100% of the staff working on the unit receives and has received annual in-service training which shall include but not be limited to the following subject areas:

Basic facts about the causes, progression and management of Alzheimer’s Disease and related disorders;
Dealing with dysfunctional behavior and catastrophic reactions in the residents;
Identifying and alleviating safety risks to the residents;
Providing assistance in the activities of daily living for the residents; and 5. Communicating with families and other persons interested in the residents.

(11) The facility shall ensure that no person on the grounds of race, color, national origin, or handicap, will be excluded from participation in, be denied benefits of, or otherwise subjected to discrimination in the provision of any care or service of the facility. The facility shall protect the civil rights of residents under the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

(12) Any residential facility licensed by the board of licensing health care facilities shall upon admission provide to each resident the division of adult protective services’ statewide toll-free number: 888-277-8366.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-210, 68-11- 257, and 71-6-121.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Amendment filed August 16, 1988; effective September 30, 1988. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Amendment filed April 20, 2006; effective July 4, 2006. Amendment filed February 23, 2007; effective May 9, 2007. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.06 PERSONAL SERVICES

(1) Personal services must include protective care of the resident, responsibility for the safety of the resident when in the facility, daily awareness of the resident’s whereabouts and the ability and readiness to intervene if crises arise. Personal services do not include nursing or medical care. Personal services must be provided by employees of the home.

(2) Medications shall be self-administered. If the home chooses to employ a currently licensed nurse, medications may be administered by the nurse.

(3) Assistance in reading labels, opening bottles, reminding residents of their medication, observing the resident while taking medication and checking the self-administered dose against the dosage shown on the prescription are permissible in the self-administration of medications.

(4) All medications shall be stored so that no resident can obtain another resident’s medication.

(5) Residents shall be provided assistance, if needed, in personal care such as bathing, grooming and dressing.

(6) The home for the aged shall provide laundry arrangements for linens for the home and for residents’ clothing.

(7) Appropriate storage areas for soiled linen and residents’ clothing shall be provided.

(8) Clean linen shall be maintained in sufficient quantity to provide for the needs of the residents.

Linens shall be changed whenever necessary.

(9) There must be a designated person responsible for the food service, including the purchasing of adequate food supplies and the maintenance of sanitary practices in food storage, preparation and distribution. Sufficient arrangements or employees shall be maintained to cook and serve the food.

(10) Residents shall be provided at least three (3) meals per day. The meals shall constitute an acceptable diet. There shall be no more than fourteen (14) hours between the evening and morning meals. All food served to the residents shall be of good quality and variety, sufficient quantity, attractive and at safe temperatures. Prepared foods shall be kept hot (140°F or above) or cold (41°F or less). The food must be adapted to the habits, preferences, needs and physical abilities of the residents.

(11) Sufficient food provision capabilities and dining space shall be provided.

(12) A forty-eight (48) hour supply of food shall be maintained and properly stored at all times.

(13) Appropriate equipment and utensils for cooking and serving food shall be provided in sufficient quantity to serve all residents and must be in good repair.

(14) The kitchen shall be maintained in a clean and sanitary condition.

(15) Equipment, utensils and dishes shall be washed after each use.

(16) A suitable and comfortable furnished area shall be provided in the facility for activities and family visits. Furnishings shall include a current calendar and a functioning television set, radio and clock.

(17) The facility shall provide current newspapers, magazines or other reading materials.

(18) The home must have a telephone accessible to all residents to make and receive personal telephone calls twenty-four (24) hours per day.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, and 68-11-204.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Amendment filed August 16, 1988; effective September 30, 1988. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.07 BUILDING STANDARDS

(1) An RHA shall construct, arrange, and maintain the condition of the physical plant and the overall RHA environment in such a manner that the safety and well-being of the patients are assured.

(3) The codes in effect at the time of submittal of plans and specifications, as defined by these rules, shall be the codes to be used throughout the project.

(4) The licensed contractor shall perform all new construction and renovations to RHAs, other than minor alterations not affecting fire and life safety or functional issues, in accordance with the specific requirements of these regulations governing new construction in RHAs, including the submission of phased construction plans and the final drawings and the specifications to each.

(5) No new RHA shall be constructed, nor shall major alterations be made to an existing RHA without prior written approval of the department, and unless in accordance with plans and specifications approved in advance by the department. Before any new RHA is licensed or before any alteration or expansion of a licensed RHA can be approved, the applicant must furnish two (2) complete sets of plans and specifications to the department, together with fees and other information as required. Plans and specifications for new construction and major renovations, other than minor alterations not affecting fire and life safety or functional issues, shall be prepared by or under the direction of a licensed architect and/or a licensed engineer and in accordance with the rules of the Board of Architectural and Engineering Examiners.

(a) The project architect or engineer shall forward two (2) sets of plans to the appropriate

(b) Review of plans does not eliminate responsibility of owner and/or architect to comply with all rules and regulations.

(8) Specifications shall supplement all drawings. They shall describe the characteristics of all materials, products and devices, unless fully described and indicated on the drawings.

Specification copies should be bound in an 8½ x 11 inch folder.

(9) Drawings and specifications shall be prepared for each of the following branches of work:

Architectural, Structural, Mechanical, Electrical and Sprinkler.

(10) Architectural drawings shall include where applicable:

(a) Plot plan(s) showing property lines, finish grade, location of existing and proposed structures, roadways, walks, utilities and parking areas;

(b) Floor plan(s) showing scale drawings of typical and special rooms, indicating all fixed and movable equipment and major items of furniture;

(d) The elevation of each facade;

(e) The typical sections throughout the building;

(f) The schedule of finishes;

(g) The schedule of doors and windows;

(h) Roof plans;

(i) Details and dimensions of elevator shaft(s), car platform(s), doors, pit(s), equipment in the machine room, and the rates of car travel must be indicated for elevators; and (j) Code analysis.

(11) Structural drawings shall include where applicable:

(a) Plans of foundations, floors, roofs and intermediate levels which show a complete design with sizes, sections and the relative location of the various members;

(b) Schedules of beams, girders and columns; and (c) Design live load values for wind, roof, floor, stairs, guard, handrails, and seismic.

(12) Mechanical drawings shall include where applicable:

(a) Specifications which show the complete heating, ventilating, fire protection, medical gas systems and air conditioning systems;

(b) Water supply, sewerage and HVAC piping systems;

(d) Heating, ventilating, HVAC piping, medical gas systems and air conditioning systems with all related piping and auxiliaries to provide a satisfactory installation;

(13) Electrical drawings shall include where applicable:

(a) A seal, certifying that all electrical work and equipment is in compliance with all applicable codes and that all materials are currently listed by recognized testing laboratories;

(d) Color coding to show all items on emergency power;

(14) The electrical drawings shall not include knob and tube wiring, shall not include electrical cords that have splices, and shall not show that the electrical system is overloaded.

(15) In all new facilities or renovations to existing electrical systems, the installation must be approved by an inspector or agency authorized by the State Fire Marshal.

(16) Sprinkler drawings shall include where applicable:

(a) Shop drawings, hydraulic calculations, and manufacturer cut sheets;

(17) The licensed contractor shall not install a system of water supply, plumbing, sewage, garbage or refuse disposal nor materially alter or extend any existing system until the architect or engineer submits complete plans and specifications for the installation, alteration or extension to the department demonstrating that all applicable codes have been met and the department has granted necessary approval.

(a) Before the RHA is used, Tennessee Department of Environment and Conservation shall approve the water supply system.

(18) It shall be demonstrated through the submission of plans and specifications that in each RHA:

(b) A minimum of eighty (80) square feet of bedroom space must be provided each resident. No bedroom shall have more than two (2) beds. Privacy screens or curtains must be provided and used when required by the resident;

(c) Living room and dining areas capable of accommodating all residents shall be provided, with a minimum of fifteen (15) square feet per resident per dining area; and (d) Each toilet, lavatory, bath or shower shall serve no more than six (6) persons. Grab bars and non-slip surfaces shall be installed at tubs and showers.

(20) In the event submitted materials do not appear to satisfactorily comply with 0720-21-.07(2), the department shall furnish a letter to the party submitting the plans which shall list the particular items in question and request further explanation and/or confirmation of necessary modifications.

(21) The licensed contractor shall execute all construction in accordance with the approved plans and specifications.

(22) If construction begins within one hundred eighty (180) days of the date of department approval, the department’s written notification of satisfactory review constitutes compliance with 0720-21-.07(2). This approval shall in no way permit and/or authorize any omission or deviation from the requirements of any restrictions, laws, regulations, ordinances, codes or rules of any responsible agency.

(24) The department requires the following alarms that shall be monitored twenty-four (24) hours per day:

(a) Fire alarms; and (b) Generators (if applicable).

(26) Each RHA shall ensure that an emergency keyed lock box is installed next to each bank of functioning elevators located on the main level. Such lock boxes shall be permanently mounted seventy-two inches (72”) from the floor to the center of the box, be operable by a universal key no matter where such box is located, and shall contain only fire service keys and drop keys to the appropriate elevators.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-261.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Amendment filed August 16, 1988; effective September 30, 1988. Amendment filed January 30, 1992; effective March 15, 1992. Amendment filed December 7, 1993; effective February 20, 1994. Amendment filed January 6, 1995; effective March 22, 1995. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Amendment filed February 18, 2003; effective May 4, 2003. Amendment filed September 6, 2006; effective November 22, 2006. Amendment filed February 23, 2007; effective May 9, 2007. Repeal and new rule filed December 20, 2011; effective March 19, 2012. Amendment filed January 21, 2016; effective April 20, 2016. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.08 LIFE SAFETY

(1) Any residential home for the aged which complies with the required applicable building and fire safety regulations at the time the board adopts new codes or regulations will, so long as such compliance is maintained (either with or without waivers of specific provisions), be considered to be in compliance with the requirements of the new codes or regulations.

(2) The residential home for the aged shall provide fire protection by the elimination of fire hazards, by the installation of necessary fire fighting equipment and by the adoption of a written fire control plan. Fire drills shall be held at least quarterly for each work shift for residential home for the aged personnel in each separate building. There shall be one fire drill per quarter during sleeping hours. There shall be a written report documenting the evaluation of each drill and the action recommended or taken for any deficiencies found.

Records which document and evaluate these drills must be maintained for at least three (3) years. All fires which result in a response by the local fire department shall be reported to the department within seven (7) days. The report shall contain sufficient information to ascertain the nature and location of the fire, its probable cause and any injuries incurred by any person or persons as a result of the fire. Initial reports by the facility may omit the name(s) of resident(s) and parties involved, however, should the department find the identities of such persons to be necessary to an investigation, the facility shall provide such information.

(3) Residents who cannot evacuate within thirteen (13) minutes may be retained in the facility so long as such residents are retained in designated areas in accordance with of the Standard Building Code and the National Fire Protection Code (NFPA).

(4) Each resident’s room shall have a door that opens directly to the outside or a corridor which leads directly to an exit door and must always be capable of being unlocked by the resident.

(5) Doors to residents’ rooms shall not be louvered.

(6) Corridors shall be lighted at all times, to a minimum of one foot candle.

(7) General lighting and night lighting shall be provided for each resident. Night lighting shall be equipped with emergency power.

(8) Corridors and exit doors shall be kept clear of equipment, furniture and other obstacles at all times. There shall be a clear passage at all times from the exit doors to a safe area.

(9) Combustible finishes and furnishings shall not be used.

(10) Open flame and portable space heaters shall not be permitted in the home. Cooking appliances other than microwave ovens shall not be allowed in sleeping rooms.

(11) All heaters shall be guarded and spaced to prevent ignition of combustible material and accidental burns. The guard shall not have a surface temperature greater than 120° F.

(12) Fireplaces and/or fireplace inserts may be used only if provided with guards or screens which are secured in place. Fireplaces and chimneys shall be inspected and cleaned annually and verified documentation shall be maintained.

(13) All electrical equipment shall be maintained in good repair and in safe operating condition.

(14) Electrical cords shall not be run under rugs or carpets.

(15) The electrical systems shall not be overloaded. Power strips must be equipped with circuit breakers. Extension cords shall not be used.

(16) All facilities must have electrically operated smoke detectors with battery back-up power operating at all times in, at least, sleeping rooms, day rooms, corridors, laundry room, and any other hazardous areas.

(17) Fire extinguishers, complying with NFPA 10, shall be provided and mounted so they are accessible to all residents in the kitchen, laundries and at all exits. Extinguishers in the kitchen and laundries shall be a minimum of 2-A: 10-BC and an extinguisher with a rating of 20-A shall be adjacent to every hazardous area. The minimum travel distance shall not exceed fifty (50) feet between the extinguishers.

(18) Smoking and smoking materials shall be permitted only in designated areas under supervision. Ashtrays must be provided wherever smoking is permitted. Smoking in bed is prohibited. The facility shall have written policies and procedures for smoking within the facility which shall designate a room or rooms to be used exclusively for residents who smoke. The designated smoking room or rooms shall not be the dining room or activity room.

(19) No smoking signs shall be posted in areas where oxygen is used or stored.

(20) Trash and other combustible waste shall not be allowed to accumulate within and around the home and shall be stored in appropriate containers with tight-fitting lids. Resident rooms shall be furnished with a UL approved trash container.

(21) All safety equipment shall be maintained in good repair and in a safe operating condition.

(22) Janitorial supplies shall not be stored in the kitchen, food storage area, dining area or resident accessible areas.

(23) Flammable liquids shall be stored in approved containers and stored away from the living areas of the facility.

(24) Floor and dryer vents shall be cleaned as frequently as needed to prevent accumulation of lint, soil and dirt.

(25) Emergency telephone numbers must be posted near a telephone accessible to the residents.

(26) The physical environment shall be maintained in a safe, clean and sanitary manner.

(a) Any condition on the facility site conducive to the harboring or breeding of insects, rodents or other vermin shall be prohibited. Chemical substances of a poisonous nature used to control or eliminate vermin shall be properly identified. Such substances shall not be stored with or near food or medications.

(b) The building shall not become overcrowded with a combination of the facility’s residents and other occupants.

(c) Each resident bedroom shall contain a chair, bed, mattress, springs, linens, chest of drawers and wardrobe or closet space, either provided by the facility or by the resident if the resident prefers. All furniture provided by the resident must meet NFPA. All resident’s clothing must be maintained in good repair and suitable for the use of elderly persons.

(d) The building and its heating, cooling, plumbing and electrical systems shall be maintained in good repair and a clean condition at all times.

(e) Temperatures in residents’ rooms and common areas shall not be less than 65°F and no more than 85°F.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Amendment filed August 16, 1988; effective September 30, 1988. Amendment filed January 39, 1992; effective March 15, 1992. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Amendment filed September 6, 2006; effective November 6, 2006. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.09 INFECTIOUS AND HAZARDOUS WASTE

(1) Each home for the aged must develop, maintain and implement written policies and procedures for the definition and handling of its infectious waste. These policies and procedures must comply with the standards of this section.

(2) The following waste shall be considered to be infectious waste:

(a) Waste contaminated by residents who are isolated due to communicable disease, as provided in the U.S. Centers for Disease Control “Guidelines for Isolation Precautions in Hospitals”;

(b) Cultures and stocks of infectious agents including specimen cultures collected from medical and pathological laboratories, cultures and stocks of infectious agents from research and industrial laboratories, wastes from the production of biologicals, discarded live and attenuated vaccines, and culture dishes and devices used to transfer, inoculate, and mix cultures;

(d) Pathological waste, such as tissues, organs, body parts, and body fluids that are removed during surgery and autopsy;

(e) All discarded sharps (including but not limited to, hypodermic needles, syringes, pasteur pipettes, broken glass, scalpel blades) used in resident care or which have come into contact with infectious agents during use in medical, research, or industrial laboratories;

(f) Other waste determined to be infectious by the facility in its written policy.

(3) Infectious and hazardous waste must be segregated from other waste at the point of generation (i.e., the point at which the material becomes a waste) within the facility.

(4) Waste must be packaged in a manner that will protect waste handlers and the public from possible injury and disease that may result from exposure to the waste. Such packaging must provide for containment of the waste from the point of generation up to the point of proper treatment or disposal. Packaging must be selected and utilized for the type of waste the packages will contain, how the waste will be treated and disposed, and how it will be handled and transported, prior to treatment and disposal.

(a) Contaminated sharps must be directly placed in leakproof, rigid, and puncture-resistant containers which must be tightly sealed.

(b) Whether disposable or reusable, all containers, bags, and boxes used for containment and disposal of infectious waste must be conspicuously identified. Packages containing infectious waste which pose additional hazards (including but not limited to, chemical, radiologicals) must also be conspicuously identified to clearly indicate those additional hazards.

(d) Opaque packaging must be used for pathological waste.

(5) After packaging, waste must be handled and transported by methods ensuring containment and preservation of the integrity of the packaging, including the use of secondary containment where necessary. Plastic bags of infectious waste must be transported by hand.

(b) Pathological waste must be promptly treated, disposed of, or placed into refrigerated storage.

(7) In the event of spills, ruptured packaging, or other incidents where there is a loss of containment of waste, the facility must ensure that proper actions are immediately taken to:

(a) Isolate the area from the public and non-essential personnel;

(b) To the extent practicable, repackage all spilled waste and contaminated debris in accordance with the requirements of paragraph (6) of this section;

(c) Sanitize all contaminated equipment and surfaces according to written policies and procedures which specify how this will be done appropriately; and, (d) Complete an incident report and maintain a copy on file.

(8) Except as provided otherwise in this rule, a facility must treat or dispose of infectious waste by one or more of the methods specified in this paragraph.

(a) A facility may treat infectious waste in an on-site sterilization or disinfection device, or in an incinerator or a steam sterilizer, which has been designed, constructed, operated and maintained so that infectious waste treated in such a device is rendered noninfectious and is, if applicable, authorized for that purpose pursuant to current rules of the Department of Environment and Conservation. A valid permit or other written evidence of having complied with the Tennessee Air Pollution Control Regulations shall be available for review, if required. Each sterilizing or disinfecting cycle must contain appropriate indicators to assure that conditions were met for proper sterilization or disinfection or materials included in the cycle, and appropriate records kept. Proper operation of such devices must be verified at least monthly, and records of the monthly verifications shall be available for review. Waste that contains toxic chemicals that would be violatilized by steam must not be treated in steam sterilizers. Infectious waste that has been rendered to carbonized or mineralized ash shall be deemed noninfectious. Unless otherwise hazardous and subject to the hazardous waste management requirements of the current rules of the Department of Environment and Conservation, such ash shall be disposable as a (non-hazardous) solid waste under current rules of the Department of Environment and Conservation.

(b) A facility may discharge liquid or semi-liquid infectious waste to the collection sewerage system of a wastewater treatment facility which is subject to a permit pursuant to T.C.A. §§ 69-3-101, et seq., provided that such discharge is in accordance with any applicable terms of that permit and/or any applicable municipal sewer use requirements.

(9) The facility may have waste transported off-site for storage, treatment, or disposal. Such arrangements must be detailed in a written contract, available for review. If such off-site location is located within Tennessee, the facility must ensure that it has all necessary State and local approvals, and such approvals shall be available for review. If the off-site location is within another state, the facility must notify in writing all public health agencies with jurisdiction that the location is being used for management of the facility’s waste. Waste shipped off-site must be packaged in accordance with applicable federal and state requirements. Waste transported to a sanitary landfill in this state must meet the requirements of current rules of the Department of Environment and Conservation.

(10) Human anatomical remains which are transferred to a mortician for cremation or burial shall be exempt from the requirements of this rule.

(11) All garbage, trash and other non-infectious waste shall be stored and disposed of in a manner that must not permit the transmission of disease, create a nuisance, provide a breeding place for insects and rodents, or constitute a safety hazard. All containers for waste shall be water tight, constructed of easily cleanable material, and shall be kept on elevated platforms.

History

Authority: T.C.A. §§ 4-5-202 through 4-5-206, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.10 RECORDS AND REPORTS

(1) An individual resident file shall be maintained for each resident in the home. Personal information shall be confidential and shall not be disclosed, except to the resident, the department and others with written authorization from the resident. These files shall be retained for one (1) year after the resident is transferred or discharged. The resident file shall include:

(a) Name, Social Security Number, veteran status and number, marital status, age, sex, previous address and any health insurance provider and number, including Medicare and Medicaid numbers;

(b) Name, address and telephone number of next of kin, legal guardian and any other person identified by the resident to contact on his/her behalf;

(d) Date of admission, transfer, discharge and any new forwarding address;

(e) Name and address of the resident’s preferred physician, hospital, pharmacist, assisted care living facility and nursing home, and any other instructions from the resident to be followed in case of emergency;

(f) Record of all monies and other valuables entrusted to the home for safekeeping, with appropriate updates;

(g) Health information including all current prescriptions, major changes in resident’s habits or health status, results of physician’s visits, and any health care instructions; and (h) A copy of the admission agreement signed and dated by the resident.

(2) The RHA shall report all incidents of abuse, neglect, and misappropriation to the Department of Health in accordance with T.C.A. § 68-11-211.

(3) The RHA shall report the following incidents to the Department of Health in accordance with T.C.A. § 68-11-211.

(a) Strike by staff at the facility;

(b) External disasters impacting the facility;

(c) Disruption of any service vital to the continued safe operation of the RHA or to the health and safety of its residents and personnel; and (d) Fires at the RHA that disrupt the provision of resident services or cause harm to the residents or staff, or that are reported by the facility to any entity, including but not limited to a fire department charged with preventing fires.

(4) Legible copies of the following records and reports shall be retained in the facility, shall be maintained in a single file, and shall be made available for inspection during normal business hours for thirty-six (36) months following their issuance. Each resident and each person assuming any financial responsibility for a resident must be fully informed, before admission, of their existence in the home and given the opportunity to inspect the file before entering into any monetary agreement with the facility.

(a) Local fire safety inspections;

(b) Local building code inspections, if any;

(d) Orders of the Commissioner or Board, if any; and (e) Maintenance records of all safety equipment.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11-209, 68-11- 210, 68-11-211, and 68-11-213.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Amendment filed February 26, 1985; effective March 28, 1985. Amendment filed August 16, 1988; effective September 30, 1988. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed December 23, 2009; effective March 23, 2010. Amendments filed January 3, 2012; effective April 2, 2012. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.11 RESIDENT RIGHTS

Each resident has at least the following rights:

(1) To privacy in treatment and personal care;

(2) To be free from mental and physical abuse. Should this right be violated, the facility must notify the department within five (5) working days. The Tennessee Department of Human Services, Adult Protective Services shall be notified immediately as required in T.C.A. § 71-6- 103;

(3) To refuse treatment. The resident must be informed of the consequences of that decision, and the refusal and its reason must be reported to the physician and documented in the resident’s record;

(4) To have his or her file kept confidential and private. Written consent by the resident must be obtained prior to release of information except to persons authorized by law;

(5) To be fully informed of the Resident’s Rights, of any policies and procedures governing resident conduct, any services available in the home and the schedule of all fees for all services;

(6) To participate in drawing up the terms of the admission agreement, including providing for the resident’s preferences for physician care, hospitalization, assisted living facility care, nursing home care, acquisition of medication, emergency plans and funeral arrangements;

(7) To be given thirty (30) days written notice prior to transfer or discharge, except when ordered by any physician because a higher level of care is required;

(8) To voice grievances and recommend changes in policies and services of the home with freedom from restraint, interference, coercion, discrimination or reprisal. The resident shall be informed of procedures for registering complaints confidentially and to voice grievances;

(9) To manage his or her personal financial affairs, including the right to keep and spend his or her own money. If the resident requests assistance from the home in managing his or her personal financial affairs, the request must be in writing and may be terminated by the resident at any time. The home must separate such monies from the home’s operating funds and all other deposits or expenditures, submit a written accounting to the resident at least quarterly, and immediately return the balance upon transfer or discharge. A current copy of this report shall be maintained in the resident’s file maintained by the licensee;

(10) To be treated with consideration, respect and full recognition of his or her dignity and individuality;

(11) To be accorded privacy for sleeping and for storage space for personal belongings;

(12) To have free access to day rooms, dining and other group living or common areas at reasonable hours and to come and go from the home, unless such access infringes upon the rights of other residents or unless the resident is admitted to the secured unit;

(13) To wear his or her own clothes, to keep and use his or her own toilet articles and personal possessions;

(14) To send and receive unopened mail;

(15) To associate and communicate privately with persons of his or her choice, including receiving visitors at reasonable hours;

(16) To participate or to refuse to participate in community activities, including cultural, educational, religious, community service, vocational and recreational activities;

(17) To not be required to perform services for the home. The resident and licensee may mutually agree, in writing, for the resident to perform certain activities or services as part of the fee for his or her stay; and, (18) To execute, modify, or rescind a Living Will.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Amendment filed August 16, 1988; effective September 30, 1988. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.12 POLICIES AND PROCEDURES FOR HEALTH CARE DECISION-MAKING

(1) Pursuant to this rule, each home for the aged shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a resident who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from individual residents. An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.

(8) An advance directive may include the individual’s nomination of a court-appointed guardian.

(10) No health care provider or institution shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care.

(12) A resident having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.

(13) A resident having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke.

(15) An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.

(16) Surrogates.

(a) An adult or emancipated minor may designate any individual to act as surrogate by personally informing the supervising health care provider. The designation may be oral or written.

(b) A surrogate may make a health care decision for a resident who is an adult or emancipated minor if and only if:

The resident has been determined by the designated physician to lack capacity, and 2. No agent or guardian has been appointed, or 3. The agent or guardian is not reasonably available.

(e) Consideration may be, but need not be, be given in order of descending preference for service as a surrogate to:

The resident’s spouse, unless legally separated;
The resident’s adult child;
The resident’s parent;
The resident’s adult sibling;
Any other adult relative of the resident; or 6. Any other adult who satisfies the requirements of 0720-21-.12(16)(d).

(f) No person who is the subject of a protective order or other court order that directs that person to avoid contact with the resident shall be eligible to serve as the resident’s surrogate.

(g) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:

Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the resident or in accordance with the resident’s best interests;
The proposed surrogate’s regular contact with the resident prior to and during the incapacitating illness;
The proposed surrogate’s demonstrated care and concern;
The proposed surrogate’s availability to visit the resident during his or her illness; and 5. The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.

(h) If the resident lacks capacity and none of the individuals eligible to act as a surrogate under 0720-21-.12(16)(c) through 0720-21-.12(16)(g) is reasonably available, the designated physician may make health care decisions for the resident after the designated physician either:

Consults with and obtains the recommendations of a facility’s ethics mechanism or standing committee in the facility that evaluates health care issues; or 2. Obtains concurrence from a second physician who is not directly involved in the resident’s health care, does not serve in a capacity of decision-making, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.

(j) A surrogate shall make a health care decision in accordance with the resident’s individual instructions, if any, and other wishes to the extent known to the surrogate.

(l) Except as provided in 0720-21-.12(16)(m):

Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution nor an employee of an operator of a health care institution may be designated as a surrogate; and 2. A health care provider or employee of a health care provider may not act as a surrogate if the health care provider becomes the resident’s treating health care provider.

(m) An employee of the treating health care provider or an employee of an operator of a health care institution may be designated as a surrogate if:

The employee so designated is a relative of the resident by blood, marriage, or adoption; and 2. The other requirements of this section are satisfied.

(17) Guardian.

(a) A guardian shall comply with the resident’s individual instructions and may not revoke the resident’s advance directive absent a court order to the contrary.

(b) Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.

(19) Except as provided in 0720-21-.12(20) through 0720-21-.12(22), a health care provider or institution providing care to a resident shall:

(20) A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.

(21) A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:

(23) A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 0720-21-.12(20) through 0720-21-.12(22) shall:

(a) Promptly so inform the resident, if possible, and any person then authorized to make health care decisions for the resident;

(b) Provide continuing care to the resident until a transfer can be effected or until the determination has been made that transfer cannot be effected;

(a) Complying with a health care decision of a person apparently having authority to make a health care decision for a resident, including a decision to withhold or withdraw health care;

(26) An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.

(27) A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for such identification made in good faith.

(28) A copy of a written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.

(30) Physician Orders for Scope of Treatment (POST).

(a) Physician Orders for Scope of Treatment (POST) may be issued by a physician for a patient with whom the physician has a bona fide physician-patient relationship, but only:

With the informed consent of the patient;
If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or 3. If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available, if the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

No physician, who has a bona fide physician-patient relationship with the patient, is present and available for discussion with the patient (or if the patient is a minor or is otherwise incapable of making an informed decision, with the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act);
Such authority to issue is contained in the physician assistant’s, nurse practitioner’s or clinical nurse specialist’s protocols;
Either:

(i) With the informed consent of the patient;

(d) A POST issued in accordance with this section shall remain valid and in effect until revoked. In accordance with this rule and applicable regulations, qualified emergency medical services personnel; and licensed health care practitioners in any facility, program, or organization operated or licensed by the Board for Licensing Health Care Facilities, the Department of Mental Health and Substance Abuse Services, or the Department of Intellectual and Developmental Disabilities, or operated, licensed, or owned by another state agency, shall follow a POST that is available to such persons in a form approved by the Board for Licensing Health Care Facilities.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-224, and 68- 11-1801 through 68-11-1815.
Administrative History: Original rule filed June 22, 1992; effective August 6, 1992. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Amendment filed April 28, 2003; effective July 12, 2003. Amendment filed September 8, 2006; effective November 22, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Amendments filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200- 08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-21-.13 DISASTER PREPAREDNESS

(a) Fire Safety Procedures Plan shall include:

Minor fires;
Major fires;
Fighting the fire;
Evacuation procedures; and 5. Staff functions.

(b) Tornado/Severe Weather Procedures Plan shall include:

Staff duties; and 2. Evacuation procedures.

Staff duties;
Search team, searching the premises;
Notification of authorities;
Location of suspicious objects; and 5. Evacuation procedures.

(d) Flood Procedure Plan, if applicable:

Staff duties;
Evacuation procedures; and 3. Safety procedures following the flood.

(e) Severe Cold Weather and Severe Hot Weather Procedure Plans:

Staff duties;
Equipment failures;
Evacuation procedures; and 4. Emergency food service.

(f) Earthquake Disaster Procedures Plan:

Staff duties;
Evacuation procedures;
Safety procedures; and 4. Emergency services.

(2) Emergency Planning with Local Government Authorities.

(b) Each facility shall conduct both the physical facility and community emergency drills as required in these regulations, even if the local Emergency Management Agency is unable to participate.

(3) For facilities which elect to have an emergency generator, the generator shall be designed to meet the facility’s HVAC and essential needs and shall have a minimum of twenty-four (24) hours of fuel designed to operate at its rated load. This requirement shall be coordinated with the Disaster Preparedness Plan or with local resources.

(a) All generators shall be exercised for thirty (30) minutes each month under full load, including automatic and manual transfer of equipment.

(b) The emergency generator shall be operated at the existing connected load and not on dual power, and a monthly log shall be maintained by the facility. The facility shall have trained staff familiar with the generator’s operation.

History

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.

Tenn. Comp. R. & Regs. 0720-21-.14 APPENDIX I

(1) Physician Orders for Scope of Treatment (POST) Form.

A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED

Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”)

Patient’s Last Name First Name/Middle Initial Date of Birth

Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Section B Check One Box Only MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.  Comfort Measures Only. Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.  Limited Additional Interventions. In addition to care described in Comfort Measures Only above, use medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. Treatment Plan: Basic medical treatments.  Full Treatment. In addition to care described in Comfort Measures Only and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including in the intensive care unit.

Other Instructions:

Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify)

The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other)

Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge)

MD/NP/CNS/PA Phone Number:

Name (print) Signature Relationship (write “self” if patient)

Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel.

Photocopies/faxes of signed POST forms are legal and valid.

Using POST Any incomplete section of POST implies full treatment for that section.

No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.”

Oral fluids and nutrition must always be offered if medically feasible.

IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”

A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.

Reviewing POST This POST should be reviewed if:

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.

(2) Advance Directive for Health Care Form.

ADVANCE DIRECTIVE FOR HEALTH CARE*

(Tennessee)

Instructions: Parts 1 and 2 may be used together or independently. Please mark out/void any unused part(s).

Part 5, Block A or Block B must be completed for all uses.

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.

Part 3 Other instructions, such as hospice care, burial arrangements, etc.:

(Attach additional pages if necessary)

Part 5 Your signature must either be witnessed by two competent adults (“Block A”) or by a notary public (“Block B”).

Signature: _______________________________________ Date: ____________________ (Patient)

Block A Neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.

Witnesses:

I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form.

Signature of witness number 2 Block B You may choose to have your signature witnessed by a notary public instead of the witnesses described in Block A.

STATE OF TENNESSEE

COUNTY OF

My commission expires:

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1801 through 68-11-815.
Administrative History: Original rule filed February 16, 2007; effective May 2, 2007. Repeal and new rule filed August 28, 2012; effective November 26, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed February 8, 2017; effective May 9, 2017. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-202, 68-11-204, 68-11- 206, 68-11-207, 68-11-208, 68-11-209, and 68-11-221.
Administrative History: Original rule filed June 21, 1979; effective August 6, 1979. Amendment filed August 16, 1988; effective September 30, 1988. Repeal and new rule filed July 27, 2000; effective October 10, 2000. Amendment filed March 1, 2007; effective May 15, 2007. Transferred from chapter 1200-08-11 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-22 Trauma Centers (Transferred from 1200-08-12)

Tenn. Comp. R. & Regs. 0720-22-.01 PREAMBLE

The Tennessee Health Facilities Commission is empowered to adopt such regulations and standards pertaining to the operation and management of hospitals as are necessary for the public interest. On November 24, 1982, the EMS Advisory Council prepared and presented to the Board for Licensing Health Care Facilities (“Board”) a recommendation that a formal review of the issues involved in the designation of trauma centers for the State of Tennessee be explored. Subsequently, on February 17, 1983, the Board requested a presentation regarding the City of Memphis Hospital Trauma Center in an effort to further define the need for action on trauma center designation and/or categorization. As a result of that presentation, the Board created a Task Force to evaluate and recommend criteria concerning the development of trauma systems and the operation of trauma centers in the state. Trauma Rules were transferred from chapter 1200-08-12 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

The process of Designation and Reverification is voluntary on the part of hospitals in the state. It is meant to identify those hospitals that make a commitment to provide a given level of care of the acutely injured patient. Knowledge of statewide trauma care capabilities and the use of trauma triage protocols will enable providers to make timely decisions, promote appropriate utilization of the trauma care delivery system, and ultimately save lives.

History

Authority: T.C.A. §§ 68-11-201, 68-11-202, and 68-11-203(f)(1).
Administrative History: Original rule filed September 18, 1985; effective October 18, 1985. Repeal and new rule filed December 5, 2011; effective March 4, 2012. Repeal and new rules filed August 6, 2019; effective November 4, 2019. Transferred from chapter 1200-08-12 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed February 5, 2026; effective May 6, 2026.

Tenn. Comp. R. & Regs. 0720-22-.02 DEFINITIONS

(1) “AAAM” means Association for the Advancement of Automotive Medicine.

(2) “ACS-COT” means American College of Surgeons Committee on Trauma.

(3) “Advisory Council” means the Tennessee Trauma Care Advisory Council.

(4) “ATLS” means Advanced Trauma Life Support.

(5) “CAISS” means Certified Abbreviated Injury Scale Specialists.

(6) “CE” means Continuing Education.

(7) “CME” means Continuing Medical Education.

(8) “Commission” means the Health Facilities Commissioner.

(9) “Comprehensive Regional Pediatric Center (CRPC)” means a facility that shall be capable of providing comprehensive specialized pediatric medical and surgical care to all acutely ill and injured children. The center shall be responsible for serving as a regional referral center for the specialized care of pediatric patients or in special circumstances provide safe and timely transfer of children to other resources for specialized care. Rules and regulations governing CRPCs are delineated in Chapter 0720-31.

(10) “CT” means Computed Tomography.

(11) “D” means desired and is strongly recommended for patient care at the corresponding facility level, but not required for designation.

(12) “Data” means the original information contained on the report required by the regulations, including, but not limited to, both identifying and non-identifying information.

(13) “Deficiencies” means components of the site review that do not meet designation criteria.

(14) “DIED” means Died in the Emergency Department.

(15) “DMEP” means Disaster Management and Emergency Preparedness.

(16) “DOA” means Dead on Arrival.

(17) “E” means essential and is required for designation at the corresponding facility level.

(18) “ECG” means Electrocardiogram.

(19) “ED” means Emergency Department.

(20) “EMTALA” means Emergency Medical Treatment and Labor Act.

(21) “Facility” shall have the same meaning as defined in T.C.A. § 68-11-201(15).

(22) “FAST” means Focused Assessment with Sonography in Trauma.

(23) “FTE” means Full Time Equivalent.

(24) “GCS” means Glascow Coma Scale.

(25) “Health Care Practitioner” means a physician, surgeon, or other health care professional licensed under T.C.A. Title 63 or Title 68 who is engaged in diagnosing and/or treating patients within the trauma care system.

(26) “ICP” means Increased Intracranial Pressure.

(27) “Identifying Information” means any information that could lead to the identification of a patient who has been diagnosed or treated within the trauma care system.

(28) “ICU” means Intensive Care Unit.

(29) “ISS” means Injury Severity Score.

(30) “Levels of Care” means the type of trauma service provided by the facility as shown by the degree of commitment in personnel and facilities made to the delivery of that service.

(31) “Level I” means a hospital capable of providing care for the acutely injured patient and which meets all requirements in these regulations defined as Level of Care I.

(32) “Level II” means a hospital capable of providing care for the acutely injured patient and which meets all requirements in these regulations defined as Level of Care II.

(33) “Level III” means a hospital capable of providing care for the acutely injured patient and which meets all requirements in these regulations defined as Level of Care III. The Level III facility generally serves communities without all the resources usually associated with Level I or II facilities. Planning for care of the injured in small communities or suburban settings usually calls for transfer agreements and protocols for the most severely injured patients.

Designation of the Level III facility may also require innovative use of the region’s resources.

For example, if there is no neurosurgeon in a large, sparsely populated region it may require that a general surgeon be prepared to provide the emergency decompression of mass lesions and arrangement for patient transfer to the most appropriate Level I or II hospital after the surgeon has carried out the patient’s life-saving operation. Staffing of the Level III hospital is another example of the innovative use of a region’s resources. It will be impractical to require a general surgeon to be in-house in many instances. With modern communication systems it seems reasonable that the surgeon should be promptly available and in a great majority of instances meet the patient in the emergency room on arrival. When a Level III hospital first receives notification of a critically injured patient, it can activate on-call personnel to respond promptly to the hospital. The intent of this flexibility should be clear: to provide the best possible care even in the most remote circumstances.

(34) “Level IV” means a hospital capable of providing care for the acutely injured patient and which meets all requirements in these regulations defined as Level of Care IV. The hospital shall have treatment protocols for resuscitation, transfer protocols on record, shall submit trauma data elements to the state trauma registry as outlined in the Tennessee Trauma Data Dictionary, and participate in system performance improvement. The Level IV facility will maintain a good working relationship with the nearest Level I, II, or III trauma center.

(35) “MTP” means Massive Transfusion Protocol.

(36) “Medical Record” means medical histories, records, reports, summaries, diagnoses, prognoses, records of treatment and medication ordered and given, entries, x-rays, radiology interpretations, and other written, electronic, or graphic data prepared, kept, made or maintained in a facility that pertains to confinement or services rendered to patients admitted or receiving care.

(37) “Non-Physician Practitioner (NPP)” means a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA).

(38) “OR” means Operating Room.

(39) “Person” means any member of the “medical, scientific, and academic research community.”

(40) “PGY” means postgraduate year.

(41) “PI” means Performance Improvement.

(42) “PIPS” means Performance Improvement and Patient Safety.

(43) “Reporting Period” means interval of time over which components of designation assessment occurs.

(44) “RN” means Registered Nurse.

(45) “TBI” means Traumatic Brain Injury.

(46) “Trauma Center” shall have the same definition as provided in T.C.A. § 68-59-102(6).

(47) “TMD” means Trauma Medical Director.

(48) “TPM” means Trauma Program Manager.

(49) “Trauma Registry” means a central registry compiled of injury incidence information supplied by designated trauma centers and Comprehensive Pediatric Emergency Centers for the

purpose of allowing the Commission to analyze data and conduct special studies regarding the causes and consequences of traumatic injury.

History

Authority: T.C.A. §§ 68-11-201, 68-11-202, 68-11-209, and 68-11-259.
Administrative History: Original rule filed September 18, 1985; effective October 18, 1985. Repeal and new rule filed December 5, 2011; effective March 4, 2012. Repeal and new rules filed August 6, 2019; effective November 4, 2019. Transferred from chapter 1200-08-12 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed February 5, 2026; effective May 6, 2026.

Tenn. Comp. R. & Regs. 0720-22-.03 FACILITY OUTREACH

All Level I, II, and III trauma centers shall help facilitate their educational outreach to Level IV trauma centers in the form of professional education, consultation, or community outreach. A mechanism will exist between these centers to provide feedback about individual patient care and outcome analysis to the referring hospital.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-209, and 68-11-259.
Administrative History: Original rule filed September 18, 1985; effective October 18, 1985. Amendment filed March 31, 1989; effective May 15, 1989. Amendment filed August 16, 2006; effective October 30, 2006. Repeal and new rule filed December 5, 2011; effective March 4, 2012. Amendment filed February 12, 2013; effective May 13, 2013. Repeal and new rules filed August 6, 2019; effective November 4, 2019. Transferred from chapter 1200-08-12 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-22-.04 REQUIREMENTS

(1) Trauma registry requirements shall include the following:

(a) Each trauma center and CRPC shall submit trauma registry data electronically to the trauma registry on all closed patient files.

(b) Each trauma center and CRPC shall submit trauma registry data to be received no later than ninety (90) days after the end of each quarter of the year. Trauma centers and CRPC’s shall receive confirmation of successful submission no later than two (2) weeks after submission.

(c) Trauma centers and CRPC’s which fail to submit required data to the trauma registry for two (2) consecutive quarters risk not receiving compensation from the Tennessee Trauma Center Fund.

(2) Levels of Care (a) Hospital Origination 1. Trauma Service I II III IV A recognizable program within the hospital which has a qualified trauma surgeon as its director/coordinator/physician in charge.

The intent is to ensure the coordination of services and performance improvement for the trauma patient. The service includes personnel and other resources necessary to ensure appropriate and efficient provision of care and will vary according to facility and level of designation.

In a Level I and II trauma center, the trauma team shall evaluate seriously injured patients based upon written institutional graded activation criteria and those patients shall be admitted by an identifiable surgical service staffed by credentialed trauma providers. Level I and II trauma centers shall have sufficient infrastructure and support to ensure adequate provision of care for this service. Sufficient infrastructure and support may require additional qualified physicians, residents, or non-physician practitioners. This composite should be determined by the volume of patients requiring care and the complexity of their conditions. In teaching facilities, the requirements of the Residency Review Committee also must be met. Level I trauma centers must care for at least 1200 trauma patients per year or at least 240 pts with an ISS>15 per year.

In Level III centers, the center may admit the injured patients to individual surgeons, but the structure of the program must allow the trauma director to have oversight authority for the care of those injured patients. The center shall ensure that there is a method to identify the injured patients, monitor the provision of health care services, make periodic rounds, and hold formal and informal discussions with individual practitioners. It is particularly important for team members to attend trauma committee meetings regularly and participate in peer review activities to maintain cohesion within the service.

E E E

Written graded activation criteria. Criteria for highest level of activation is clearly defined and evaluated by the performance improvement program (PIPs).

E E E E

Administration supportive of the trauma program E E E E Evidence of an annual budget for the trauma program E E E E The trauma team may be organized by a qualified physician, but care must be directed by a board certified or board eligible general surgeon on a trauma service that is committed to the care of the injured. All patients with multiple-system or major injury must be initially evaluated by the trauma team, and the surgeon who shall be responsible for overall care of a patient E E E D (the team leader) identified. A team approach is required for optimal care of patients with multiple-system injuries.

Surgery Departments/Divisions/Services/Sections (each staffed by qualified specialists)

Cardiothoracic Surgery E E General Surgery E E E D Neurologic Surgery E E Obstetrics-Gynecologic Surgery E Ophthalmic Surgery E Oral and Maxillofacial Surgery - Dentistry E E Orthopedic Surgery E E E Otorhinolaryngologic Surgery E E Pediatric Surgery E Plastic Surgery E Urologic Surgery E Surgical Critical Care E D 3. Emergency Department/Division/Service/Section (staffed by qualified specialists)

E E E

E 4. Surgical Specialty Availability In-house 24 hours a day General Surgery E Neurologic Surgery E Neurosurgical evaluation must occur within 30 minutes of request for the following:

(i) Severe TBI (GCS less than 9) with head CT evidence of intracranial trauma (ii) Moderate TBI (GCS 9–12) with head CT evidence of potential intracranial mass lesion (iii) Neurologic deficit as a result of potential spinal cord injury (applicable to spine surgeon, whether a neurosurgeon or orthopedic surgeon)

(iv) Trauma surgeon discretion Neurosurgery attending must be involved in the clinical decision-making for the care of these patients E E Level I and II trauma centers must have a neurotrauma contingency plan and must implement the plan when E E neurosurgery capabilities are encumbered or overwhelmed.

Level III and Level IV trauma centers must have a written plan approved by the TMD that defines the types of neurotrauma injuries that may be treated at the center.

E E Surgical Critical Care E D 5. Surgical Specialty Availability from inside or outside hospital 24/7/365. All specialists are required for Level I & II centers.

Cardiac Surgery E E General Surgery E E D Neurologic Surgery E D Microsurgery capabilities E E Gynecologic Surgery E E Hand Surgery E E Obstetrics E E Ophthalmic Surgery E E D Oral and Maxillofacial Surgery - Dentistry E E D Orthopedic Surgery E E E Must have an orthopedic surgeon who has completed Orthopedic Trauma Association fellowship, alternate training criteria.

E E In trauma centers, an orthopedic surgeon (resident, nonphysician practitioner, trauma surgeon with ortho privileges) must be at bedside within 30 minutes of request for the following:

(i) Hemodynamically unstable, secondary to pelvic fracture (ii) Suspected extremity compartment syndrome (iii) Fractures/dislocations with risk of avascular necrosis (e.g., femoral head or talus)

(iv) Vascular compromise related to a fracture or dislocation trauma surgeon discretion The orthopedic surgeon must be involved in the clinical decisionmaking for care of these patients E E E Otorhinolaryngologic Surgery E E D Pediatric Surgery E E Plastic Surgery E E D Thoracic Surgery E E D Urologic Surgery E E D Vascular Surgery E E 6. Non-Surgical Specialty Availability in-hospital 24 hours a day Emergency Medicine E E E E Anesthesiology E E E 7. Non-Surgical Specialty Availability on call from inside or outside hospital Cardiology E E D Chest (pulmonary) Medicine E E Gastroenterology E E Hematology E E D Infectious Diseases E E Internal Medicine E E E Nephrology E E Pathology E E Pediatrics E E Psychiatry E E Radiology E E E (i) Interventional Radiology response for hemorrhage control E E (ii) Level I & II centers must have necessary human & physical resources continuously available for so that an endovascular or interventional radiology procedure for hemorrhage control can begin within 60 minutes of request.

E E Allied Health (i) Respiratory therapy 24/7/365 E E E (ii) Nutrition support E E E (iii) Speech Therapy E E E (iv) Social Worker E E E (v) Occupational Therapy E E E (vi) Physical Therapy E E E Intensivists: at least one intensivist must be board certified or board eligible in critical care E E (b) Special Facilities/Resources/Capabilities 1.(i) Emergency Department (ED) – Personnel I II III IV Designated Physician Director E E E E In all trauma centers, emergency medicine physicians must be board certified, board eligible or have been approved through the Alternate Pathway. All emergency medicine physicians must have taken the ATLS course at least once. Physicians who are board certified or board eligible in a specialty other than emergency medicine must hold current ATLS certification. All physicians must be physically present in the ED 24 hours a day.

E E E E

Full-time emergency department RN personnel 24 hours a day trained in trauma specific education/competencies E E E E Non-physician practitioners that are clinically involved in the initial evaluation and resuscitation of trauma patients during the activation phase must have current ATLS certification.

E E E E 1.(ii) Emergency Department – Equipment for resuscitation and to provide support for the critically or seriously injured must include but shall not be limited to:

Airway control and ventilation equipment including laryngoscopes and endotracheal tubes of all sizes, bag-mask resuscitator, sources of oxygen, and mechanical ventilator E E E E All trauma centers must have a provider and equipment immediately available to establish an emergency airway.

E E E E

Suction devices E E E E Electrocardiography defibrillator E E E E Bedside ultrasound capability for FAST examination E E E E Capability for advanced hemodynamic monitoring i.e. central lines, ICP monitoring, arterial lines etc.

E E D

All standard intravenous fluids and administration devices, E E E E including intravenous catheters Sterile surgical sets for procedures standard for ED, such as thoracostomy, cutdown, etc.

E E E E

Drugs and supplies necessary for emergency care E E E E X-ray capability, 24-hour coverage by in-house technicians E E E E Two-way radio linked with vehicles of emergency medical services E E E E Cervical collars E E E E Long Spine Board E E E E Splinting materials and devices E E E E Helipad or Helicopter Landing Area E E E E End Tidal Carbon Dioxide Monitoring E E E E Tourniquets E E E E Appropriate sized catheters for the performance of needle chest decompression E E E E Appropriate equipment for the performance of interosseous cannulation E E E E A rapid volume infuser for the utilization of transfusion protocol E E E D 2.(i) Intensive Care Units (ICU) for Trauma Patients Designated Surgeon Medical Director. Level I director must be a surgeon boarded in surgical critical care. Level II Director or co-director must be a surgeon boarded in surgical critical care.

Level III director or co-director must be a surgeon boarded in general surgery.

E E E

If admitting traumatically injured patients, director or codirector must be a board certified general surgeon E Physician on duty in ICU 24 hours a day or immediately available from in-hospital (PGY4/5 qualify)

E E E

Provider coverage must be available within 30 minutes of request, with a formal plan in place for emergency coverage.

E Nurse-patient minimum ratio of 1:2 on each shift depending on patient acuity E E E Immediate access to clinical laboratory service E E E 2.(ii) Equipment:

Airway control and ventilation devices E E E E Oxygen source with concentration controls E E E E Cardiac emergency cart E E E E Temporary transvenous pacemaker E E E E Electrocardiograph defibrillator E E E E Cardiac output monitoring E E D End Tidal Carbon Dioxide Monitoring/Waveform capnography E E E E Electronic Arterial pressure monitoring E E E E Mechanical ventilator-respirators E E E E Patient weighing devices E E E E Temperature control devices E E E E Drugs, intravenous fluids and supplies E E E E Intracranial pressure monitoring devices E E D D A rapid volume infuser for the utilization of transfusion protocol E E E E 3. Post-anesthetic recovery room (ICU is acceptable)

Registered nurses 24 hours a day E E E Monitoring and resuscitation equipment E E E 4. Acute hemodialysis capability E E E 5. Organized burn care: Physician directed burn center/unit staffed by personnel trained in burn care and equipped properly E E E 6. Acute spinal cord management capability OR written transfer agreement with a hospital capable of caring for a spinal cord patient E E 7. Acute head injury management capability OR written transfer agreement with a hospital capable of caring for a patient with a head injury E E 8. Radiological Special Capabilities Interventional radiology (includes angiography) E E D Angiography of all types E E D Sonography E E E Nuclear scanning E E D In-house computerized tomography. In all trauma centers, documentation of the final interpretation of CT scans must occur no later than 12 hours after completion of the scan.

E E E E

MRI (magnetic resonance imaging) E E D Must have mechanism to remote view images from referring hospitals in catchment area E E 9. Organ donation protocol E E E E (c) Operating suite special requirements 1. Equipment/instrumentation I II III IV Operating room, dedicated to the trauma service, with nursing staff in-house and immediately available 24 hours a day within 15 minutes of notification E E D If first operating room is occupied an additional operating room must be staffed and available.

E E Operating room, dedicated to the trauma service, adequately staffed and available within 30 minutes of notification E Must have dedicated operating room prioritized for fracture care in nonemergent orthopedic trauma E E Cardiopulmonary bypass equipment must be immediately available when required, or a contingency plan must exist to provide emergency cardiac surgical care.

E E Operating microscope E E Thermal control equipment for patient E E E Thermal control equipment for blood E E E X-ray capability E E E Endoscopes, all varieties E E E Craniotomy instrumentation E E D Monitoring equipment (e.g., ECG, blood pressure monitoring) E E E A rapid volume infuser for the utilization of transfusion protocol E E E (d) Clinical Laboratory Services available 24 hours a day 1. Standard analysis of blood, urine, and other body fluids E E E E 2. Blood typing and cross-matching E E E E 3. Coagulation studies E E E E 4. Blood bank or access to a community central blood bank and hospital storage facilities E E E E 5. Blood gases and pH determinations E E E E 6. Serum and urine osmolality E E E D 7. Microbiology E E E E 8. Drug and alcohol screening E E E E 9. Thromboelastography (TEG) E E 10. Must have transfusion protocol developed collaboratively between the trauma service and blood bank E E E E 11. Must have adequate supply of blood products E E E E (e) Trauma Medical Director 1. A physician board certified in general surgery E E E D In Level IV centers, there must be a Trauma Medical Director who is a physician and has, at a minimum, the following authority and responsibilities:

(i) Develop and enforce clinical protocols and practice management guidelines relevant to the care of the injured patient.

(ii) Ensure clinicians meet all requirements and adhere to institutional standards of practice related to trauma care.

(iii) Work across departments and /or other administrative units to address deficiencies in care.

(iv) Determine clinician participation in trauma care, which might be guided by findings from the PIPS process or professional practice reviews.

(v) Oversee the structure and process of the trauma PIPS program.

(vi) Participate in committees relevant to the regional trauma system.

E (vii) Chair or co-chair (with the TPM) the committee where discussions/decisions occur related to trauma operations.

(viii) Lead discussions pertaining to trauma multidisciplinary case reviews.

(ix) Be active in the participation of trauma care in the trauma center.

Minimum of three years clinical experience on a trauma service or trauma fellowship training E E D 3. 36 hours of category I trauma/critical care CME every 3 years or 12 hours each year and attend one national meeting whose focus is trauma or critical care E E E Provide evidence of 24 hours of trauma-related continuing medical education (CME/CE) per 3 years E 4. Participates in call E E E 5. Has the authority to manage all aspects of trauma care E E E 6. Authorizes trauma service privileges of the on-call panel E E E 7. Works in cooperation with nursing administration to support the nursing needs of trauma patients E E E E 8. Develops treatment protocols along with the trauma team E E D 9. Coordinates performance improvement and peer review processes E E E E 10. With the assistance of the hospital administrator and the TPM, be involved in coordinating the budgetary process for the trauma program E E E 11. Participates in the Tennessee Chapter of the ACS-COT E E E E 12. Participates in regional and national trauma organizations E E E 13. Retain a current certification of ATLS and participates in the provision of trauma-related instruction to other health care personnel E E E E 14. Is involved in trauma research E D 15. In trauma centers, the shared roles and responsibilities of trauma surgeons and emergency medicine physicians for trauma resuscitation must be defined and approved by the Trauma Medical Director.

E E E D

(f) Attending General Surgeon on the Trauma Service 1. Must be currently board certified or board eligible in General Surgery E E E E 2. All attending general surgeons on the trauma service must have taken the ATLS course at least once.

E E E E

Surgery coverage must be continually available. E E E 4. In Level I and II trauma centers, the trauma surgeon must be dedicated to a single trauma center while on call.

E E 5. Level I and II trauma centers must have a published backup call schedule for trauma surgery.

E E 6. Trauma surgeon must be present in the operating room for key portions of operative procedures for which they are the responsible surgeon and must be immediately available throughout the procedure.

E E E 7.

In Level I centers with surgery training programs, they must:

(i) Have a trauma rotation with defined objectives and curriculum for PGY3, PGY4, or PGY5 general surgical residents.

(ii) General surgery residents must be assigned to the trauma rotation for a minimum of three months during their PGY4 or PGY5 to ensure sufficient exposure to trauma care. For pediatric trauma centers, PGY3 surgical residents are acceptable.

(iii) Must have trauma surgery coverage by PGY4 or PGY5 general surgery residents. If the number of PGY4 or PGY5 residents is insufficient to ensure coverage, PGY3 surgical residents and/or fellows are acceptable. All general surgery residents and/or fellows must be from an Accreditation Council for Graduate Medicine Education (ACGME) accredited program.

E (g) Trauma Program Manager (TPM)/Trauma Nurse Coordinator (TNC)

Must have a full-time TPM/TNC dedicated to the trauma program E E E D 2. Must have a part-time TPM/TNC with the trauma program as a major focus of their job description E 3. Must be a Registered Nurse licensed by the Tennessee Board of Nursing in good standing or a licensed Registered Nurse in another state with a multistate privilege to practice in Tennessee E E E E 4. Must possess experience in Emergency/Critical Care Nursing E E E E 5. Must have a defined job description and organizational chart delineating the TNC/TPM role and responsibilities including a E E E E reporting structure that includes the TMD 6. Must be provided the administrative and budgetary support to complete educational, clinical, research, administrative and outreach activities for the trauma program E E E 7. Shall attend one national meeting within the 3-year designation cycle, 36 hour continuing education (CE) during the designation cycle, and hold current membership in national organization E E E E (h) Trauma Registrar 1. A full-time equivalent registrar for each 500 patients per year who were admitted and/or who met institutional criteria for trauma team activation and were discharged home from the ED E E E E 2. At least one registrar must be a current CAISS specialist. E E E E 3.

Staff members that have a registry role in data abstraction and entry, injury coding, ISS calculation, data reporting, or data validation for the trauma registry must fulfill all of the following requirements:

(i) Participate and pass the most current version of the AAAM’s Abbreviated Injury Scale (AIS) course that your center is using (ii) Participate on a trauma registry course that includes all of the following content:

(I) Abstraction (II) Data management (III) Reports/report analysis (IV) Data validation (V) HIPAA (iii) Participate in an ICD-10 course or an ICD-10 refresher course every five years E E E E 4. Each trauma registrar must accrue at least 24 hours traumarelated CE during the designation cycle.

E E E E

(i) Programs for Quality Assurance 1. Medical Care Education Morbidity and Mortality Reviews to encompass all trauma deaths E E E E 2. Trauma Process Improvement (PI)

The institution must provide resources to support the trauma process improvement program.

E E E E

In all trauma centers, the trauma PIPS program must be independent of the hospital or departmental PI program, but it must report to the hospital or departmental PI program.

E E E E

Trauma centers must have a written PIPS plan that:

(i) Outlines the organizational structure of the trauma PIPS process, with a clearly defined relationship to the hospital PI program (ii) Specifies the processes for event identification. As an example, these events may be brought forth by a variety of sources, including but not limited to: individual personnel reporting, morning report or daily signouts, case abstraction, registry surveillance, use of clinical guideline variances, patient relations, or risk management. The scope for event review must extend from prehospital care to hospital discharge.

(iii) Includes a list of audit filters, event review, and report review that must include, at minimum, those listed as audit filters, events, or report reviews below (iv) Defines levels of review (primary, secondary, tertiary, and/or quaternary), with a listing for each level that clarifies:

(I) Which cases are to be reviewed (II) Who performs the review (III) When cases can be closed or must be advanced to the next level (v) Specifies the members and responsibilities of the trauma multidisciplinary PIPS committee (vi) Outlines an annual process for identification of priority areas for PI, based on audit Audit filters, event or report reviews:

(i) Surgeon arrival time for the highest level of activation (ii) Delay in response for urgent assessment by the neurosurgery and orthopedic specialists (iii) Delayed recognition of or missed injuries (iv) Compliance with prehospital triage criteria, as dictated by regional protocols (v) Delays or adverse events associated with prehospital trauma care (vi) Compliance of trauma team activation, as dictated by program protocols (vii) Accuracy of trauma team activation protocols (viii) Delays in care due to the unavailability of emergency department physician (Level III)

(ix) Unanticipated return to the OR (x) Unanticipated transfer to the ICU or intermediate care (xi) Transfers out of the facility for appropriateness and safety (xii) All nonsurgical admissions (excludes isolated hip fractures)

(xiii) Radiology interpretation errors or discrepancies between the preliminary and final reports (xiv) Delays in access to time-sensitive diagnostic or therapeutic interventions (xv) Compliance with policies related to timely access to the OR for urgent surgical intervention (xvi) Delays in response to the ICU for patients with critical needs (xvii) Lack of availability of essential equipment for E E E E resuscitation or monitoring (xviii) MTP activations (xix) Significant complications and adverse events (xx) Transfers to hospice (xxi) All deaths: inpatient, died in emergency department (DIED), DOA (xxii) Inadequate or delayed blood product availability (xxiii) Patient referral and organ procurement rates (xxiv) Screening of eligible patients for psychological sequelae (xxv) Delays in providing rehab services (xxvi) Screening of eligible patients for alcohol misuse (xxvii) Pediatric admissions to non-pediatric trauma centers (xxviii)Neurotrauma care at Level III trauma centers (xxix) Neurotrauma diversion Must have a performance improvement coordinator dedicated to the trauma program. 0.5 FTE when annual volume exceeds 500 patients. 1 FTE when annual volume exceeds 1,000 pt. entries E E E E Must have a Trauma Performance Improvement Committee that meets at least quarterly and includes physician liaisons from the following services: Orthopedics, Radiology, Anesthesia, Emergency Medicine, Neurosurgery, Geriatric and core trauma surgeons as well as nursing, prehospital personnel and other healthcare providers. The Committee reviews policies and procedures as well as system issues, and its members or designees attend at least 50% of regular Committee meetings.

The Trauma Medical Director must attend at least 60 percent of regular Trauma Performance Improvement Committee meetings.

Attendance cannot be delegated to the associate Trauma Medical Director. The committee shall:

E E E

E (i) Monitor team notification times. For highest level of activation trauma attending must be present within 15 minutes of patient arrival 80% of the time.

E E D

(ii) Monitor team notification times. For highest level of activation, trauma attending must be present within 30 minutes of patient arrival 80% of the time.

E All trauma centers must have documented evidence of event identification; effective use of audit filters; demonstrated loop closure; attempts at corrective actions; and strategies for sustained improvement measured over time.

E E E E

Operational Process Improvement (Evaluation of System Issues)

This is a multidisciplinary conference presided over by the Trauma Medical Director and shall include hospital administrative staff over trauma services as well as the staff in charge of all traumaprogram related services. This committee addresses, assesses, and corrects global trauma program and system issues, and corrects overall program deficiencies to continue to optimize E E E E patient care. This should be held at least quarterly, attendance noted, and minutes recorded.

Trauma Bypass Log All trauma centers must not exceed 400 hours of diversion during the reporting period.

E E E E

Trauma centers must have evidence-based clinical practice guidelines, protocols, or algorithms that are reviewed at least every three years.

E E E D

Level I and II trauma centers must have the following protocols for care of the injured older adult:

(i) Identification of vulnerable geriatric patients (ii) Identification of patients who will benefit from the input of a health care provider with geriatric expertise (iii) Prevention, identification, and management of dementia, depression, and delirium (iv) Process to capture and document what matters to patients, including preferences and goals of care, code status, advanced directives, and identification of a proxy decision-maker (v) Medication reconciliation and avoidance of inappropriate medications (vi) Screening for mobility limitations and assurance of early, frequent, and safe mobility Implementation of safe transitions to home or other health care facility E E D 7. All trauma centers must have a process in place to assess children for nonaccidental trauma.

E E E E 8.

All trauma centers must have a rapid reversal protocol in place for patients on anticoagulants.

E E E E

In all trauma centers, the emergency department must evaluate its pediatric readiness and have a plan to address any deficiencies.

E E E E

Trauma centers must have treatment guidelines for, at minimum, the following orthopedic injuries:

(i) Patients who are hemodynamically unstable attributable to pelvic ring injuries (ii) Long bone fractures in patients with multiple injuries (e.g., time to fixation, order of fixation, and damage control versus definitive fixation strategies)

(iii) Open extremity fractures (e.g., time to antibiotics, time to OR for operative debridement, and time to wound coverage for open fractures)

(iv) Hip fractures in geriatric patients (e.g., expected time to OR)

E E E

Trauma centers must meet the rehabilitation needs of trauma patients by:

E E E

(i) Developing protocols that identify which patients will require rehabilitation services during their acute inpatient stay (ii) Establishing processes that determine the rehabilitation care, needs, and services required during the acute inpatient stay (iii) Ensuring that the required services during acute inpatient stay are provided in a timely manner 12. Rehabilitation and discharge planning. Trauma centers must have a process to determine the level of care patients require after trauma center discharge, as well as the specific rehabilitation care services required at the next level of care. The level of care and services required must be documented in the medical record.

E E E

Trauma centers must meet the mental health needs of trauma patients by having a protocol to screen patients at high risk for psychological sequelae with subsequent referral to a mental health provider.

E E 14. A process for referral to a mental health provider when required E D 15. Alcohol misuse screening. Trauma centers must screen all admitted trauma patients greater than 12 years old for alcohol misuse with a validated tool or routine blood alcohol content testing. Programs must achieve a screening rate of at least 80 percent.

E E E D

Alcohol misuse intervention. Trauma centers, at least 80 percent of patients who have screened positive for alcohol misuse must receive a brief intervention by appropriately trained staff prior to discharge. This intervention must be documented. Level III trauma centers must have a mechanism for referral if brief intervention is not available as an inpatient.

E E E D

Trauma centers must have a written data quality plan and demonstrate compliance with that plan. At minimum, the plan must require quarterly review of data quality.

E E E

Trauma centers must participate in a risk-adjusted benchmarking program and use the results to determine whether there are opportunities for improvement in patient care and registry data quality.

E E D D

All nonsurgical trauma admissions must be reviewed by the trauma program. Nonsurgical admissions (NSA) without trauma or other surgical consultation, with ISS > 9, or with identified opportunities for improvement must, at a minimum, be reviewed by the TMD in secondary review.

E E E D

(j) System Development 1. Level I and II centers shall maintain a commitment to provide ATLS and other educational activities deemed appropriate and E E timely to surrounding referral centers.

Be involved with local and regional EMS agencies and/or personnel and assist in trauma education, performance improvement, and feedback regarding care E E E 3. All trauma centers shall participate in trauma system planning and development under the auspices of the Trauma Care Advisory Council.

E E E E

The trauma center shall be involved in community awareness of trauma and the trauma system.

E E E E

(k) Injury Prevention 1. Participate in statewide trauma center collaborative injury prevention efforts focused on common needs throughout the state E E E E 2. Perform studies in injury control while monitoring the effects of prevention programs. Implement at least two activities over the course of the designation cycle with specific objectives and deliverables that address separate major causes of injury in the community E E D 3. Must have a full-time injury prevention coordinator dedicated to the trauma program to ensure community and regional injury prevention activities are implemented and evaluated for effectiveness E E D D (l) Institutional Commitment 1. Demonstrates knowledge, familiarity, and commitment of upper level administrative personnel to trauma service E E E E 2. Upper level administration participation in multidisciplinary trauma conferences/committees E E E E 3. Evidence of yearly budget for the trauma program E E E E 4. Hospital administration must demonstrate support for research efforts of the Trauma Service E D 5.

Must demonstrate the following scholarly activities during the verification (designation) cycle:

(i) At least 10 trauma-related research articles (ii) Participation by at least one trauma program faculty member as a visiting professor, invited lecturer, or speaker at a regional, national, or international trauma conference Support of residents or fellows in any of the following scholarly E activities: laboratory experience; clinical trials; resident trauma paper competition at the state, regional, or national level; and other resident trauma research presentations (m) Activation Criteria 1. Each center shall have clearly defined graded activation criteria.

For the highest level of activation, the trauma team (trauma Chief resident: PGY 4/5 or ED attending) shall be immediately available and the trauma attending available within 15 minutes of patient arrival.

E E 2. For the highest level of activation for Level III centers, the trauma attending shall be available within 30 minutes of patient arrival unless the patient is immediately being transferred to a higher level of care.

E (n) Disaster Preparedness 1. The trauma program must be a part of the hospital disaster planning process.

E E E E

A trauma surgeon from the trauma panel must be a part of the disaster planning committee.

E E E

Ortho trauma surgeon from the trauma panel must be a part of the disaster planning committee.

E Trauma programs must participate in two hospital drills/exercise per year.

E E E

Surgeon liaison to disaster committee must complete DMEP course at least once.

E (3) References (a) The following references refer to the superscripts in the Table in paragraph (2) of this

rule:

If cardiopulmonary bypass equipment is not immediately available, a contingency plan, including immediate transfer to an appropriate center and one hundred percent performance review of all patients transferred must be in place.
This requirement may be substituted by a department or division capable of treating maxillofacial trauma as demonstrated by staff privileges.
This requirement may be substituted by a current signed transfer agreement with an institution having a Pediatric Surgery Service.
The emergency department staffing must provide immediate and appropriate care for the trauma patient. The emergency department physician must function as a designated member of the trauma team.
Requirements may be fulfilled by a Senior Surgical Resident (PGY 4 or higher) capable of assessing emergency situations in trauma patients and initiating proper treatment. A staff surgeon trained and capable of carrying out definitive treatment must be available within 15 minutes of patient arrival.
Requirements may be fulfilled by in-house neurosurgeon or neurosurgery resident, senior general surgery resident or trauma attending who has special competence as defined by the hospital, as documented by the Chief of Neurosurgery Service, in the care of patients with neural trauma, and who is capable of initiating measures directed toward stabilizing the patient and initiating diagnostic procedures. An attending neurosurgeon dedicated to the hospital’s trauma service must be available within thirty (30) minutes from notification.
This requirement may be substituted by a current signed transfer agreement with an institution having a Hand Surgery Service.
Requirements may be fulfilled by senior level (last year in training) Emergency Medicine Residents capable of assessing emergency situations and initiating proper treatment. The staff specialist responsible for the resident must be available within thirty (30) minutes.
A non-physician practitioner with current certification as an ATLS provider may fulfill this role.
Requirements for Level II Trauma Center may be fulfilled when local conditions assure that a staff anesthesiologist is on call and available within thirty (30) minutes. During the interim period prior to the arrival of a staff anesthesiologist, a Certified Registered Nurse Anesthetist (CRNA) operating under the direction of the anesthesiologist, the trauma team surgeon director or the emergency medicine physician may initiate appropriate supportive care.
Requirements for Level III Trauma Center may be fulfilled when local conditions assure that a staff anesthesiologist is on call and available within thirty (30) minutes. However, when there is not an anesthesiologist on the hospital staff, this requirement may be fulfilled by a CRNA operating under the supervision of the surgeon, the anesthesiologist, and/or the responsible physician.
Forensic pathologist must be available either as part of the hospital staff or on a consulting basis.
This requirement may be substituted by current signed transfer agreement with hospital having hemodialysis capabilities.
This requirement may be substituted by current signed transfer agreement with burn center or hospital with burn unit.
This requirement may be substituted by a current signed transfer agreement with a hospital having Microsurgical capabilities.
Each center must have an organized protocol with a transplant team or service to identify possible organ donors and in procuring organs for donation.
All specialists must be available within thirty (30) minutes from notification.
Qualified radiologists must be available within 30 minutes in person or by teleradiology for interpretation of radiographs.
This requirement may be substituted by a current signed transfer agreement with a hospital having an orthopedic surgeon who has completed Orthopedic Trauma Association fellowship alternate training criteria.
For Level I and II centers, these requirements will/shall be available 7 days a week.
For Level III centers, 7 day a week coverage is not required.
Coverage may include an intensivist, hospitalist, or non-physician practitioner.

The formal plan for emergency coverage should allow for patients’ immediate needs to be met until the attending surgeon is available. 23 For Level IV centers. All equipment is to be required if admitting trauma patients to the ICU, except cardiac output monitoring.

Essential only for those Level I centers with surgery training programs.

(4) Designation (a) The Commission shall implement and oversee the designation process.

(b) The preliminary designation process for facilities aspiring for designation as a Level I, II, III, or IV Trauma Center shall consist of the following:

Each facility desiring designation shall submit an application to the Commission;
The Commission shall review each submitted application and communicate deemed application deficiencies to the facility in writing; 3 . The facility shall have thirty (30) days to submit required information; and 4 . Arrangements shall be made for a provisional site visit for those facilities meeting application requirements.

A trauma surgeon medical director or a trauma surgeon who has previously been a medical director from an out-of-state trauma center who shall serve as team leader; If the out-of-state surgeon is not available, he/she may be substituted by an in-state surgeon from a different grand division at the discretion of the center being reviewed.
A trauma surgeon from an in-state Level I trauma center;
An in-state trauma nurse coordinator/program manager from a Level I trauma center; and 4. The state trauma system director/asst. director.

(d) The site visit team shall consist of the following for Level III centers:

A trauma surgeon from an in-state Level I or Level II trauma center;
An in-state trauma nurse coordinator/program manager from a Level I trauma center; and 3. The state trauma system director/asst. director.

(e) The site visit team shall consist of the following for Level IV centers:

An in-state trauma nurse coordinator/program manager from a Level I trauma center; and 2. The state trauma system director/asst. director.
If deficiencies are found necessitating a focused visit, a trauma surgeon from an in-state Level I trauma center shall be part of the focused site visit team.

(f) The team shall be appointed by the following organizations:

The state trauma system director/asst. director shall consult with the State Committee on Trauma of the American College of Surgeons for assistance in identifying the out-of-state surgeon; and 2. The state trauma system director/asst. director, in consultation with the chairman and vice chairpersons of the Tennessee Committee on Trauma, shall select the in-state members of the site visiting team.

(g) The team shall conduct a provisional visit to ensure compliance with all criteria required for designation as a Trauma Center with the requested level of designation before the Commission grants an institution designation as a Trauma Center. During the provisional visit, the applicant shall demonstrate that the required mechanisms to meet the criteria for the desired designation level are in place.

(h) The team shall identify deficiencies and areas of improvement it deems necessary for designation.

(i) If the team does not cite any deficiencies and concludes that the facility is otherwise in compliance with all applicable standards, it shall approve the applicant to function with provisional status for a period of one (1) year.

(j) If, during the provisional visit, the team cites deficiencies, it shall not approve provisional status for the applicant to function as a trauma center. Centers with deficiencies shall have fifteen (15) days from report receipt to provide documentation demonstrating compliance. If the facility is unable to correct the deficiencies within fifteen (15) days, the application shall be denied and the applicant may not resubmit an application for trauma center designation for at least one (1) year from the date of denial.

(k) Facilities granted provisional status as a trauma center shall adhere to the following:

The facility shall be prepared to provide:

(i) A description of changes made after the grant of provisional status;

(ii) A description of areas for improvement cited during the provisional visit; and (iii) A summary of the hospital’s trauma service based on the trauma registry report.

The team shall conduct a site visit at the termination of the applicant’s one (1) year provisional designation as a trauma center.
During the follow-up visit, the team shall identify the presence of any deficiencies and areas for improvement.

(l) Upon completion of the follow-up visit, the team shall submit its findings and designation recommendations to the Commission.

If the team cites deficiencies found during its follow-up visit, they shall be included in its report to the Commission.
The facility requesting trauma center designation shall be allowed to present evidence demonstrating action taken to correct cited deficiencies to the Commission during the ratification process.

(m) The final decision regarding trauma center designation shall be rendered by the Commission. If granted, trauma center designation is applicable for a period of three (3) years.

(n) If the Commission denies the applicant trauma center designation, the facility may not reapply for at least one (1) year and will have its provisional status revoked.

(o) The facility applying for trauma center designation shall bear all costs of the application process, including costs of a site visit.

(p) A facility requesting an American College of Surgeons trauma center consultation/verification site visit shall coordinate with the state trauma system director/ asst. director to ensure his/her attendance at the review. If the state trauma system director/asst. director is unable to attend the site visit, the facility shall share the finalized report from the site visit with the state trauma system director/asst. director for presentation to the Commission if the facility seeks a reciprocal state designation.

(q) Denial of Provisional or Full Designation, When the Commission denies provisional or full designation, it must provide the center with a written notification of the action and the basis for the action. The notice will inform the center of the right to appeal and the procedure to appeal the action under the provisions of the Uniform Administrative Procedures Act.

(5) Verification (a) Following designation as a trauma center, a verification site visit shall be conducted at the facility every three (3) years.

(b) The team shall advise the center of an upcoming verification visit at least sixty (60) days prior to the visit. After the facility receives notice of the upcoming verification site visit, it shall prepare all materials the team requests for submission.

(c) The team shall conduct an exit interview with the facility at the conclusion of the verification visit. During the exit interview the team shall communicate the following:

The presence of deficiencies;
The facility’s strengths and weaknesses; and 3. Recommendations for improvements and correction of deficiencies.

(d) The team shall submit a site visit report within sixty (60) days of completion of the site visit. It shall submit a copy of the report to the Commission, the Chief Executive Officer of the hospital, the Trauma Medical Director and the Trauma Program Manager (TPM).

(e) If the team does not cite deficiencies and the center is in compliance with all applicable standards, the team shall recommend that the facility be confirmed at its current level of trauma designation for a period of three (3) additional years.

(f) The facility shall bear all costs of the verification process, including the costs of a site visit.

(g) If a trauma center already designated by the Commission elects to undergo an American College of Surgeons trauma center consultation/verification site visit, the facility shall coordinate with the state trauma director/asst. director to ensure his/her attendance at the review. If the state trauma director/asst. director is unable to attend the site visit, the finalized report from the site visit shall be shared with the state trauma director/asst. director for presentation to the Commission if a reciprocal state designation is to be granted.

(6) Disciplinary Action (a) If during the site visit the team determines that deficiencies exist, the center’s designation shall be placed on provisional status and the center shall have a period not to exceed thirty (30) days to submit a corrective action plan (CAP) that shall include the process for deficiency resolution and a timeline for compliance. A focused review will be scheduled within one (1) year either through a desk review or on-site review to ensure compliance, if deemed necessary by the site review team. Immediate referral for termination of designation may be made by the review team, if the deficiency is determined to be severe and pervasive.

(b) Whether a desk review or onsite visit shall be required is dependent upon the scope and severity of the deficiency cited and is within the purview of the site team to make the decision on the type of revisit required.

(c) If the team ascertains that deficiencies have not been corrected within one (1) year, whether through desk review or an on-site visit, the center must present an explanation to the Commission at its next scheduled meeting.

(d) The Commission may, in accordance with the Uniform Administrative Procedures Act, revoke, suspend, place on probation, or otherwise discipline, a facility’s trauma center designation.

(e) The Commission may revoke, suspend, place on probation, or otherwise discipline, the designation or provisional status of a center when an owner, officer, director, manager, employee or independent contractor:

Fails or refuses to comply with the provisions of these rules;
Makes a false statement of material fact about the center’s capabilities or other pertinent circumstances in any record or matter under investigation for any purposes connected with these rules;
Prevents, interferes with, or attempts to impede in any way, the work of a representative of the Commission;
Falsely advertises, or in any way misrepresents the facility’s ability to care for patients based on its designation status;
Is substantially out of compliance with these rules and has not rectified such noncompliance;
Fails to provide reports required by the trauma registry or the Commission in a timely and complete fashion;
Fails to comply with or complete a plan of correction in the time or manner specified;
Has engaged in a deliberate and willful violation of these rules; or 9. Acts in a manner that endangers the public’s health, safety, or welfare.

(7) Prohibitions (a) It shall be a violation of these regulations for any health care facility to hold out, advertise or otherwise represent itself to be a “trauma center” as licensed by the Commission unless it has complied with the regulations set out herein and the Commission has so licensed it.

(b) Any facility the Commission designates as a trauma center, at any level, shall comply with the requirements of EMTALA. The medical needs of a patient and the available medical resources of the facility, rather than the financial resources of a patient, shall be the determining factors concerning the scope of service provided.

(c) The term “trauma center” refers to a main hospital campus that has met all requirements to satisfy trauma center rule designation. Off campus sites are excluded in this designation.

History

Authority: T.C.A. §§ 68-11-201, 68-11-202, 68-11-209, and 68-11-259.
Administrative History: Original rule filed September 18, 1985; effective October 18, 1985. Amendment filed March 31, 1989; effective May 15, 1989. Amendment filed August 31, 1990; effective October 15, 1990. Amendment filed October 20, 1992; effective December 4, 1992. Amendment filed July 21, 1993; effective October 4, 1993. Amendment filed August 16, 2006; effective October 30, 2006. Repeal and new rule filed December 5, 2011; effective March 4, 2012. Repeal and new rules filed August 6, 2019; effective November 4, 2019. Transferred from chapter 1200-08-12 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed February 5, 2026; effective May 6, 2026.

Tenn. Comp. R. & Regs. 0720-22-.05 TRAUMA REGISTRY DATA

(1) Reporting (a) All designated Trauma Centers and CRPC’s shall participate in the collection of data for the Trauma Registry.

(b) All designated Trauma Centers and CRPC’s shall record and report the payor source for patient care on patient discharge. Final payment data shall be classed as self-pay, commercial insurance, Medicare, Medicaid, or worker compensation.

(c) Each trauma center and CRPC shall submit trauma registry data to be received no later than ninety (90) days after the end of each quarter.

(2) Confidentiality (a) T.C.A. § 68-11-259 provides for the confidentiality of data obtained from the reports of trauma patients.

(b) Information contained in the trauma registry that reasonably could be expected to reveal the identity of any patient or a reporting facility may not be made available to the public.

(c) Trauma registry responsibilities 1. The trauma registry shall take strict measures to ensure that all patient identifying information is treated as confidential and privileged.

Protection of report sources. Hospitals, laboratories, facilities, or health care practitioners who disclose trauma care data to the trauma registry or its employees in conformity with T.C.A. § 68-11-259 and rules and regulations promulgated thereto shall not be held liable for the release of such data to the department, unless the person or entity has knowledge of any falsity of the information reported or disclosed.

(d) Protection of patient identifying information obtained by special studies and other research studies.

All identifying information such as records of interviews, questionnaires, reports, statements, notes, and memoranda that are procured or prepared by employees or agents of the trauma registry shall be used solely for statistical, scientific and medical research purposes and shall be held strictly confidential by the trauma registry.
This applies also to identifying information procured by any other person, agency, or organization, including public or private colleges and universities acting jointly with the trauma registry in connection with special health studies and research investigations.

(3) Release of Data (a) Release of non-identifying information 1. To the general public:

(i) Public reports published by the trauma registry shall include aggregate, not patient identifying information or facility identifying information.

(ii) Information that would potentially identify a trauma patient shall not be published.

(iii) Non-identifying information may be made available to the general public upon request to the Commission.

(iv) The availability of any data shall depend upon the Commission’s financial or other ability to comply with such requests. The trauma registry shall respond to public requests as quickly as possible, subject to staffing constraints.

(b) Release of identifying information 1. Identifying information collected from any hospital, laboratory, facility, or health care practitioner may be released to qualified persons for the purposes of traumatic injury prevention, control, care, and research, provided that each request for identifying information completes the individual level data release forms and agreements as outlined in the individual level data release policy and receives prior approval by the department.

Identifying information that is collected solely by the trauma registry for its own special studies shall not be released.

(c) Annual Report. A statistical report shall be prepared at the completion of each year’s data collection cycle and will be distributed as requested.

(4) Request procedure for patient identifying information (a) Requests for identifying information shall be reviewed and approved by the Commission according to the policies of the Health Facilities Commission and the trauma registry.

(b) A detailed description of the procedures for requesting identifying information can be obtained from the trauma registry.

History

Authority: T.C.A. §§ 68-11-202, 68-11-209, and 68-11-259.
Administrative History: Original rule filed March 31, 1989; effective May 18, 1989. Amendment filed July 21, 1993; effective October 4, 1993. Repeal filed December 5, 2011; effective March 4, 2012. Repeal and new rules filed August 6, 2019; effective November 4, 2019. Transferred from chapter 1200-08-12 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed February 5, 2026; effective May 6, 2026.

Tenn. Comp. R. & Regs. 0720-22-.06 REPEALED

History

Authority: T.C.A. §§ 68-11-209 and 68-11-259.
Administrative History: New rule filed February 12, 2013; effective May 13, 2013. Repeal filed August 6, 2019; effective November 4, 2019. Transferred from chapter 1200-08-12 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-23 Standards for Residential Hospices (Transferred from 1200-08-15)

Tenn. Comp. R. & Regs. 0720-23-.01 DEFINITIONS

(1) Abuse. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) Administrator. An individual appointed by a governing body who is responsible for the day to day management of the hospice program.

(3) Adult. An individual who has capacity and is at least 18 years of age.

(5) Agent. An individual designated in an advance directive for health care to make a health care decision for the individual granting the power.

(6) Bereavement Counseling. Counseling services provided to the patient’s or resident’s family both prior to and after the patient’s or resident’s death.

(7) Bereavement Counselor. An individual who has at least a bachelor’s degree in social work, counseling, psychology, pastoral care, or specialized training or experience in bereavement theory and counseling.

(8) Board. The Tennessee Board for Licensing Health Care Facilities.

(9) Capacity. An individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. These regulations do not affect the right of a patient or resident to make health care decisions while having the capacity to do so. A patient or resident shall be presumed to have capacity to make a health care decision, to give or revoke an advance directive, and to designate or disqualify a surrogate. Any person who challenges the capacity of a patient or resident shall have the burden of proving lack of capacity.

(10) Cardiopulmonary Resuscitation (CPR). The administering of any means or device to support cardiopulmonary functions in a patient or resident, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilations or respirations, defibrillation, the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a patient or resident where cardiac or respiratory arrest has occurred or is believed to be imminent.

(11) Certified Master Social Worker. A person currently certified as such by the Tennessee Board of Social Worker Certification and Licensure.

(12) Clinical Fellow. A Speech Language Pathologist who is in the process of obtaining his or her paid professional experience, as defined by a Communications Disorders and Sciences Board-approved accreditation agency, before being qualified for licensure.

(13) Clinical Note. A written and dated notation containing a patient or resident assessment, responses to medications, treatments and services, and/or any changes in condition signed by a health team member who made contact with the patient or resident.

(14) Commissioner. The Commissioner of the Tennessee Department of Health or his or her authorized representative.

(15) Competent. A patient or resident who has capacity.

(16) Core Services. Services consisting of nursing, medical social services, physician services and counseling services.

(17) Department. The Tennessee Department of Health.

(19) Dietitian. A person currently licensed as such by the Tennessee Board of Dietitian/Nutritionist Examiners. Persons exempt from licensure shall be registered with the American Diabetics Association pursuant to T.C.A. § 63-25-204.

(20) Do-Not-Resuscitate Order (DNR). A written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(21) Emancipated Minor. Any minor who is or has been married or has by court order or otherwise been freed from the care, custody and control of the minor’s parents.

(22) Emergency Responder. A paid or volunteer firefighter, law enforcement officer, or other public safety official or volunteer acting within the scope of his or her proper function under law or rendering emergency care at the scene of an emergency.

(23) Guardian. A judicially appointed guardian or conservator having authority to make a health care decision for an individual.

(24) Hazardous Waste. Materials whose handling, use, storage, and disposal are governed by local, state, or federal regulations.

(25) Health Care. Any care, treatment, service or procedure to maintain, diagnose, treat, or otherwise affect an individual’s physical or mental condition, and includes medical care as defined in T.C.A. § 32-11-103(5).

(26) Health Care Decision. Consent, refusal of consent or withdrawal of consent to health care.

(27) Health Care Decision-Maker. In the case of a patient or resident who lacks capacity, the patient’s or resident’s health care decision-maker is one of the following: the patient’s or resident’s health care agent as specified in an advance directive, the patient’s or resident’s court-appointed guardian or conservator with health care decision-making authority, the patient’s or resident’s surrogate as determined pursuant to Rule 0720-23-.13 or T.C.A. § 33- 3-220, the designated physician pursuant to these rules or in the case of a minor child, the person having custody or legal guardianship.

(28) Health Care Institution. A health care institution as defined in T.C.A. § 68-11-1602.

(29) Health Care Provider. A person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care in the ordinary course of business or practice of a profession.

(30) HIV Resident. An individual who is in need of domiciliary care and who has been diagnosed and certified in writing by a licensed physician as being HIV (human immunodeficiency virus) positive.

(31) Home Care Organization. As defined by T.C.A. § 68-11-201 “home care organization” provides home health services, home medical equipment services or hospice services to patients on an outpatient basis in either their regular or temporary place of residence.

(32) Home Health Aide/Hospice Aide. A person who has completed a total of seventy-five (75) hours of training which included sixteen (16) hours of clinical training prior to or during the first three (3) months of employment and who is qualified to provide basic services, including simple procedures as an extension of therapy services, personal care regarding nutritional needs, ambulation and exercise.

(33) Hospice Care Clinical Coordinator. A person identified as being responsible for the clinical management of all aspects of a hospice program. The hospice clinical coordinator must have at least one (1) year of supervisory experience in hospice or home health care and be either a licensed physician or a registered nurse.

(34) Hospice Patient. An individual who:

(a) Has been diagnosed as terminally ill;

(b) Has been certified in writing by a physician to have an anticipated life expectancy of six (6) months or less; and, (c) Has voluntarily requested admission to, and been accepted by a licensed hospice.

(35) Hospice Services. As defined by T.C.A. § 68-11-201, “hospice services” means a coordinated program of care, under the direction of an identifiable hospice administrator, providing palliative and supportive medical and other services to hospice patients and their families in the patient’s regular or temporary place of residence. Hospice services shall be available twenty-four (24) hours a day, seven (7) days a week pursuant to the patient’s Hospice plan of care. A licensed hospice may provide services to a non-hospice patient; provided, that services to a non-hospice patient shall be limited to palliative care only.

(36) Incompetent. A patient or resident who has been adjudicated incompetent by a court of competent jurisdiction and has not been restored to legal capacity.

(37) Individual Instruction. An individual’s direction concerning a health care decision for the individual.

(39) Involuntary Transfer. The movement of a patient or resident without the consent of the resident, the resident’s legal guardian, next of kin or representative, with required notification to the appropriate agencies.

(40) Licensed Clinical Social Worker. A person currently licensed as such by the Tennessee Board of Social Workers.

(41) Licensed Practical Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(42) Licensed Psychologist. A person currently licensed as such by the Tennessee Board of Examiners in Psychology.

(43) Licensee. The person or entity to whom the license is issued. The licensee is held responsible for compliance with all rules and regulations.

(44) Life Threatening or Serious Injury. Injury requiring the patient to undergo significant additional diagnostic or treatment measures.

(45) Medical Director. A licensed physician employed by the residential hospice to be responsible for medical care in the facility.

(46) Medical Emergency. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s or resident’s health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or

part.

(47) Medical Record. Medical histories, records, reports, clinical notes, summaries, diagnoses, prognoses, records of treatment and medication ordered and given, entries, and other written electronics, or graphic data prepared, kept, made or maintained in an agency that pertains to confinement or services rendered to patients and residents.

(48) Medically Inappropriate Treatment. Resuscitation efforts that cannot be expected either to restore cardiac or respiratory function to the patient or resident or other medical or surgical treatments to achieve the expressed goals of the informed patient or resident. In the case of the incompetent patient or resident, the patient’s or resident’s representative expresses the goals of the patient or resident.

(49) Medical Social Services. When provided, shall be given by a certified master social worker, a licensed clinical social worker, or by a social worker or social work assistant employed by the residential hospice and under the supervision of a certified master social worker or licensed clinical social worker, and in accordance with the plan of care. The medical social services provider shall assist the physician and other team members in understanding the significant social and emotional factors related to the health problems, participate in the development of the plan of care, prepare clinical and progress notes, work with the family, utilize appropriate community resources, participate in discharge planning and in-service programs, and act as a consultant to other organization personnel.

(50) Misappropriation of Patient/Resident Property. The deliberate misplacement, exploitation or wrongful, temporary or permanent use of an individual’s belongings or money without the individual’s consent.

(51) Neglect. The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; however, the withholding of authorization for or provision of medical care to any terminally ill person who has executed an irrevocable living will in accordance with the Tennessee Right to Natural Death Law, or other applicable state law, if the provision of such medical care would conflict with the terms of the living will, shall not be deemed “neglect” for purposes of these rules.

(52) N.F.P.A. The National Fire Protection Association.

(53) Occupational Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(54) Occupational Therapy Assistant. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(55) Palliative. The reduction or abatement of pain or troubling symptoms by appropriate coordination of all elements of the hospice care team to achieve needed relief of distress.

(56) Person. An individual, corporation, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency, or instrumentality, or any other legal or commercial entity.

(57) Personally Informing. A communication by any effective means from the patient or resident directly to a health care provider.

(58) Pharmacist. A person currently licensed as such by the Tennessee Board of Pharmacy.

(59) Physical Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(60) Physical Therapist Assistant. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(61) Physician. An individual authorized to practice medicine or osteopathy under Tennessee Code Annotated, Title 63, Chapters 6 or 9.

(62) Physician Assistant. A person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(63) Physician Orders for Scope of Treatment or POST. Written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(64) Power of Attorney for Health Care. The designation of an agent to make health care decisions for the individual granting the power under T.C.A. Title 34, Chapter 6, Part 2.

(65) Qualified Emergency Medical Service Personnel. Includes, but shall not be limited to, emergency medical technicians, paramedics, or other emergency services personnel, providers, or entities acting within the usual course of their professions, and other emergency responders.

(66) Reasonably Available. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the patient’s or resident’s health care needs. Such availability shall include, but not be limited to, availability by telephone.

(67) Registered Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(68) Residential Hospice. A licensed homelike residential facility designed, staffed and organized to provide hospice and/or HIV care services, except such services shall be provided at such residential facility rather than the patient’s or resident’s regular or temporary place of residence. A residential hospice shall not provide hospice and/or HIV care services to any person other than a hospice and/or HIV resident.

(69) Respiratory Therapist. A person currently licensed as such by the Tennessee Board of Respiratory Care.

(70) Respiratory Therapy Technician. A person currently licensed as such by the Tennessee Board of Respiratory Care.

(71) Respite Care. A short-term period of inpatient care provided to a hospice patient only when necessary to relieve the family members or other persons caring for the patient.

(72) Secured Unit. A facility or distinct part of a facility where the residents are intentionally denied egress by any means.

(73) Shall or Must. Compliance is mandatory.

(74) Social Worker. An individual who has at least a bachelor’s degree from a school accredited or approved by the Council on Social Work Education and has one (1) year of social work experience in a health care setting.

(75) Social Work Assistant. A person who has a baccalaureate degree in social work, psychology, sociology, or other field related to social work, and has at least one (1) year of social work experience in a health care setting. Social work related fields include bachelor/masters degrees in psychology, sociology, human services (behavioral sciences, not human resources), masters degree in counseling fields (psychological guidance and guidance counseling) and degrees in gerontology.

(76) Speech Language Pathologist. As defined in T.C.A. § 63-17-103, a person currently licensed as such by the Tennessee Board of Communications Disorders and Sciences.

(77) Spiritual Counselor. A person who has met the requirements of a religious organization to serve the constituency of that organization.

(78) State. A state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States.

(79) Student. A person currently enrolled in a course of study that is approved by the appropriate licensing board or equivalent body.

(80) Supervising Health Care Provider. The designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual’s health care.

(81) Supervision. Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity with initial direction and periodic inspection of the actual act of accomplishing the function or activity. Periodic supervision must be provided if the person is not a licensed or certified assistant, unless otherwise provided in accordance with these regulations.

(82) Surrogate. An individual, other than a patient’s or resident’s agent or guardian, authorized to make a health care decision for the patient or resident.

(83) Terminally Ill. An individual with a medical prognosis that his or her life expectancy is six (6) months or less if the illness runs its normal course.

(84) Transfer. The movement of a patient or resident at the direction of a physician or other qualified medical personnel when a physician is not readily available, but does not include such movement of a patient or resident who leaves the facility against medical advice.

(85) Treating Health Care Provider. A health care provider who at the time is directly or indirectly involved in providing health care to the patient or resident.

(86) Volunteer. An individual who agrees to provide services to a hospice care patient or HIV resident and/or family member(s), without monetary compensation, with appropriate supervision by the facility.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11- 207, 68-11-209, 68-11-210, 68-11-211, 68-11-213, 68-11-224, and 68-11-1802.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed April 28, 2003; effective July 12, 2003. Amendments filed November 22, 2005; effective February 5, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendment filed September 15, 2015; effective December 14, 2015. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.02 LICENSING PROCEDURES

(1) No person, partnership, association, corporation, or state, county or local government unit, or any division, department, board or agency thereof, shall establish, conduct, operate, or maintain in the State of Tennessee any residential hospice without having a license. A license shall be issued to the person or persons named and for the premises listed in the application for licensure and for the geographic areas specified by the certificate of need or at the time of the original licensing. The name of the residential hospice shall not be changed without first notifying the department in writing. Licenses are not transferable or assignable and shall expire and become invalid annually on the anniversary date of their original issuance. The license shall be conspicuously posted in the residential hospice.

(2) In order to make application for a license:

(a) The applicant shall submit an application on a form prepared by the department.

(b) Each applicant for a license shall pay an annual license fee based on the number of beds as follows:

Less than 25 beds $1,040.00 2. 25 to 49 beds, inclusive $1,333.00 3. 50 to 74 beds, inclusive $1,593.00 4. 75 to 99 beds, inclusive $1,853.00 5. 100 to 124 beds, inclusive $2,133.00 6. 125 to 149 beds, inclusive $2,373.00 7. 150 to 174 beds, inclusive $2,633.00 8. 175 to 199 beds, inclusive $2,893.00 For a residential hospice of two hundred (200) beds or more the fee shall be two thousand eight hundred and ninety-three dollars ($2,893.00) plus two hundred dollars ($200.00) for each twenty-five (25) beds or fraction thereof in excess of one hundred ninety-nine (199) beds. The fee shall be submitted with the application or renewal and is not refundable.

(c) The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the department. Patients or residents shall not be admitted to the residential hospice until a license has been issued. Applicants shall not hold themselves out to the public as being a residential hospice until the license has been issued. A license shall not be issued until the residential hospice is in substantial compliance with these rules and regulations, including submission of all information required by T.C.A. § 68-11-206(l) or as later amended, and all information required by the Commissioner.

(d) The applicant must prove the ability to meet the financial needs of the residential hospice.

(f) The applicant shall allow the residential hospice to be inspected by a Department surveyor. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action to the Board that must be accepted by the Board. Once the deficiencies have been corrected, then the Board shall consider the application for licensure.

(a) For the purposes of licensing, the licensee of a residential hospice has the ultimate responsibility for the operation of the residential hospice, including the final authority to make or control operational decisions and legal responsibility for the business management. A change of ownership occurs whenever this ultimate legal authority for the responsibility of the residential hospice’s operation is transferred.

(b) A change of ownership occurs whenever there is a change in the legal structure by which the residential hospice is owned and operated.

Transfer of the residential hospice’s legal title;
Lease of the residential hospice’s operations;
Dissolution of any partnership that owns, or owns a controlling interest in, the residential hospice;
One partnership is replaced by another through the removal, addition or substitution of a partner;
Removal of the general partner or general partners, if the residential hospice is owned by a limited partnership;
Merger of a residential hospice owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are canceled;
The consolidation of a corporate residential hospice owner with one or more corporations; or, 8. Transfers between levels of government.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors or board of trustees;
Two (2) or more corporations merge and the originally-licensed corporation survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government; or, 5. Corporate stock transfers or sales, even when a controlling interest.

(e) Management agreements are generally not changes of ownership if the owner continues to retain ultimate authority for the operation of the residential hospice.

However, if the ultimate authority is surrendered and transferred from the owner to a new manager, then a change of ownership has occurred.

(f) Sale/lease-back agreements shall not be treated as changes in ownership if the lease involves the residential hospice’s entire real and personal property and if the identity of the lessee, who shall continue the operation, retains the exact same legal form as the former owner.

(4) Renewal.

(a) In order to renew a license, each residential hospice shall submit to periodic inspections by Department surveyors for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action and shall remedy the deficiencies. In addition, each licensee shall submit a renewal form approved by the board and applicable renewal fee prior to the expiration date of the license.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late; provided that the late penalty shall not exceed twice the renewal fee.

A completed application for licensure;
The license fee provided in Rule 0720-23-.02(2)(b); and 3. Any other information required by the Health Services and Development Agency.

(d) Upon reapplication, the licensee shall submit to an inspection of the facility by Department of Health surveyors.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-206(a)(5) [effective January 1, 2009], 68-11-209, 68-11-209(a)(1), 68-11-210, and 68-11-216 and Chapter 846 of the Public Acts of 2008, § 1.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed November 19, 2003; effective February 2, 2004. Amendment filed January 19, 2007; effective April 4, 2007. Public necessity rules filed April 29, 2009; effective through October 11, 2009. Emergency rules filed October 9, 2009; effective through April 7, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed March 26, 2019; effective June 24, 2019. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.03 DISCIPLINARY PROCEDURES

(1) The board may suspend or revoke a license for:

(a) Violation of federal or state statutes;

(b) Violation of the rules as set forth in this chapter;

(d) Conduct or practice found by the board to be detrimental to the health, safety, or welfare of the patients or residents of the residential hospice; or (e) Failure to renew the license.

(2) The board may consider all factors which it deems relevant, including but not limited to the following when determining sanctions:

(a) The degree of sanctions necessary to ensure immediate and continued compliance;

(b) The character and degree of impact of the violation on the health, safety and welfare of the patients in the residential hospice;

(c) The conduct of the residential hospice in taking all feasible steps or procedures necessary or appropriate to comply or correct the violation; and, (d) Any prior violations by the residential hospice of statutes, regulations or orders of the board.

(3) When a facility is found by the department to have committed a violation of this chapter, the department will issue to the facility a statement of deficiencies. Within ten (10) days of the receipt of the statement of deficiencies the facility must return a plan of correction indicating the following:

(a) How the deficiency will be corrected;

(b) The date upon which each deficiency will be corrected;

(4) Either the failure to submit a plan of correction in a timely manner or a finding by the department that the plan of correction is unacceptable shall subject the facility’s license to possible disciplinary action.

(5) Any licensee or applicant for a license aggrieved by a decision or action of the department or board pursuant to this chapter may request a hearing before the board. The proceedings and judicial review of the board’s decision shall be in accordance with the Uniform Administrative Procedures Act, T.C.A. §§ 4-5-101, et seq.

(6) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to Rule

Tenn. Comp. R. & Regs. 0720-23-.04 ADMINISTRATION

(1) The residential hospice shall have a full-time (working at least 32 hours per week) administrator. Any change of administrators shall be reported in writing to the department within fifteen (15) days. The administrator shall designate in writing an individual to act in his/her absence in order to provide the residential hospice with administrative direction at all times. The administrator shall assure the provision of appropriate fiscal resources and personnel required to meet the needs of the patients and/or residents.

(2) The residential hospice must organize, manage, and administer its hospice and HIV care services to attain and maintain the highest obtainable quality of life for each patient and resident in a manner consistent with acceptable standards of practice.

(3) The residential hospice shall ensure a framework for addressing issues related to care at the end of life.

(4) The residential hospice 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) A residential hospice may contract for another individual or entity to furnish services, other than core services, to the residential hospice’s patients or HIV residents. If services are provided under agreement or contract, the residential hospice must meet the following standards:

(a) Continuity of care. The residential hospice assures the continuity of resident and patient/family care.

(b) Written agreement. The residential hospice has a legally binding written agreement for the provision of contracted hospice services. The agreement must include at least the following:

Identification of the services to be provided.
A stipulation that services may be provided only with the express authorization of the residential hospice.
The manner in which the contracted services are coordinated, supervised, and evaluated by the residential hospice.
The delineation of the role(s) of the residential hospice and the contractor in the admission process, resident and patient/family assessment, and the interdisciplinary group care conferences.
Requirements for documenting that services are furnished in accordance with the agreement.
The qualifications of the personnel providing the services.

(c) Professional management responsibility. The residential hospice 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

part, and in accordance with the patient’s and/or HIV resident’s plan of care and the other requirements of this part.

(d) Financial responsibility. The residential hospice retains responsibility for payment for services.

(8) The facility shall make reasonable efforts to safeguard personal property and promptly investigate complaints of such loss. A record shall be prepared of all clothing, personal possessions, and money brought by the patient and/or HIV resident to the residential hospice at the time of admission. The record shall be filled out in duplicate. One copy of the record shall be given to the patient or resident or the patient’s or resident’s representative and the original shall be maintained in the residential hospice record. This record shall be updated as additional personal property is brought to the facility.

(9) If the facility keeps patient or resident funds, such funds shall be kept in an account separate from the facility’s funds. Patient or resident funds shall not be used by the facility. The facility shall maintain and allow each patient or resident access to a written record of all financial arrangements and transactions involving the individual patient’s or resident’s funds. The facility shall provide each patient and resident or his/her representative with a written itemized statement at least quarterly of all financial transactions involving the patient’s or resident’s funds.

(10) Within thirty (30) days of a patient’s or resident’s death, the facility shall provide an accounting of the patient’s or resident’s funds held by the facility and an inventory of the patient’s or resident’s personal property held by the facility to the patient’s or resident’s executor, administrator or other person authorized by law to receive the decedent’s property.

The facility shall obtain a signed receipt from any person to whom the decedent’s property is transferred.

(11) Upon the sale of the facility, the seller shall provide written verification that all the patient’s or resident’s funds and property have been transferred and shall obtain a signed receipt from the new owner. Upon receipt, the buyer shall provide, to the patients and resident’s, an accounting of funds and property held on their behalf.

Documentation that references were verified shall be on file. Adequate medical screenings to exclude communicable disease shall be required of each employee.

(13) 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. A residential hospice which violates a required policy also violates the rule and regulation establishing the requirement.

(14) Policies and procedures shall be consistent with professionally recognized standards of practice.

(15) No residential hospice 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, the long term care ombudsman, the Comptroller of the State Treasury, or any government agency. A residential hospice 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.

(16) Each residential hospice shall adopt safety policies for the protection of patients and residents from accident and injury.

(17) A record pertaining to the payment agreement between the residential hospice and the patient or resident shall be accomplished prior to admission. A copy of the agreement record shall be given to the patient or resident and the original shall be maintained in the facility’s records.

(18) 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;

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.

History

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, 68-11-268, and 71-6-121.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 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. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.05 ADMISSIONS, DISCHARGES, AND TRANSFERS

(1) The residential hospice shall have a policy to admit only patients who meet the following criteria, or HIV care residents:

(a) Has been diagnosed as terminally ill;

(b) Has been certified by a physician, in writing, to have an anticipated life expectancy of six (6) months or less;

(c) Has personally, or through a representative, voluntarily requested admission to and been accepted by a licensed residential hospice; and (d) Has personally or through a representative, in writing, given informed consent to receive hospice care.

(2) Patients shall be admitted to receive hospice services or residents admitted to receive HIV care on the basis of a reasonable expectation that the patient’s or resident’s medical, nursing and psychosocial needs can be met adequately by the residential hospice.

(3) Care shall follow a written plan of care established and reviewed by the attending physician, the medical director, or the physician’s designee and the interdisciplinary group. Care shall continue under the supervision of the attending physician.

(4) The residential hospice staff shall determine that the patient’s or resident’s needs can be met by the facility’s services and capabilities.

(5) Every person admitted for care or treatment to any residential hospice covered by these rules shall be under the supervision of a physician who holds a license in good standing to practice in Tennessee. The name of the patient’s attending physician shall be recorded in the patient’s medical record.

(6) The residential hospice staff shall obtain the patient’s or resident’s written consent for hospice or HIV care services.

(7) The signed consent form shall be included with the patient’s or resident’s individual clinical record.

(8) A diagnosis must be entered in the admission records of the residential hospice for every person admitted for care or treatment.

(9) Any admission in excess of the licensed bed capacity is prohibited except when an emergency admission is approved by the department.

(10) A medical record shall be developed and maintained for each patient or resident admitted.

(11) No patient or resident shall be discharged without a written order from the attending physician or the medical director stating the patient does not meet hospice criteria or the resident does not meet HIV care criteria, or through other legal processes, and timely notification of next of kin and/or the authorized representative.

(12) When a patient or resident is discharged, a summary of the significant findings and events of the patient’s or resident’s care, the patient’s or resident’s condition on discharge and the recommendation and arrangement for future care, if any, is required.

(13) When a patient or resident is transferred, a summary of treatment given at the residential hospice, condition of the patient or resident at time of transfer and date and place to which he is transferred shall be entered in the record. If the transfer is due to an emergency, this information will be recorded within forty-eight (48) hours, otherwise, it will precede the transfer of the patient or resident.

(14) When a patient or resident is transferred, a copy of the clinical summary shall, with consent of the patient or resident, be sent to the facility that will continue the care of the patient or resident.

(15) Except when the Board has revoked or suspended the license, a residential hospice which intends to close, cease doing business, or reduce its licensed bed capacity by ten percent (10%) or more, shall notify the Department at the earliest moment of the decision, but not later than thirty (30) days before the action is to be implemented. The facility shall establish a protocol, subject to the Department’s approval, for the transfer or discharge of the patients and/or residents. Should the residential hospice violate the provisions of this subsection, the department shall request the Attorney General of the State of Tennessee to intervene to protect the patients and/or residents, as is provided by T.C.A. § 68-11-213(a).

(16) The residential hospice shall ensure that no person on the grounds of race, color, national origin, or handicap, will be excluded from participation in, be denied benefits of, or otherwise subjected to discrimination in the provision of any care or service of the residential hospice.

The residential hospice shall protect the civil rights of patients and residents under the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

(17) Facilities utilizing secured units must be able to provide survey staff with twelve (12) months of the following performance information specific to the secured unit and its residents:

(a) Documentation that each secured patient or resident has been evaluated by an interdisciplinary team consisting of at least a physician, a social worker, a registered nurse, and a family member and/or significant other (or patient care advocate) prior to admittance to the unit;

(b) Ongoing and up-to-date documentation of quarterly review by each patient or resident’s interdisciplinary team as to the appropriateness of placement in the secured unit;

(d) A current listing of all unusual incidents and/or complications on the unit;

(e) An up-to-date staffing pattern and staff ratios for the unit that is recorded on a daily

basis. The staffing pattern must ensure that there is a minimum of one (1) attendant, awake, on duty, and physically located on the unit twenty-four (24) hours per day, seven (7) days per week at all times;

(f) A formulated calendar of daily group activities scheduled including a resident attendance record for the previous three (3) months;

Basic facts about the causes, progression and management of Alzheimer’s Disease and related disorders;
Dealing with dysfunctional behavior and catastrophic reactions in the residents;
Identifying and alleviating safety risks to the resident;
Providing assistance in the activities of daily living for the resident; and, 5. Communicating with families and other persons interested in the resident.

(18) Any residential facility licensed by the board of licensing health care facilities shall upon admission provide to each resident the division of adult protective services’ statewide toll-free number: 888-277-8366.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 71- 6-121.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed April 20, 2006; effective July 4, 2006. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.06 BASIC HOSPICE FUNCTIONS

(1) Core Functions. A residential hospice must ensure that substantially all core services are routinely provided directly by hospice employees. A residential hospice may use contracted staff if necessary to supplement residential hospice employees in order to meet the needs of patients and residents.

(a) Nursing services. The residential hospice must provide nursing care and services by, or under the supervision of, a registered nurse (R.N.) at all times.

Nursing services must be directed and staffed to assure the nursing needs of patients and residents are met.
Patient and resident care responsibilities of nursing personnel must be specified.
Hospice services and HIV care services must be provided in accordance with recognized standards of practice.
Nursing services include the authorization of a Registered Nurse to pronounce the death of a patient or resident.

(b) Medical Social Services. Medical Social Services must be provided by a qualified social worker under the direction of a physician.

(c) Physician Services. In addition to palliation and management of terminal illness and related conditions and HIV care, physician employees of the residential hospice including the physician member(s) of the interdisciplinary group, must also meet the general medical needs of the patients and residents to the extent these needs are not met by the attending physician.

(d) Counseling Services. Counseling services must be made available to both the individual and the family. Counseling includes bereavement counseling, provided both prior to and after the patient’s or resident’s death, as well as dietary, therapeutic, spiritual and may include any other counseling services identified in the plan of care for the individual and family provided while the individual is a patient or resident of the residential hospice.

Bereavement counseling. There must be an organized program for the provision of bereavement services under the supervision of a qualified professional. The plan of care for these services should reflect family needs, services to be provided, and the frequency of services.
Dietary counseling. Dietary counseling, when required, must be provided by a qualified individual.
Spiritual counseling. Spiritual counseling must include notice to patients as to the availability of clergy.
Additional counseling. Counseling may be provided by other members of the interdisciplinary group as well as by other qualified professionals as determined by the residential hospice.

(2) Plan of Care.

A written plan of care must be established and maintained for each individual admitted to a residential hospice, and the care provided to an individual must be in accordance with the plan.

(a) Establishment of plan. The plan must be established by the attending physician, the medical director or the physician’s designee and the interdisciplinary group prior to providing care.

(b) Review of plan. The plan must be reviewed and updated as the patient’s condition changes, but at intervals of no more than fifteen (15) days, by the attending physician, the medical director or the physician’s designee and the interdisciplinary group. These reviews must be documented.

(c) Content of plan. The plan must include an assessment of the individual’s needs and identification of the HIV care services or hospice services required including the management of discomfort and symptom relief. It must state in detail the scope and frequency of services needed to meet the patient’s or resident’s and family’s needs.

(3) Interdisciplinary Group.

The organization providing hospice services must designate an interdisciplinary group and groups composed of individuals who provide or supervise the care and services offered by the residential hospice:

(a) Composition of Group. The residential hospice must have an interdisciplinary group or groups that include at least the following individuals who are employees of the residential hospice:

A doctor of medicine or osteopathy;
A registered nurse;
A social worker; and 4. A pastoral or other counselor.

(b) Role of Group. The interdisciplinary group is responsible for:

Participation in the establishment of the plan of care;
Provision or supervision of the quality of hospice care and services and/or HIV care services;
Periodic review and updating of the plan of care for each individual receiving hospice care or HIV care; and 4. Establishing and maintaining policies governing the day-to-day provision of hospice care and services and/or HIV care and services.

(c) If a residential hospice has more than one interdisciplinary group, it must designate in advance the group it chooses to execute the functions described in paragraph (b)4. of this section.

(d) Coordinator. The residential hospice must designate a registered nurse to coordinate the implementation of the plan of care of each patient and/or resident.

(e) Volunteers. The residential hospice may use volunteers, in defined roles, under the supervision of a designated residential hospice employee.

Training. The residential hospice must provide appropriate orientation and training that is consistent with acceptable standards of residential hospice practice.
Role. Volunteers may be used in administrative or direct patient or resident care roles.
Recruiting and retaining. The hospice must document active and ongoing efforts to recruit and train volunteers.
Availability of clergy. The residential hospice must make reasonable efforts to arrange for visits of clergy and other members of religious organizations in the community to patients or residents who request such visits and must advise patients and/or residents of this opportunity.

(4) Continuation of Care. A residential hospice must assist in coordinating continued care should the patient or resident be transferred or discharged from the residential hospice.

(5) Drug and Treatments. Drugs and treatments shall be administered by appropriately licensed facility personnel acting within the scope of their license. Oral orders for drugs and treatments shall be given to appropriately licensed personnel acting within the scope of their licenses, immediately recorded, signed and dated, and countersigned and dated by the physician.

(6) Performance Improvement Program. The residential hospice must ensure that there is an effective facility-wide performance improvement program to evaluate resident care and performance of the organization. The performance improvement program must be ongoing and have a written plan of implementation which assures that:

(a) All organized services related to resident care, including services furnished by a contractor, are evaluated;

(b) Nosocomial infections and medication therapy are evaluated;

(d) The residential hospice must have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically related needs of its patients and/or HIV care residents;

(e) The facility must develop and implement plans for improvement to address deficiencies identified by the performance improvement program and must document the outcome of the remedial action;

(f) Performance improvement program records are not disclosable except when such disclosure is required to demonstrate compliance with this section;

(g) Good faith attempts by the Performance Improvement Program Committee to identify and correct deficiencies will not be used as a basis for sanctions.

(7) Infection Control.

(a) The residential hospice must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.

(b) The administrator shall assure that an infection control committee, including the medical director and members of the nursing staff and administrative staff, develops guidelines and techniques for the prevention, surveillance, control and reporting of facility infections. Duties of the committee shall include the establishment of:

Written infection control policies;
Techniques and systems for identifying, reporting, investigating and controlling infections in the facility;
Written procedures governing the use of aseptic techniques and procedures in the facility;
Written procedures concerning food handling, laundry practices, disposal of environmental and patient and/or resident wastes, traffic control and visiting rules, sources of air pollution, and routine culturing of autoclaves and sterilizers;
A log of incidents related to infectious and communicable diseases;
Formal provisions to educate and orient all appropriate personnel in the practice of aseptic techniques such as handwashing, proper grooming, masking and dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of patient and/or resident equipment and supplies; and, 7. Continuing education for all facility personnel on the cause, effect, transmission, prevention, and elimination of infections.

(c) The administrator, the medical director and a registered nurse must ensure that the facility-wide performance improvement program and training programs address problems identified by the infection control program and must be responsible for the implementation of successful corrective action plans in affected problem areas.

(d) The facility shall develop policies and procedures for testing a patient’s or resident’s blood for the presence of the hepatitis B virus and the HIV (AIDS) virus in the event that an employee of the facility, a student studying at the facility, or other health care provider rendering services at the facility is exposed to a patient’s or resident’s blood or other body fluid. The testing shall be performed at no charge to the patient or resident, and the test results shall be confidential.

(e) The facility and its employees shall adopt and utilize standard or universal precautions for preventing transmission of infections, HIV, and communicable diseases.

(f) A Residential Hospice shall have an annual influenza vaccination program which shall include at least:

The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Residential Hospice will encourage all staff and independent practitioners to obtain an influenza vaccination;
A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider);
Education of all employees about the following:

(i) Flu vaccination, (ii) Non-vaccine control measures, and (iii) The diagnosis, transmission, and potential impact of influenza;

An annual evaluation of the influenza vaccination program and reasons for nonparticipation; and 5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee.

(g) Every residential hospice 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.

(h) Precautions shall be taken to prevent the contamination of sterile supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents. Decontamination and preparation areas shall be separated.

(i) Space and facilities for housekeeping equipment and supply storage shall be provided in each service area. Storage for bulk supplies and equipment shall be located away from patient and resident care areas. The building shall be kept in good repair, clean, sanitary and safe at all times.

(j) The facility shall appoint a housekeeping supervisor who shall be responsible for:

Organizing and coordinating the facility’s housekeeping service;
Acquiring and storing sufficient housekeeping supplies and equipment for facility maintenance; and, 3. Assuring the clean and sanitary condition of the facility to provide a safe hygienic environment for patients and/or residents and staff. Cleaning shall be accomplished in accordance with the infection control rules and regulations herein and facility policy.

(k) Laundry facilities located in the residential hospice shall:

Be equipped with an area for receiving, processing, storing and distributing clean linen;
Be located in an area that does not require transportation for storage of soiled or contaminated linen through food preparation, storage or dining areas;
Provide space for storage of clean linen and for bulk storage within clean areas of the facility; and, 4. Provide carts, bags or other acceptable containers appropriately marked to identify those used for soiled linen and those used for clean linen to prevent dual utilization of the equipment and cross contamination.

(l) The facility shall name an individual who is responsible for laundry service. This individual shall be responsible for:

Establishing a laundry service, either within the residential hospice or by contract, that provides the facility with sufficient clean, sanitary linen at all times;
Knowing and enforcing infection control rules and regulations for the laundry service;
Assuring the collection, packaging, transportation and storage of soiled, contaminated, and clean linen is in accordance with all applicable infection control rules, regulations and procedures; and, 4. Assuring that a contract laundry service complies with all applicable infection control rules, regulations and procedures.

(8) Hospice Aide Services. Aide Services must be available and adequate in frequency to meet the needs of the patients.

(a) The hospice aide shall be assigned to a particular patient or resident by a registered nurse. Written instructions for patient or resident care shall be prepared by a registered nurse or therapist as appropriate. Duties may include the performance of simple procedures as an extension of therapy services, personal care, ambulation and exercises, reporting changes in the patient’s or resident’s condition and needs, and completing appropriate records.

(b) The registered nurse, or appropriate professional staff member, shall monitor and assess the hospice aide’s competence in providing care, relationships and determine whether goals are being met.

(c) There shall be regularly scheduled continuing in-service programs which include onthe-job training as issues are identified.

(9) Physical therapy, occupational therapy, respiratory therapy and speech language pathology.

(a) Physical therapy services, occupational therapy services, respiratory therapy services and speech language pathology services must be available, and when provided, offered in a manner consistent with accepted standards of practice.

Tenn. Comp. R. & Regs. 0720-23-.07 RESERVED

Administrative History: Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.08 BUILDING STANDARDS

(1) A residential hospice shall construct, arrange, and maintain the condition of the physical plant and the overall residential hospice environment in such a manner that the safety and wellbeing of the patients are assured.

(3) The codes in effect at the time of submittal of plans and specifications, as defined by these rules, shall be the codes to be used throughout the project.

(4) The licensed contractor shall perform all new construction and renovations to residential hospices, other than minor alterations not affecting fire and life safety or functional issues, in accordance with the specific requirements of these regulations governing new construction in residential hospices, including the submission of phased construction plans and the final drawings and the specifications to each.

(5) No new residential hospice shall be constructed, nor shall major alterations be made to an existing resident hospice without prior written approval of the department, and unless in accordance with plans and specifications approved in advance by the department. Before any new residential hospice is licensed or before any alteration or expansion of a licensed residential hospice can be approved, the applicant must furnish two (2) complete sets of plans and specifications to the department, together with fees and other information as required. Plans and specifications for new construction and major renovations, other than minor alterations not affecting fire and life safety or functional issues, shall be prepared by or under the direction of a licensed architect and/or a licensed engineer and in accordance with the rules of the Board of Architectural and Engineering Examiners.

(a) The project architect or engineer shall forward two (2) sets of plans to the appropriate

(b) Review of plans does not eliminate responsibility of owner and/or architect to comply with all rules and regulations.

(8) Specifications shall supplement all drawings. They shall describe the characteristics of all materials, products and devices, unless fully described and indicated on the drawings.

Specification copies should be bound in an 8½ x 11 inch folder.

(9) Drawings and specifications shall be prepared for each of the following branches of work:

Architectural, Structural, Mechanical, Electrical and Sprinkler.

(10) Architectural drawings shall include where applicable:

(a) Plot plan(s) showing property lines, finish grade, location of existing and proposed structures, roadways, walks, utilities and parking areas;

(b) Floor plan(s) showing scale drawings of typical and special rooms, indicating all fixed and movable equipment and major items of furniture;

(d) The elevation of each facade;

(e) The typical sections throughout the building;

(f) The schedule of finishes;

(g) The schedule of doors and windows;

(h) Roof plans;

(i) Details and dimensions of elevator shaft(s), car platform(s), doors, pit(s), equipment in the machine room, and the rates of car travel must be indicated for elevators; and (j) Code analysis.

(11) Structural drawings shall include where applicable:

(a) Plans of foundations, floors, roofs and intermediate levels which show a complete design with sizes, sections and the relative location of the various members;

(b) Schedules of beams, girders and columns; and (c) Design live load values for wind, roof, floor, stairs, guard, handrails, and seismic.

(12) Mechanical drawings shall include where applicable:

(a) Specifications which show the complete heating, ventilating, fire protection, medical gas systems and air conditioning systems;

(b) Water supply, sewerage and HVAC piping systems;

(d) Heating, ventilating, HVAC piping, medical gas systems and air conditioning systems with all related piping and auxiliaries to provide a satisfactory installation;

(13) Electrical drawings shall include where applicable:

(a) A seal, certifying that all electrical work and equipment is in compliance with all applicable codes and that all materials are currently listed by recognized testing laboratories;

(d) Color coding to show all items on emergency power;

(14) The electrical drawings shall not include knob and tube wiring, shall not include electrical cords that have splices, and shall not show that the electrical system is overloaded.

(15) In all new facilities or renovations to existing electrical systems, the installation must be approved by an inspector or agency authorized by the State Fire Marshal.

(16) Sprinkler drawings shall include where applicable:

(a) Shop drawings, hydraulic calculations, and manufacturer cut sheets;

(17) The licensed contractor shall not install a system of water supply, plumbing, sewage, garbage or refuse disposal nor materially alter or extend any existing system until the architect or engineer submits complete plans and specifications for the installation, alteration or extension to the department demonstrating that all applicable codes have been met and the department has granted necessary approval.

(a) Before the residential hospice is used, Tennessee Department of Environment and Conservation shall approve the water supply system.

(18) It shall be demonstrated through the submission of plans and specifications that in each residential hospice a negative air pressure shall be maintained in the soiled utility area, toilet room, janitor’s closet, dishwashing and other such soiled spaces, and a positive air pressure shall be maintained in all clean areas including, but not limited to, clean linen rooms and clean utility rooms.

(20) In the event submitted materials do not appear to satisfactorily comply with 0720-23-.08(2), the department shall furnish a letter to the party submitting the plans which shall list the particular items in question and request further explanation and/or confirmation of necessary modifications.

(21) The licensed contractor shall execute all construction in accordance with the approved plans and specifications.

(22) If construction begins within one hundred eighty (180) days of the date of department approval, the department’s written notification of satisfactory review constitutes compliance with 0720-23-.08(2). This approval shall in no way permit and/or authorize any omission or deviation from the requirements of any restrictions, laws, regulations, ordinances, codes or rules of any responsible agency.

(24) The department requires the following alarms that shall be monitored twenty-four (24) hours per day:

(a) Fire alarms; and (b) Generators (if applicable).

(25) Each residential hospice shall ensure that an emergency keyed lock box is installed next to each bank of functioning elevators located on the main level. Such lock boxes shall be permanently mounted seventy-two inches (72”) from the floor to the center of the box, be operable by a universal key no matter where such box is located, and shall contain only fire service keys and drop keys to the appropriate elevators.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-261.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed February 18, 2003; effective May 4, 2003. Repeal and new rule filed November 22, 2005; effective February 5, 2006. Amendment filed February 23, 2007; effective May 9, 2007. Repeal and new rule filed December 20, 2011; effective March 19, 2012. Amendment filed January 21, 2016; effective April 20, 2016. Transferred from chapter 1200-08- 15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-202, 68-11-204, and 68-11-206 through 68-11-209.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed March 1, 2007; effective May 15, 2007. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1370-01-.10 .

(10) Medical supplies. Medical supplies and appliances including drugs and biologicals, must be provided as needed for the palliation and management of the terminal illness or conditions directly attributable to the terminal diagnosis.

(a) Administration. All drugs and biologicals must be administered in accordance with accepted standards of practice, only by appropriately licensed employees of the hospice.

(b) The residential hospice must have a policy for the disposal of controlled drugs when those drugs are no longer needed by the patient.

(c) Drugs and biologicals may be administered by the patient or resident or his/her family member if the patient’s or resident’s attending physician has approved.

(11) Medical Records.

(a) A medical record containing past and current findings in accordance with accepted professional standards shall be maintained for every residential hospice patient and/or HIV care resident. The record must be complete, promptly and accurately documented, readily accessible and systematically organized to facilitate retrieval. Each clinical record is a comprehensive compilation of information. Entries are made for all services provided. Entries are made and signed by the person providing the services. The record includes all services whether furnished directly or under arrangements made by the hospice. Each individual’s record must contain:

The initial and subsequent assessments;
The plan of care;
Identification data;
Consent and authorization and election forms;
Pertinent medical history; and 6. Complete documentation of all services and events, including but not limited to evaluations, treatments and progress notes.

(b) All medical records, either written, electronic, graphic or otherwise acceptable form, must be retained in their original or legally reproduced form for a minimum period of at least (10) years after which such records may be destroyed. However, in cases of patients or residents under mental disability or minority, their complete residential hospice records shall be retained for the period of minority or known mental disability, plus one (1) year, or ten (10) years following the discharge of the patient or resident, whichever is longer. Records destruction shall be accomplished by burning, shredding or other effective method in keeping with the confidential nature of the contents. The destruction of records must be made in the ordinary course of business, must be documented and in accordance with the residential hospice’s policies and procedures, and no record may be destroyed on an individual basis.

(c) Even if the residential hospice discontinues operations, records shall be maintained as mandated by these rules and the Tennessee Medical Records Act (see T.C.A. § 68-11- 308). If a patient or resident is transferred to another health care facility or agency, a copy of the record or an abstract shall accompany the patient or resident when the residential hospice is directly involved in the transfer.

(d) The residential hospice must have a procedure for ensuring the confidentiality of patient and resident records. Information from, or copies of, records may be released only to authorized individuals, and the facility must ensure that unauthorized individuals cannot gain access to, or alter, patient or resident records. Original medical records must be released by the facility only in accordance with federal and state laws.

(e) For purposes of this rule, the requirements for signature or countersignature by a physician or other person responsible for signing, countersigning and entry may be satisfied by the electronic entry by such person of a unique code assigned exclusively to him or her, or by entry of other unique electronic or mechanical symbols, provided that such person has adopted same as his or her signature in accordance with established protocol or rules.

(f) All entries must be legible, complete, dated and authenticated according to facility policy.

(12) Pharmaceutical Services.

(a) The residential hospice shall have pharmaceutical services that meet the needs of the residents and are in accordance with the Tennessee Board of Pharmacy statutes and regulations. The facility is responsible for developing policies and procedures that minimize drug errors.

(b) Test reagents, germicides, and disinfectants shall be stored separately from drugs, devices and related materials. External drugs and related materials must be stored separately from internal drugs, devices and related materials. All drugs, devices and related materials must be properly labeled. They shall be properly stored in medicine compartments, including cabinets on wheels, or drug rooms. Such cabinets or drug rooms shall be kept securely locked when not in use and the key must be in the possession of the supervising nurse or other authorized persons.

(c) Schedule II drugs must be stored behind two (2) separately locked doors at all times and accessible only to persons in charge of administering medication.

(d) Every residential hospice shall comply with all state and federal regulations governing Schedule II drugs.

(e) A notation shall be made in a Schedule II drug book and in the patient’s or resident’s nursing notes each time a Schedule II drug is given. The notation shall include the name of the patient or resident receiving the drug, name of the drug, the dosage given, the method of administration, the date and time given and the name of the physician prescribing the drug.

(f) All oral orders shall be immediately recorded, designated as such and signed by the person receiving them and countersigned by the physician within ten (10) days.

(g) All orders for drugs, devices and related materials must be in writing and signed by the practitioner or practitioners responsible for the care of the patient or resident. Electronic and computer-generated records and signature entries are acceptable. When telephone or oral orders must be used, they shall be:

Accepted only by personnel that are authorized to do so by the medical staff policies and procedures, consistent with federal and state law; and, 2. Signed or initialed by the prescribing practitioner according to residential hospice policy.

(i) Medication administration records (MAR) shall be checked against the physician’s orders. Each dose shall be properly recorded in the clinical record after it has been administered.

(j) Preparation of doses for more than one scheduled administration time shall not be permitted.

(k) Medication shall be administered only by licensed medical or licensed nursing personnel or other licensed health professionals acting within the scope of their license.

(l) Unless the unit dose package system is used, individual prescriptions of drugs shall be kept in the original container with the original label intact showing the name of the patient or resident, the drug, the physician, the prescription number and the date dispensed.

(m) Legend drugs shall be dispensed by a licensed pharmacist.

(n) Any unused portions of prescriptions shall be turned over to the patient or resident only on a written order by the physician. A notation of drugs released to the patient or resident shall be entered into the medical record. All unused prescriptions left in a residential hospice shall be destroyed on the premises and recorded by a pharmacist.

Such record shall be kept in the residential hospice.

(13) Laboratory Services.

The residential hospice must maintain or have available, either directly or through a contractual agreement, adequate laboratory services to meet the needs of the patients and/or residents. The residential hospice must ensure that all laboratory services provided to its patients and/or residents are performed in a facility licensed in accordance with the Tennessee Medical Laboratory Act (TMLA). All technical laboratory staff shall be licensed in accordance with the TMLA and shall be qualified by education, training and experience for the type of services rendered.

(14) Food and Dietetic Services.

(a) The residential hospice must designate a person, either directly or by contractual agreement, to serve as the food and dietetic services director with responsibility for the daily management of the dietary services.

(b) There must be a qualified dietitian, full-time, part-time, or on a consultant basis who is responsible for the development and implementation of a nutrition care process to meet the needs of patients and/or residents for health maintenance, disease prevention and, when necessary, medical nutrition therapy to treat an illness, injury or condition.

Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the patients and/or residents and must be prepared and served as prescribed.
Special diets shall be prepared and served as ordered.
Nutritional needs must be met in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the patients and/or residents.
A current therapeutic diet manual approved by the dietitian and medical director must be readily available to all medical, nursing, and food service personnel.

(d) Education programs, including orientation, on-the-job training, inservice education, and continuing education shall be offered to dietetic services personnel on a regular basis.

Programs shall include instruction in the use of equipment, personal hygiene, proper inspection, and the handling, preparing and serving of food.

(e) A minimum of three (3) meals in each twenty-four (24) hour period shall be offered. A supplemental night meal shall be offered if more than fourteen (14) hours lapse between supper and breakfast. Additional nourishments shall be provided to patients and/ or residents with special dietary needs. A minimum of three (3) days supply of food shall be on hand.

(f) Food shall be protected from dust, flies, rodents, unnecessary handling, droplet infection, overhead leakage and other sources of contamination whether in storage, while being prepared and served, and/or transported through hallways.

(g) Perishable food shall not be allowed to stand at room temperature except during necessary periods of preparation or serving. Prepared foods shall be kept hot (140 °F or above) or cold (45 °F or less). Appropriate equipment for temperature maintenance, such as hot and cold serving units or insulated containers, shall be used.

(h) Dishwashing machines shall be used according to manufacturer specifications.

(i) All dishes, glassware and utensils used in the preparation and serving of food and drink shall be cleaned and sanitized after each use.

(j) The cleaning and sanitizing of handwashed dishes shall be accomplished by using a three-compartment sink according to the current “U.S. Public Health Service Sanitation Manual.”

(k) The kitchen shall contain sufficient refrigeration equipment and space for the storage of perishable foods.

(l) All refrigerators and freezers shall have thermometers. Refrigerators shall be kept at a temperature not to exceed 45 °F. Freezers shall be kept at a temperature not to exceed 0 °F.

(m) Written policies and procedures shall be followed concerning the scope of food services in accordance with the current edition of the “U.S. Public Health Service Recommended Ordinance and Code Regulating Eating and Drinking Establishments” and the current “U.S. Public Health Service Sanitation Manual” should be used as a guide to food sanitation.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed November 22, 2005; effective February 5, 2006. Amendment filed March 27, 2015; effective June 25, 2015. Amendment filed September 15, 2015; effective December 14, 2015. Amendments filed July 18, 2016; effective October 16, 2016. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.09 LIFE SAFETY

(1) Any residential hospice facility which complies with the required applicable building and fire safety regulations at the time the board adopts new codes or regulations will, so long as such compliance is maintained (either with or without waivers of specific provisions), be considered to be in compliance with the requirements of the new codes or regulations.

(2) The residential hospice facility shall provide fire protection by the elimination of fire hazards, by the installation of necessary fire fighting equipment and by the adoption of a written fire control plan. All fires which result in a response by the local fire department shall be reported to the department within seven (7) days. The report shall contain sufficient information to ascertain the nature and location of the fire, its probable cause and any injuries incurred by any person or persons as a result of the fire.

(3) The residential hospice facility must be designed and equipped for the comfort and privacy of each hospice patient and or HIV care resident and family member(s) by providing physical space for private patient/family or resident/family visiting, accommodations for family members to remain with the patient and/or resident throughout the night, accommodations for family privacy following a patient’s or resident’s death, and decor which is home-like in design and function.

(a) Any condition on the residential hospice site conducive to the harboring or breeding of insects, rodents or other vermin shall be prohibited. Chemical substances of a poisonous nature used to control or eliminate vermin shall be properly identified. Such substances shall not be stored with or near food or medications.

(b) Telephones shall be readily accessible and at least one (1) shall be equipped with sound amplification and shall be accessible to wheelchair patients and/or residents.

(c) Equipment and supplies for physical examination and emergency treatment of patients and/or residents shall be available.

(d) A bed complete with mattress and pillow shall be provided. In addition, patients and/or residents units shall be provided with at least one chair, a bedside table, an over bed tray and adequate storage space for toilet articles, clothing and personal belongings.

(e) Individual wash cloths, towels and bed linens must be provided for each patient and/or resident. Linen shall not be interchanged from patient to patient or resident to resident until it has been properly laundered.

(f) Bath basin water service, emesis basin, bedpan and urinal shall be individually provided.

(g) Items of equipment coming into intimate contact with patients and/or residents shall be disinfected or sterilized after each use unless individual equipment for each is provided and then sterilized or disinfected between patients and/or residents and as often as necessary to maintain them in a clean and sanitary condition. Single use, disposable items are acceptable but shall not be reused.

(h) The facility shall have written policies and procedures governing care of patients and/or residents during the failure of the air conditioning, heating or ventilation system, including plans for hypothermia and hyperthermia. When the temperature of any patient/resident area falls below 65°F. or exceeds 85°F., or is reasonably expected to do so, the facility shall be alerted to the potential danger, and the Department shall be notified.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Repeal and new rule filed November 22, 2005; effective February 5, 2006. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.10 INFECTIOUS AND HAZARDOUS WASTE

(1) Each residential hospice must develop, maintain and implement written policies and procedures for the definition and handling of its infectious and hazardous wastes. These policies and procedures must comply with the standards of this section and all other applicable state and federal regulations.

(2) The following waste shall be considered to be infectious waste:

(a) Waste contaminated by patients/residents who are isolated due to communicable disease, as provided in the U.S. Centers for Disease Control “Guidelines for Isolation Precautions in Hospitals”;

(b) Cultures and stocks of infectious agents including specimen cultures collected from medical and pathological laboratories, cultures and stocks of infectious agents from research and industrial laboratories, wastes from the production of biologicals, discarded live and attenuated vaccines, culture dishes and devices used to transfer, inoculate, and mix cultures;

(d) All discarded sharps (including but not limited to, hypodermic needles, syringes, pasteur pipettes, broken glass and scalpel blades) used in patient/resident care or which have come into contact with infectious agents during use in medical, research, or industrial laboratories;

(e) Other waste determined to be infectious by the facility in its written policy.

(3) Infectious and hazardous waste must be segregated from other waste at the point of generation (i.e., the point at which the material becomes a waste) within the facility.

(4) Waste must be packaged in a manner that will protect waste handlers and the public from possible injury and disease that may result from exposure to the waste. Such packaging must provide for containment of the waste from the point of generation up to the point of proper treatment or disposal. Packaging must be selected and utilized for the type of waste the package will contain, how the waste will be treated and disposed, and how it will be handled and transported, prior to treatment and disposal.

(a) Contaminated sharps must be directly placed in leakproof, rigid, and puncture-resistant containers which must then be tightly sealed;

(b) Whether disposable or reusable, all containers, bags, and boxes used for containment and disposal of infectious waste must be conspicuously identified. Packages containing infectious waste which pose additional hazards, including but not limited to, chemical and radiological must also be conspicuously identified to clearly indicate those additional hazards;

(5) After packaging, waste must be handled and transported by methods ensuring containment and preserving the integrity of the packaging, including the use of secondary containment where necessary.

(a) Waste must not be compacted or ground (i.e., in a mechanical grinder) prior to treatment, except that pathological waste may be ground prior to disposal; and, (b) Plastic bags of infectious waste must be transported by hand.

(6) Waste must be stored in a manner which preserves the integrity of the packaging, inhibits rapid microbial growth and putrefaction, and minimizes the potential of exposure or access by unknowing persons. Waste must be stored in a manner and location which affords protection from animals, precipitation, wind, direct sunlight, does not present a safety hazard, does not provide a breeding place or food source for insects or rodents and does not create a nuisance.

(7) In the event of spills, ruptured packaging, or other incidents where there is a loss of containment of waste, the facility must ensure that proper actions are immediately taken to:

(a) Isolate the area from the public and non-essential personnel;

(b) To the extent practicable, repackage all spilled waste and contaminated debris in accordance with the requirements of this section;

(c) Sanitize all contaminated equipment and surfaces appropriately and in accordance with written policies and procedure; and, (d) Complete an incident report and maintain a copy on file.

(8) Except as provided otherwise in this section, a facility must treat or dispose of infectious waste by one or more of the methods specified in this part.

(a) A facility may treat infectious waste in an on-site sterilization or disinfection device, or in an incinerator or a steam sterilizer, which has been designed, constructed, operated and maintained so that infectious waste treated in such a device is rendered noninfectious and is, if applicable, authorized for that purpose pursuant to current rules of the Department of Environment and Conservation. A valid permit or other written evidence of having complied with the Tennessee Air Pollution Control Regulations shall be available for review, if required. Each sterilizing or disinfecting cycle must contain appropriate indicators to assure conditions were met for proper sterilization or disinfection of materials included in the cycle, and records kept. Proper operation of such devices must be verified at least monthly, and records of these monthly checks shall be available for review. Waste that contains toxic chemicals that would be volatilized by steam must not be treated in steam sterilizers. Infectious waste that has been rendered to a carbonized or mineralized ash shall be deemed non-infectious, unless otherwise hazardous and subject to the hazardous waste management requirements of the current rules of the Department of Environment and Conservation, such ash shall be disposable as a (non-hazardous) solid waste under current rules of the Department of Environment and Conservation.

(9) The facility may have waste transported off-site for storage, treatment, or disposal. Such arrangements must be detailed in a written contract, available for review. If such off-site location is in Tennessee, the facility must ensure that it has all necessary state and local approvals, and such approvals shall be available for review. If the off-site location is in another state, the facility must notify in writing all public health agencies with jurisdiction that the location is being used for management of the facility’s waste. Waste shipped off-site must be packaged in accordance with applicable federal and state requirements. Waste transported to a sanitary landfill in this state must meet the requirements of current rules of the Department of Environment and Conservation.

(10) All garbage, trash and other non-infectious waste shall be stored and disposed of in a manner that shall not permit the transmission of disease, create a nuisance, provide a breeding place for insects and rodents, or constitute a safety hazard. All containers for waste shall be water tight, constructed of easily-cleanable material and shall be kept on elevated platforms.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.11 RECORDS AND REPORTS

(1) A yearly statistical report, the “Joint Annual Report” shall be submitted to the department. The forms are mailed to each residential hospice by the department each year. The forms must be completed and returned to the department as requested.

(2) The residential hospice shall report each case of communicable disease to the local county health officer in the manner provided by existing regulations. Failure to report a communicable disease may result in disciplinary action, including revocation of the facility’s license.

(3) The residential hospice shall report all incidents of abuse, neglect, and misappropriation to the Department of Health in accordance with T.C.A. § 68-11-211.

(4) The residential hospice shall report the following incidents to the Department of Health in accordance with T.C.A. § 68-11-211.

(a) Strike by staff at the facility;

(b) External disasters impacting the facility;

(c) Disruption of any service vital to the continued safe operation of the residential hospice or to the health and safety of its patients and personnel; and (d) Fires at the residential hospice that disrupt the provision of patient care services or cause harm to the patients or staff, or that are reported by the facility to any entity, including but not limited to a fire department charged with preventing fires.

(5) The residential hospice shall retain legible copies of the following records and reports for thirty-six (36) months following their issuance. They shall be maintained in a single file, and shall be made available for inspection during normal business hours to any person who requests to view them:

(a) Local fire safety inspections;

(b) Local building code inspections, if any;

(d) Department licensure and fire safety inspections and surveys;

(e) Federal Health Care Financing Administration surveys and inspections, if any;

(f) Orders of the Commissioner or Board, if any;

(g) Comptroller of the Treasury’s audit reports and finding, if any; and, (h) Maintenance records of all safety equipment.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11-209, 68-11- 210, 68-11-211, 68-11-213, and 68-11-216.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendments filed January 3, 2012; effective April 2, 2012. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.12 PATIENT/RESIDENT RIGHTS

(1) The residential hospice shall establish and implement written policies and procedures setting forth the rights of patients and residents for the protection and preservation of dignity and individuality. Each patient and resident has at least the following rights:

(a) To privacy in treatment and personal care;

(b) To privacy, for visits by his/her spouse or significant other;

(d) To be different in order to promote social, religious, and psychological well being;

(e) To privately talk and/or meet with and see any person;

(f) To send and receive mail promptly and unopened;

(g) To be free from mental and physical abuse. Should this right be violated, the facility must notify the Department within five (5) business days of the incident and the Tennessee Department of Human Services, Adult Protective Services as required by T.C.A. §§ 71-6-101 et seq.;

(h) To be free from chemical and physical restraints;

(i) To meet and take part in activities of social, commercial, religious, and community groups. The administrator may refuse access to the facility to any person if that person’s presence would be injurious to the health and safety of a patient/resident or staff, or would threaten the security of the property of the patient or resident, staff or facility;

(j) To retain and use personal clothing and possessions as space permits;

(k) To be free from being required by the facility to work or perform services;

(l) To be fully informed by a physician of his/her health and medical condition. The facility shall give the patient or resident and family the opportunity to participate in planning the patient’s or resident’s care and medical treatment;

(m) To have appropriate assessment and management of pain;

(n) To be involved in the decision making of all aspects of their care;

(o) To refuse treatment. The patient or resident must be informed of the consequences of that decision. The refusal and its reason must be reported to the physician and documented in the medical record;

(p) To refuse experimental treatment and drugs. The patient’s/resident’s or health care decision-maker’s written consent for participation in research must be obtained and retained in the medical record;

(q) To have records kept confidential and private. Written consent by the patient and/or resident must be obtained prior to release of information except to persons authorized by law. If the patient and/or resident lacks capacity, written consent is required from the patient and/or resident’s health care decision-maker. The residential hospice must have policies to govern access and duplication of the patient’s and/or resident’s record;

(r) To manage personal financial affairs. Any request by the patient or resident for assistance must be in writing. A request for any additional person to have access to a patient’s or resident’s funds must also be in writing;

(s) To be told in writing before or at the time of admission about the services available in the facility, about any extra charges and charges for services not covered;

(t) To be free from discrimination because of the exercise of the right to speak and voice complaints;

(u) To exercise his/her own independent judgment by executing any documents, including admission forms; and (v) To voice grievances and complaints, and to recommend changes in policies and services to the facility staff, or outside representatives of the patient’s or resident’s choice. The facility shall establish a grievance procedure and fully inform the patient or resident and family of same.

(2) The rights set forth in this section may be abridged, restricted, limited or amended only as follows:

(a) When medically contraindicated;

(b) When necessary to protect and preserve the rights of the patients or residents in the facility; or (c) When contradicted by the explicit provisions of another rule of the board.

(3) Any reduction in patients’ or resident’s rights must be explicit, reasonable, appropriate to the justification, the least restrictive response feasible, shall be explained to the patient or resident, and must be documented in the individual patient’s or resident’s record by reciting the limitation’s reason and scope.

(4) Patients’ and/or residents’ pets and other animals utilized for pet therapy programs shall be allowed in the facility. The facility shall designate in its policies and procedures those areas where animals will be excluded. The areas designated shall be determined based upon an assessment of the facility performed by medically trained personnel.

(5) Each patient or resident has a right to self-determination, which encompasses the right to make choices regarding life-sustaining treatment (including resuscitative services). This right of self-determination may be effectuated by an advance directive.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendments filed November 22, 2005; effective February 5, 2006. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.13 POLICIES AND PROCEDURES FOR HEALTH CARE DECISION-MAKING

(1) Pursuant to this rule, each residential hospice shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a patient or resident who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from individual patients or residents. An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.

(2) An adult or emancipated minor may execute an advance directive for health care. The advance directive may authorize an agent to make any health care decision the patient or resident could have made while having capacity, or may limit the power of the agent, and may include individual instructions. The effect of an advance directive that makes no limitation on the agent’s authority shall be to authorize the agent to make any health care decision the patient or resident could have made while having capacity.

(3) The advance directive shall be in writing, signed by the patient or resident, and shall either be notarized or witnessed by two (2) witnesses. Both witnesses shall be competent adults, and neither of them may be the agent. At least one (1) of the witnesses shall be a person who is not related to the patient or resident by blood, marriage, or adoption and would not be entitled to any portion of the estate of the patient or resident upon the death of the patient or resident.

The advance directive shall contain a clause that attests that the witnesses comply with the requirements of this paragraph.

(4) Unless otherwise specified in an advance directive, the authority of an agent becomes effective only upon a determination that the patient or resident lacks capacity, and ceases to be effective upon a determination that the patient or resident has recovered capacity.

(6) A determination that a patient or resident lacks or has recovered capacity, or that another condition exists that affects an individual instruction or the authority of an agent shall be made by the designated physician, who is authorized to consult with such other persons as he or she may deem appropriate.

(7) An agent shall make a health care decision in accordance with the patient’s or resident’s individual instructions, if any, and other wishes to the extent known to the agent. Otherwise, the agent shall make the decision in accordance with the patient’s or resident’s best interest.

In determining the patient’s or resident’s best interest, the agent shall consider the patient’s or resident’s personal values to the extent known.

(8) An advance directive may include the individual’s nomination of a court-appointed guardian.

(10) No health care provider or institution shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care.

(12) A patient or resident having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.

(13) A patient or resident having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke.

(15) An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.

(16) Surrogates.

(a) An adult or emancipated minor may designate any individual to act as surrogate by personally informing the supervising health care provider. The designation may be oral or written.

(b) A surrogate may make a health care decision for a patient or resident who is an adult or emancipated minor if and only if:

The patient or resident has been determined by the designated physician to lack capacity, and 2. No agent or guardian has been appointed, or 3. The agent or guardian is not reasonably available.

(c) In the case of a patient or resident who lacks capacity, the patient’s or resident’s surrogate shall be identified by the supervising health care provider and documented in the current clinical record of the facility at which the patient or resident is receiving health care.

(d) The patient’s or resident’s surrogate shall be an adult who has exhibited special care and concern for the patient or resident, who is familiar with the patient’s or resident’s personal values, who is reasonably available, and who is willing to serve.

(e) Consideration may be, but need not be, given in order of descending preference for service as a surrogate to:

The patient’s or resident’s spouse, unless legally separated;
The patient’s or resident’s adult child;
The patient’s or resident’s parent;
The patient’s or resident’s adult sibling;
Any other adult relative of the patient or resident; or 6. Any other adult who satisfies the requirements of 0720-23-.13(16)(d).

(f) No person who is the subject of a protective order or other court order that directs that person to avoid contact with the patient or resident shall be eligible to serve as the patient’s or resident’s surrogate.

(g) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:

Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the patient or resident or in accordance with the patient’s or resident’s best interests;
The proposed surrogate’s regular contact with the patient or resident prior to and during the incapacitating illness;
The proposed surrogate’s demonstrated care and concern;
The proposed surrogate’s availability to visit the patient or resident during his or her illness; and 5. The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.

(h) If the patient or resident lacks capacity and none of the individuals eligible to act as a surrogate under 0720-23-.13(16)(c) through 0720-23-.13(16)(g) is reasonably available, the designated physician may make health care decisions for the patient or resident after the designated physician either:

Consults with and obtains the recommendations of a facility’s ethics mechanism or standing committee in the facility that evaluates health care issues; or 2. Obtains concurrence from a second physician who is not directly involved in the patient’s or resident’s health care, does not serve in a capacity of decisionmaking, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.

(j) A surrogate shall make a health care decision in accordance with the patient’s or resident’s individual instructions, if any, and other wishes to the extent known to the surrogate. Otherwise, the surrogate shall make the decision in accordance with the surrogate’s determination of the patient’s or resident’s best interest. In determining the patient’s or resident’s best interest, the surrogate shall consider the patient’s or resident’s personal values to the extent known to the surrogate.

(k) A surrogate who has not been designated by the patient or resident may make all health care decisions for the patient or resident that the patient or resident could make on the patient’s or resident’s own behalf, except that artificial nutrition and hydration may be withheld or withdrawn for a patient or resident upon a decision of the surrogate only when the designated physician and a second independent physician certify in the patient’s or resident’s current clinical records that the provision or continuation of artificial nutrition or hydration is merely prolonging the act of dying and the patient or resident is highly unlikely to regain capacity to make medical decisions.

(l) Except as provided in 0720-23-.13(16)(m):

Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution nor an employee of an operator of a health care institution may be designated as a surrogate; and 2. A health care provider or employee of a health care provider may not act as a surrogate if the health care provider becomes the patient’s or resident’s treating health care provider.

(m) An employee of the treating health care provider or an employee of an operator of a health care institution may be designated as a surrogate if:

The employee so designated is a relative of the patient or resident by blood, marriage, or adoption; and 2. The other requirements of this section are satisfied.

(n) A health care provider may require an individual claiming the right to act as surrogate for a patient or resident to provide written documentation stating facts and circumstances reasonably sufficient to establish the claimed authority.

(17) Guardian.

(a) A guardian shall comply with the patient’s or resident’s individual instructions and may not revoke the patient’s or resident’s advance directive absent a court order to the contrary.

(b) Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.

(c) A health care provider may require an individual claiming the right to act as guardian for a patient or resident to provide written documentation stating facts and circumstances reasonably sufficient to establish the claimed authority.

(18) A designated physician who makes or is informed of a determination that a patient or resident lacks or has recovered capacity, or that another condition exists which affects an individual instruction or the authority of an agent, guardian, or surrogate, shall promptly record the determination in the patient’s or resident’s current clinical record and communicate the determination to the patient or resident, if possible, and to any person then authorized to make health care decisions for the patient or resident.

(19) Except as provided in 0720-23-.13(20) through 0720-23-.13(22), a health care provider or institution providing care to a patient or resident shall:

(a) Comply with an individual instruction of the patient or resident and with a reasonable interpretation of that instruction made by a person then authorized to make health care decisions for the patient or resident; and (b) Comply with a health care decision for the patient or resident made by a person then authorized to make health care decisions for the patient or resident to the same extent as if the decision had been made by the patient or resident while having capacity.

(20) A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.

(21) A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:

(a) Contrary to a policy of the institution which is based on reasons of conscience, and (b) The policy was timely communicated to the patient or resident or to a person then authorized to make health care decisions for the patient or resident.

(23) A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 0720-23-.13(20) through 0720-23-.13(22) shall:

(a) Promptly so inform the patient or resident, if possible, and any person then authorized to make health care decisions for the patient or resident;

(b) Provide continuing care to the patient or resident until a transfer can be effected or until the determination has been made that transfer cannot be effected;

(c) Unless the patient or resident or person then authorized to make health care decisions for the patient or resident refuses assistance, immediately make all reasonable efforts to assist in the transfer of the patient or resident to another health care provider or institution that is willing to comply with the instruction or decision; and (d) If a transfer cannot be effected, the health care provider or institution shall not be compelled to comply.

(24) Unless otherwise specified in an advance directive, a person then authorized to make health care decisions for a patient or resident has the same rights as the patient or resident to request, receive, examine, copy, and consent to the disclosure of medical or any other health care information.

(a) Complying with a health care decision of a person apparently having authority to make a health care decision for a patient or resident, including a decision to withhold or withdraw health care;

(26) An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.

(27) A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for such identification made in good faith.

(28) A copy of a written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.

(29) The withholding or withdrawal of medical care from a patient or resident in accordance with the provisions of the Tennessee Health Care Decisions Act shall not, for any purpose, constitute a suicide, euthanasia, homicide, mercy killing, or assisted suicide.

(30) Physician Orders for Scope of Treatment (POST).

(a) Physician Orders for Scope of Treatment (POST) may be issued by a physician for a patient with whom the physician has a bona fide physician-patient relationship, but only:

With the informed consent of the patient;
If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or 3. If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available, if the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

No physician, who has a bona fide physician-patient relationship with the patient, is present and available for discussion with the patient (or if the patient is a minor or is otherwise incapable of making an informed decision, with the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act);
Such authority to issue is contained in the physician assistant’s, nurse practitioner’s or clinical nurse specialist’s protocols;
Either:

(i) With the informed consent of the patient;

(d) A POST issued in accordance with this section shall remain valid and in effect until revoked. In accordance with this rule and applicable regulations, qualified emergency medical services personnel; and licensed health care practitioners in any facility, program, or organization operated or licensed by the Board for Licensing Health Care Facilities, the Department of Mental Health and Substance Abuse Services, or the Department of Intellectual and Developmental Disabilities, or operated, licensed, or owned by another state agency, shall follow a POST that is available to such persons in a form approved by the Board for Licensing Health Care Facilities.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-224, and 68- 11-1801 through 68-11-1815.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed April 28, 2003; effective July 12, 2003. Repeal and new rule filed November 22, 2005; effective February 5, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-23-.14 DISASTER PREPAREDNESS

(1) Emergency Electrical Power.

(a) All residential hospices must have one or more on-site electrical generators, which are capable of providing emergency electrical power to at least all life sustaining equipment and life sustaining resources such as: ventilators; blood banks, biological refrigerators, safety switches for boilers, safety lighting for corridors and stairwells and other essential equipment.

(c) The emergency power system shall have a minimum of twenty four (24) hours of either propane, gasoline or diesel fuel. The quantity shall be based on its expected or known connected load consumption during power interruptions. In addition, the residential hospice shall have a written contract with an area fuel distributor which guarantees first priority service for re-fills during power interruptions.

(d) The emergency power system (generator) shall be inspected weekly and exercised and under actual load and operating temperature conditions for at least thirty (30) minutes, once each month including automatic and manual transfer of equipment. The generator shall be exercised by trained facility staff who are familiar with the systems operation. Instructions for the operation of the systems and the manual transfer of emergency power shall be maintained with the facility’s disaster preparedness plan and shall be separately identified in the plan. Records shall be maintained for all weekly inspections and monthly tests and be kept on file for a minimum of three (3) years.

(2) Physical Facility and Community Emergency Plans.

(a) Physical Facility (Internal Situations).

Every residential hospice shall have a current internal emergency plan, or plans, that provides for fires, bomb threats, severe weather, utility service failures, plus any local high risk situations such as floods, earthquakes, toxic fumes and chemical spills. The plan should consider the probability of the types of disasters which might occur, both natural and “man-made.”
The plan(s) must include provisions for the relocation of persons within the building and/or either partial or full building evacuation. Plans that provide for the relocation of patients and/or residents to other health care facilities must have written agreements for emergency transfers. The agreements may be mutual, i.e. providing for transfers either way.
Copies of the plan(s), either complete or outlines, including specific emergency telephone numbers related to that type of disaster, shall be available to all staff.

A copy shall be readily available at all times in the telephone operator’s position or at the security center. Provisions that have security implications may be omitted from the outline versions.

The plan must provide for additional staffing, medical supplies, blood and other resources which would probably be needed.
Each of the following disaster preparedness plan drills shall be conducted annually. Drills are for the purpose of educating staff, resource determination, testing personnel safety provisions and communications with other facilities and community agencies. Records of staff orientation, education programs and drills must be maintained for at least three (3) years.

(i) Fire Safety Procedures Plan shall include:

(I) Minor fires (II) Major fires (III) Fighting the fire (IV) Evacuation procedures (V) Staff functions by department and job assignment (VI) Fire drill schedules (fire drills shall be held at least quarterly on each work shift)

(ii) External disaster procedures plan (for tornado, flood, earthquakes) shall include:

(I) Staff duties by department and job assignment (II) Evacuation procedures (iii) Bomb Threat Procedures Plan:

(I) Staff duties by department and job assignment (II) Search team, searching the premises 6. The residential hospice shall develop and periodically review with all employees a pre-arranged plan for the orderly evacuation of all patients and/or residents in case of a fire, internal disaster or other emergency. The plan of evacuation shall be posted throughout the facility. Fire drills shall be held at least quarterly for each work shift for residential hospice personnel in each separate patient/resident-occupied residential hospice building. There shall be a written report documenting the evaluation of each drill and the action recommended or taken for any deficiencies found. Records which document and evaluate these drills must be maintained for at least three (3) years.

(b) Emergency Planning with Local Government Authorities.

All residential hospices shall establish and maintain communications with the county Emergency Management Agency. This includes the provision of the information and procedures that are needed for the local comprehensive emergency plan. The residential hospices shall cooperate, to the extent possible, in area disaster drills and local emergency situations.
Each residential hospice shall conduct both the physical facility and community emergency drills as required in these regulations, even if the local Emergency Management Agency is unable to participate.
A file of documents demonstrating communications and cooperation with the local agency must be maintained.

History

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed August 18, 1995; effective November 1, 1995. Amendment filed February 9, 1998; effective April 25, 1998. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed November 22, 2005; effective February 5, 2006. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.

Tenn. Comp. R. & Regs. 0720-23-.15 APPENDIX I

(1) Physician Orders for Scope of Treatment (POST) Form.

A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED

Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”)

Patient’s Last Name First Name/Middle Initial Date of Birth

Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Section B Check One Box Only MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.  Comfort Measures Only. Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.  Limited Additional Interventions. In addition to care described in Comfort Measures Only above, use medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. Treatment Plan: Basic medical treatments.  Full Treatment. In addition to care described in Comfort Measures Only and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including in the intensive care unit.

Other Instructions:

Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify)

The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other)

Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge)

MD/NP/CNS/PA Phone Number:

Name (print) Signature Relationship (write “self” if patient)

Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel.

Photocopies/faxes of signed POST forms are legal and valid.

Using POST Any incomplete section of POST implies full treatment for that section.

No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.”

Oral fluids and nutrition must always be offered if medically feasible.

IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”

A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.

Reviewing POST This POST should be reviewed if:

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.

(2) Advance Directive for Health Care Form.

ADVANCE DIRECTIVE FOR HEALTH CARE*

(Tennessee)

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.

Instructions: Parts 1 and 2 may be used together or independently. Please mark out/void any unused part(s).

Part 3 Other instructions, such as hospice care, burial arrangements, etc.:

(Attach additional pages if necessary)

Part 5 Your signature must either be witnessed by two competent adults (“Block A”) or by a notary public (“Block B”).

Signature: _______________________________________ Date: ____________________ (Patient)

Block A Neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.

Witnesses:

I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form.

Signature of witness number 2 Block B You may choose to have your signature witnessed by a notary public instead of the witnesses described in Block A.

STATE OF TENNESSEE

COUNTY OF

My commission expires:

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1801 through 68-11-1805.
Administrative History: Original rule filed February 16, 2007; effective May 2, 2007. Repeal and new rule filed August 28, 2012; effective November 26, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed February 8, 2017; effective May 9, 2017. Transferred from chapter 1200-08-15 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-24 Civil Rights Compliance Rules and Regulations (Transferred from 1200-08-16)

Tenn. Comp. R. & Regs. 0720-24-.01 DEFINITIONS

(1) Health Care Facility (Facility): Any facility licensed under the authority of the Board for Licensing Health Care Facilities as defined in T.C.A. § 68-11-102.

(2) Civil Rights: Personal and individual rights guaranteed by the federal or state constitution and/or any federal or state statute.

(3) Commissioner: The Commissioner of the Tennessee Department of Health or his designated representative.

(4) Department: Tennessee Department of Health.

(5) Board: Board for Licensing Health Care Facilities.

(6) Title VI: Title VI of the Civil Rights Act of 1964, 45 C.F.R., Part 80.

(7) Section 504: Section 504 of the Rehabilitation Act of 1973, 45 C.F.R., Part 84.

(8) Handicapped Person: means any person who (a) has a physical or mental impairment which substantially limits one or more major life activities, (b) has a record of such an impairment, or (c) is regarded as having such an impairment.

(9) Qualified Handicapped Person: (a) With respect to receiving services, means a handicapped person who meets the eligibility requirements for receiving services offered by the facility; (b) with respect to employment, means a handicapped person who, with reasonable accommodations, can perform the essential functions of the job in question without undue hardship to the facility. Reasonable accommodations may include: Making facilities readily accessible to and usable by handicapped persons; Providing part-time or modified work schedules; and, providing readers or interpreters. In determining whether an accommodation would result in an undue hardship on the facility, factors to be considered may include: The overall size of the facility with respect to number of employees, number and type of facilities, and size of budget; and type of facility, including the composition and structure of the facility’s workforce; and, the nature and cost of the accommodation needed.

(10) Physical or Mental Impairment: means (a) Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskelatal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive, digestive, genito-urinary; hemic and lymphatic; skin; and endocrine; or (b) any mental or psychological disorder, such as mental retardation organic brain syndrome, emotional or mental illness, and specific learning disabilities.

(11) Discrimination: Any act, policy, practice, or procedure which result in different treatment based on race, color, national origin or handicapping condition that impacts negatively upon qualified handicapped individuals and others protected under Title VI of the Civil Rights Act of 1964.

(12) Office on Civil Rights Compliance (OCRC): The administrative unit established within the Tennessee Department of Health charged with the responsibility of monitoring and investigating complaints related to civil rights compliance of facilities regulated by the Board.

(13) Minority. Persons who fall within the following categories: Black, not of Hispanic origin;

Hispanic; American Indian; Asian or Pacific Islander.

History

Authority: T.C.A. §§ 4-5-202, 68-1-113, 68-11-102, and 68-11-203; 45 C.F.R., Part 80; and 45 C.F.R., Part 84.
Administrative History: Original rule filed November 21, 1990; effective January 5, 1991. Transferred from chapter 1200-08-16 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-24-.02 REQUIREMENTS FOR CIVIL RIGHTS COMPLIANCE

The Board for Licensing Health Care Facilities may deny, suspend, or revoke a facility’s license, or otherwise discipline the facility for violations of the following requirements pursuant to T.C.A. §§ 68-11- 207 and 68-1-113. Licensed health care facilities must comply with the following:

(1) Shall not directly or through licensing, contractual or other arrangements, utilize criteria or methods of administering services which have the effect of subjecting individuals to discrimination on the basis of race, color, national original or handicapped condition.

(2) Admission policies and procedures shall include measures to admit patients/residents to the facility without regard to race, color, national origin or handicapping condition.

(3) Shall include in their operational policies and procedures manuals measures to provide all services in a nondiscriminatory manner (i.e. medical, dental, nursing, laboratory, pharmacy, skilled rehabilitative, social, volunteer, dietary and housekeeping).

(4) Physical facilities including lounges, dining facilities, beauty and barber shops shall not be used in a segregated or discriminatory manner.

(5) Shall include in their operational policies and procedures manuals that patients/residents are assigned to rooms, wards, floors, sections, buildings, and other areas without regard to race; color; national origin; or handicapping conditions if medically indicated, (6) Shall include in their operational policies and procedures manuals that a aspects of all their training programs -those operated by the facility, and those operated by other institutions within their facility for which the facility provides clinical training are conducted without discrimination, on the basis of race, color, national origin or handicapping condition.

(7) Shall use all reasonable efforts to recruit minority and handicapped persons to training programs offered by the facility.

(8) Shall inform all patients/residents, potential patients/residents, and the general public that admissions and services are provided on a non-discriminatory basis. This shall be accomplished by:

(a) If a facility publishes or uses brochures, pamphlets and newsletters which are designed to acquaint potential patients/residents and members of the general public with the facility’s programs and services, a statement of the facility’s commitment and compliance to Title VI and Section 504 must be included. All efforts to communicate to the public should convey the message that services are provided in a nondiscriminatory manner.

(b) Including a statement of the facility’s commitment and compliance to Title VI and

Section 504 on all application forms for admission and employment.

(c) Notifying all customary referral sources and the minority community within the service area that the facility’s services and benefits are provided in a non-discriminatory manner.

(d) Displaying in prominent places in the facility notices indicating the Title VI and Section 504 compliance and commitment.

(9) Shall be responsible for conveying to all staff their non-discriminatory policy and how to file a complaint under Title VI or Section 504. This shall be accomplished by providing, as part of new employee’s orientation and periodic retraining of permanent employees, information regarding the obligation, intent, and meaning of Title VI and Section 504 compliance.

(10) Those facilities with fifteen or more employees shall designate a responsible employee (Section 504 Coordinator) to coordinate its efforts to comply with Section 504 regulations.

(11) Shall establish and adhere to an internal procedure for handling patient/resident and employee grievances. The grievance procedure shall include:

(a) Complainant’s right to due process.

(b) Time frames for the review, resolution and/or findings process.

(12) Shall ensure that the opportunity to participate as members of planning, advisory, and policy boards whose membership is opened to the public, is available in a non-discriminatory manner.

(13) Shall develop procedures for monitoring all aspects of its operation to ensure that no policy or practice is, or has the effect of discriminating against applicants, patients/residents, employees or other participants on the basis of race, color, national origin, or handicapping condition. Each facility shall establish a system to review annually all new and existing policies to determine compliance with such policies with Title VI and Section 504.

(14) Shall maintain and make available to the OCRC for the purpose of demonstrating compliance and upon request, all data and information necessary to determine the facility’s compliance with Title VI of the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

Such statistical data shall include racial and ethnic data showing the extent to which minority and handicapped individuals participate in the facility’s services and programs.

(15) All recruitment and employment practices shall not discriminate on the basis of race, color, national origin, handicapping condition, or have an adverse effect on the provision of services, privileges, or advantages offered to the facility’s patients/residents.

(16) Shall include in their operational policies and procedures manuals a procedure for effective communication with handicapped persons and persons with limited English proficiency for the purpose of giving notice concerning benefits, services, waiver of rights, and consent to treatment, including emergency treatment.

(17) Shall provide appropriate auxiliary aids to persons with impaired sensory, manual, or speaking skills, where necessary to afford such persons an equal opportunity to benefit from services provided by the facility. Auxiliary aids may include information in braille, taped material and interpreters.

(18) Shall include in assurance of compliance with Title VI and Section 504 in all contracts with service agencies, health care providers and other health care facilities, eg. “services will be provided in a non-discriminatory manner without regard to race, color, national origin or handicapped condition.”

History

Authority: T.C.A. §§ 4-5-202, 68-1-113, 68-11-102, and 68-11-203; 45 C.F.R., Part 80; and 45 C.F.R., Part 84.
Administrative History: Original rule filed November 21, 1990; effective January 5, 1991. Transferred from chapter 1200-08-16 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-24-.03 MONITORING PROCEDURES

(1) Periodic compliance reviews.

The Office on Civil Rights Compliance shall have the authority to periodically review the practices of facilities to determine compliance with these regulations. Whenever a deficiency in compliance is cited by OCRC, a deficiency report shall be submitted to the facility. The facility shall develop and implement an acceptable plan of correction, specifying steps to correct the deficiencies and the time frame in which corrective measures will be taken. An acceptable plan of correction must be returned to OCRC no later than ten (10) days after receipt of the deficiency report, unless an extension is granted by the Director of OCRC or his/her designee. Documentation of already corrected deficiencies may be submitted with the plan of correction. The plan must be approved by the Director of OCRC, or his/her designee.

(2) Non-Compliance Investigations.

The Office on Civil Rights Compliance shall have the authority to conduct an investigation whenever a compliance review, report, complaint, or any other information indicates a possible failure to comply with State and federal law, and these regulations.

(3) Complaints. Complaints involving discrimination prohibited by State and federal law may be filed with the Office on Civil Rights Compliance by the complainant or his or her representative. The identity of complainants shall be kept confidential to the extent the law permits.

(4) Intimidatory or Retaliatory Acts Prohibited.

No health care facility shall retaliate against or, in any manner, discriminate against any person because of a compliant made in good faith and without mace to the Board or the Department, or other agency having jurisdiction in the matter. A health care facility shall neither retaliate, nor discriminate against the compliant because of information provided to these authorities.

History

Authority: T.C.A. §§ 4-5-202, 68-1-113, 68-11-102, and 68-11-203; 45 C.F.R., Part 80; and 45 C.F.R., Part 84.
Administrative History: Original rule filed November 21, 1990; effective January 5, 1991. Transferred from chapter 1200-08-16 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-24-.04 CORRECTIVE ACTION

If the facility has discriminated, or policies and procedures have resulted in discrimination against persons on the ground, of race, color, national origin or handicapping condition, the facility must take action that will result in correcting the deficiency or the discriminatory act.

History

Authority: T.C.A. §§ 4-5-202, 68-1-113, 68-11-102, and 68-11-203; 45 C.F.R., Part 80; and 45 C.F.R., Part 84.
Administrative History: Original rule filed November 21, 1990; effective January 5, 1991. Transferred from chapter 1200-08-16 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-25 Standards for Birthing Centers (Transferred from 1200-08-24)

Tenn. Comp. R. & Regs. 0720-25-.01 DEFINITIONS

(1) Abuse. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) Adult. An individual who has capacity and is at least 18 years of age.

(3) Advance Directive. An individual instruction or a written statement relating to the subsequent provision of health care for the individual, including, but not limited to, a living will or a durable power of attorney for health care.

(4) Agent. An individual designated in an advance directive for health care to make a health care decision for the individual granting the power.

(5) Birthing Center. Any institution, facility, place or building devoted exclusively or primarily to the provision of routine delivery services and postpartum care for mothers and their newborn infants.

(6) Board. The Tennessee Board for Licensing Health Care Facilities.

Any person who challenges the capacity of a patient shall have the burden of proving lack of capacity.

(8) Cardiopulmonary Resuscitation (CPR). The administering of any means or device to restore or support cardiopulmonary functions in a patient, whether by mechanical devices, chest compression, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilators or respirations, defibrillation, the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a patient where cardiac or respiratory arrest has occurred or is believed to be imminent.

(9) Certified Nurse Midwife (CNM). A registered nurse currently licensed as such by the Tennessee Board of Nursing and certified by the American College of Nurse-Midwives and qualified to deliver midwifery services.

(10) Certified Professional Midwife (CPM). A North American Registry of Midwives (NARM) certified midwife, who must have midwifery skills and experience evaluated and pass written and skills examinations.

(11) Commissioner. The Commissioner of the Tennessee Department of Health or his or her authorized representative.

(12) Competent. A patient who has capacity.

(13) Department. The Tennessee Department of Health.

(15) Do-Not-Resuscitate Order (DNR). A written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(16) Emancipated Minor. Any minor who is or has been married or has by court order or otherwise been freed from the care, custody and control of the minor’s parents.

(18) Guardian. A judicially appointed guardian or conservator having authority to make a health care decision for an individual.

(19) Hazardous Waste. Materials whose handling, use, storage, and disposal are governed by local, state, or federal regulations.

(20) Health Care. Any care, treatment, service or procedure to maintain, diagnose, treat, or otherwise affect an individual’s physical or mental condition, and includes medical care as defined in T.C.A. § 32-11-103(5).

(21) Health Care Decision. Consent, refusal of consent or withdrawal of consent to health care.

(22) Health Care Decision-Maker. In the case of a patient who lacks capacity, the patient’s health care decision-maker is one of the following: the patient’s health care agent as specified in an advance directive, the patient’s court-appointed guardian or conservator with health care decision-making authority, the patient’s surrogate as determined pursuant to Rule 0720-25- .12 or T.C.A. § 33-3-220, the designated physician pursuant to these rules or in the case of a minor child, the person having custody or legal guardianship.

(23) Health Care Institution. A health care institution as defined in T.C.A. § 68-11-1602.

(24) Health Care Provider. A person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care in the ordinary course of business or practice of a profession.

(25) Hospital. Any institution, place, building or agency represented and held out to the general public as ready, willing and able to furnish care, accommodations, facilities and equipment for the use, in connection with services of a physician or dentist, of one (1) or more nonrelated persons who may be suffering from deformity. injury or disease or from any other condition for which nursing, medical or surgical services would be appropriate for care, diagnosis or treatment.

(26) Incompetent. A patient who has been adjudicated incompetent by a court of competent jurisdiction and has not been restored to legal capacity.

(27) Individual Instruction. An individual’s direction concerning a health care decision for the individual.

(28) Infectious Waste. Solid or liquid wastes which contain pathogens with sufficient virulence and quantity such that exposure to the waste by a susceptible host could result in an infectious disease.

(29) Licensee. The person or body to whom the license is issued. The licensee is held responsible for compliance with all rules and regulations.

(30) Life Threatening or Serious Injury. Injury requiring the patient to undergo significant additional diagnostic or treatment measures.

(31) Medical Record. Medical histories, records, reports, summaries, diagnoses, prognoses, records of treatment and medication ordered and given, entries, x-rays, radiology interpretations, and other written electronics, or graphic data prepared, kept, made or maintained in a facility that pertains to confinement or services rendered to patients admitted or receiving care.

(32) Medically Inappropriate Treatment. Resuscitation efforts that cannot be expected either to restore cardiac or respiratory function to the patient or other medical or surgical treatments to achieve the expressed goals of the informed patient. In the case of the incompetent patient, the patient’s representative expresses the goals of the patient.

(33) Member of the Professional Medical Community. A professional employed by the birthing center and on the premises at the time of a voluntary delivery.

(34) Misappropriation of Patient/Resident Property. The deliberate misplacement, exploitation or wrongful, temporary or permanent use of an individual’s belongings or money without the individual’s consent.

(35) Neglect. The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; however, the withholding of authorization for or provision of medical care to any terminally ill person who has executed an irrevocable living will in accordance with the Tennessee Right to Natural Death Law, or other applicable state law, if the provision of such medical care would conflict with the terms of the living will, shall not be deemed “neglect” for purposes of these rules.

(36) NFPA. The National Fire Protection Association.

(37) Person. An individual, corporation, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency, or instrumentality, or any other legal or commercial entity.

(38) Personally Informing. A communication by any effective means from the patient directly to a health care provider.

(39) Physician. An individual authorized to practice medicine or osteopathy under Tennessee Code Annotated, Title 63, Chapters 6 or 9.

(40) Physician Assistant. A person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(41) Physician Orders for Scope of Treatment or POST. Written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(42) Power of Attorney for Health Care. The designation of an agent to make health care decisions for the individual granting the power under T.C.A. Title 34, Chapter 6, Part 2.

(43) Qualified Emergency Medical Service Personnel. Includes, but shall not be limited to, emergency medical technicians, paramedics, or other emergency services personnel, providers, or entities acting within the usual course of their professions, and other emergency responders.

(44) Reasonably Available. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the patient’s health care needs. Such availability shall include, but not be limited to, availability by telephone.

(45) Routine Delivery Services. Services provided by a physician or a certified professional midwife practicing when these rules become final or a certified nurse midwife related to the normal, uncomplicated prenatal course as determined by adequate prenatal care and prospects for a normal uncomplicated birth as defined by reasonable and generally accepted criteria of maternal and fetal health, promoting a family-centered approach to care and viewing pregnancy and delivery as a normal physiological process requiring limited technological and pharmacological support.

(46) Shall or Must. Compliance is mandatory.

(47) Stabilize. To provide such medical treatment of the emergency medical condition as may be necessary to assure, within reasonable medical probability, that the condition will not materially deteriorate due to the transfer as determined by a physician or other qualified medical personnel when a physician is not readily available.

(48) State. A state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States.

(49) Student. A person currently enrolled in a course of study that is approved by the appropriate licensing board or equivalent body.

(50) Supervising Health Care Provider. The designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual’s health care.

(51) Surrogate. An individual, other than a patient’s agent or guardian, authorized to make a health care decision for the patient.

(52) Transfer. The movement of a patient to a hospital at the direction of a physician or other qualified medical personnel when a physician is not readily available but does not include such movement of a patient who leaves the facility against medical advice.

(53) Treating Health Care Provider. A health care provider who at the time is directly or indirectly involved in providing health care to the patient.

(54) Voluntary Delivery. The action of a mother in leaving an unharmed infant aged seventy-two (72) hours or younger on the premises of a birthing center with any birthing center employee or member of the professional medical community without expressing any intention to return for such infant, and failing to visit or seek contact with such infant for a period of thirty (30) days thereafter.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11- 209, 68-11-210, 68-11-211, 68-11-213, 68-11-224, 68-11-255, and 68-11-1802.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Amendment filed September 17, 2002; effective December 1, 2002. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed April 28, 2003; effective July 12, 2003. Amendments filed January 3, 2006; effective March 19, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200- 08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.02 LICENSING PROCEDURES

(2) In order to make application for a license:

(a) The applicant shall submit an application on a form prepared by the department.

(b) Each applicant for a license shall pay an annual license fee in the amount of one thousand four hundred and four dollars ($1,404.00). The fee must be submitted with the initial application or renewal application and is not refundable.

(c) The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the department. Patients shall not be admitted to the birthing center until a license has been issued. Applicants shall not hold themselves out to the public as being a birthing center until the license has been issued. A license shall not be issued until the facility is in substantial compliance with these rules and regulations.

(d) The applicant must prove the ability to meet the financial needs of the facility.

(f) The applicant shall allow the birthing center to be inspected by a Department surveyor.

(a) For the purposes of licensing, the licensee of a birthing center has the ultimate responsibility for the operation of the facility, including the final authority to make or control operational decisions and legal responsibility for the business management. A change of ownership occurs whenever this ultimate legal authority for the responsibility of the facilities operation is transferred.

(b) A change of ownership occurs whenever there is a change in the legal structure by which the birthing center is owned and operated.

Transfer of the facility’s legal title;
Lease of the facility’s operations;
Dissolution of any partnership that owns, or owns a controlling interest in, the facility;
One partnership is replaced by another through the removal, addition or substitution of a partner;
Removal of the general partner or general partners, if the facility is owned by a limited partnership;
Merger of a facility owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are canceled;
The consolidation of a corporate facility owner with one or more corporations; or, 8. Transfers between levels of government.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors or board of trustees;
Two (2) or more corporations merge and the originally-licensed corporation survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government; or, 5. Corporate stock transfers or sales, even when a controlling interest.

(e) Management agreements are generally not changes of ownership if the owner continues to retain ultimate authority for the operation of the facility. However. if the ultimate authority is surrendered and transferred from the owner to a new manager, then a change of ownership has occurred.

(4) Renewal.

(a) In order to renew a license, each birthing center shall submit to periodic inspections by Department surveyors for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action and shall remedy the deficiencies. In addition, each licensee shall submit a renewal form approved by the board and applicable renewal fee prior to the expiration date of the license.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late; provided that the late penalty shall not exceed twice the renewal fee.

A completed application for licensure;
The license fee provided in Rule 0720-25-.02(2)(b); and 3. Any other information required by the Health Services and Development Agency.

(d) Upon reapplication, the licensee shall submit to an inspection of the facility by Department of Health surveyors.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-206(a)(5), 68-11-209, 68-11-209(a)(1), 68-11-210, and 68-11-216 and Chapter 846 of the Public Acts of 2008, §1.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Amendment filed November 19, 2003; effective February 2, 2004. Amendment filed January 19, 2007; effective April 4, 2007. Public necessity rules filed April 29, 2009; effective through October 11, 2009. Emergency rules filed October 9, 2009; effective through April 7, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed March 26, 2019; effective June 24, 2019. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.03 DISCIPLINARY PROCEDURES

(1) The board may suspend or revoke a license for:

(a) Violation of federal or state statutes;

(b) Violation of the rules as set forth in this chapter;

(d) Conduct or practice found by the board to be detrimental to the health, safety, or welfare of the patients of the facility; and (e) Failure to renew license.

(2) The board may consider all factors which it deems relevant, including but not limited to the following, when determining sanctions:

(a) The degree of sanctions necessary to ensure immediate and continued compliance;

(b) The character and degree of impact of the violation on the health, safety and welfare of the patient in the facility;

(3) Inappropriate transfers are prohibited and violation of the transfer provisions shall be deemed sufficient grounds to suspend or revoke a birthing center’s license.

(4) When a birthing center is found by the department to have committed a violation of this

chapter, the department will issue to the facility a statement of deficiencies. Within ten (10) days of the receipt of the statement of deficiencies the facility must return a plan of correction indicating the following:

(a) How the deficiency will be corrected;

(b) The date upon which each deficiency will be corrected;

(5) Either failure to submit a plan of correction in a timely manner or a finding by the department that the plan of correction is unacceptable shall subject the birthing center’s license to possible disciplinary action.

(6) Any licensee or applicant for a license, aggrieved by a decision or action of the department or board, pursuant to this chapter, may request a hearing before the board. The proceedings and judicial review of the board’s decision shall be in accordance with the Uniform Administrative Procedures Act, T.C.A. §§ 4-5-101, et seq.

(7) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to Rule

Tenn. Comp. R. & Regs. 0720-25-.04 ADMINISTRATION

(1) Birthing centers must have a governing body which is legally responsible for:

(a) The overall operation and maintenance of the facility;

(b) The provision of personnel, facilities, equipment, supplies, and services to mothers and families;

(d) Appointing an administrator or director responsible for implementing the adopted policies;

(e) Establishing and maintaining a written organizational plan;

(f) Appointing a clinical staff and assuring its competence; and (g) Documenting all of the above.

(2) 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.

(3) 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. A birthing center which violates a required policy also violates the rule and regulation establishing the requirement.

(4) Policies and procedures shall be consistent with professionally recognized standards of practice.

(5) The facility shall develop policies and procedures for testing a patient’s blood for the presence of the hepatitis B virus and the HIV virus in the event that an employee of the facility, a student studying at the facility; or other health care provider rendering services at the facility is exposed to a patient’s blood or other body fluid. The testing shall be performed at no charge to the patient, and the test results shall be confidential.

(6) The facility and its employees shall adopt and utilize standard precautions of the Centers for Disease Control (CDC) for preventing transmission of infections, HIV, and communicable diseases.

(7) All birthing centers 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.

(8) Each birthing center utilizing students shall establish policies and procedures for their supervision.

(9) Each birthing center shall establish policies for permitting visitors.

(10) No birthing 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. A birthing 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.

(11) 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;

Postings of (a) and (b) shall be on a sign no smaller than eleven inches (11”) in width and seventeen inches (17”) in height.

(12) “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.

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

History

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.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. 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. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.05 ADMISSIONS, DISCHARGES, AND TRANSFERS

(1) Prior to admission for services, the birthing center shall inform the patient of:

(a) The qualifications of the birthing center staff;

(b) The risks related to out-of-hospital childbirth;

(c) The benefits of out-of-hospital childbirth; and (d) The possibility of referral or transfer if complications arise during pregnancy or labor.

(2) The birthing center clinical staff shall obtain the patient’s written consent for birthing center services.

(3) The signed consent form shall be included with the patient’s individual clinical record.

(5) Birthing center patients are limited to those women who are initially determined to be at low risk and who are evaluated regularly throughout pregnancy to assure that they remain at low risk.

(6) Each birthing center shall establish a written risk assessment system which shall be a part of the policy and procedure manual. The individual risk assessment shall be included in the patient’s clinical record.

(7) Written policies, procedures and practice guidelines for management of emergencies and discharge must be developed and implemented.

(8) Each birthing center shall have a written agreement with a hospital(s), which is licensed to provide obstetrical services, for emergency care. Each physician practicing or consulting in the birthing center shall have admitting privileges at a designated back-up hospital.

(9) The birthing center shall have written practice guidelines which shall include at a minimum:

(a) The name, address, telephone numbers and contact persons of the licensed transport service, the hospital licensed to provide emergency obstetrical and neonatal services and other hospitals in the vicinity;

(b) The criteria to determine risk status which require medical consultation or transfer to a hospital will be outlined in the clinical practice guidelines; and, (c) The criteria and practice guidelines for transfer shall be readily accessible to clinical staff at all times.

(10) The names and telephone numbers of the ambulance service, neonatal transport service, and hospital shall be clearly posted at each telephone in the birthing center.

(11) Infant Abandonment.

(a) Any birthing center shall receive possession of any newborn infant left on birthing center premises with any birthing center employee or member of the professional medical community, if the infant:

Was born within the preceding seventy-two (72) hour period, as determined within a reasonable degree of medical certainty;
Is left in an unharmed condition; and 3. Is voluntarily left by a person who purported to be the child’s mother and who did not express an intention of returning for the infant.

(b) The birthing center, any birthing center employee and any member of the professional medical community at such birthing center shall inquire whenever possible about the medical history of the mother or newborn and whenever possible shall seek the identity of the mother, infant, or the father of the infant. The birthing center shall also inform the mother that she is not required to respond, but that such information will facilitate the adoption of the child. Any information obtained concerning the identity of the mother, infant or other parent shall be kept confidential and may only be disclosed to the Department of Children’s Services. The birthing center may provide the parent contact information regarding relevant social service agencies, shall provide the mother the name, address and phone number of the department contact person, and shall encourage the mother to involve the Department of Children’s Services in the relinquishment of the infant. If practicable, the birthing center shall also provide the mother with both orally delivered and written information concerning the requirements of these rules relating to recovery of the child and abandonment of the child.

(c) The birthing center, any birthing center employee and any member of the professional medical community at such birthing center shall perform any act necessary to protect the physical health or safety of the child.

(d) As soon as reasonably possible, and no later than twenty-four (24) hours after receiving a newborn infant, the birthing center shall contact the Department of Children’s Services, but shall not do so before the mother leaves the birthing center premises. Upon receipt of notification, the department shall immediately assume care, custody and control of the infant.

(e) Notwithstanding any provision of law to the contrary, any birthing center, any birthing center employee and any member of the professional medical community shall be immune from any criminal or civil liability for damages as a result of any actions taken pursuant to the requirements of these rules, and no lawsuit shall be predicated thereon; provided, however, that nothing in these rules shall be construed to abrogate any existing standard of care for medical treatment or to preclude a cause of action based upon violation of such existing standard of care for medical treatment.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-255.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Amendment filed September 17, 2002; effective December 1, 2002. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.06 BASIC BIRTHING CENTER FUNCTIONS

(1) Quality Assurance. The birthing center governing body must ensure that there is an established program for evaluating the quality of direct care services to childbearing families, and the environment in which the services are provided. with an organizational plan to identify and resolve problems.

(2) Staff.

(a) The governing body must ensure that there are adequate numbers of qualified and, where required, licensed personnel to provide services needed by mothers and families and to provide for safe maintenance of the birthing center.

(b) The governing body must appoint a medical director who:

Is a qualified specialist in obstetrics/gynecology or family practice;
Approves all policies, procedures and practice guidelines for the medical management of care;
Approves standardized criteria for admission screening and monitoring the risk status of each mother during pregnancy, labor, birth and postpartum; and 4. Is available for consultation and referral in obstetrics or pediatrics or has made arrangements with a qualified physician for these services.

(3) Equipment.

(a) A readily accessible emergency cart or tray for the mother, equipped to carry out the written emergency procedures of the center and securely placed with a written log of routine maintenance for readiness.

(b) A readily accessible emergency cart or tray for the newborn, equipped to carry out the written emergency procedures of the center and securely placed with a written log of routine maintenance for readiness.

A heat source for infant examination or resuscitation;
Transfer incubator or isolette or demonstrated capability of ready access to transfer incubator;
Sterilizer or demonstration of sterilizing capability;
Blood pressure equipment, thermometers, fetoscope/doptone;
Intravenous equipment;
Oxygen equipment for mother and newborn; and, 7. Instruments for episiotomy and repair.

(4) Prenatal Care. The physician, certified professional midwife and nurse-midwife shall ensure that patients have adequate education and prenatal care by generally accepted definitions.

Records of this care should be available in the center at the time of admission. When, in the course of prenatal care. risk factors are identified which preclude childbirth at the center, the woman shall be referred for care in a hospital setting and her prenatal records made available to the attending clinicians.

(5) Surgical Services. Surgical procedures shall be limited to those normally accomplished during uncomplicated childbirth, such as episiotomy and repair, and must not include operative obstetrics or cesarean section.

(6) If intervention beyond what is allowed in the practice guidelines is required at any time during the course of pregnancy and/or labor, the woman and her newborn must be managed at a more intensive level of care.

(7) Laboratory Services. The birthing center shall have the capacity to perform on site routinely necessary tests such as hematocrit and urinalysis for glucose, protein, bacteria, and specific gravity.

(8) Intrapartum Care. Labor shall not be inhibited, stimulated. or augmented with chemical agents during the first or second stage of labor. Drugs for induction or augmentation of labor, vacuum extractors, forceps, continuous electronic fetal monitoring and ultrasound imaging are not appropriate during normal labor. A nurse midwife. certified professional midwife or physician must be in attendance or available to attend during all stages of the delivery.

(9) Analgesia and Anesthesia. General and conduction anesthesia shall not be administered at birthing centers. Local anesthesia for pudendal block may be performed. Systemic analgesia may be administered, but pain control should depend primarily on close emotional support and adequate preparation for the birth experience.

(10) Postpartum Care. Mothers and infants must be discharged in accordance with standards set by the clinical staff and specified in the policy and procedures manual, including laboratory tests required by state laws. A program for prompt follow-up care and postpartum evaluation after discharge shall be ensured and outlined in the manual of policies and procedures. This program should include assessment of infant health including physical examination, laboratory screening tests at the appropriate times, maternal postpartum status, instruction in child care including immunization, referral to sources of pediatric care, provision of family planning services, and assessment of mother-child relationship including breast feeding.

(11) Food Services. The birthing center must provide mothers and families with nutritious liquids and snacks as required. Food may be prepared by the family, catered, or prepared in the birthing center’s kitchen. Meals that are prepared and served by the birthing center will be subject to local regulations for food preparation and service.

(12) The physical environment of the facility shall be maintained in a safe, clean and sanitary manner.

(a) Any condition on the birthing center site conducive to the harboring or breeding of insects, rodents or other vermin shall be prohibited. Chemical substances of a poisonous nature used to control or eliminate vermin shall be properly identified. Such substances shall not be stored with or near food or medications.

(b) Cats, dogs or other animals shall not be allowed in any part of the facility except for specially trained animals for the handicapped. The facility shall designate in its policies and procedures those areas where animals will be excluded. The areas designated shall be determined based upon an assessment of the facility performed by medically trained personnel.

(13) Infection Control. A birthing center shall have an annual influenza vaccination program which shall include at least:

(a) The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The birthing center will encourage all staff and independent practitioners to obtain an influenza vaccination;

Flu vaccination, 2. Non-vaccine control measures, and 3. The diagnosis, transmission, and potential impact of influenza;

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Amendment filed January 3, 2006; effective March 19, 2006. Amendments filed July 18, 2016; effective October 16, 2016. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.07 BUILDING STANDARDS

(1) A birthing center shall construct, arrange, and maintain the condition of the physical plant and the overall birthing center environment in such a manner that the safety and well-being of the patients are assured.

(3) The codes in effect at the time of submittal of plans and specifications, as defined by these rules, shall be the codes to be used throughout the project.

(4) The licensed contractor shall perform all new construction and renovations to birthing centers, other than minor alterations not affecting fire and life safety or functional issues, in accordance with the specific requirements of these regulations governing new construction in birthing centers, including the submission of phased construction plans and the final drawings and the specifications to each.

(5) No new birthing center shall be constructed, nor shall major alterations be made to an existing birthing center without prior written approval of the department, and unless in accordance with plans and specifications approved in advance by the department. Before any new birthing center is licensed or before any alteration or expansion of a licensed birthing center can be approved, the applicant must furnish two (2) complete sets of plans and specifications to the department, together with fees and other information as required. Plans and specifications for new construction and major renovations, other than minor alterations not affecting fire and life safety or functional issues, shall be prepared by or under the direction of a licensed architect and/or a licensed engineer and in accordance with the rules of the Board of Architectural and Engineering Examiners.

(a) The project architect or engineer shall forward two (2) sets of plans to the appropriate

(b) Review of plans does not eliminate responsibility of owner and/or architect to comply with all rules and regulations.

(8) Specifications shall supplement all drawings. They shall describe the characteristics of all materials, products and devices, unless fully described and indicated on the drawings.

Specification copies should be bound in an 8½ x 11 inch folder.

(9) Drawings and specifications shall be prepared for each of the following branches of work:

Architectural, Structural, Mechanical, Electrical and Sprinkler.

(10) Architectural drawings shall include where applicable:

(a) Plot plan(s) showing property lines, finish grade, location of existing and proposed structures, roadways, walks, utilities and parking areas;

(b) Floor plan(s) showing scale drawings of typical and special rooms, indicating all fixed and movable equipment and major items of furniture;

(d) The elevation of each facade;

(e) The typical sections throughout the building;

(f) The schedule of finishes;

(g) The schedule of doors and windows;

(h) Roof plans;

(i) Details and dimensions of elevator shaft(s), car platform(s), doors, pit(s), equipment in the machine room, and the rates of car travel must be indicated for elevators; and (j) Code analysis.

(11) Structural drawings shall include where applicable:

(a) Plans of foundations, floors, roofs and intermediate levels which show a complete design with sizes, sections and the relative location of the various members;

(b) Schedules of beams, girders and columns; and (c) Design live load values for wind, roof, floor, stairs, guard, handrails, and seismic.

(12) Mechanical drawings shall include where applicable:

(a) Specifications which show the complete heating, ventilating, fire protection, medical gas systems and air conditioning systems;

(b) Water supply, sewerage and HVAC piping systems;

(d) Heating, ventilating, HVAC piping, medical gas systems and air conditioning systems with all related piping and auxiliaries to provide a satisfactory installation;

(13) Electrical drawings shall include where applicable:

(a) A seal, certifying that all electrical work and equipment is in compliance with all applicable codes and that all materials are currently listed by recognized testing laboratories;

(d) Color coding to show all items on emergency power;

(14) The electrical drawings shall not include knob and tube wiring, shall not include electrical cords that have splices, and shall not show that the electrical system is overloaded.

(15) In all new facilities or renovations to existing electrical systems, the installation must be approved by an inspector or agency authorized by the State Fire Marshal.

(16) Sprinkler drawings shall include where applicable:

(a) Shop drawings, hydraulic calculations, and manufacturer cut sheets;

(17) The licensed contractor shall not install a system of water supply, plumbing, sewage, garbage or refuse disposal nor materially alter or extend any existing system until the architect or engineer submits complete plans and specifications for the installation, alteration or extension to the department demonstrating that all applicable codes have been met and the department has granted necessary approval.

(a) Before the birthing center is used, Tennessee Department of Environment and Conservation shall approve the water supply system.

(18) It shall be demonstrated through the submission of plans and specifications that in each birthing center a negative air pressure shall be maintained in the soiled utility area, toilet room, janitor’s closet, dishwashing and other such soiled spaces, and a positive air pressure shall be maintained in all clean areas including, but not limited to, clean linen rooms and clean utility rooms.

(20) In the event submitted materials do not appear to satisfactorily comply with 0720-25-.07(2), the department shall furnish a letter to the party submitting the plans which shall list the particular items in question and request further explanation and/or confirmation of necessary modifications.

(21) The licensed contractor shall execute all construction in accordance with the approved plans and specifications.

(22) If construction begins within one hundred eighty (180) days of the date of department approval, the department’s written notification of satisfactory review constitutes compliance with 0720-25-.07(2). This approval shall in no way permit and/or authorize any omission or deviation from the requirements of any restrictions, laws, regulations, ordinances, codes or rules of any responsible agency.

(24) The department requires the following alarms that shall be monitored twenty-four (24) hours per day:

(a) Fire alarms; and (b) Generators (if applicable).

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Amendment filed February 18, 2003; effective May 4, 2003. Repeal and new rule filed January 3, 2006; effective March 19, 2006. Repeal and new rule filed December 20, 2011; effective March 19, 2012. Amendment filed January 21, 2016; effective April 20, 2016. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.08 LIFE SAFETY

(1) Any birthing center which complies with the required applicable building and fire safety regulations at the time the board adopts new codes or regulations will, so long as such compliance is maintained (either with or without waivers of specific provisions), be considered to be in compliance with the requirements of the new codes or regulations.

(2) The birthing center shall provide fire protection by the elimination of fire hazards, by the installation of necessary fire fighting equipment and by the adoption of a written fire control plan. All fires which result in a response by the local fire department shall be reported to the department within seven (7) days. The report shall contain sufficient information to ascertain the nature and location of the fire, its probable cause and any injuries incurred by any person or persons as a result of the fire. Initial reports by the facility may omit the name(s) of patient(s) and parties involved, however, should the department find the identities of such persons to be necessary to an investigation, the facility shall provide such information.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Amendment filed January 3, 2006; effective March 19, 2006. Repeal and new rule filed December 20, 2011; effective March 19, 2012. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-202, 68-11-204, 68-11- 206, 68-11-207, 68-11-208, and 68-11-209.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Amendment filed March 1, 2007; effective May 15, 2007. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.09 INFECTIOUS AND HAZARDOUS WASTE

(1) Each birthing center must develop, maintain and implement written policies and procedures for the definition and handling of its infectious and hazardous waste, including a specific policy and procedure on containment and repackaging of spilled waste. These policies and procedures must comply with the standards of this section and all other applicable state and federal regulations.

(2) The following waste shall be considered to be infectious waste:

(a) Waste contaminated by patients who are isolated due to communicable disease, as provided in the U.S. Centers for Disease Control “Guidelines for Isolation, Precautions in Hospitals”;

(b) Cultures and stocks of infectious agents including specimen cultures collected from medical and pathological laboratories, cultures and stocks of infectious agents from research and industrial laboratories, wastes from the production of biologicals, discarded live and attenuated vaccines, culture dishes and devices used to transfer, inoculate, and mix cultures;

(d) Pathological waste, such as tissues, organs, body parts, and body fluids that are removed during surgery and autopsy;

(f) Contaminated carcasses, body parts, and bedding of animals that were exposed to pathogens in research, in the production of biologicals, or in the in vivo testing of pharmaceuticals; and, (g) Other waste determined to be infectious by the facility in its written policy.

(3) Infectious and hazardous waste must be segregated from other waste at the point of generation (i.e., the point at which the material becomes a waste) within the facility.

(4) Waste must be packaged in a manner that will protect waste handlers and the public from possible injury and disease that may result from exposure to the waste. Such packaging must provide for containment of the waste from the point of generation up to the point of proper treatment or disposal. Packaging must be selected and utilized for the type of waste the package will contain, how it will be handled and transported, and how the waste will be treated and disposed of.

(a) Contaminated sharps must be directly placed in leakproof, rigid and puncture-resistant containers which must then be tightly sealed.

(d) Opaque packaging must be used for pathological waste.

(a) Waste must not be compacted or ground (i.e., in a mechanical grinder) prior to treatment, except that pathological waste may be ground prior to disposal.

(b) Plastic bags of infectious waste must be transported by hand.

(b) Pathological waste must be promptly treated, disposed of, or placed in refrigerated storage.

(7) In the event of spills, ruptured packaging, or other incidents where there is a loss of containment of waste, the facility must ensure that proper actions are immediately taken to:

(a) Isolate the area from the public and all except essential personnel;

(b) To the extent practicable, repackage all spilled waste and contaminated debris in accordance with the requirements of paragraph (6) of this section;

(c) Sanitize all contaminated equipment and surfaces appropriately; and, (d) Complete an incident report and maintain a copy on file.

(8) Except as provided otherwise in this rule a facility must treat or dispose of infectious waste by one or more of the methods specified in this paragraph.

(a) A facility may treat infectious waste in an on-site sterilization or disinfection device, or in an incinerator or a steam sterilizer, which has been designed, constructed, operated and maintained so that infectious waste treated in such a device is rendered noninfectious and is, if applicable, authorized for that purpose pursuant to current rules of the Department of Environment and Conservation. A valid permit or other written evidence of having complied with the Tennessee Air Pollution Control Regulations shall be available for review, if required. Each sterilizing or disinfection cycle must contain appropriate indicators to assure that conditions were met for proper sterilization or disinfection of materials included in the cycle, and appropriate records kept. Proper operation of such devices must be verified at least monthly, and records of the monthly verifications shall be available for review. Waste that contains toxic chemicals that would be volatilized by steam must not be treated in steam sterilizers. Infectious waste that has been rendered to carbonized or mineralized ash shall be deemed noninfectious. Unless otherwise hazardous and subject to the hazardous waste management requirements of the current rules of the Department of Environment and Conservation, such ash shall be disposable as a (non-hazardous) solid waste under current rules of the Department of Environment and Conservation.

(9) The facility may have waste transported off-site for storage, treatment, or disposal. Such arrangements must be detailed in a written contract, available for review. If such off-site location is located within Tennessee, the facility must ensure that it has all necessary State and local approvals, and such approvals shall be available for review. If the off-site location is within another state, the facility must notify in writing all public health agencies with jurisdiction that the location is being used for management of the facility’s waste. Waste shipped off-site must be packaged in accordance with applicable federal and state requirements. Waste transported to a sanitary landfill in this state must meet the requirements of current rules of the Department of Environment and Conservation.

(10) Human anatomical remains which are transferred to a mortician for cremation or burial shall be exempt from the requirements of this rule. Any other human limbs and recognizable organs must be incinerated or discharged (following grinding) to the sewer.

(11) All garbage, trash and other non-infectious waste shall be stored and disposed of in a manner that must not permit the transmission of disease, create a nuisance, provide a breeding place for insects and rodents, or constitute a safety hazard. All containers for waste shall be water tight, constructed of easily-cleanable material, and shall be kept on elevated platforms.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, and 68-11-209. Administrative pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.10 RECORDS AND REPORTS

(1) A report of all births, deaths and stillbirths which have occurred in the birthing center shall be filed with the local registrar in the county where the institution is located. The report shall be filed on the third (3rd) working day of each month on a form furnished by the State Registrar.

The report shall state whether or not the list is complete for all events which have occurred in the facility during the preceding calendar month, and if not complete, shall show the number of events not included in the report. If no birth, death, or stillbirth occurred in the facility, the words “No Report” shall be entered on the form and forwarded to the local registrar.

(2) The Joint Annual Report, a calendar year statistical report, shall be filed with the department’s Bureau of Information Resources no later than sixty (60) days following the twelve (12) months ending December 31.

(3) The birthing center shall report each case of communicable disease to the local county health officer in the mariner provided by existing regulations of the department. Repeated failure to report communicable diseases shall be cause for revocation of a facility license.

(4) The birthing center shall report all incidents of abuse, neglect, and misappropriation to the Department of Health in accordance with T.C.A. § 68-11-211.

(5) The birthing center shall report the following incidents to the Department of Health in accordance with T.C.A. § 68-11-211.

(a) Strike by staff at the facility;

(b) External disasters impacting the facility;

(c) Disruption of any service vital to the continued safe operation of the birthing center or to the health and safety of its patients and personnel; and (d) Fires at the birthing center that disrupt the provision of patient care services or cause harm to the patients or staff, or that are reported by the facility to any entity, including but not limited to a fire department charged with preventing fires.

(6) The birthing center shall report information contained in the medical records of patients who have cancer or precancerous or tumorous diseases as provided by existing regulations.

These reports shall be sent to the Cancer Reporting System of the department on a quarterly schedule no later than six (6) months after the date of the diagnosis or treatment.

(7) The birthing center shall retain legible copies of the records and reports specified in this paragraph for the thirty-six (36) month period following their issuance. Copies of these reports shall be maintained in a single file at a location convenient to the public and, during normal business hours, they shall be promptly produced for the inspection of any person who requests to view them. Each patient and each person assuming any financial responsibility for a patient must be fully informed, before or at the time of admission, of the availability of these reports to the public, of their location within the facility, and given an opportunity to inspect the file before entering into any monetary agreement with the facility.

(a) Local fire safety inspections.

(b) Local building code inspections, if any.

(d) Department licensure and fire safety inspections and surveys.

(e) Department quality assurance surveys, including follow-up visits, and certification inspections, if any.

(f) Federal Health Care Financing Administration surveys and inspections, if any.

(g) Orders of the Commissioner or Board, if any.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11-209, 68-11- 210, 68-11-211, and 68-11-213.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Amendment filed April 11, 2003; effective June 25, 2003. Amendments filed January 3, 2012; effective April 2, 2012. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.11 PATIENT RIGHTS

(1) Each patient has at least the following rights:

(a) To privacy in treatment and personal care;

(b) To be free from mental and physical abuse. Should this right be violated, the facility must notify the department and the Tennessee Department of Human Services, Adult Protective Services;

(c) To refuse treatment. The patient must be informed of the consequences of that decision, the refusal and its reason must be reported to the physician and documented in the medical record;

(d) To refuse experimental treatment and drugs. The patient’s or health care decision maker’s written consent for participation in research must be obtained and retained in his or her medical record; and (e) To have their records kept confidential and private. Written consent by the patient must be obtained prior to release of information except to persons authorized by law. If the patient lacks capacity, written consent is required from the patient’s health care decision maker. The birthing center must have policies to govern access and duplication of the patient’s record.

(2) Each patient has a right to self-determination, which encompasses the right to make choices regarding life-sustaining treatment, including resuscitative services. This right of selfdetermination may be effectuated by an advance directive.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Amendment filed January 3, 2006; effective March 19, 2006. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.12 POLICIES AND PROCEDURES FOR HEALTH CARE DECISION-MAKING

(1) Pursuant to this rule, each birthing center shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a patient who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from individual patients. An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.

(8) An advance directive may include the individual’s nomination of a court-appointed guardian.

(10) No health care provider or institution shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care.

(12) A patient having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.

(13) A patient having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke.

(15) An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.

(16) Surrogates.

(a) An adult or emancipated minor may designate any individual to act as surrogate by personally informing the supervising health care provider. The designation may be oral or written.

(b) A surrogate may make a health care decision for a patient who is an adult or emancipated minor if and only if:

The patient has been determined by the designated physician to lack capacity, and 2. No agent or guardian has been appointed, or 3. The agent or guardian is not reasonably available.

(e) Consideration may be, but need not be, given in order of descending preference for service as a surrogate to:

The patient’s spouse, unless legally separated;
The patient’s adult child;
The patient’s parent;
The patient’s adult sibling;
Any other adult relative of the patient; or 6. Any other adult who satisfies the requirements of 0720-25-.12(16)(d).

(f) No person who is the subject of a protective order or other court order that directs that person to avoid contact with the patient shall be eligible to serve as the patient’s surrogate.

(g) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:

Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the patient or in accordance with the patient’s best interests;
The proposed surrogate’s regular contact with the patient prior to and during the incapacitating illness;
The proposed surrogate’s demonstrated care and concern;
The proposed surrogate’s availability to visit the patient during his or her illness; and 5. The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.

(h) If the patient lacks capacity and none of the individuals eligible to act as a surrogate under 0720-25-.12(16)(c) through 0720-25-.12(16)(g) is reasonably available, the designated physician may make health care decisions for the patient after the designated physician either:

Consults with and obtains the recommendations of a facility’s ethics mechanism or standing committee in the facility that evaluates health care issues; or 2. Obtains concurrence from a second physician who is not directly involved in the patient’s health care, does not serve in a capacity of decision-making, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.

(j) A surrogate shall make a health care decision in accordance with the patient’s individual instructions, if any, and other wishes to the extent known to the surrogate.

(l) Except as provided in 0720-25-.12(16)(m):

Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution nor an employee of an operator of a health care institution may be designated as a surrogate; and 2. A health care provider or employee of a health care provider may not act as a surrogate if the health care provider becomes the patient’s treating health care provider.

(m) An employee of the treating health care provider or an employee of an operator of a health care institution may be designated as a surrogate if:

The employee so designated is a relative of the patient by blood, marriage, or adoption; and 2. The other requirements of this section are satisfied.

(17) Guardian.

(a) A guardian shall comply with the patient’s individual instructions and may not revoke the patient’s advance directive absent a court order to the contrary.

(b) Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.

(19) Except as provided in 0720-25-.12(20) through 0720-25-.12(22), a health care provider or institution providing care to a patient shall:

(20) A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.

(21) A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:

(23) A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 0720-25-.12(20) through 0720-25-.12(22) shall:

(a) Promptly so inform the patient, if possible, and any person then authorized to make health care decisions for the patient;

(b) Provide continuing care to the patient until a transfer can be effected or until the determination has been made that transfer cannot be effected;

(a) Complying with a health care decision of a person apparently having authority to make a health care decision for a patient, including a decision to withhold or withdraw health care;

(26) An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.

(27) A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for such identification made in good faith.

(28) A copy of a written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.

(30) Physician Orders for Scope of Treatment (POST).

(a) Physician Orders for Scope of Treatment (POST) may be issued by a physician for a patient with whom the physician has a bona fide physician-patient relationship, but only:

With the informed consent of the patient;
If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or 3. If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available, if the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

No physician, who has a bona fide physician-patient relationship with the patient, is present and available for discussion with the patient (or if the patient is a minor or is otherwise incapable of making an informed decision, with the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act);
Such authority to issue is contained in the physician assistant’s, nurse practitioner’s or clinical nurse specialist’s protocols;
Either:

(i) With the informed consent of the patient;

(d) A POST issued in accordance with this section shall remain valid and in effect until revoked. In accordance with this rule and applicable regulations, qualified emergency medical services personnel; and licensed health care practitioners in any facility, program, or organization operated or licensed by the Board for Licensing Health Care Facilities, the Department of Mental Health and Substance Abuse Services, or the Department of Intellectual and Developmental Disabilities, or operated, licensed, or owned by another state agency, shall follow a POST that is available to such persons in a form approved by the Board for Licensing Health Care Facilities.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-224, and 68- 11-1801 through 68-11-1815 .
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Amendment filed April 28, 2003; effective July 12, 2003. Repeal and new rule filed January 3, 2006; effective March 19, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-25-.13 DISASTER PREPAREDNESS

(1) Physical Facility and Community Emergency Plans.

(a) Every birthing center shall have a current internal emergency plan, or plans, that provides for fires, bomb threats, severe weather, utility service failures, plus any local high risk situations such as floods, earthquakes, toxic fumes and chemical spills.

(b) The plan(s) must include provisions for the relocation of persons within the building and/or either partial or full building evacuation. Plans that provide for the relocation of patients to other healthcare facilities must have written agreements for emergency transfers. Their agreements may be mutual, i.e., providing for transfer either way.

Provisions that have security implications may be omitted from the outline versions.

Familiarization information shall be included in employee orientation sessions and more detailed instructions must be included in continuing education programs. Records of orientation and education programs must be maintained for at least three (3) years.

(d) Drills of the fire safety plan shall be conducted at least once a year on each major work shift, for a minimum of three times a year for each facility. A combined drill of the other internal emergency plans shall be conducted at least once a year. The risk focus may vary by drill. Both types of drills are for the purposes of educating staff, resource determination, testing personal safety provisions and communications with other facilities and community agencies. Records which document and evaluate these drills must be maintained for at least three (3) years.

(e) As soon as possible, real situations that result in a response by local authorities must be documented. This includes a critique of the activation of the plan. Actual documented situations that provided educational and training value may be substituted for a drill.

(2) Emergency Planning with Local Government Authorities.

(a) All birthing centers shall establish and maintain communications with the county Emergency Management Agency. This includes the provision of the information and procedures that are needed for the local comprehensive emergency plan. The birthing centers shall cooperate, to the extent possible, in area disaster drills and local emergency situations.

(b) Each birthing center shall conduct both the physical facility and community emergency drills as required in these regulations, even if the local Emergency Management Agency is unable to participate.

History

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed March 31, 1998; effective June 12, 1998. Transferred from chapter 1200-08-24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.

Tenn. Comp. R. & Regs. 0720-25-.14 APPENDIX I

(1) Physician Orders for Scope of Treatment (POST) Form.

(This space intentionally left blank)

A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED

Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”)

Patient’s Last Name First Name/Middle Initial Date of Birth

Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Section B Check One Box Only MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.  Comfort Measures Only. Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.  Limited Additional Interventions. In addition to care described in Comfort Measures Only above, use medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. Treatment Plan: Basic medical treatments.  Full Treatment. In addition to care described in Comfort Measures Only and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including in the intensive care unit.

Other Instructions:

Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify)

The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other)

Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge)

MD/NP/CNS/PA Phone Number:

Name (print) Signature Relationship (write “self” if patient)

Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel.

Photocopies/faxes of signed POST forms are legal and valid.

Using POST Any incomplete section of POST implies full treatment for that section.

No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.”

Oral fluids and nutrition must always be offered if medically feasible.

IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”

A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.

Reviewing POST This POST should be reviewed if:

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.

(2) Advance Directive for Health Care Form.

ADVANCE DIRECTIVE FOR HEALTH CARE*

(Tennessee)

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.

Instructions: Parts 1 and 2 may be used together or independently. Please mark out/void any unused part(s).

Part 3 Other instructions, such as hospice care, burial arrangements, etc.:

(Attach additional pages if necessary)

Part 5 Your signature must either be witnessed by two competent adults (“Block A”) or by a notary public (“Block B”).

Signature: _______________________________________ Date: ____________________ (Patient)

Block A Neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.

Witnesses:

I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form.

Signature of witness number 2 Block B You may choose to have your signature witnessed by a notary public instead of the witnesses described in Block A.

STATE OF TENNESSEE

COUNTY OF

My commission expires:

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1805.
Administrative History: Original rule filed February 16, 2007; effective May 2, 2007. Repeal and new rule filed August 28, 2012; effective November 26, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed February 8, 2017; effective May 9, 2017. Transferred from chapter 1200-08- 24 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-26 Standards for Assisted-Care Living Facilities (Transferred from 1200-08-25)

Tenn. Comp. R. & Regs. 0720-26-.01 PURPOSE

(1) The purpose of assisted-care living services is to:

(a) Promote the availability of appropriate residential facilities for the elderly and adults with disabilities in the least restrictive and most homelike environment;

(b) Provide assisted-care living services to residents in facilities by meeting each individual’s medical and other needs safely and effectively; and (c) Enhance the individual’s ability to age in place while promoting personal individuality, respect, independence, and privacy.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11- 207, 68-11-209, 68-11-210, 68-11-211, 68-11-213, 68-11-224, and 68-11-1802.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed November 25, 1998; effective February 8, 1999. Amendment filed September 13, 2002; effective November 27, 2002. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed April 28, 2003; effective July 12, 2003. Amendments filed January 24, 2006; effective April 9, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.02 DEFINITIONS

(1) “Abuse” means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) “Activities of Daily Living (ADL’s)” means those activities which indicate an individual’s independence in eating, dressing, personal hygiene, bathing, toileting, ambulating, and medication management.

(3) “Administering Medication” means the direct application of a single dose of medication to the body of a resident by injection, inhalation, ingestion, topical application or by any other means and the placement of a single dose of medication into a container.

(4) “Administrator” means a natural person designated by the licensee to have the authority and responsibility to manage the ACLF and who is appropriately certified as an assisted-care living facility administrator or is currently licensed in Tennessee as a nursing home administrator as required by T.C.A. §§ 63-16-101, et seq.

(5) “Adult” means a person 18 years of age or older.

(6) “Ambulatory” means the resident’s ability to bear weight, pivot and safely walk with the use of a cane, walker, or other mechanical supportive device with or without the minimal assistance of another person. The resident must be physically and mentally capable of self-preservation by evacuating in response to an emergency. A resident who requires a wheelchair must be capable of transferring to and propelling the wheelchair independently.

(7) “Assisted-care living facility (ACLF)” means a building, establishment, complex or distinct part thereof that accepts primarily aged persons for domiciliary care and services.

(8) “Assistance with Self-Administration of Medication” means assistance in reading labels, opening medication containers or packaging, reminding residents of their medication, or observing the resident while taking medication in accordance with the plan of care.

(9) “Assisted-care living facility resident” or “resident” means primarily an aged person who requires domiciliary care, and who upon admission to the facility, if not ambulatory, is capable of self-transfer from the bed to a wheelchair or similar device and is capable of propelling such wheelchair or similar device independently. Such a resident may require one or more of the following services: room and board, assistance with non-medical activities of daily living, administration of typically self-administered medications, and medical services subject to the limitations of these rules.

(10) “Assessment” means a procedure for determining the nature and extent of the problem(s) and needs of a resident or potential resident to ascertain if the ACLF can adequately address those problems, meet those needs, and secure information for the use in the development of the individual care plan.

(11) “Cardiopulmonary resuscitation (CPR)” means the administering of any means or device to restore or support cardiopulmonary functions in a resident, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilators or respirators, defibrillation, the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a resident where cardiac or respiratory arrest has occurred or is believed to be imminent.

(12) “Continuous nursing care” means round-the-clock observation, assessment, monitoring, supervision, or provision of nursing services that can only be performed by a licensed nurse.

(13) “Distinct part” means a unit or part thereof that is organized and operated to give a distinct type of care within the larger organization which renders other types or levels of care.

“Distinct” denotes both organizational and physical separateness. A distinct part of an ACLF must be physically identifiable and be operated distinguishably from the rest of the institution.

It must consist of all the beds within that unit such as a separate building, floor, wing or ward.

Several rooms at one end of a hall or one side of a corridor is acceptable as a distinct part of an ACLF.

(14) “Do-Not-Resuscitate Order (DNR)” means a written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(15) “Emergency” means any situation or condition which presents an imminent danger of death or serious physical or mental harm to residents.

(16) “Health care” means any care, treatment, service or procedure to maintain, diagnose, treat, or otherwise affect an individual’s physical or mental condition, and includes medical care as defined in T.C.A. § 32-11-103(5).

(17) “Health care decision” means an individual’s consent, refusal of consent or withdrawal of consent to health care.

(18) “Health care decision-maker” means that in the case of a resident who lacks capacity, the resident’s health care decision-maker is one of the following: the resident’s health care agent as specified in an advance directive, the resident’s court-appointed guardian or conservator with health care decision-making authority, the resident’s surrogate as determined pursuant T.C.A. § 68-11-1806, or the individual’s designated physician pursuant to T.C.A. § 68-11- 1802(a)(4).

(19) “Infectious waste” means solid or liquid wastes which contain pathogens with sufficient virulence and quantity such that exposure could result in an infectious disease.

(20) “Licensed health care professional” means:

(a) Any health care professional currently licensed by the State of Tennessee to practice within the scope of a regulated profession, such as a nurse practitioner, dietitian, dentist, occupational therapist, pharmacist, physical therapist, physician, physician assistant, psychologist, social worker, speech-language pathologist, and emergency service personnel; or (b) A medication aide (as defined in Tennessee Code Annotated § 63-7-127).

(21) “Licensee” means the person, association, partnership, corporation, company or public agency to which the license is issued.

(22) “Life threatening or serious injury” means an injury requiring the resident to undergo significant diagnostic or treatment measures.

(23) “Medical record” means documentation of medical histories, nursing and treatment records, care needs summaries, physician orders, and records of treatment and medication ordered and given which must be maintained by the ACLF, regardless of whether such services are rendered by ACLF staff or by arrangement with an outside source.

(24) “Medically inappropriate treatment” means resuscitation efforts that cannot be expected either to restore cardiac or respiratory function to the resident or other medical or surgical treatments that cannot be expected to achieve the expressed goals of the informed resident.

(25) “Medication Aide” means an individual who administers medications, as set forth in Tennessee Code Annotated § 63-7-127, under the general supervision of a licensed nurse pursuant to this section.

(26) “Misappropriation of patient/resident property” means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of an individual’s belongings or money without the individual’s consent.

(27) “Neglect” means the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; however, the withholding of authorization for or provision of medical care to any terminally ill person who has executed an irrevocable living will in accordance with the Tennessee Right to Natural Death Law, or other applicable state law, if the provision of such medical care would conflict with the terms of the living will, shall not be deemed “neglect” for purposes of these rules.

(28) “NFPA” means the National Fire Protection Association.

(29) “Person” means an individual, association, estate, trust, corporation, partnership, joint venture, government, governmental subdivision, agency, or instrumentality, or any other legal or commercial entity.

(30) “Personal services” means those services rendered to residents who need supervision or assistance in activities of daily living. Personal services do not include nursing or medical care.

(31) “Physician Assistant” means a person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(32) “Physician Orders for Scope of Treatment” or “POST” means written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(33) “Power of Attorney for Health Care” means the legal designation of an agent to make health care decisions for the individual granting such power under T.C.A. Title 34, Chapter 6, Part 2.

(34) “Primarily aged” means that a minimum of fifty-one percent (51%) of the population of the facility is at least sixty-two (62) years of age.

(35) “Resident sleeping unit” means a single unit providing sleeping facilities for one or more persons. Resident sleeping units can also include permanent provisions for living, eating and sanitation.

(36) “Responsible attendant” means the individual person designated by the licensee to provide personal services to the residents.

(37) “Secured unit” means a distinct part of an ACLF where the residents are intentionally denied egress except as is necessary to comply with life safety requirements.

(38) “Self-Administration of Medication” means the ability to administer medicine to oneself without assistance other than receiving help with reading labels or with physically opening the container or packaging, being reminded of one’s medication, or being observed while taking medication in accordance with the plan of care.

(39) “Supervising health care provider” means the health care provider who has undertaken primary responsibility for an individual’s health care.

(40) “Surrogate” means an individual, other than a resident’s agent or guardian, authorized to make a health care decision for the resident pursuant to T.C.A. § 68-11-1806.

(41) “Treating health care provider” means a health care provider directly or indirectly involved in providing health care to a resident at the time such care is needed by the resident.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11- 210, and 68-11-211.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed November 19, 2003; effective February 2, 2004. Amendment filed January 19, 2007; effective April 4, 2007. Amendment filed February 23, 2007; effective May 9, 2007. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.03 LICENSING REQUIREMENTS

(1) An applicant for an ACLF license shall submit the following to the office of the Board for Licensing Health Care Facilities:

(a) A completed application on a form approved by the Board;

(b) Nonrefundable application fee;

(c) Demonstration of the ability to meet the financial obligations of the ACLF with a financial statement prepared by a certified public accountant;

(d) A copy of a local business license (if one is required by the locality);

(e) A copy of any and all documents demonstrating the legal status of the business organization that owns the ACLF. If the applicant is a corporation or a limited liability company the applicant must submit a certificate of good standing; and (f) Any other documents or information requested by the Board.

(2) Before a license is granted, the applicant shall submit to an inspection conducted by Department of Health inspectors to ensure compliance with all applicable laws and rules.

(3) The applicant shall not use subterfuge or other evasive means to obtain a license, such as filing for a license through a second party when an applicant has been denied a license or has had a license disciplined or has attempted to avoid the survey and review process.

(4) ACLF licenses shall expire and become invalid annually on the anniversary date of their original issuance.

(a) In order to successfully renew a license, Department inspectors will periodically inspect each ACLF to determine its compliance with these rules and regulations. If the inspectors find deficiencies, the licensee shall submit an acceptable corrective action plan and shall remedy the deficiencies.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late; provided that the late penalty shall not exceed twice the renewal fee.

A completed application for licensure; and 2. The license fee provided in Rule 0720-26-.04(1).

(d) Upon reapplication, the licensee shall submit to an inspection of the ACLF by Department of Health inspectors.

(5) The Board shall issue a license only for the licensee and the location designated on the license application. If an ACLF moves to a new location, it shall obtain a new license and submit to an inspection of the new building before admitting residents.

(6) A separate license shall be required for each ACLF when more than one facility is operated under the same management or ownership.

(7) Any admission in excess of the licensed bed capacity is prohibited.

(8) Change of Ownership.

(a) A change of ownership occurs whenever the ultimate legal authority for the responsibility of the ACLF’s operation is transferred, including a change in the legal structure by which the ACLF is owned and operated, and/or whenever ownership of the preceding or succeeding entity changes.

(b) A licensee shall notify the Board’s administrative office of a proposed change of ownership within at least thirty (30) days prior to its occurrence by submitting the following to the Board office:

A completed change of ownership application on a form approved by the Board;
Nonrefundable application fee;
Demonstration of ability to meet the financial obligations of the ACLF with a financial statement prepared by a certified public accountant;
A copy of a local business license (if one is required by the locality);
A copy of any and all documents demonstrating the formation of the business organization that owns the ACLF;
The bill of sale and/or closing documents indicating the transfer of operations of the business entity; and 7. Any other documents or information requested by the Board.

Transfer of the ACLF’s legal title;
Lease of the ACLF’s operations;
Dissolution of any partnership that owns, or owns a controlling interest in, the ACLF;
The removal, addition or substitution of a partner;
Removal of the general partner or general partners, if the ACLF is owned by a limited partnership;
Merger of an ACLF owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are canceled;
The consolidation of a corporate ACLF owner with one or more corporations; or 8. Transfers between levels of government.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors or board of trustees;
Merger of two (2) or more corporations where one of the originally-licensed corporations survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government;
Corporate stock transfers or sales, even when a controlling interest.
Sale/lease-back agreements if the lease involves the ACLF’s entire real and personal property and if the identity of the lessee, who shall continue the operation, retains the same legal form as the former owner; or 7. Management agreements if the owner continues to retain ultimate authority for the operation of the ACLF; however, if the ultimate authority is surrendered and transferred from the owner to a new manager, then a change of ownership has occurred.

(9) Certification of Administrator.

(a) Each ACLF must have an administrator who shall be certified by the Board, unless the administrator is currently licensed in Tennessee as a nursing home administrator as required by T.C.A. §§ 63-16-101, et seq.

(b) An applicant for certification as an ACLF administrator shall submit the following to the Board office:

A completed application on a form approved by the Board;
Nonrefundable application fee;
Proof that the applicant is at least twenty-one (21) years of age;
Proof that the applicant is a high school graduate or the holder of a general equivalency diploma;
Results of a criminal background check; and 6. Proof that the applicant has not been convicted of a criminal offense involving the abuse or intentional neglect of an elderly or vulnerable individual.

Certification shall be renewed biennially on June 30.
The initial biennial re-certification expiration date of ACLF administrator candidates who receive their first certification between the dates of January 1 and June 30 of any year will be extended to two (2) years plus the additional months remaining in the fiscal year.
In order to renew certification, the ACLF administrator shall submit the following to the Board office: renewal application; fee established by Rule 0720-26-.04; and proof of having obtained at least twenty-four (24) classroom hours of continuing education during the previous two (2) years.
An ACLF administrator shall complete twenty-four (24) classroom hours of continuing education approved by the Board prior to attendance, including, but not limited to the following topics:

(i) State rules and regulations for ACLFs;

(ii) Health care management;

(iii) Nutrition and food service;

(iv) Financial management; and (v) Healthy lifestyles.

All educational courses sponsored by the National Association of Boards of Examiners for Nursing Home Administrators (NAB) and continuing education courses sponsored by State and/or national associations that focus on geriatric care are board approved.
An ACLF administrator who allows an administrator certification to lapse and reapplies for new certification must submit written proof of attendance of at least twenty-four (24) classroom hours of continuing education courses, as described in Part 4 above, within six (6) months after submitting a new application.

(10) The licensee shall immediately notify the Board’s administrative office in the event of an absence or change of administrator due to serious illness, incapacity, death or resignation of its named administrator.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-201, 68-11-202, 68-11- 204, 68-11-206, 68-11-207, 68-11-208, 68-11-209, 68-11-213, and 68-11-216 and Chapter 846 of the Public Acts of 2008, § 1.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed March 1, 2007; effective May 15, 2007. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.04 FEES

(1) Each ACLF, except those operated by the United States of America or the State of Tennessee, making application for licensure under this chapter shall pay annually to the Board’s administrative office, a fee based on the number of ACLF beds, as follows:

(a) Less than 25 beds $1,040.00 (b) 25 to 49 beds, inclusive $1,300.00 (c) 50 to 74 beds, inclusive $1,560.00 (d) 75 to 99 beds, inclusive $1,820.00 (e) 100 to 124 beds, inclusive $2,080.00 (f) 125 to 149 beds, inclusive $2,340.00 (g) 150 to 174 beds, inclusive $2,600.00 (h) 175 to 199 beds, inclusive $2,860.00 For ACLFs of two hundred (200) beds or more, the fee shall be two thousand eight hundred and sixty dollars ($2,860.00) plus two hundred dollars ($200.00) for each twenty-five (25) beds or fraction thereof in excess of one hundred ninety-nine (199) beds. The fee shall be submitted with the application or renewal and is not refundable.

(2) Each ACLF administrator shall submit to the Board’s administrative office an application fee of one hundred eighty dollars ($180.00). The fee shall be submitted with the initial application or renewal application and is not refundable.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-3-511, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11- 209, 68-11-216, 68-11-257, and 71-6-121.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed November 25, 1998; effective February 8, 1999. Amendment filed September 21, 2001; effective December 5, 2001. 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. Public necessity rule filed May 13, 2009; through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendments filed March 26, 2019; effective June 24, 2019. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.05 REGULATORY STANDARDS

(1) A Department of Health representative shall make an unannounced inspection of every ACLF holding a license granted by the Board for its compliance with applicable state law and regulations within fifteen (15) months following the date of its last inspection, and as necessary, to protect the public’s health, safety and welfare. An ACLF must cooperate during Department of Health conducted inspections, including allowing entry at any hour and providing all required records.

(2) Plan of Correction. When Department of Health inspectors find that an ACLF has committed a violation of this chapter, the Department of Health, as the Board’s representative, will issue a statement of deficiencies to the ACLF. Within ten (10) days of receipt of the statement of deficiencies, the ACLF must return a plan of correction including the following:

(a) How the deficiency will be corrected;

(b) The date upon which each deficiency will be corrected;

(3) Either failure to submit a plan of correction in a timely manner or a finding by the Department of Health that the plan of correction is unacceptable may subject the ACLF’s license to disciplinary action.

(4) Upon a finding by the Board that an ACLF has violated any provision of the Health Facilities and Resources Act, Part 2—Regulation of Health and Related Facilities (T.C.A. §§ 68-11- 201, et seq.) or the rules promulgated pursuant thereto, action may be taken, upon proper notice to the licensee, to impose a civil penalty, deny, suspend, or revoke its license.

(5) Civil Penalties. The Board may, in a lawful proceeding respecting licensing (as defined in the Uniform Administrative Procedures Act), in addition to or in lieu of other lawful disciplinary action, assess civil penalties for violations of statutes, rules or orders enforceable by the Board in accordance with the following schedule:

Violation Penalty T.C.A. § 68-11-201(4)(B) $0-$1000 (Provision of Room and Board and Non-Medical Living Assistance Services)

T.C.A. § 68-11-201(4)(C) $0-$1000

(Provision of Medical and other Professional Services;

Medicare Services;

Oversight of Medical Services;

Plan of Care & Assessment;

Personal and Medical Records; and, Fire Safety)

T.C.A. § 68-11-213(i)(2) $0-$3000 (Admission or Retention of Inappropriately Placed Resident. )

Each resident shall constitute a separate violation.)

T.C.A. § 68-11-213(i)(1) $0-$5000 (Operating ACLF without Required License.

Each day of operation shall constitute a separate violation.)

In determining the amount of any civil penalty to be assessed pursuant to this rule the Board may consider such factors as the following:

(a) Willfulness of the violation;

(b) Repetitiveness of the violation;

(6) Each violation of any statute, rule or order enforceable by the Board shall constitute a separate and distinct offense and may render the ACLF committing the offense subject to a separate penalty for each violation.

(7) A licensee may appeal any disciplinary action taken against it in accordance with the Uniform Administrative Procedures Act, Tennessee Code Annotated § 4-5-101, et seq.

(8) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to rule

Tenn. Comp. R. & Regs. 0720-26-.06 ADMINISTRATION

(1) Each ACLF shall meet the following staffing and procedural standards:

(a) Staffing Requirements:

The licensee must designate in writing a capable and responsible person to act on administrative matters and to exercise all the powers and responsibilities of the licensee as set forth in this chapter in the absence of the licensee.
If the licensee is a natural person, the licensee shall be at least eighteen (18) years of age, of reputable and responsible character, able to comply with these rules, and must maintain financial resources and income sufficient to provide for the needs of the residents, including their room, board, and personal services.
An ACLF shall have an identified responsible attendant who is alert and awake at all times and a sufficient number of employees to meet the residents’ needs, including medical services as prescribed. The responsible attendant and direct care staff must be at least eighteen (18) years of age and capable of complying with statutes and rules governing ACLFs.
An ACLF shall have a licensed nurse available as needed.
An ACLF shall employ a qualified dietitian, full-time, part-time, or on a consultant

basis.

An ACLF may not employ an individual listed on the Abuse Registry maintained by the Department of Health.

(b) Policies and Procedures:

An ACLF shall have a written statement of policies and procedures outlining the facility’s responsibilities to its residents, any obligation residents have to the facility, and methods by which residents may file grievances and complaints.
An ACLF shall develop and implement an effective facility-wide performance improvement plan that addresses plans for improvement for self-identified deficiencies and documents the outcome of remedial action.
An ACLF shall develop a written policy, plan or procedure concerning a subject and adhere to its provisions whenever required to do so by these rules. A licensee that violates its own policy established as required by these rules and regulations also violates the rules and regulations establishing the requirement.
An ACLF shall develop a written policy and procedure governing smoking practices of residents.

(i) Residents of the facility are exempt from the smoking prohibition that otherwise applies to the ACLF.

(ii) Smoke from permissible smoking areas shall not infiltrate into areas where smoking is prohibited.

An ACLF shall develop a concise statement of its charity care policies and shall post such statement in a place accessible to the public.

(d) An ACLF shall allow pets in the ACLF only when they are not a nuisance and do not pose a health hazard. Plans for pet management must be approved by the Department.

(e) No person associated with the licensee or ACLF shall act as a court-appointed guardian, trustee, or conservator for any resident of the ACLF or any of such resident’s property or funds, except as provided by Rule 0720-26-.14(1)(i).

(f) An ACLF shall not 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 ACLF shall neither retaliate nor discriminate, because any person lawfully provides information to these authorities, cooperates with them, or is subpoenaed to testify at a hearing involving them.

(2) In the event a resident dies at an ACLF, a registered nurse may make the actual determination and pronouncement of death under the following circumstances.

(a) Death was anticipated and the attending physician has agreed in writing to sign the death certificate. Such agreement by the attending physician must be present and with the deceased at the place of death;

(b) The nurse is licensed by the Tennessee Board of Nursing; and (c) The nurse is employed by the ACLF in which the deceased resided.

(3) In the event that resident, receiving services of a Medicare certified hospice program licensed by the state, dies at an ACLF, a registered nurse may make the actual determination and pronouncement of death under the following circumstances:

(a) The deceased was suffering from a terminal illness;

(b) Death was anticipated and the attending physician has agreed in writing to sign the death certificate. Such agreement by the attending physician must be present and with the deceased at the place of death;

(c) The nurse is licensed by the Tennessee Board of Nursing; and (d) The nurse is employed by the hospice program from which the deceased had been receiving hospice services.

(4) An ACLF shall post the following at the main public entrance:

(a) 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 of Adult Protective Services. The statement shall include the statewide toll-free number for the Division and the telephone number for the local district attorney’s office. The posting shall be on a sign no smaller than eleven inches by seventeen inches. (This same information shall be provided to each resident in writing upon admission to any facility);

(b) A statement that any person, regardless of age, who may be the victim of domestic violence may call the nationwide domestic violence hotline for immediate assistance, with that number printed in boldface type, and posted on a sign no smaller than eight and one-half inches (8½”) in width and eleven inches (11”) in height;

(c) A statement regarding whether it has liability insurance, the identity of their primary insurance carrier, and if self-insured, the corporate entity responsible for payment of any claims. It shall be posted on a sign no smaller than eleven inches (11”) in width and seventeen inches (17”) in height; and (d) “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.

(e) A statement that any person who has experienced a problem with a specific licensed ACLF may file a complaint with the Division of Health Care Facilities. The posting shall include the statewide toll-free telephone number for the Division’s centralized complaint intake unit.

(5) Infection Control (a) An ACLF shall ensure that neither a resident nor an employee of the ACLF with a reportable communicable disease shall reside or work in the ACLF unless the ACLF has a written protocol approved by the Board’s administrative office.

(b) An Assisted-Care Living Facility shall have an annual influenza vaccination program which shall include at least:

The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Assisted-Care Living Facility will encourage all staff and independent practitioners to obtain an influenza vaccination;
A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider);
Education of all employees about the following:

(i) Flu vaccination;

(ii) Non-vaccine control measures; and (iii) The diagnosis, transmission, and potential impact of influenza;

An annual evaluation of the influenza vaccination program and reasons for nonparticipation; and 5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee.

(c) An ACLF and its employees shall adopt and utilize standard precautions in accordance with guidelines established by the Centers for Disease Control and Prevention (CDC) for preventing transmission of infections, HIV, and communicable diseases, including adherence to a hand hygiene program which shall include:

Use of alcohol-based hand rubs or use of non-antimicrobial or antimicrobial soap and water before and after each resident contact if hands are not visibly soiled;
Use of gloves during each resident contact with blood or where other potentially infectious materials, mucous membranes, and non-intact skin could occur and gloves shall be changed before and after each resident contact;
Use of either non-antimicrobial soap and water or antimicrobial soap and water for visibly soiled hands; and 4. Health care worker education programs which may include:

(i) Types of resident care activities that can result in hand contamination;

(ii) Advantages and disadvantages of various methods used to clean hands;

(iii) Potential risks of health care workers’ colonization or infection caused by organisms acquired from residents; and (iv) Morbidity, mortality, and costs associated with health care associated infections.

(d) An ACLF shall develop and implement a system for measuring improvements in adherence to the hand hygiene program and influenza vaccination program.

(6) An ACLF shall ensure that no person will be excluded from participation in, be denied benefits of, or be otherwise subjected to discrimination in the provision of any care or service of the ACLF on the grounds of race, color, national origin, or handicap. An ACLF shall protect the civil rights of residents under the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

History

Authority: T.C.A. §§ 4-5-202, 39-17-1804, 39-17-1805, 68-3-511, 68-11-202, 68-11-204, 68-11-206, 68- 11-207, 68-11-209, 68-11-213, 68-11-254, 68-11-268, and 71-6-121.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed January 7, 2000; effective March 22, 2000. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed July 18, 2016; effective October 16, 2016. Emergency rules filed May 29, 2020; effective through November 25, 2020. Emergency rules expired effective November 26, 2020, and the rules reverted to their previous statuses. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.07 SERVICES PROVIDED

(1) An ACLF may provide medical services as follows:

(a) Administer medications to residents that are typically self-administered as subject to limitations described within these rules and regulations.

(b) All other medical services prescribed by the physician that could be provided to a private citizen in the citizen’s home, including, but not limited to:

Part-time or intermittent nursing care;
Various therapies;
Podiatry care;
Medical social services;
Medical supplies;
Durable medical equipment; and 7. Hospice services.

Existing residents who receive them on an intermittent basis; and 2. Residents receiving hospice care.

(2) Medical services in an ACLF shall be provided by:

(a) Appropriately licensed or qualified staff of an ACLF;

(b) Appropriately licensed or qualified contractors of an ACLF;

(d) Another appropriately licensed entity; or (e) Appropriately licensed staff of a nursing home.

(3) Oversight of medical services in an ACLF shall be consistent with oversight provided in private residential settings as defined through rules and regulations promulgated by the applicable licensing boards and shall ensure quality of care to residents.

(4) Medicare reimbursable services shall be provided to an ACLF resident by a certified Medicare provider.

(5) Resident medication. An ACLF shall:

(a) Ensure that medication shall be self-administered in accordance with the resident’s plan of care;

(b) Ensure that all drugs and biologicals shall be administered by a licensed or certified health care professional operating within the scope of the professional license or certification and according to the resident’s plan of care.

(c) Ensure that during the course of administering medication, a medication aide shall not be assigned any other non-medication administration duties. However, a medication aide shall not be precluded from responding, as appropriate, to an emergency;

(d) Store all medications via a locked or closed container and/or room which includes, but is not limited to, some type of box, piece of furniture, an individual resident room, and/or a designated room within the facility which maintains resident medication out of the sight of other residents; and (e) Ensure that facility staff shall not repackage medication and shall not administer medication from repackaging.

(6) An ACLF shall dispose of medications as follows:

(a) Upon discharge of a resident, unused prescription medication shall be released to the resident, the resident’s family member, or the resident’s legal representative, unless specifically prohibited by the attending physician.

(b) Upon death of a resident, unused prescription medication must be destroyed in the manner outlined, and by the individuals designated, in the facility’s medication disposal policy, unless otherwise requested by the resident’s family member or the resident’s legal representative and accompanied by a written order by a physician. The ACLF’s medication disposal policy shall be written in accordance with current FDA or current DEA medication disposal guidelines;

(c) The ACLF shall properly dispose of prescription medication administered by the facility in accordance with the facility’s medication disposal policy, which shall be written in accordance with current FDA or current DEA medication disposal guidelines.

(d) The ACLF may dispose of prescription medication that is self-administered by the resident according to the facility’s medication disposal policy, which shall be written in accordance with current FDA or current DEA medication disposal guidelines, or the facility may provide information to the resident’s family member or the resident’s legal representative regarding the proper method to dispose of the medication.

(e) If the resident is a hospice patient, hospice shall be responsible for disposing of the prescription medication upon the death of the resident.

(f) The ACLF’s medication disposal policy shall be performed by a licensed or certified health care professional and either the facility’s administrator, or a second licensed or certified health care professional.

(g) The ACLF’s medication disposal policy shall also address the disposal of scheduled drugs, non-scheduled drugs, and devices that are misbranded, expired, deteriorated, not kept under proper conditions, and kept in containers with illegible or missing labels.

(7) An ACLF shall provide personal services as follows:

(a) Each ACLF shall provide each resident with at least the following personal services:

Protective care;
Safety when in the ACLF;
Daily awareness of the individual’s whereabouts;
The ability and readiness to intervene if crises arise;
Room and board; and 6. Non-medical living assistance with activities of daily living.

(b) Laundry services. An ACLF shall:

Provide arrangements for laundry of ACLF linens and residents’ clothing;
Provide appropriate separate storage areas for soiled linens and residents’ clothing; and 3. Maintain clean linens in sufficient quantity to provide for the needs of the residents. Linens shall be changed whenever necessary.

An ACLF shall have organized dietary services that are directed and staffed by adequate qualified personnel. An ACLF may contract with an outside food management company if the company has a dietitian who serves the ACLF on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section while providing for constant liaison with the ACLF for recommendations on dietetic policies affecting resident treatment.
An ACLF shall have an employee who:

(i) Serves as director of the food and dietetic service;

(ii) Is responsible for the daily management of the dietary services and staff training; and (iii) Is qualified by experience or training.

An ACLF shall ensure that menus meet the needs of the residents as follows:

(i) The practitioner or practitioners, as qualified within the scope of practice, responsible for the care of the residents shall prescribe therapeutic diets as necessary.

(ii) An ACLF shall meet nutritional needs, in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the residents.

(iii) An ACLF shall have a current therapeutic diet manual approved by the dietitian readily available to all ACLF personnel.

(iv) Menus shall be planned one week in advance.

An ACLF shall:

(i) Provide at least three (3) meals constituting an acceptable and/or prescribed diet per day. There shall be no more than fourteen (14) hours between the evening and morning meals. All food served to the residents shall be of good quality and variety, sufficient quantity, attractive and at safe temperatures. Prepared foods shall be kept hot (140°F. or above) or cold (41°F. or less) as appropriate. The food must be adapted to the habits, preferences and physical abilities of the residents. Additional nourishment and/or snacks shall be provided to residents with special dietary needs or upon request.

(ii) Provide sufficient food provision capabilities and dining space.

(iii) Maintain and properly store a forty-eight (48) hour food supply at all times.

(iv) Provide appropriate, properly-repaired equipment and utensils for cooking and serving food in sufficient quantity to serve all residents.

An ACLF shall maintain a clean and sanitary kitchen.
Employees shall wash and sanitize equipment, utensils and dishes after each use.

(d) An ACLF shall provide a suitable and comfortable furnished area for activities and family visits. Furnishings shall include a calendar and a functioning television set, radio, and clock.

(e) An ACLF shall provide current newspapers, magazines or other reading materials.

(f) An ACLF shall have a telephone accessible to all residents to make and receive personal telephone calls twenty-four (24) hours per day.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68- 11-261.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed November 25, 1999; effective February 8, 1999. Amendment filed August 26, 2002; effective November 9, 2002. Amendment filed February 18, 2003; effective May 4, 2003. Repeal and new rule filed January 24, 2006; effective April 9, 2006. Amendment filed February 23, 2007; effective May 9, 2007. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.08 ADMISSIONS, DISCHARGES, AND TRANSFERS

(1) An ACLF shall not admit or permit the continued stay of any ACLF resident who has any of the following conditions:

(a) Requires treatment for stage III or stage IV decubitus ulcers or with exfoliative dermatitis;

(b) Requires continuous nursing care;

(d) Exhibits verbal or physical aggressive behavior which poses an imminent physical threat to self or others, based on behavior, not diagnosis;

(e) Requires physical or chemical restraints, not including psychotropic medications for a manageable mental disorder or condition; or (f) Has needs that cannot be safely and effectively met in the ACLF.

(2) An ACLF resident shall be discharged and transferred to another appropriate setting such as home, a hospital, or a nursing home when the resident, the resident’s legal representative, ACLF administrator, or the resident’s treating physician determine that the ACLF cannot safely and effectively meet the resident’s needs, including medical services.

(a) The Board may require that an ACLF resident be discharged or transferred to another level of care if it determines that the resident’s needs, including medical services, cannot be safely and effectively met in the ACLF.

(3) Except for the limitations set forth in (4)(a) and (4)(b) of this rule, an ACLF may admit and permit the continued stay of an individual meeting the level of care requirement for nursing facility services, if:

(a) The resident’s treating physician certifies in writing that the resident’s needs, including medical services, can be safely and effectively met by care provided in the ACLF; and (b) The ACLF can provide assurances that the resident can be timely evacuated in case of fire or emergency.

(4) An ACLF shall not admit, but may permit the continued stay of residents who require:

(a) The following treatments on an intermittent basis of up to three (3) twenty-one (21) day periods. The resident’s treating physician must certify that treatment can be safely and effectively provided by the ACLF for the last two (2) twenty-one (21) day periods.

Nasopharyngeal or tracheotomy aspiration;
Nasogastric feedings;
Gastrostomy feedings; or 4. Intravenous therapy or intravenous feedings.

(b) The treatments described in parts (1)-(4) above can be provided on an on-going basis if:

The resident is receiving hospice services;
The resident does not qualify for nursing facility level care and the board grants a waiver; or 3. The resident is able to care for the specified conditions without assistance of facility personnel or other appropriately licensed entity. Such a resident may be admitted or permitted to continue as a resident of the ACLF.

(5) An ACLF resident qualifying for hospice care shall be able to receive hospice care services and continue as a resident if the resident’s treating physician certifies that such care can be appropriately provided in the ACLF.

(a) In the event that the resident is able to receive hospice services in an ACLF, the resident’s hospice provider and the ACLF shall be jointly responsible for a plan of care that is prepared pursuant to current hospice guidelines promulgated by the Centers for Medicaid and Medicare and ensures both the safety and well-being of the resident’s living environment and provision of the resident’s health care needs.

(b) The hospice provider shall be available to assess, plan, monitor, direct and evaluate the resident’s palliative care with the resident’s treating physician and in cooperation with the ACLF.

(6) An ACLF shall:

(a) Be able to identify at the time of admission and during continued stay those residents whose needs for services are consistent with these rules and regulations, and those residents who should be transferred to a higher level of care;

(b) Have a written admission agreement that includes a procedure for handling the transfer or discharge of residents and that does not violate the residents’ rights under the law or these rules;

(d) Give a thirty (30) day notice to all residents before making any changes in fee schedules;

(e) Ensure that residents see a physician for acute illness or injury and are transferred in accordance with any physician’s orders;

(f) Provide to each resident at the time of admission a copy of the resident’s rights for the resident’s review and signature;

(g) Have written policies and procedures to assist residents in the proper development, filing, modification and rescission of an advance directive, a living will, a do-notresuscitate order, and the appointment of a durable power of attorney for health care;

(h) Prior to the admission of a resident or prior to the execution of a contract for the care of a resident (whichever occurs first), each ACLF shall disclose in writing to the resident or to the resident’s legal representative, whether the ACLF has liability insurance and the identity of the primary insurance carrier. If the ACLF is self-insured, its statement shall reflect that fact and indicate the corporate entity responsible for payment of any claims;

(i) Document evidence of annual vaccination against influenza for each resident, in accordance with the recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control most recent to the time of vaccine, unless such vaccination is medically contraindicated or the resident has refused the vaccine.

Influenza vaccination for all residents accepting the vaccine shall be completed by November 30 of each year or within ten (10) days of the vaccine becoming available.

Residents admitted after this date during the flu season and up to February 1, shall as medically appropriate, receive influenza vaccination prior to or on admission unless refused by the resident; and (j) Document evidence of vaccination against pneumococcal disease for all residents who are sixty-five (65) years of age or older, in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control at the time of vaccination, unless such vaccination is medically contraindicated or the resident has refused offer of the vaccine. The facility shall provide or arrange the pneumococcal vaccination of residents who have not received this immunization prior to or on admission unless the resident refuses offer of the vaccine.

(k) Prior to the admission of a resident or prior to the execution of a contract for the care of a resident (whichever occurs first), each ACLF shall disclose in writing to the resident or to the resident’s legal representative a copy of the medication disposal policy, which shall be written in accordance with current FDA or current DEA medication disposal guidelines.

(7) An ACLF shall have documented plans and procedures to show evacuation of all residents.

(8) An ACLF may not retain a resident who cannot evacuate within thirteen (13) minutes unless the ACLF complies with Chapter 19 of the 2006 edition of the NFPA Life Safety Code, and the Institutional Unrestrained Occupancy of the 2006 edition of the International Building Code.

(9) An ACLF utilizing secured units shall provide survey staff with twelve (12) months of the following performance information specific to the secured unit and its residents at its annual survey:

(a) Documentation that an interdisciplinary team consisting of at least a physician, a registered nurse, and a family member (or patient care advocate) has evaluated each secured resident prior to admittance to the unit;

(b) Ongoing and up-to-date documentation that each resident’s interdisciplinary team has performed a quarterly review as to the appropriateness of placement in the secured unit;

(d) A current listing of all unusual incidents and/or complications on the unit;

(e) An up-to-date staffing pattern and staff ratios for the unit that is recorded on a daily

(f) A formulated calendar of daily group activities scheduled, including a resident attendance record for the previous three (3) months;

(g) An up-to-date listing of any incidences of decubitus and/or nosocomial infections, including resident identifiers; and (h) Documentation showing that 100% of the staff working on the unit receives annual inservice training which shall include, but not be limited to, the following subject areas:

Basic facts about the causes, progression and management of Alzheimer’s disease and related disorders;
Dealing with dysfunctional behavior and catastrophic reactions in the residents;
Identifying and alleviating safety risks to the resident;
Providing assistance in the activities of daily living for the resident; and 5. Communicating with families and other persons interested in the resident.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201(5), 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68- 11-211, 68-11-263, and 68-11-266.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed January 7, 2000; effective March 22, 2000. Amendment filed February 18, 2003; effective May 4, 2003. Repeal and new rule filed January 24, 2006; effective April 9, 2006. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.09 BUILDING STANDARDS

(1) An ACLF shall construct, arrange, and maintain the condition of the physical plant and the overall ACLF living facility environment in such a manner that the safety and well-being of residents are assured.

(3) The codes in effect at the time of submittal of plans and specifications, as defined by these rules, shall be the codes to be used throughout the project.

(4) The licensed contractor shall perform all new construction and renovations to assisted care living facilities, other than minor alterations not affecting fire and life safety or functional issues, in accordance with the specific requirements of these regulations governing new construction in assisted care living facilities, including the submission of phased construction plans and the final drawings and the specifications to each.

(5) No new ACLF shall be constructed, nor shall major alterations be made to an existing ACLF without prior approval of the department, and unless in accordance with plans and specifications approved in advance by the department. Before any new ACLF is licensed or before any alteration or expansion of a licensed ACLF can be approved, the applicant must furnish two (2) complete sets of plans and specifications to the department, together with fees and other information as required. Plans and specifications for new construction and major renovations, other than minor alterations not affecting fire and life safety or functional issues, shall be prepared by or under the direction of a licensed architect and/or a licensed engineer and in accordance with the rules of the Board of Architectural and Engineering Examiners.

(a) The project architect or engineer shall forward two (2) sets of plans to the appropriate

(b) Review of plans does not eliminate responsibility of owner and/or architect to comply with all rules and regulations.

(8) Specifications shall supplement all drawings. They shall describe the characteristics of all materials, products and devices, unless fully described and indicated on the drawings.

Specification copies should be bound in an 8½ x 11 inch folder.

(9) Drawings and specifications shall be prepared for each of the following branches of work:

Architectural, Structural, Mechanical, Electrical and Sprinkler.

(10) Architectural drawings shall include:

(a) Plot plan(s) showing property lines, finish grade, location of existing and proposed structures, roadways, walks, utilities and parking areas;

(b) Floor plan(s) showing scale drawings of typical and special rooms, indicating all fixed and movable equipment and major items of furniture;

(d) The elevation of each facade;

(e) The typical sections throughout the building;

(f) The schedule of finishes;

(g) The schedule of doors and windows;

(h) Roof plans;

(i) Details and dimensions of elevator shaft(s), car platform(s), doors, pit(s), equipment in the machine room, and the rates of car travel must be indicated for elevators; and (j) Code analysis.

(11) Structural drawings shall include:

(a) Plans of foundations, floors, roofs and intermediate levels which show a complete design with sizes, sections and the relative location of the various members;

(b) Schedules of beams, girders and columns; and (c) Design live load values for wind, roof, floor, stairs, guard, handrails, and seismic.

(12) Mechanical drawings shall include:

(a) Specifications which show the complete heating, ventilating, fire protection, medical gas systems and air conditioning systems;

(b) Water supply, sewerage and HVAC piping systems;

(d) Heating, ventilating, HVAC piping, medical gas systems and air conditioning systems with all related piping and auxiliaries to provide a satisfactory installation;

(13) Electrical drawings shall include where applicable:

(a) A seal, certifying that all electrical work and equipment is in compliance with all applicable codes and that all materials are currently listed by recognized testing laboratories;

(d) Color coding to show all items on emergency power;

(14) The electrical drawings shall not include knob and tube wiring, shall not include electrical cords that have splices, and shall not show that the electrical system is overloaded.

(15) In all new facilities or renovations to existing electrical systems, the installation must be approved by an inspector or agency authorized by the State Fire Marshal.

(16) Sprinkler drawings shall include:

(a) Shop drawings, hydraulic calculations, and manufacturer cut sheets;

(17) The licensed contractor shall not install a system of water supply, plumbing, sewage, garbage or refuse disposal nor materially alter or extend any existing system until the architect or engineer submits complete plans and specifications for the installation, alteration or extension to the department demonstrating that all applicable codes have been met and the department has granted necessary approval.

(a) Before the ACLF is used, Tennessee Department of Environment and Conservation shall approve the water supply system.

(18) The licensed contractor shall ensure through the submission of plans and specifications that in each ACLF:

(19) With the submission of plans the facility shall specify the evacuation capabilities of the residents as defined in the National Fire Protection Code (NFPA). This declaration will determine the design and construction requirements of the facility.

(20) The department shall acknowledge that it has reviewed plans and specifications in writing with copies sent to the project architect, the project engineer and the owner as well as the manager or other executive of the institution. The department may modify the distribution of such review at its discretion.

(21) In the event submitted materials do not appear to satisfactorily comply with 0720-26-.09(2), the department shall furnish a letter to the party submitting the plans which shall list the particular items in question and request further explanation and/or confirmation of necessary modifications.

(22) The licensed contractor shall execute all construction in accordance with the approved plans and specifications.

(23) If construction begins within one hundred eighty (180) days of the date of department approval, the department’s written notification of satisfactory review constitutes compliance with 0720-26-.09(20). This approval shall in no way permit and/or authorize any omission or deviation from the requirements of any restrictions, laws, regulations, ordinances, codes or rules of any responsible agency.

(24) Prior to final inspection, a CD Rom disc, in TIF or PDF format, of the final approved plans including all shop drawings, sprinkler, calculations, hood and duct, addenda, specifications, etc., shall be submitted to the department.

(25) The department requires the following alarms that shall be monitored twenty-four (24) hours per day:

(a) Fire alarms; and (b) Generators (if applicable).

(26) Each ACLF shall ensure that an emergency keyed lock box is installed next to each bank of functioning elevators located on the main level. Such lock boxes shall be permanently mounted seventy-two inches (72”) from the floor to the center of the box, be operable by a universal key no matter where such box is located, and shall contain only fire service keys and drop keys to the appropriate elevators.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-261.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendments filed December 20, 2011; effective March 19, 2012. Amendment filed January 21, 2016; effective April 20, 2016. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-213 (i), and 68-11-257.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed November 25, 1998; effective February 8, 1999. Amendment filed February 15, 2000; effective April 30, 2000. Amendment filed September 13, 2002; effective November 27, 2002. Amendment filed May 24, 2004; effective August 7, 2004. Amendment filed April 20, 2006; effective July 4, 2006. Amendment filed February 23, 2007; effective May 9, 2007. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.10 LI FE SAFETY

(1) The department will consider any ACLF that complies with the required applicable building and fire safety regulations at the time the Board adopts new codes or regulations, so long as such compliance is maintained (either with or without waivers of specific provisions), to be in compliance with the requirements of the new codes or regulations.

(2) An ACLF shall ensure fire protection for residents by doing at least the following:

(a) Eliminate fire hazards;

(b) Install necessary fire fighting equipment;

(d) Ensure that each resident sleeping unit shall have a door that opens directly to the outside or to a corridor which leads directly to an exit door and that is always capable of being unlocked by the resident;

(e) Ensure that louvers shall not be present in doors to residents’ sleeping units;

(f) Keep corridors and exit doors clear of equipment, furniture and other obstacles at all times. Passage to exit doors leading to a safe area shall be clear at all times;

(g) Prohibit use of combustible finishes and furnishings;

(h) Prohibit open flame and portable space heaters;

(i) Ensure that upon entering the ACLF, the resident or his or her responsible party is asked if they wish to have a cooking appliance that is appropriate for their level of cognition. If the facility chooses to provide a requested cooking appliance, it shall be used in accordance with the facility’s policies. If the resident or his or her responsible party wishes to provide their own cooking appliance, it shall meet the facility’s policies and safety standards. The cooking appliances shall be designed so that they can be disconnected and removed for resident safety or if the resident chooses not to have cooking capability within his or her apartment. The cooking appliances shall have an automatic timer;

(j) Ensure that all heaters shall be guarded and spaced to prevent ignition of combustible material and accidental burns. The guard shall not have a surface temperature greater than 120°F;

(k) Allow use of fireplaces and/or fireplace inserts only if the ACLF ensures that they have guards or screens which are secured in place;

(l) Inspect and clean fireplaces and chimneys annually and maintain documentation that such inspection has occurred;

(m) Ensure that there are electrically-operated smoke detectors with battery back-up power operating at all times in, at least, resident sleeping units, day rooms, corridors, laundry room, and any other hazardous areas; and (n) Provide and mount fire extinguishers and maintain travel distance between fire extinguishers, complying with NFPA 10, so they are accessible to all residents in the kitchen, laundries and at all exits.

(3) An ACLF shall conduct fire drills in accordance with the following:

(a) Fire drills shall be held for each ACLF work shift in each separate ACLF building at least quarterly;

(b) There shall be one (1) fire drill per quarter during sleeping hours;

(c) An ACLF shall prepare a written report documenting the evaluation of each drill that includes the action that is recommended or taken to correct any deficiencies found; and, (d) An ACLF shall maintain records that document and evaluate these drills for at least three (3) years.

(4) An ACLF shall take the following action should a fire occur:

(a) An ACLF shall report all fires which result in a response by the local fire department to the department within seven (7) days of its occurrence.

(b) An ACLF’s report to the department shall contain the following:

Sufficient information to ascertain the nature and location of the fire;
Sufficient information to ascertain the probable cause of the fire; and 3. A list and description of any injuries to any person or persons as a result of the fire.
An ACLF may omit the name(s) of resident(s) and parties involved in initial reports. Should the department later find the identities of such persons to be necessary to an investigation, the ACLF shall provide such information.

(5) An ACLF shall take the following precautions regarding electrical equipment to ensure the safety of residents:

(a) Provide lighted corridors at all times, to a minimum of one foot candle;

(b) Provide general and night lighting for each resident and equip night lighting with emergency power;

(d) Ensure that electrical cords shall not run under rugs or carpets;

(e) Ensure that electrical systems shall not be overloaded;

(f) Ensure that power strips are equipped with circuit breakers; and (g) Prohibit use of extension cords.

(6) If an ACLF allows residents to smoke, it shall ensure the following:

(a) Permit smoking and smoking materials only in designated areas under supervision;

(b) Provide ashtrays wherever smoking is permitted;

(d) Written policies and procedures for smoking within the ACLF shall designate a room or rooms to be used exclusively for residents who smoke. The designated smoking room or rooms shall not be the dining room, the activity room, or an individual resident sleeping unit, and;

(e) Post no smoking signs in areas where oxygen is used or stored.

(7) An ACLF shall not allow trash and other combustible waste to accumulate within and around the ACLF. It shall store trash in appropriate containers with tight-fitting lids. An ACLF shall furnish resident sleeping units with an UL approved trash container.

(8) An ACLF shall ensure that:

(a) The ACLF maintains all safety equipment in good repair and in a safe operating condition;

(b) The ACLF stores janitorial supplies away from the kitchen, food storage area, dining area or other resident accessible areas;

(c) The ACLF stores flammable liquids in approved containers and away from the facility living areas; and (d) The ACLF cleans floor and dryer vents as frequently as needed to prevent accumulation of lint, soil and dirt.

(9) An ACLF shall post emergency telephone numbers near a telephone accessible to the residents.

(10) An ACLF shall maintain its physical environment in a safe, clean and sanitary manner by doing at least the following:

(a) Prohibit any condition on the ACLF site conducive to the harboring or breeding of insects, rodents or other vermin;

(b) Properly identify chemical substances of a poisonous nature used to control or eliminate vermin and store such substances away from food or medications;

(c) Ensure that the building shall not become overcrowded with a combination of the ACLF’s residents and other occupants;

(d) Ensure that each resident sleeping unit shall contain a chair, bed, mattress, springs, linens, chest of drawers and wardrobe or closet space, either provided by the ACLF or by the resident if the resident prefers. All furniture provided by the resident must meet NFPA standards;

(e) Maintain all residents’ clothing in good repair and ensure that it is suitable for the use of elderly persons;

(f) Maintain the building and its heating, cooling, plumbing and electrical systems in good repair and in clean condition at all times; and (g) Maintain temperatures in resident sleeping units and common areas at not less than 65°F and no more than 85°F.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11-209, 68-11- 210, 68-11-211, and 68-11-213.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed April 11, 2003; effective June 25, 2003. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendments filed July 10, 2018; effective October 8, 2018. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.11 INFECTIOUS AND HAZARDOUS WASTE

(1) An ACLF must develop, maintain and implement written policies and procedures for the definition and handling of its infectious waste. These policies and procedures must comply with the standards of this rule.

(2) The following waste shall be considered to be infectious waste:

(a) Waste contaminated by residents who are isolated due to communicable disease, as provided in the U.S. Centers for Disease Control “Guidelines for Isolation Precautions in Hospitals”;

(b) Cultures and stocks of infectious agents including specimen cultures collected from medical and pathological laboratories, cultures and stocks of infectious agents from research and industrial laboratories, wastes from the production of biologicals, discarded live and attenuated vaccines, and culture dishes and devices used to transfer, inoculate, and mix cultures;

(d) Pathological waste, such as tissues, organs, body parts, and body fluids that are removed during surgery and autopsy;

(e) All discarded sharps (e.g., hypodermic needles, syringes, pasteur pipettes, broken glass, scalpel blades) used in resident care or which have come into contact with infectious agents during use in medical, research, or industrial laboratories; and (f) Other waste determined to be infectious by the ACLF in its written policy.

(3) Infectious and hazardous waste must be segregated from other waste at the point of generation (i.e., the point at which the material becomes a waste) within the ACLF.

(4) Waste must be packaged in a manner that will protect waste handlers and the public from possible injury and disease that may result from exposure to the waste. Such packaging must provide for containment of the waste from the point of generation up to the point of proper treatment or disposal. Packaging must be selected and utilized for the type of waste the package will contain, how the waste will be treated and disposed, and how it will be handled and transported, prior to treatment and disposal.

(a) Contaminated sharps must be directly placed in leakproof, rigid, and puncture-resistant containers which must then be tightly sealed.

(d) Opaque packaging must be used for pathological waste.

(b) Pathological waste must be promptly treated, disposed of, or placed into refrigerated storage.

(7) In the event of spills, ruptured packaging, or other incidents where there is a loss of containment of waste, the ACLF must ensure that proper actions are immediately taken to:

(a) Isolate the area from the public and all except essential personnel;

(b) To the extent practicable, repackage all spilled waste and contaminated debris in accordance with the requirements of paragraph 6 of this rule;

(c) Sanitize all contaminated equipment and surfaces according to written policies and procedures which specify how this will be done appropriately; and (d) Complete an incident report and maintain a copy on file.

(8) Except as provided otherwise in this rule a facility must treat or dispose of infectious waste by one or more of the methods specified in this paragraph.

(a) An ACLF may treat infectious waste in an on-site sterilization or disinfection device, or in an incinerator or a steam sterilizer, which has been designed, constructed, operated and maintained so that infectious waste treated in such a device is rendered noninfectious and is, if applicable, authorized for that purpose pursuant to current rules of the Department of Environment and Conservation. A valid permit or other written evidence of having complied with the Tennessee Air Pollution Control Regulations shall be available for review, if required. Each sterilizing or disinfection cycle must contain appropriate indicators to assure that conditions were met for proper sterilization or disinfection of materials included in the cycle, and appropriate records kept. Proper operation of such devices must be verified at least monthly, and records of the monthly verifications shall be available for review. Waste that contains toxic chemicals that would be volatilized by steam must not be treated in steam sterilizers. Infectious waste that has been rendered to carbonized or mineralized ash shall be deemed noninfectious. Unless otherwise hazardous and subject to the hazardous waste management requirements of the current rules of the Department of Environment and Conservation, such ash shall be disposable as a (non-hazardous) solid waste under current rules of the Department of Environment and Conservation.

(b) An ACLF may discharge liquid or semi-liquid infectious waste to the collection sewerage system of a wastewater treatment facility which is subject to a permit pursuant to T.C.A. §§ 69-3-101, et seq., provided that such discharge is in accordance with any applicable terms of that permit and/or any applicable municipal sewer use requirements.

(9) An ACLF may have waste transported off-site for storage, treatment, or disposal. Such arrangements must be detailed in a written contract, available for review. If such off-site location is located within Tennessee, the ACLF must ensure that it has all necessary State and local approvals, and such approvals shall be available for review. If the off-site location is within another state, the ACLF must notify in writing all public health agencies with jurisdiction that the location is being used for management of the ACLF’s waste. Waste shipped off-site must be packaged in accordance with applicable federal and state requirements. Waste transported to a sanitary landfill in this state must meet the requirements of current rules of the Department of Environment and Conservation.

(10) Human anatomical remains which are transferred to a mortician for cremation or burial shall be exempt from the requirements of this rule.

(11) All garbage, trash and other non-infectious waste shall be stored and disposed of in a manner that must not permit the transmission of disease, create a nuisance, provide a breeding place for insects and rodents, or constitute a safety hazard. All containers for waste shall be water tight, constructed of easily-cleanable material, and shall be kept on elevated platforms.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.12 RESIDENT RECORDS

(1) An ACLF shall develop and maintain an organized record for each resident and ensure that all entries shall be written legibly in ink, typed, or kept electronically, and signed, and dated.

(2) Personal record. An ACLF shall ensure that the resident’s personal record includes at a minimum the following:

(a) Name, Social Security Number, veteran status and number, marital status, age, sex, any health insurance provider and number, including Medicare and/or Medicaid number, and photograph of the resident;

(b) Name, address and telephone number of next of kin, legal representative (if applicable), and any other person identified by the resident to contact on the resident’s behalf;

(c) Name and address of the resident’s preferred physician, hospital, pharmacist and nursing home, and any other instructions from the resident to be followed in case of emergency;

(d) Record of all monies and other valuables entrusted to the ACLF for safekeeping, with appropriate updates;

(e) Date of admission, transfer, discharge and any new forwarding address;

(f) A copy of the admission agreement that is signed and dated by the resident;

(g) A copy of any advance directives, DNR Order, Durable Power of Attorney, or living will, when applicable, and made available upon request; and (h) A record that the resident has received a copy of the ACLF’s resident’s rights and procedures policy.

(3) Medical record. An ACLF shall ensure that its employees develop and maintain a medical record for each resident who requires health care services at the ACLF regardless of whether such services are rendered by the ACLF or by arrangement with an outside source, which shall include at a minimum:

(a) Medical history;

(b) Consultation by physicians or other authorized healthcare providers;

(c) Orders and recommendations for all medication, medical/and other care, services, procedures, and diet from physicians or other authorized healthcare providers, which shall be completed prior to, or at the time of admission, and subsequently, as warranted. Verbal orders received shall include the time of receipt of the order, description of the order, and identification of the individual receiving the order;

(d) Care/services provided, including identification of providing party;

(e) Medications administered and procedures followed if an error is made;

(f) Special procedures and preventive measures performed;

(g) Notes, including, but not limited to, observation notes, progress notes, and nursing notes;

(h) Listing of current vaccinations, (i) Time and circumstances of discharge or transfer, including condition at discharge or transfer, or death;

(j) Provisions of routine and emergency medical care, to include the name and telephone number of the resident’s physician, plan for payment, and plan for securing medications;

(k) Special information, e.g., do-not resuscitate orders, allergies, etc.; and (l) Copy of quarterly Alzheimer’s review, if medically indicated.

(4) An ACLF shall complete a written assessment of the resident to be conducted by a direct care staff member within a time-period determined by the ACLF, but no later than seventytwo (72) hours after admission.

(5) Plan of care.

(a) An ACLF shall develop a plan of care for each resident admitted to the ACLF with input and participation from the resident or the resident’s legal representative, treating physician, or other licensed health care professionals or entity delivering patient services within five (5) days of admission. The plan of care shall be reviewed and/or revised as changes in resident needs occur, but not less than semi-annually by the above-appropriate individuals.

(b) The plan of care shall describe:

The needs of the resident, including the activities of daily living and medical services for which the resident requires assistance, i.e., what assistance/care, how much, who will provide the assistance/care, how often, and when;
Requirements and arrangements for visits by or to physicians or other authorized health providers;
Advance care directive, healthcare power-of-attorney; as applicable;
Recreational and social activities which are suitable, desirable, and important to the well-being of the resident; and 5. Dietary needs.

(6) Personal information shall be confidential and shall not be disclosed, except to the resident, the department and others with written authorization from the resident. Records shall be retained for three (3) years after the resident has been transferred or discharged.

(7) An ACLF shall retain legible copies of the following records and reports for thirty-six (36) months following their issuance. The reports shall be maintained in a single file, and shall be made available for inspection during normal business hours to any resident who requests to view them. Each resident and each person assuming any financial responsibility for a resident must be fully informed, before admission, of the existence of the reports in the ACLF and given the opportunity to inspect the file before entering into any monetary agreement with the ACLF.

(a) Local fire safety inspections.

(b) Local building code inspections, if any.

(d) Orders of the Commissioner or Board, if any.

(e) Maintenance records of all safety equipment.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11- 224, and 68-11-1801 through 68-11-1815.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed April 28, 2003; effective July 12, 2003. Repeal and new rule filed January 24, 2006; effective April 9, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.13 REPORTS

(1) The ACLF shall report all incidents of abuse, neglect, and misappropriation to the Department of Health in accordance with T.C.A. § 68-11-211.

(2) The ACLF shall report the following incidents to the Department of Health in accordance with T.C.A. § 68-11-211.

(a) Strike by staff at the facility;

(b) External disasters impacting the facility;

(c) Disruption of any service vital to the continued safe operation of the ACLF or to the health and safety of its patients and personnel; and (d) Fires at the ACLF that disrupt the provision of patient care services or cause harm to the patients or staff, or that are reported by the facility to any entity, including but not limited to a fire department charged with preventing fires.

(3) An ACLF shall file the Joint Annual Report of Assisted Care Living Facilities with the department. The forms shall be furnished and mailed to each ACLF by the department each year and the forms must be completed and returned to the department as required.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-211.
Administrative History: Original rule filed February 9, 1998; effective April 25, 1998. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.14 RESIDENT RIGHTS

(1) An ACLF shall ensure at least the following rights for each resident:

(a) To be afforded privacy in treatment and personal care;

(b) To be free from mental and physical abuse. Should this right be violated, the ACLF shall notify the department and the Tennessee Department of Human Services, Adult Protective Services at 1-888-277-8366;

(c) To refuse treatment. An ACLF must inform the resident of the consequences of that decision. The ACLF must report the resident’s refusal and its reason to the resident’s treating physician and it must document such in the resident’s record;

(d) To have his or her file kept confidential and private. An ACLF shall obtain the resident’s written consent prior to release of information except as otherwise authorized by law;

(e) To be fully informed of the Resident’s Rights, of any policies and procedures governing resident conduct, of any services available in the ACLF, and of the schedule of all fees for any and all services;

(f) To participate in drawing up the terms of the admission agreement, including, but not limited to, providing for resident’s preferences for physician care, hospitalization, nursing home care, acquisition of medication, emergency plans and funeral arrangements;

(g) To be given thirty (30) days written notice prior to transfer or discharge, except when any physician orders the transfer because the resident requires a higher level of care;

(h) To voice grievances and recommend changes in policies and services of the ACLF without restraint, interference, coercion, discrimination or reprisal. An ACLF shall inform the resident of procedures to voice grievances and for registering complaints confidentially;

(i) To manage his or her personal financial affairs, including the right to keep and spend his or her own money. If the resident requests assistance from the ACLF in managing his or her personal financial affairs, the request must be in writing and the resident may terminate it at any time. The ACLF must separate such monies from the ACLF’s operating funds and all other deposits or expenditures, submit a written accounting to the resident at least quarterly, and immediately return the balance upon transfer or discharge. The ACLF shall maintain a current copy of this report in the resident’s file;

(j) To be treated with consideration, respect and full recognition of his or her dignity and individuality;

(k) To be accorded privacy for sleeping and for storage space for personal belongings;

(l) To have free access to day rooms, dining and other group living or common areas at reasonable hours and to come and go from the ACLF, unless such access infringes upon the rights of other residents;

(m) To wear his or her own clothes, to keep and use his or her own toilet articles and personal possessions;

(n) To send and receive unopened mail;

(o) To associate and communicate privately with persons of his or her choice, including receiving visitors at reasonable hours;

(p) To participate, or to refuse to participate, in community activities, including cultural, educational, religious, community service, vocational and recreational activities;

(q) To not be required to perform services for the ACLF. The resident and licensee may mutually agree, in writing, that the resident may perform certain activities or services as

part of the fee for his or her stay; and (r) To execute, modify, or rescind a Living Will, Do-Not-Resuscitate Order or advance directive.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1805.
Administrative History: Original rule filed February 16, 2007; effective May 2, 2007. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.15 POLICIES AND PROCEDURES FOR HEALTH CARE DECISION-MAKING

(1) Pursuant to this rule, each ACLF shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a resident who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from individual residents. An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.

(2) An adult or emancipated minor may execute an advance directive for health care. The advance directive may authorize an agent to make any health care decision the resident could have made while having capacity, or it may limit the power of the agent, and it may include individual instructions. An advance directive that makes no limitation on the agent’s

authority shall authorize the agent to make any health care decision the resident could have made while having capacity.

(3) The advance directive shall be in writing, signed by the resident, and shall either be notarized or witnessed by two (2) witnesses. Both witnesses shall be competent adults, and neither of them may be the agent. At least one (1) of the witnesses shall be a person who is not related to the resident by blood, marriage, or adoption and would not be entitled to any portion of the resident’s estate upon his or her death. The advance directive shall contain a clause that attests that the witnesses comply with the requirements of this paragraph.

(4) Unless otherwise specified in an advance directive, the agent’s authority becomes effective only upon a determination that the resident lacks capacity, and it ceases to be effective upon a determination that the resident has recovered capacity.

(5) An ACLF may use the model advance directive form that meets the requirements of the Tennessee Health Care Decisions Act and has been developed and issued by the Board for Licensing Health Care Facilities.

(6) The resident’s designated physician shall make a determination that a resident either lacks or has recovered capacity. The designated physician shall also have authority to make a determination that another condition exists that affects an individual instruction or the

authority of an agent. To make such determinations the resident’s designated physician shall be authorized to consult with such other persons as the physician may deem appropriate.

(8) An advance directive may include the individual’s nomination of a court-appointed guardian.

(9) An ACLF shall honor an advance directive that is executed outside of this state by a nonresident of this state at the time of execution if that advance directive is in compliance with the laws of Tennessee or the state of the resident’s residence.

(10) No health care provider or institution shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care.

(12) A resident having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.

(13) A resident having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in any manner that communicates intent to revoke.

(15) An advance directive that conflicts with a previously executed advance directive revokes the earlier directive to the extent of the conflict.

(16) Surrogates.

(a) An adult or emancipated minor may designate any individual to act as surrogate by personally informing, either orally or in writing, the supervising health care provider.

(b) A surrogate may make a health care decision for a resident who is an adult or emancipated minor if and only if:

The designated physician determines that the resident lacks capacity, and 2. There is not an appointed agent or guardian; or 3. The agent or guardian is not reasonably available.

(c) In the case of a resident who lacks capacity, the resident’s current clinical record of the ACLF shall identify his or her surrogate.

(e) Consideration may be, but need not be, given in order of descending preference for service as a surrogate to:

The resident’s spouse, unless legally separated;
The resident’s adult child;
The resident’s parent;
The resident’s adult sibling;
Any other adult relative of the resident; or 6. Any other adult who satisfies the requirements of 0720-26-.15(16)(d).

(f) No person who is the subject of a protective order or other court order that directs that person to avoid contact with the resident shall be eligible to serve as the resident’s surrogate.

(g) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:

Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the resident’s known wishes or best interests;
The proposed surrogate’s regular contact with the resident prior to and during the incapacitating illness;
The proposed surrogate’s demonstrated care and concern;
The proposed surrogate’s availability to visit the resident during his or her illness; and 5. The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.

(h) If the resident lacks capacity and none of the individuals eligible to act as a surrogate under 0720-26-.15(16)(c) through 0720-26-.15(16)(g) is reasonably available, the designated physician may make health care decisions for the resident after the designated physician either:

Consults with and obtains the recommendations of a facility’s ethics mechanism or standing committee in the facility that evaluates health care issues; or 2. Obtains concurrence from a second physician who is not directly involved in the resident’s health care, does not serve in a capacity of decision-making, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.

(j) A surrogate shall make a health care decision in accordance with the resident’s individual instructions, if any, and other wishes to the extent known to the surrogate.

(l) Except as provided in 0720-26-.15(16)(m):

A designated surrogate may not be one of the following:

(i) The treating health care provider;

(ii) An employee of the treating health care provider;

(iii) An operator of a health care institution; or (iv) An employee of an operator of a health care institution; and 2. A health care provider or employee of a health care provider may not act as a surrogate if the health care provider becomes the resident’s treating health care provider.

(m) A designated surrogate may be an employee of the treating health care provider or an employee of an operator of a health care institution if:

The employee so designated is a relative of the resident by blood, marriage, or adoption; and 2. The other requirements of this section are satisfied.

(17) Guardian.

(a) A guardian shall comply with the resident’s individual instructions and may not revoke the resident’s advance directive absent a court order to the contrary.

(b) Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.

(18) A designated physician who makes or is informed of a determination that a resident lacks or has recovered capacity, or that another condition exists which affects an individual instruction or the authority of an agent, guardian, or surrogate, shall promptly record such a determination in the resident’s current clinical record and communicate the determination to the resident, if possible, and to any person then authorized to make health care decisions for the resident.

(19) Except as provided in 0720-26-.15(20) through 0720-26-.15(22), a health care provider or institution providing care to a resident shall:

(20) A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.

(21) A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:

(a) Contrary to the institution’s policy which is based on reasons of conscience, and (b) The institution timely communicated the policy to the resident or to a person then authorized to make health care decisions for the resident.

(23) A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 0720-26-.15(20) through 0720-26-.15(22) shall:

(a) Promptly inform the resident, if possible, and/or any other person then authorized to make health care decisions for the resident;

(b) Provide continuing care to the resident until he can be transferred to another health care provider or institution or it is determined that such a transfer is not possible;

(c) Immediately make all reasonable efforts to assist in the transfer of the resident to another health care provider or institution that is willing to comply with the instruction or decision unless the resident or person then authorized to make health care decisions for the resident refuses assistance; and (d) If a transfer cannot be effected, the health care provider or institution shall not be compelled to comply.

(a) Complying with a health care decision of a person apparently having authority to make a health care decision for a resident, including a decision to withhold or withdraw health care;

(26) An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.

(27) A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct if such identification is made in good faith.

(28) A copy of a written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.

(30) Physician Orders for Scope of Treatment (POST).

(a) Physician Orders for Scope of Treatment (POST) may be issued by a physician for a patient with whom the physician has a bona fide physician-patient relationship, but only:

With the informed consent of the patient;
If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or 3. If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available, if the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

No physician, who has a bona fide physician-patient relationship with the patient, is present and available for discussion with the patient (or if the patient is a minor or is otherwise incapable of making an informed decision, with the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act);
Such authority to issue is contained in the physician assistant’s, nurse practitioner’s or clinical nurse specialist’s protocols;
Either:

(i) With the informed consent of the patient;

(d) A POST issued in accordance with this section shall remain valid and in effect until revoked. In accordance with this rule and applicable regulations, qualified emergency medical services personnel; and licensed health care practitioners in any facility, program, or organization operated or licensed by the Board for Licensing Health Care Facilities, the Department of Mental Health and Substance Abuse Services, or the Department of Intellectual and Developmental Disabilities, or operated, licensed, or owned by another state agency, shall follow a POST that is available to such persons in a form approved by the Board for Licensing Health Care Facilities.

History

Authority: T.C.A. §§ 68-11-209, 68-11-224, and 68-11-1801, et seq.
Administrative History: Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-26-.16 DISASTER PREPAREDNESS

(1) An ACLF shall have in effect and available for all supervisory personnel and staff written copies of the following disaster, refuge and/or evacuation plans readily available at all times:

(a) Fire Safety Procedures Plan shall include:

Minor fires;
Major fires;
Fighting the fire;
Evacuation procedures; and 5. Staff functions.

(b) Tornado/Severe Weather Procedures Plan shall include:

Staff duties; and 2. Evacuation procedures.

Staff duties;
Search team, searching the premises;
Notification of authorities;
Location of suspicious objects; and, 5. Evacuation procedures.

(d) Flood Procedure Plan, if applicable, shall include:

Staff duties;
Evacuation procedures; and 3. Safety procedures following the flood.

(e) Severe Cold Weather and Severe Hot Weather Procedure Plans shall include:

Staff duties;
Equipment failures;
Evacuation procedures; and 4. Emergency food service.

(f) Earthquake Disaster Procedures Plan shall include:

Staff duties;
Evacuation procedures;
Safety procedures; and 4. Emergency services.

(2) An ACLF shall comply with the following:

(a) Maintain a detailed log with staff signatures designating training each employee receives regarding disaster preparedness.

(b) Train all employees annually as required in the plans listed above and keep each employee informed with respect to the employee’s duties under the plans.

(3) Emergency Planning with Local Government Authorities.

(a) All ACLFs shall establish and maintain communications with the county Emergency Management Agency. This includes the provision of the information and procedures that are needed for the local comprehensive emergency plan. The ACLFs shall cooperate, to the extent possible, in area disaster drills and local emergency situations.

(b) Each ACLF shall conduct both the physical facility and community emergency drills as required in these regulations, even if the local Emergency Management Agency is unable to participate.

(4) ACLFs which elect to have an emergency generator shall ensure that the generator is designed to meet the ACLF’s HVAC and essential needs and shall have a minimum of twenty-four (24) hours of fuel designed to operate at its rated load. This requirement shall be coordinated with the Disaster Preparedness Plan or with the local resources.

(a) All generators shall be exercised for thirty (30) minutes each month under full load, including automatic and manual transfer of equipment.

(b) The emergency generator shall be operated at the existing connected load and not on dual power. The ACLF shall maintain a monthly log and have trained staff familiar with the generator’s operation.

History

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.

Tenn. Comp. R. & Regs. 0720-26-.17 APPENDIX I

(1) Physician Orders for Scope of Treatment (POST) Form.

(This space intentionally left blank)

A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED

Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”)

This is a Physician Order Sheet based on the medical conditions and wishes of the person identified at right (“patient”).

Any section not completed indicates full treatment for that section. When need occurs, first follow these orders, then contact physician.

Patient’s Last Name First Name/Middle Initial Date of Birth

Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Section B Check One Box Only MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.  Comfort Measures Only. Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.  Limited Additional Interventions. In addition to care described in Comfort Measures Only above, use medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. Treatment Plan: Basic medical treatments.  Full Treatment. In addition to care described in Comfort Measures Only and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including in the intensive care unit.

Other Instructions:

Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify)

The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other)

Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge)

MD/NP/CNS/PA Phone Number:

Name (print) Signature Relationship (write “self” if patient)

Verbal orders are acceptable with follow-up signature by physician in accordance with facility/community policy.

Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel.

Photocopies/faxes of signed POST forms are legal and valid.

Using POST Any incomplete section of POST implies full treatment for that section.

No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.”

Oral fluids and nutrition must always be offered if medically feasible.

IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”

A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.

Reviewing POST This POST should be reviewed if:

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.

(2) Advance Directive for Health Care Form.

ADVANCE DIRECTIVE FOR HEALTH CARE*

(Tennessee)

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.

Part 2 Indicate Your Wishes for Quality of Life: By marking “yes” below, I have indicated conditions I would be willing to live with if given adequate comfort care and pain management. By marking “no” below, I have indicated conditions I would not be willing to live with (that to me would create an unacceptable quality of life).   Yes No Permanent Unconscious Condition: I become totally unaware of people or surroundings with little chance of ever waking up from the coma.   Yes No Permanent Confusion: I become unable to remember, understand, or make decisions. I do not recognize loved ones or cannot have a clear conversation with them.   Yes No Dependent in all Activities of Daily Living: I am no longer able to talk or communicate clearly or move by myself. I depend on others for feeding, bathing, dressing, and walking. Rehabilitation or any other restorative treatment will not help.   Yes No End-Stage Illnesses: I have an illness that has reached its final stages in spite of full treatment.

Instructions: Parts 1 and 2 may be used together or independently. Please mark out/void any unused part(s).

Part 3 Other instructions, such as hospice care, burial arrangements, etc.:

(Attach additional pages if necessary)

Part 5 Your signature must either be witnessed by two competent adults (“Block A”) or by a notary public (“Block B”).

Signature: _______________________________________ Date: ____________________ (Patient)

Block A Neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.

Witnesses:

I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form.

Signature of witness number 2 Block B You may choose to have your signature witnessed by a notary public instead of the witnesses described in Block A.

STATE OF TENNESSEE

COUNTY OF

My commission expires:

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1805.
Administrative History: Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Repeal and new rule filed August 28, 2012; effective November 26, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed February 8, 2017; effective May 9, 2017. Transferred from chapter 1200-08-25 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-27 Standards for Home Care Organizations Providing Home Health Services (Transferred from 1200-08-26)

Tenn. Comp. R. & Regs. 0720-27-.01 DEFINITIONS

(1) Abuse. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) Administrator. A person who:

(a) Is a licensed physician with at least one (1) year supervisory or administrative experience in home health care, hospice care or related health programs; or (b) Is a registered nurse with at least one (1) year supervisory or administrative experience in home health care, hospice care or related health programs; or (c) Has training and experience in health service administration and at least one (1) year of supervisory or administrative experience in home health care, hospice care or related health programs.

(3) Adult. An individual who has capacity and is at least 18 years of age.

(5) Agency. A Home Care Organization providing home health services.

(6) Agent. An individual designated in an advance directive for health care to make a health care decision for the individual granting the power.

(7) Board. The Tennessee Board for Licensing Health Care Facilities.

(8) Branch Office. A location or site from which a home care organization provides home health services within a portion of the total geographic area served by the licensed organization.

The branch office is part of the home care organization providing home health services and is located sufficiently close to share administration, supervision, and services in a manner that renders it unnecessary for the branch independently to meet the requirements for licensing as a home care organization providing home health services. At all times a branch office must operate solely under the name of the licensed organization.

(9) Capacity. An individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. These regulations do not affect the right of a patient to make health care decisions while having the capacity to do so. A patient shall be presumed to have capacity to make a health care decision, to give or revoke an advance directive, and to designate or disqualify a surrogate.

Any person who challenges the capacity of a patient shall have the burden of proving lack of capacity.

(10) Cardiopulmonary Resuscitation (CPR). The administering of any means or device to support cardiopulmonary functions in a patient, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilations or respirations, defibrillation, the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a patient where cardiac or respiratory arrest has occurred or is believed to be imminent.

(11) Certified Master Social Worker. A person currently certified as such by the Tennessee Board of Social Worker Certification and Licensure.

(13) Clinical Note. A written and dated notation containing a patient assessment, responses to medications, treatments, services, any changes in condition and signed by a health team member who made contact with the patient.

(14) Commissioner. The Commissioner of the Tennessee Department of Health or his or her authorized representative.

(15) Competent. A patient who has capacity.

(16) Department. The Tennessee Department of Health.

(17) Designated Physician. A physician designated by an individual or the individual’s agent, guardian, or surrogate, to have primary responsibility for the individual’s health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes such responsibility.

(18) Do-Not-Resuscitate Order (DNR). A written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(19) Emancipated Minor. Any minor who is or has been married or has by court order or otherwise been freed from the care, custody and control of the minor’s parents.

(20) Emergency Responder. A paid or volunteer firefighter, law enforcement officer, or other public safety official or volunteer acting within the scope of his or her proper function under law or rendering emergency care at the scene of an emergency.

(21) Guardian. A judicially appointed guardian or conservator having authority to make a health care decision for an individual.

(22) Hazardous Waste. Materials whose handling, use, storage and disposal are governed by local, state or federal regulations.

(23) Health Care. Any care, treatment, service or procedure to maintain, diagnose, treat, or otherwise affect an individual’s physical or mental condition, and includes medical care as defined in T.C.A. § 32-11-103(5).

(24) Health Care Decision. Consent, refusal of consent or withdrawal of consent to health care.

(25) Health Care Decision-Maker. In the case of a patient who lacks capacity, the patient’s health care decision-maker is one of the following: the patient’s health care agent as specified in an advance directive, the patient’s court-appointed guardian or conservator with health care decision-making authority, the patient’s surrogate as determined pursuant to Rule 0720-27- .13 or T.C.A. § 33-3-220, the designated physician pursuant to these rules or in the case of a minor child, the person having custody or legal guardianship.

(26) Health Care Institution. A health care institution as defined in T.C.A. § 68-11-1602.

(27) Health Care Provider. A person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care in the ordinary course of business or practice of a profession.

(28) Home Care Organization. As defined by T.C.A. § 68-11-201, a “home care organization” provides home health services, home medical equipment services or hospice services to patients on an outpatient basis in either their regular or temporary place of residence.

(29) Home Health Aide. A person who has completed a total of seventy-five (75) hours of training which included sixteen (16) hours of clinical training prior to or during the first three (3) months of employment and who is qualified to provide basic services, including simple procedures as extension of therapy services, personal care regarding nutritional needs, ambulation and exercise, and household services essential to health care at home.

(30) Home Health Service. As defined by T.C.A. § 68-11-201, “home health service” means a service provided an outpatient by an appropriately licensed health care professional or an appropriately qualified staff member of a licensed home care organization in accordance with orders recorded by a physician, and which includes one (1) or more of the following:

(a) Skilled nursing care including part-time or intermittent supervision;

(b) Physical, occupational or speech therapy;

(d) Home health aide services;

(e) Medical supplies and medical appliances, other than drugs and pharmaceuticals, when provided or administered as part of or through the provision of, the services described in subparagraph (a) through (d); and (f) Any of the foregoing items and services which are provided on an outpatient basis under arrangements made by the home care organization at a hospital, nursing home facility or rehabilitation center and the furnishing of which involves the use of equipment of such a nature that the items and services cannot readily be made available to the individual in the individual’s home, or which are furnished at such facility while the individual is there to receive any such item or service, but not including transportation of the individual in connection with any such item or service.

(g) Home health service does not include services provided in the home by a sole practice therapist, when such services are within the scope of the therapist’s license and incidental to services provided by the sole practice therapist in the office. A sole practice therapist means a therapist licensed under Title 63, Chapter 13 or 17, who is in sole practice and not in a business arrangement with any other therapist or other healthcare provider. Sole practice therapists are not excluded from the requirements of professional support services.

(31) Homemaker Service. A non-skilled service in the home to maintain independent living which does not require a physician’s order. An agency does not have to be licensed as a home care organization to provide such services.

(32) Incompetent. A patient who has been adjudicated incompetent by a court of competent jurisdiction and has not been restored to legal capacity.

(33) Individual instruction. An individual’s direction concerning a health care decision for the individual.

(34) Infectious Waste. Solid or liquid wastes which contain pathogens with sufficient virulence and quantity such that exposure to the waste by a susceptible host could result in an infectious disease.

(35) Licensed Clinical Social Worker. A person currently licensed as such by the Tennessee Board of Social Workers.

(36) Licensed Practical Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(37) Licensee. The person or entity to whom the license is issued. The licensee is held responsible for compliance with all rules and regulations.

(38) Life Threatening or Serious Injury. Injury requiring the patient to undergo significant additional diagnostic or treatment measures.

(39) Medical Record. Medical histories, records, reports, clinical notes, summaries, diagnoses, prognoses, records of treatment and medication ordered and given, entries and other written electronic or graphic data prepared, kept, made or maintained in an agency that pertains to confinement or services rendered to patients.

(40) Medical Social Services. When provided, shall be given by a certified master social worker, a licensed clinical social worker, or by a social worker or social work assistant employed by the home care organization and under the supervision of a certified master social worker or licensed clinical social worker, in accordance with the plan of care. The medical social services provider shall assist the physician and other team members in understanding the significant social and emotional factors related to the health problems, participate in the development of the plan of care, prepare clinical and progress notes, work with the family, utilize appropriate community resources, participate in discharge planning and in-service programs, and act as a consultant to other organized personnel.

(41) Medically Inappropriate Treatment. Resuscitation efforts that cannot be expected either to restore cardiac or respiratory function to the patient or other medical or surgical treatments to achieve the expressed goals of the informed patient. In the case of the incompetent patient, the patient’s representative expresses the goals of the patient.

(42) Occupational Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(43) Occupational Therapy Assistant. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(44) Misappropriation of Patient/Resident Property. The deliberate misplacement, exploitation or wrongful, temporary or permanent use of an individual’s belongings or money without the individual’s consent.

(45) Neglect. The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; however, the withholding of authorization for or provision of medical care to any terminally ill person who has executed an irrevocable living will in accordance with the Tennessee Right to Natural Death Law, or other applicable state law, if the provision of such medical care would conflict with the terms of the living will, shall not be deemed “neglect” for purposes of these rules.

(46) Patient. Includes but is not limited to any person who is suffering from an acute or chronic illness or injury or who is crippled, convalescent or infirm, or who is in need of obstetrical, surgical, medical, nursing or supervisory care.

(48) Personally Informing. A communication by any effective means from the patient directly to a health care provider.

(49) Physical Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(50) Physical Therapy Assistant. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(51) Physician. A person currently licensed as such by the Tennessee Board of Medical Examinations or currently licensed by the Tennessee Board of Osteopathic Examination. For the purposes of defining “home health services” only, “physician” includes a podiatrist licensed under Title 63, Chapter 3, provided, that any home health service ordered is a follow-up to treatment provided to the patient by the podiatrist. A physician who is licensed to practice medicine, osteopathy or podiatry in a state contiguous to Tennessee may refer a patient residing in this state to a home care organization providing home health services duly licensed under this chapter; however, this shall not be construed as authorizing an unlicensed physician to practice medicine in violation of T.C.A. §§ 63-6-201, 63-9-104 or 63- 3-204, and such a physician shall have previously provided treatment to that patient, and shall have had an ongoing physician-patient relationship with the person for whom the referral is to be made.

(52) Physician Assistant. A person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(53) Physician Orders for Scope of Treatment or POST. Written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(54) Power of Attorney for Health Care. The designation of an agent to make health care decisions for the individual granting the power under T.C.A. Title 34, Chapter 6, Part 2.

(55) Qualified Emergency Medical Service Personnel. Includes, but shall not be limited to, emergency medical technicians, paramedics, or other emergency services personnel, providers, or entities acting within the usual course of their professions, and other emergency responders.

(56) Reasonably Available. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the patient’s health care needs. Such availability shall include, but not be limited to, availability by telephone.

(57) Registered Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(58) Respiratory Technician. A person currently licensed as such by the Tennessee Board of Respiratory Care.

(59) Respiratory Therapist. A person currently licensed as such by the Tennessee Board of Respiratory Care.

(60) Shall or Must. Compliance is mandatory.

(61) Social Work Assistant. A person who has a baccalaureate degree in social work, psychology, sociology or other field related to social work, and has at least one (1) year of social work experience in a health care setting. Social work related fields include bachelor/masters degrees in psychology, sociology, human services (behavioral sciences, not human resources), masters degree in counseling fields (psychological guidance and guidance counseling) and degrees in gerontology.

(62) Speech Language Pathologist. As defined in T.C.A. § 63-17-103, a person currently licensed as such by the Tennessee Board of Communications Disorders and Sciences.

(63) State. A state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States.

(64) Student. A person currently enrolled in a course of study that is approved by the appropriate licensing board or equivalent body.

(65) Supervising Health Care Provider. The designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual’s health care.

(66) Supervision. Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity with initial direction and periodic inspection of the actual act of accomplishing the function or activity. Periodic supervision must be provided if the person is not a licensed or certified assistant, unless otherwise provided in accordance with these rules.

(67) Surrogate. An individual, other than a patient’s agent or guardian, authorized to make a health care decision for the patient.

(68) Treating Health Care Provider. A health care provider who at the time is directly or indirectly involved in providing health care to the patient.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-11-201, 68-11-202, 68-11-207, 68-11-209, 68-11- 210, 68-11-211, 68-11-213, 68-11-224, and 68-11-1802.
Administrative History: Original rule filed May 31, 2000; effective August 14, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed April 28, 2003; effective July 12, 2003. Amendment filed May 27, 2004; effective August 10, 2004. Amendments filed December 2, 2005; effective February 15, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendment filed September 15, 2015; effective December 14, 2015. Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.02 LICENSING PROCEDURES

(1) No person, partnership, association, corporation, or state, county or local government unit, or any division, department, board or agency thereof, shall establish, conduct, operate, or maintain in the State of Tennessee any home care organization providing home health services without having a license. A license shall be issued to the person or persons named and for the premises listed in the application for licensure and for the geographic areas specified by the certificate of need or at the time of the original licensing. The name of the home care organization providing home health services shall not be changed without first notifying the department in writing. Licenses are not transferable or assignable and shall expire and become invalid annually on the anniversary date of their original issuance. The license shall be conspicuously posted in the home care organization providing home health services.

(2) In order to make application for a license:

(a) The applicant shall submit an application on a form prepared by the Department.

(c) The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the Department. Patients shall not be admitted to the agency until a license has been issued. Applicants shall not hold themselves out to the public as being an agency until the license has been issued.

A license shall not be issued until the agency is in substantial compliance with these rules, including submission of all information required by T.C.A. § 68-11-206(1) or as later amended, and all information required by the Commissioner.

(d) The applicant must prove the ability to meet the financial needs of the agency.

(f) The applicant shall allow the home care agency providing home health services to be inspected by a Department surveyor. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action to the Board that must be accepted by the Board. Once the deficiencies have been corrected, then the Board shall consider the application for licensure.

(3) A proposed change of ownership, including a change in a controlling interest, must be reported to the Department a minimum of thirty (30) days prior to the change. A new application and fee must be received by the Department before the license may be issued.

(a) For the purposes of licensing, the licensee of an agency has the ultimate responsibility for the operation of the agency, including the final authority to make or control operational decisions and legal responsibility for the business management. A change of ownership occurs whenever this ultimate legal authority for the responsibility of the agency’s operation is transferred.

(b) A change of ownership occurs whenever there is a change in the legal structure by which the agency is owned and operated.

Transfer of the agency’s legal title;
Lease of the agency’s operations;
Dissolution of any partnership that owns, or owns a controlling interest in, the agency;
One partnership is replaced by another through the removal, addition or substitution of a partner;
Removal of the general partner or general partners, if the agency is owned by a limited partnership;
Merger of an agency owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are canceled;
The consolidation of a corporate agency owner with one or more corporations; or 8. Transfers between levels of government.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors or board of trustees;
Two (2) or more corporations merge and the originally-licensed corporation survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government; or 5. Corporate stock transfers or sales, even when a controlling interest.

(e) Management agreements are generally not changes of ownership if the owner continues to retain ultimate authority for the operation of the agency. However, if the ultimate authority is surrendered and transferred from the owner to a new manager, then a change of ownership has occurred.

(f) Sale/lease-back agreements shall not be treated as changes in ownership if the lease involves the agency’s entire real and personal property and if the identity of the lessee, who shall continue the operation, retains the exact same legal form as the former owner.

(4) Renewal.

(a) In order to renew a license, each home care agency providing home health services shall submit to periodic inspections by Department surveyors for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action and shall remedy the deficiencies. In addition, each licensee shall submit a renewal form approved by the board and applicable renewal fee prior to the expiration date of the license.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late; provided that the late penalty shall not exceed twice the renewal fee.

A completed application for licensure;
The license fee provided in Rule 0720-27-.02(2)(b); and 3. Any other information required by the Health Services and Development Agency.

(d) Upon reapplication, the licensee shall submit to an inspection of the facility by Department of Health surveyors.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-206(a)(5) [effective January 1, 2009], 68-11-209, 68-11-209(a)(1), 68-11-210, and 68-11-216 and Chapter 846 of the Public Acts of 2008, § 1.
Administrative History: Original rule filed May 31, 2000; effective August 14, 2000. Amendment filed November 19, 2003; effective February 2, 2004. Amendment filed January 19, 2007; effective April 4, 2007. Public necessity rules filed April 29, 2009; effective through October 11, 2009. Emergency rules filed October 9, 2009; effective through April 7, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed March 21, 2018; to have been effective June 19, 2018. However, on May 24, 2018, the Government Operations Committee filed a 5-day stay; new effective date June 24, 2018. Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.03 DISCIPLINARY PROCEDURES

(1) The Board may suspend or revoke a license for:

(a) Violation of federal or state statutes;

(b) Violation of the rules as set forth in this chapter;

(d) Conduct or practice found by the Board to be detrimental to the health, safety, or welfare of the patients of the agency; or (e) Failure to renew the license.

(2) The Board may consider all factors which it deems relevant, including but not limited to the following when determining sanctions:

(a) The degree of sanctions necessary to ensure immediate and continued compliance;

(b) The character and degree of impact of the violation on the health, safety and welfare of the patient of the agency;

(c) The conduct of the agency in taking all feasible steps or procedures necessary or appropriate to comply or correct the violation; and (d) Any prior violations by the agency of statutes, rules or orders of the Board.

(3) Inappropriate transfers are prohibited and violation of the transfer provisions shall be deemed sufficient grounds to suspend or revoke an agency’s license.

(4) When an agency is found by the Department to have committed a violation of this chapter, the Department will issue to the agency a statement of deficiencies. Within ten (10) days of receipt of the statement of deficiencies the agency must return a plan of correction indicating the following:

(a) How the deficiency will be corrected;

(b) The date upon which each deficiency will be corrected;

(5) Either failure to submit a plan of correction in a timely manner or a finding by the Department that the plan of correction is unacceptable shall subject the agency’s license to possible disciplinary action.

(6) Any licensee or applicant for a license, aggrieved by a decision or action of the Department or Board, pursuant to this chapter, may request a hearing before the Board. The proceedings and judicial review of the Board’s decision shall be in accordance with the Uniform Administrative Procedures Act, T.C.A. §§ 4-5-101, et seq.

(7) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to rule

Tenn. Comp. R. & Regs. 0720-27-.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;

(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;

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.

History

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.
Administrative History: 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 June 25, 2015. Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.05 ADMISSIONS, DISCHARGE, AND TRANSFERS

(1) Patients shall be accepted to receive home health services on the basis of a reasonable expectation that the patient’s medical, nursing and psychosocial needs can be met adequately by the organization in the patient’s regular or temporary place of residence.

(2) Care shall follow a written plan of care established and reviewed by a physician, and care shall continue under the supervision of a physician.

(3) The agency staff shall determine if the patient’s needs can be met by the organization’s services and capabilities.

(4) Every person admitted for care or treatment to any agency covered by these rules shall be under the supervision of a physician, as defined in this chapter, who holds a license in good standing. The name of the patient’s attending physician shall be recorded in the patient’s medical record.

(5) The agency staff shall obtain the patient’s written consent for home health services.

(6) The signed consent form shall be included with the patient’s individual clinical record.

(7) A diagnosis must be entered in the admission records of the agency for every person admitted for care or treatment.

(8) No medication or treatment shall be provided to any patient of an agency except on the order of a physician or dentist lawfully authorized to give such an order.

(9) A medical record shall be developed and maintained for each patient admitted.

(10) A discharge plan and summary shall be completed on each patient.

(11) The agency must provide an effective discharge planning process that applies to all patients.

The agency’s discharge planning process, including discharge policies and procedures, must be in writing and must:

(a) Be developed and/or supervised by a registered nurse, social worker or other appropriately qualified personnel;

(b) Begin upon admission of any patient;

(d) Identify the patient’s continuing physical, emotional, housekeeping, transportation, social and other needs;

(e) Involve the patient, the patient’s family or individual acting on the patient’s behalf, the physician, nursing and social work professionals and other appropriate staff, and must be documented in the patient’s medical record; and (f) Be conducted on an ongoing basis throughout the continuum of care. Coordination of services may involve promoting communication to facilitate family support, social work, nursing care, consultation, referral or other follow-up.

(12) The patient and family members or interested persons must be taught and/or counseled to prepare them for post-agency care.

(13) The agency shall ensure that no person on the grounds of race, color, national origin or handicap, will be excluded from participation in, be denied benefits of, or otherwise subjected to discrimination in the provision of any care or service of the agency. The agency shall protect the civil rights of residents under the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, and 68-11-209.
Administrative History: Original rule filed May 31, 2000; effective August 14, 2000. Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.06 BASIC AGENCY FUNCTIONS

(1) An agency shall provide at least one of the qualifying home health services directly through agency employees, but may arrange with another licensed organization or health care professional to provide any additional home health services. Home health services provided under arrangements with another licensed home care organization or professional organization shall be subject to a written contract conforming with the requirements of this

chapter.

(2) All personnel providing home health services shall assure that their efforts effectively complement one another and support the objectives outlined in the plan of care. The medical record or minutes of case conferences shall establish that effective interchange, reporting, and coordinated patient evaluation does occur. A written summary report for each patient shall be sent to the attending physician at least every sixty-two (62) days.

(3) Plan of Care.

(a) The written plan of care, developed in consultation with the organization staff, shall cover all pertinent diagnoses, including mental status, types of services and equipment required, frequency of services, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. If a physician refers a patient under a plan of care which cannot be completed until after an evaluation visit, the physician shall be consulted to approve additions or modifications to the original plan. Orders for home health therapy services shall include the specific treatment or modalities to be used and their amount, frequency and duration. The therapist and other organization personnel shall participate in developing the plan of care.

(b) The total plan of care shall be reviewed by the attending physician and agency personnel involved in the patient’s care as often as the severity of the patient’s condition requires, but at least once every sixty-two (62) days. Evidence of review by the physician must include the physician’s signature and date of the review on the plan of care. A facsimile of the physician’s signature is acceptable. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the plan of care.

(4) Drugs and treatments shall be administered by appropriately licensed agency personnel, acting within the scope of their licenses. Oral orders for drugs and treatments shall be given to appropriately licensed personnel acting within the scope of their licenses, immediately recorded, signed and dated, and countersigned and dated by the physician.

(5) Skilled Nursing Services.

(a) The agency shall provide skilled nursing services by or under the supervision of a registered nurse who has no current disciplinary action against his/her license, in accordance with the plan of care. This person shall be available at all times during operating hours and participate in all activities relevant to the professional home health services provided, including the development of qualifications and assignment of personnel.

(b) The registered nurse’s duties shall include but are not limited to the following: make the initial evaluation visit, except in those circumstances where the physician has ordered therapy services as the only skilled service; regularly evaluate the patient’s nursing needs; initiate the plan of care and necessary revisions; provide those services requiring substantial specialized nursing skill; initiate appropriate preventive and rehabilitative nursing procedures; prepare clinical and progress notes; coordinate services; inform the physician and other personnel of changes in the patient’s condition and needs; counsel the patient and family in meeting nursing and related needs; participate in in-service programs; supervise and teach other nursing personnel. The registered nurse or appropriate agency staff shall initially and periodically evaluate drug interactions, duplicative drug therapy and non-compliance to drug therapy.

(c) The licensed practical nurse shall provide services in accordance with agency policies, which may include but are not limited to the following: prepare clinical and progress notes; assist the physician and/or registered nurse in performing specialized procedures; prepare equipment and materials for treatments; observe aseptic technique as required; and assist the patient in learning appropriate self-care techniques.

(d) A registered nurse may make the actual determination and pronouncement of death under the following circumstances:

The deceased was receiving the services of a licensed home care organization;
The death was anticipated, and the attending physician has agreed in writing to sign the death certificate. Such agreement by the attending physician must be present with the deceased at the place of death;
The nurse is licensed by the state; and 4. The nurse is employed by the home care organization providing services to the deceased.

(6) Therapy Services.

(a) All therapy services offered by the agency directly or under arrangement shall be planned, delegated, supervised or provided by a qualified therapist in accordance with the plan of care. A qualified therapist assistant may provide therapy services under the supervision of a qualified therapist in accordance with the plan of care. The therapist shall assist the physician in evaluating the level of function, helping develop the plan of care (revising as necessary), preparing clinical and progress notes, advising and consulting with the family and other agency personnel, and participating in in-service programs.

Tenn. Comp. R. & Regs. 0720-27-.07 RESERVED

Administrative History: Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.08 RESERVED

Administrative History: Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-202, 68-11-204, and 68-11-206 through 68-11-209.
Administrative History: Original rule filed May 31, 2000; effective August pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1370-01-.10 .

(7) Home Health Aide Services.

(a) Aides shall be selected on the basis of such factors as: a sympathetic attitude toward the care of the sick; the ability to read, write and carry out directions; and the maturity and ability to deal effectively with the demands of the job. Aides shall be formally and carefully trained in: methods of assisting patients to achieve maximum self-reliance in nutrition and meal preparation; the aging process and emotional problems of illness; procedures for maintaining a clean, healthy and pleasant environment; changes in a patient’s condition that should be reported; work of the agency and the health team; ethics; confidentiality; respect for human dignity and the awareness of individual differences; and record keeping. Any home health aide training programs must comply with the federal home health aide training and competency regulations. Copies of these regulations may be obtained from the department.

(b) The home health aide shall be assigned to a particular patient by a registered nurse.

Written instructions for patient care shall be prepared by a registered nurse or therapist as appropriate. Duties may include the performance of simple procedures as an extension of therapy services, personal care, ambulation and exercises, household services essential to health care at home, assistance with medications that are ordinarily self-administered, reporting changes in the patient’s condition and needs, and completing appropriate records.

(c) The registered nurse, or appropriate professional staff member if other home health services are provided, shall make a supervisory visit to the patient’s residence at least monthly, either when the aide is present to observe and assist or when the aide is absent (preferably alternating visits), to assess the aide’s competence in providing care and determine whether goals are being met.

(d) There shall be continuing in-service programs on a regularly scheduled basis with onthe-job training during supervisor visits and more often as needed.

(8) Medical Social Services, when provided, shall be given by a certified master social worker, a licensed clinical social worker, or by a social work assistant employed by the agency and under the supervision of a certified master social worker or licensed clinical social worker, and in accordance with the plan of care. The medical social services provider shall assist the physician and other team members in understanding the significant social and emotional factors related to the health problems, participate in the development of the plan of care, prepare clinical and progress notes, work with the family, utilize appropriate community resources, participate in discharge planning and in-service programs, and act as a consultant to other agency personnel.

(9) Performance Improvement.

(a) An agency shall have a committee to review, at least annually, past and present home health services including contract services, in accordance with a written plan, to determine their appropriateness and effectiveness and to ascertain that professional policies are followed in providing these services.

(b) The objectives of the review committee shall be:

To assist the agency in using its personnel and facilities to meet individual and community needs;
To identify and correct deficiencies which undermine quality of care and lead to waste of agency and personnel resources;
To help the agency make critical judgments regarding the quality and quantity of its services through self-examination;
To provide opportunities to evaluate the effectiveness of agency policies and when necessary make recommendations to the administration as to controls or changes needed to assure high standards of patient care;
To augment in-service staff education;
To provide data needed to satisfy state licensure and certification requirements;
To establish criteria to measure the effectiveness and efficiency of the home health services provided to patients; and 8. To develop a record review system for the agency to evaluate the necessity or appropriateness of the home health services provided and their effectiveness and efficiency.

(10) Infection Control.

(a) There must be an active performance improvement program for developing guidelines, policies, procedures and techniques for the prevention, control and investigation of infections and communicable diseases.

(b) Formal provisions must be developed to educate and orient all appropriate personnel and/or family members in the practice of aseptic techniques such as handwashing and scrubbing practices, proper hygiene, use of personal protective equipment, dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of patient care equipment and supplies.

(c) Continuing education shall be provided for all agency patient care providers on the cause, effect, transmission, prevention and elimination of infections, as evidenced by the ability to verbalize/or demonstrate an understanding of basic techniques.

(d) A Home Care Organization Providing Home Health Services shall have an annual influenza vaccination program which shall include at least:

The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Home Care Organization Providing Home Health Services will encourage all staff and independent practitioners to obtain an influenza vaccination;
A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider);
Education of all employees about the following:

(i) Flu vaccination, (ii) Non-vaccine control measures, and (iii) The diagnosis, transmission, and potential impact of influenza;

An annual evaluation of the influenza vaccination program and reasons for nonparticipation; and 5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee.

(e) The agency shall develop policies and procedures for testing a patient’s blood for the presence of the hepatitis B virus and the HIV (AIDS) virus in the event that an employee of the agency, a student studying at the agency or other health care provider rendering services at the agency is exposed to a patient’s blood or other body fluid.

The testing shall be performed at no charge to the patient, and the test results shall be confidential.

(f) The agency and its employees shall adopt and utilize standard precautions (per CDC) for preventing transmission of infections, HIV and communicable diseases.

(g) Precautions shall be taken to prevent the contamination of sterile and clean supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents.

(11) Medical Records.

(a) A medical record containing past and current findings in accordance with accepted professional standards shall be maintained for every patient receiving home health services. In addition to the plan of care, the record shall contain: appropriate identifying information; name of physician; all medications and treatments; signed and dated clinical notes. Clinical notes shall be written the day on which service is rendered and incorporated no less often than weekly; copies of summary reports shall be sent to the physician; and a discharge summary shall be dated and signed within 7 days of discharge.

(b) A home care organization providing home health services is authorized to receive and appropriately act on a written order for a plan of care for a patient concerning a home health service signed by a physician that is transmitted to the agency by electronically signed electronic mail. Such order that is transmitted by electronic mail shall be deemed to meet any requirement for written documentation imposed by this regulation.

(c) All medical records, either written, electronic, graphic or otherwise acceptable form, must be retained in their original or legally reproduced form for a minimum period of at least ten (10) years after which such records may be destroyed. However, in cases of patients under mental disability or minority, their complete agency records shall be retained for the period of minority or known mental disability, plus one (1) year, or ten (10) years following the discharge of the patient, whichever is longer. Records destruction shall be accomplished by burning, shredding or other effective method in keeping with the confidential nature of the contents. The destruction of records must be made in the ordinary course of business, must be documented and in accordance with the agency’s policies and procedures, and no record may be destroyed on an individual

basis.

(d) Even if the agency discontinues operations, records shall be maintained as mandated by this chapter and the Tennessee Medical Records Act (T.C.A. § 68-11-308). If a patient is transferred to another health care facility or agency, a copy of the record or an abstract shall accompany the patient when the agency is directly involved in the transfer.

(e) Medical records information shall be safeguarded against loss or unauthorized use.

Written procedures govern use and removal of records and conditions for release of information. The patient’s written consent shall be required for release of information when the release is not otherwise authorized by law.

(f) For purposes of this rule, the requirements for signature or countersignature by a physician or other person responsible for signing, countersigning or authenticating an entry may be satisfied by the electronic entry by such person of a unique code assigned exclusively to him or her, or by entry of other unique electronic or mechanical symbols, provided that such person has adopted same as his or her signature in accordance with established protocol or rules.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-3-511, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11- 260, and 68-11-304.
Administrative History: Original rule filed May 31, 2000; effective August 14, 2000. Amendment filed September 13, 2002; effective November 27, 2002. Amendment filed February 23, 2007; effective May 9, 2007. Amendment filed September 15, 2015; effective December 14, 2015. pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.09 RESERVED

Administrative History: Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.10 INFECTIOUS AND HAZARDOUS WASTE

(1) Each agency must develop, maintain and implement written policies and procedures for the definition and handling of its infectious and hazardous waste. These policies and procedures must comply with the standards of this rule and all other applicable state and federal regulations.

(2) The following waste shall be considered to be infectious waste:

(a) Waste human blood and blood products such as serum, plasma, and other blood components;

(b) All discarded sharps (including but not limited to, hypodermic needles, syringes, pasteur pipettes, broken glass, scalpel blades) used in patient care; and (c) Other waste determined to be infectious by the agency in its written policy.

(3) Waste must be packaged in a manner that will protect waste handlers and the public from possible injury and disease that may result from exposure to the waste. Such packaging must provide for containment of the waste from the point of generation up to the point of proper treatment or disposal. Packaging must be selected and utilized for the type of waste the package will contain, how the waste will be treated and disposed, and how it will be handled and transported prior to treatment and disposal.

(a) Contaminated sharps must be directly placed in leakproof, rigid and puncture-resistant containers which must then be tightly sealed.

(b) Infectious and hazardous waste must be secured in fastened plastic bags before placement in a garbage can with other household waste.

(4) After packaging, waste must be handled, transported and stored by methods ensuring containment and preserving of the integrity of the packaging, including the use of secondary containment where necessary.

(5) Waste must be stored in a manner which preserves the integrity of the packaging, inhibits rapid microbial growth and putrefaction, and minimizes the potential of exposure or access by unknowing persons. Waste must be stored in a manner and location which affords protection from animals, precipitation, wind and direct sunlight, does not present a safety hazard, does not provide a breeding place or food source for insects or rodents and does not create a nuisance.

(6) In the event of spills, ruptured packaging, or other incidents where there is a loss of containment of waste, the agency must ensure that proper actions are immediately taken to:

(a) Isolate the area;

(b) Repackage all spilled waste and contaminated debris in accordance with the requirements of this rule; and, (c) Sanitize all contaminated equipment and surfaces appropriately.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, and 68-11-209.
Administrative History: Original rule filed May 31, 2000; effective August 14, 2000. Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.11 RECORDS AND REPORTS

(1) A yearly statistical report, the “Joint Annual Report of Home Care Organizations,” shall be submitted to the Department. The forms are mailed to each home care organization by the Department each year. The forms must be completed and returned to the Department as requested.

(2) The agency providing home health services shall report all incidents of abuse, neglect, and misappropriation to the Department of Health in accordance with T.C.A. § 68-11-211.

(3) The agency providing home health services shall report the following incidents to the Department of Health in accordance with T.C.A. § 68-11-211.

(a) Strike by staff at the facility;

(b) External disasters impacting the facility;

(c) Disruption of any service vital to the continued safe operation of the home care organization providing home health services or to the health and safety of its patients and personnel; and (d) Fires at the home care organization providing home health services that disrupt the provision of patient care services or cause harm to the patients or staff, or that are reported by the facility to any entity, including but not limited to a fire department charged with preventing fires.

(4) The agency shall retain legible copies of the following records and reports for thirty-six (36) months following their issuance. They shall be maintained in a single file and shall be made available for inspection during normal business hours to any person who requests to view them:

(a) Department licensure and fire safety inspections and surveys;

(b) Federal Health Care Financing Administration surveys and inspections, if any;

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-207, 68-11-209, 68-11-210, 68-11-211, and 68- 11-213.
Administrative History: Original rule filed May 31, 2000; effective August 14, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendments filed January 3, 2012; effective April 2, 2012. Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.12 PATIENT RIGHTS

(1) Each patient has at least the following rights:

(a) To privacy in treatment and personal care;

(b) To have appropriate assessment and management of pain;

(d) To be free from mental and physical abuse. Should this right be violated, the agency must notify the Department within five (5) business days and the Tennessee Department of Human Services, Adult Protective Services as required by T.C.A. §§ 71- 6-101 et seq.;

(e) To refuse treatment. The patient must be informed of the consequences of that decision, and the refusal and its reason must be reported to the physician and documented in the medical record;

(f) To refuse experimental treatment and drugs. The patient’s or health care decisionmaker’s written consent for participation in research must be obtained and retained in the medical record; and (g) To have their records kept confidential and private. Written consent by the patient must be obtained prior to release of information except to persons authorized by law. If the patient lacks capacity, written consent is required from the patient’s health care decision-maker. The agency must have policies to govern access and duplication of the patient’s record.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed May 31, 2000; effective August 14, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendment filed December 2, 2005; effective February 15, 2006. Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.13 POLICIES AND PROCEDURES FOR HEALTH CARE DECISION-MAKING

(1) Pursuant to this Rule, each home health agency shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a patient who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from individual patients. An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.

(8) An advance directive may include the individual’s nomination of a court-appointed guardian.

(10) No health care provider or institution shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care.

(12) A patient having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.

(13) A patient having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke.

(15) An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.

(16) Surrogates.

(a) An adult or emancipated minor may designate any individual to act as surrogate by personally informing the supervising health care provider. The designation may be oral or written.

(b) A surrogate may make a health care decision for a patient who is an adult or emancipated minor if and only if:

The patient has been determined by the designated physician to lack capacity, and 2. No agent or guardian has been appointed, or 3. The agent or guardian is not reasonably available.

(e) Consideration may be, but need not be, given in order of descending preference for service as a surrogate to:

The patient’s spouse, unless legally separated;
The patient’s adult child;
The patient’s parent;
The patient’s adult sibling;
Any other adult relative of the patient; or 6. Any other adult who satisfies the requirements of 0720-27-.13(16)(d).

(f) No person who is the subject of a protective order or other court order that directs that person to avoid contact with the patient shall be eligible to serve as the patient’s surrogate.

(g) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:

Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the patient or in accordance with the patient’s best interests;
The proposed surrogate’s regular contact with the patient prior to and during the incapacitating illness;
The proposed surrogate’s demonstrated care and concern;
The proposed surrogate’s availability to visit the patient during his or her illness; and 5. The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.

(h) If the patient lacks capacity and none of the individuals eligible to act as a surrogate under 0720-27-.13(16)(c) through 0720-27-.13(16)(g) is reasonably available, the designated physician may make health care decisions for the patient after the designated physician either:

Consults with and obtains the recommendations of a facility’s ethics mechanism or standing committee in the facility that evaluates health care issues; or 2. Obtains concurrence from a second physician who is not directly involved in the patient’s health care, does not serve in a capacity of decision-making, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.

(j) A surrogate shall make a health care decision in accordance with the patient’s individual instructions, if any, and other wishes to the extent known to the surrogate.

(l) Except as provided in 0720-27-.13(16)(m):

Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution nor an employee of an operator of a health care institution may be designated as a surrogate; and 2. A health care provider or employee of a health care provider may not act as a surrogate if the health care provider becomes the patient’s treating health care provider.

(m) An employee of the treating health care provider or an employee of an operator of a health care institution may be designated as a surrogate if:

The employee so designated is a relative of the patient by blood, marriage, or adoption; and 2. The other requirements of this section are satisfied.

(17) Guardian.

(a) A guardian shall comply with the patient’s individual instructions and may not revoke the patient’s advance directive absent a court order to the contrary.

(b) Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.

(19) Except as provided in 0720-27-.13(20) through 0720-27-.13(22), a health care provider or institution providing care to a patient shall:

(20) A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.

(21) A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:

(23) A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 0720-27-.13(20) through 0720-27-.13(22) shall:

(a) Promptly so inform the patient, if possible, and any person then authorized to make health care decisions for the patient;

(b) Provide continuing care to the patient until a transfer can be effected or until the determination has been made that transfer cannot be effected;

(a) Complying with a health care decision of a person apparently having authority to make a health care decision for a patient, including a decision to withhold or withdraw health care;

(26) An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.

(27) A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for such identification made in good faith.

(28) A copy of a written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.

(30) Physician Orders for Scope of Treatment (POST).

(a) Physician Orders for Scope of Treatment (POST) may be issued by a physician for a patient with whom the physician has a bona fide physician-patient relationship, but only:

With the informed consent of the patient;
If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or 3. If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available, if the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

No physician, who has a bona fide physician-patient relationship with the patient, is present and available for discussion with the patient (or if the patient is a minor or is otherwise incapable of making an informed decision, with the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act);
Such authority to issue is contained in the physician assistant’s, nurse practitioner’s or clinical nurse specialist’s protocols;
Either:

(i) With the informed consent of the patient;

(d) A POST issued in accordance with this section shall remain valid and in effect until revoked. In accordance with this rule and applicable regulations, qualified emergency medical services personnel; and licensed health care practitioners in any facility, program, or organization operated or licensed by the Board for Licensing Health Care Facilities, the Department of Mental Health and Substance Abuse Services, or the Department of Intellectual and Developmental Disabilities, or operated, licensed, or owned by another state agency, shall follow a POST that is available to such persons in a form approved by the Board for Licensing Health Care Facilities.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-224, and 68- 11-1801 through 68-11-1815.
Administrative History: Original rule filed May 31, 2000; effective August 14, 2000. Amendment filed April 28, 2003; effective July 12, 2003. Repeal and new rule filed December 2, 2005; effective February 15, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-27-.14 DISASTER PREPAREDNESS

(1) Disaster Preparedness Policies and Procedures.

(a) All licensed home care organizations shall develop, implement, and maintain a written emergency response policy and corresponding procedures to ensure the continuous provision of patient services as scheduled during a natural disaster, public health emergency, or other emergency event. The policy and procedures shall, at a minimum:

Contain the information needed to ensure compliance with the local comprehensive emergency plan;
Address contingency plans to address service interruptions and provisions for the continued operation or alternative arrangements for power-dependent medical equipment in the patient’s home.

(b) Branch offices shall follow the policies and procedures established by the licensed home health agency of which they are a part.

(2) Emergency Planning Coordination With Local Government Authorities.

(a) All home care organizations shall establish and maintain communications with the county Emergency Management Agency in the county of their license. The home care organizations shall cooperate, to the extent possible, in area disaster drills and local emergency situations.

(b) Branch offices may adopt and follow the disaster preparedness procedures established by the licensed home health organization of which they are a part. Branch offices who do so are not required to establish or maintain communications with the county Emergency Management Agency; however, they should collaborate with emergency management agencies when appropriate and as directed by the licensed home health organization. A branch office that develops its own disaster preparedness procedures must establish and maintain communications with the local county Emergency Management Agency.

(c) Each home care organization shall conduct both the physical facility and community emergency drills as required in these regulations, even if the local Emergency Management Agency is unable to participate.

(d) A file of documents demonstrating communications and cooperation with the local agency must be maintained.

History

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed May 31, 2000; effective August 14, 2000. Transferred from chapter 1200-08-26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.

Tenn. Comp. R. & Regs. 0720-27-.15 APPENDIX I

(1) Physician Orders for Scope of Treatment (POST) Form.

(This space intentionally left blank)

A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED

Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”)

This is a Physician Order Sheet based on the medical conditions and wishes of the person identified at right (“patient”). Any section not completed indicates full treatment for that section. When need occurs, first follow these orders, then contact physician.

Patient’s Last Name First Name/Middle Initial Date of Birth

Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Section B Check One Box Only MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.  Comfort Measures Only. Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.  Limited Additional Interventions. In addition to care described in Comfort Measures Only above, use medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. Treatment Plan: Basic medical treatments.  Full Treatment. In addition to care described in Comfort Measures Only and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including in the intensive care unit.

Other Instructions:

Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify)

The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other)

Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge)

MD/NP/CNS/PA Phone Number:

Name (print) Signature Relationship (write “self” if patient)

Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel.

Photocopies/faxes of signed POST forms are legal and valid.

Using POST Any incomplete section of POST implies full treatment for that section.

No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.”

Oral fluids and nutrition must always be offered if medically feasible.

IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”

A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.

Reviewing POST This POST should be reviewed if:

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.

(2) Advance Directive for Health Care Form.

ADVANCE DIRECTIVE FOR HEALTH CARE*

(Tennessee)

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.

Part 5, Block A or Block B must be completed for all uses. improve), I direct that medically appropriate treatment be provided as follows. By marking “yes” below, I have indicated treatment I want. By marking “no” below, I have indicated treatment I do not want.   Yes No CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it has stopped. Usually this involves electric shock, chest compressions, and breathing assistance.   Yes No Life Support/Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys, and other organs to continue to work.   Yes No Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a new condition but will not help the main illness.   Yes No Tube feeding/IV fluids: Use of tubes to deliver food and water to a patient’s stomach or use of IV fluids into a vein, which would include artificially delivered nutrition and hydration.

Part 3 Other instructions, such as hospice care, burial arrangements, etc.:

(Attach additional pages if necessary)

Part 5 Your signature must either be witnessed by two competent adults (“Block A”) or by a notary public (“Block B”).

Signature: _______________________________________ Date: ____________________ (Patient)

Block A Neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.

Witnesses:

I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form.

Signature of witness number 2 Block B You may choose to have your signature witnessed by a notary public instead of the witnesses described in Block A.

STATE OF TENNESSEE

COUNTY OF

My commission expires:

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1805.
Administrative History: Original rule filed February 16, 2007; effective May 2, 2007. Repeal and new rule filed August 28, 2012; effective November 26, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed February 8, 2017; effective May 9, 2017. Transferred from chapter 1200-08- 26 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-28 Standards for Home Care Organizations Providing Hospice Services (Transferred from 1200-08-27)

Tenn. Comp. R. & Regs. 0720-28-.01 DEFINITIONS

(1) Abuse. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) Administrator. A person who:

(3) Adult. An individual who has capacity and is at least 18 years of age.

(5) Agent. An individual designated in an advance directive for health care to make a health care decision for the individual granting the power.

(6) Agency. A Home Care Organization providing hospice services.

(7) Bereavement Counselor. An individual who has at least a bachelor’s degree in social work, counseling, psychology, pastoral care or specialized training or experience in bereavement theory and counseling.

(8) Board. The Tennessee Board for Licensing Health Care Facilities.

(9) Capacity. An individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. These regulations do not affect the right of a patient to make health care decisions while having the capacity to do so. A patient shall be presumed to have capacity to make a health care decision, to give or revoke an advance directive, and to designate or disqualify a surrogate.

Any person who challenges the capacity of a patient shall have the burden of proving lack of capacity.

(11) Certified Master Social Worker. A person currently certified as such by the Tennessee Board of Social Worker Certification and Licensure.

(14) Commissioner. The Commissioner of the Tennessee Department of Health or his or her authorized representative.

(15) Competent. A patient who has capacity.

(16) Core Services. Services consisting of nursing, medical social services, physician services and counseling services.

(17) Department. The Tennessee Department of Health.

(19) Do-Not-Resuscitate Order (DNR). A written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(20) Emancipated Minor. Any minor who is or has been married or has by court order or otherwise been freed from the care, custody and control of the minor’s parents.

(21) Emergency Responder. A paid or volunteer firefighter, law enforcement officer, or other public safety official or volunteer acting within the scope of his or her proper function under law or rendering emergency care at the scene of an emergency.

(22) Guardian. A judicially appointed guardian or conservator having authority to make a health care decision for an individual.

(23) Hazardous Waste. Materials whose handling, use, storage and disposal are governed by local, state or federal regulations.

(24) Health Care. Any care, treatment, service or procedure to maintain, diagnose, treat, or otherwise affect an individual’s physical or mental condition, and includes medical care as defined in T.C.A. § 32-11-103(5).

(25) Health Care Decision. Consent, refusal of consent or withdrawal of consent to health care.

(26) Health Care Decision-Maker. In the case of a patient who lacks capacity, the patient’s health care decision-maker is one of the following: the patient’s health care agent as specified in an advance directive, the patient’s court-appointed guardian or conservator with health care decision-making authority, the patient’s surrogate as determined pursuant to Rule 0720-28- .13 or T.C.A. § 33-3-220, the designated physician pursuant to these rules or in the case of a minor child, the person having custody or legal guardianship.

(27) Health Care Institution. A health care institution as defined in T.C.A. § 68-11-1602.

(28) Health Care Provider. A person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care in the ordinary course of business or practice of a profession.

(29) Home Care Organization. As defined by T.C.A. § 68-11-201, a “home care organization” provides home health services, home medical equipment services or hospice services to patients on an outpatient basis in either their regular or temporary place of residence.

(30) Home Health Aide/Hospice Aide. A person who has completed a total of seventy-five (75) hours of training which included sixteen (16) hours of clinical training prior to or during the first three (3) months of employment and who is qualified to provide basic services, including simple procedures as an extension of therapy services, personal care regarding nutritional needs, ambulation and exercise, and household services essential to health care at home.

(32) Hospice Services. As defined by T.C.A. § 68-11-201, hospice services means a coordinated program of care, under the direction of an identifiable hospice administrator, providing palliative and supportive medical and other services to hospice patients and their families in the patient’s regular or temporary place of residence. Hospice services shall be available twenty-four (24) hours a day, seven (7) days a week pursuant to the patient’s Hospice plan of care. A licensed hospice services program may provide services to a non-hospice patient; provided, that services to a non-hospice patient shall be limited to palliative care only.

(33) Incompetent. A patient who has been adjudicated incompetent by a court of competent jurisdiction and has not been restored to legal capacity.

(34) Individual Instruction. An individual’s direction concerning a health care decision for the individual.

(35) Infectious Waste. Solid or liquid wastes which contain pathogens with sufficient virulence and quantity such that exposure to the waste by a susceptible host could result in an infectious disease.

(36) Licensed Clinical Social Worker. A person currently licensed as such by the Tennessee Board of Social Workers.

(37) Licensed Practical Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(38) Licensee. The person or entity to whom the license is issued. The licensee is held responsible for compliance with all rules and regulations.

(39) Life Threatening or Serious Injury. Injury requiring the patient to undergo significant additional diagnostic or treatment measures.

(40) Medical Record. Medical histories, records, reports, clinical notes, summaries, diagnoses, prognoses, records of treatment and medication ordered and given, entries and other written electronic or graphic data prepared, kept, made or maintained in an agency that pertains to confinement or services rendered to patients.

(41) Medical Social Services. Medical social services must be provided by a qualified social worker under the direction of a physician, in accordance with the plan of care.

(42) Medically Inappropriate Treatment. Resuscitation efforts that cannot be expected either to restore cardiac or respiratory function to the patient or other medical or surgical treatments to achieve the expressed goals of the informed patient. In the case of the incompetent patient, the patient’s representative expresses the goals of the patient.

(43) Misappropriation of Patient/Resident Property. The deliberate misplacement, exploitation or wrongful, temporary or permanent use of an individual’s belongings or money without the individual’s consent.

(44) Neglect. The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; however, the withholding of authorization for or provision of medical care to any terminally ill person who has executed an irrevocable living will in accordance with the Tennessee Right to Natural Death Law, or other applicable state law, if the provision of such medical care would conflict with the terms of the living will, shall not be deemed “neglect” for purposes of these rules.

(45) Occupational Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(46) Occupational Therapy Assistant. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(47) Palliative. The reduction or abatement of pain or troubling symptoms, by appropriate coordination of all elements of the hospice care team, to achieve needed relief of distress.

(48) Patient. Hospice patient means only a person who has been diagnosed as terminally ill; been certified by a physician in writing to have an anticipated life expectancy of six (6) months or less; has voluntarily though self or a surrogate requested admission to a hospice; and been accepted by a licensed hospice. Patient will also include a non-hospice patient receiving only palliative care.

(49) Person. An individual, corporation, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency, or instrumentality, or any other legal or commercial entity.

(50) Personally Informing. A communication by any effective means from the patient directly to a health care provider.

(51) Physical Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(52) Physical Therapy Assistant. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(53) Physician. An individual authorized to practice medicine or osteopathy under Tennessee Code Annotated, Title 63, Chapters 6 or 9.

(54) Physician Assistant. A person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(55) Physician Orders for Scope of Treatment or POST. Written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(56) Power of Attorney for Health Care. The designation of an agent to make health care decisions for the individual granting the power under T.C.A. Title 34, Chapter 6, Part 2.

(58) Reasonably Available. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the patient’s health care needs. Such availability shall include, but not be limited to, availability by telephone.

(59) Registered Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(60) Respiratory Technician. A person currently licensed as such by the Tennessee Board of Respiratory Care.

(61) Respiratory Therapist. A person currently licensed as such by the Tennessee Board of Respiratory Care.

(62) Respite Care. A short-term period of inpatient care provided to the patient only when necessary to relieve the family members or other persons caring for the patient.

(63) Shall or Must. Compliance is mandatory.

(64) Social Work Assistant. A person who has a baccalaureate degree in social work, psychology, sociology or other field related to social work, and has at least one (1) year of social work experience in a health care setting. Social work related fields include bachelor/masters degrees in psychology, sociology, human services (behavioral sciences, not human resources), masters degree in counseling fields (psychological guidance and guidance counseling) and degrees in gerontology.

(65) Speech Language Pathologist. As defined in T.C.A. § 63-17-103, a person currently licensed as such by the Tennessee Board of Communications Disorders and Sciences.

(66) Spiritual Counselor. A person who has met the requirements of a religious organization to serve the constituency of that religious organization.

(67) State. A state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States.

(68) Student. A person currently enrolled in a course of study that is approved by the appropriate licensing board or equivalent body.

(69) Supervising Health Care Provider. The designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual’s health care.

(70) Supervision. Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity with initial direction and periodic inspection of the actual act of accomplishing the function or activity. Periodic supervision must be provided if the person is not a licensed or certified assistant, unless otherwise provided in accordance with these rules.

(71) Surrogate. An individual, other than a patient’s agent or guardian, authorized to make a health care decision for the patient.

(72) Terminally Ill. An individual with a medical prognosis that his or her life expectancy is six (6) months or less if the illness runs its normal course.

(73) Treating Health Care Provider. A health care provider who at the time is directly or indirectly involved in providing health care to the patient.

(74) Volunteer. An individual who agrees to provide services to a hospice care patient and/or family member(s), without monetary compensation, in either direct patient care or an administrative role and supervised by an appropriate hospice care employee.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-11-201, 68-11-202, 68-11-204, 68-11-207, 68-11- 209, 68-11-210, 68-11-211, 68-11-213, 68-11-224, and 68-11-1802.
Administrative History: Original rule filed April 17, 2000; effective July 1, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed April 28, 2003; effective July 12, 2003. Amendments filed December 2, 2005; effective February 15, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendment filed December 23, 2009; effective March 23, 2010. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendment filed September 15, 2015; effective December 14, 2015. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.02 LICENSING PROCEDURES

(1) No person, partnership, association, corporation, or state, county or local government unit, or any division, department, board or agency thereof, shall establish, conduct, operate, or maintain in the State of Tennessee any home care organization providing hospice services without having a license. A license shall be issued to the person or persons named and for the premises listed in the application for licensure and for the geographic area specified by the certificate of need or at the time of the original licensing. The name of the home care organization providing hospice services shall not be changed without first notifying the department in writing. Licenses are not transferable or assignable and shall expire and become invalid annually on the anniversary date of their original issuance. The license shall be conspicuously posted in the home care organizations providing hospice services.

(2) In order to make application for a license:

(a) The applicant shall submit an application on a form prepared by the Department.

(d) The applicant must prove the ability to meet the financial needs of the agency.

(f) The applicant shall allow the home care agency providing hospice services to be inspected by a Department surveyor. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action to the Board that must be accepted by the Board. Once the deficiencies have been corrected, then the Board shall consider the application for licensure.

(b) A change of ownership occurs whenever there is a change in the legal structure by which the agency is owned and operated.

Transfer of the agency’s legal title;
Lease of the agency’s operations;
Dissolution of any partnership that owns, or owns a controlling interest in, the agency;
One partnership is replaced by another through the removal, addition or substitution of a partner;
Removal of the general partner or general partners, if the agency is owned by a limited partnership;
Merger of an agency owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are canceled;
The consolidation of a corporate agency owner with one or more corporations; or 8. Transfers between levels of government.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors or board of trustees;
Two (2) or more corporations merge and the originally-licensed corporation survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government; or 5. Corporate stock transfers or sales, even when a controlling interest.

(4) Renewal.

(a) In order to renew a license, each home care agency providing hospice services shall submit to periodic inspections by Department surveyors for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action and shall remedy the deficiencies. In addition, each licensee shall submit a renewal form approved by the board and applicable renewal fee prior to the expiration date of the license.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late; provided that the late penalty shall not exceed twice the renewal fee.

A completed application for licensure;
The license fee provided in Rule 0720-28-.02(2)(b); and 3. Any other information required by the Health Services and Development Agency.

(d) Upon reapplication, the licensee shall submit to an inspection of the facility by Department of Health surveyors.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-206(a)(5) [effective January 1, 2009], 68-11-209, 68-11-209(a)(1), 68-11-210, and 68-11-216 and Chapter 846 of the Public Acts of 2008, § 1.
Administrative History: Original rule filed April 17, 2000; effective July 1, 2000. Amendment filed November 19, 2003; effective February 2, 2004. Amendment filed January 19, 2007; effective April 4, 2007. Public necessity rules filed April 29, 2009; effective through October 11, 2009. Emergency rules filed October 9, 2009; effective through April 7, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendment filed December 12, 2013; effective March 16, 2014. Amendments filed March 26, 2019; effective June 24, 2019. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.03 DISCIPLINARY PROCEDURES

(1) The Board may suspend or revoke a license for:

(a) Violation of federal or state statutes;

(b) Violation of the rules as set forth in this chapter;

(d) Conduct or practice found by the Board to be detrimental to the health, safety, or welfare of the patients of the agency; or (e) Failure to renew the license.

(2) The Board may consider all factors which it deems relevant, including but not limited to the following when determining sanctions:

(a) The degree of sanctions necessary to ensure immediate and continued compliance;

(b) The character and degree of impact of the violation on the health, safety and welfare of the patient in the agency;

(3) When an agency is found by the Department to have committed a violation of this chapter, the Department will issue to the agency a statement of deficiencies. Within ten (10) days of receipt of the statement of deficiencies the agency must return a plan of correction indicating the following:

(a) How the deficiency will be corrected;

(b) The date upon which each deficiency will be corrected;

(4) Either failure to submit a plan of correction in a timely manner or a finding by the Department that the plan of correction is unacceptable shall subject the agency’s license to possible disciplinary action.

(5) Any licensee or applicant for a license, aggrieved by a decision or action of the Department or Board, pursuant to this chapter, may request a hearing before the Board. The proceedings and judicial review of the board’s decision shall be in accordance with the Uniform Administrative Procedures Act, T.C.A. §§ 4-5-101, et seq.

(6) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to Rule

Tenn. Comp. R. & Regs. 0720-28-.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.

(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:

Identification of the services to be provided.
A stipulation that services may be provided only with the express authorization of the hospice program.
The manner in which the contracted services are coordinated, supervised and evaluated by the hospice program.
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.
Requirements for documenting that services are furnished in accordance with the agreement.
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.

(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;

(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;

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.

History

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.
Administrative History: 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. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.05 ADMISSIONS, DISCHARGES AND TRANSFERS

(1) The hospice service program shall have a policy to admit only patients who meet the following criteria:

(a) Has been diagnosed as terminally ill;

(b) Has been certified by a physician, in writing, to have an anticipated life expectancy of six (6) months or less;

(c) Has personally or through a representative voluntarily requested admission to, and been accepted by, a licensed hospice service organization; and (d) Has personally or through a representative, in writing, given informed consent to receive hospice care; or (e) Is a non-hospice patient that has been determined to need palliative care only.

(2) Patients shall be accepted to receive hospice services on the basis of a reasonable expectation that the patient’s medical, nursing and psychosocial needs can be met adequately by the organization in the patient’s regular or temporary place of residence.

(3) Care shall follow a written plan of care established and reviewed by the attending physician, the medical director or physician designee and the interdisciplinary group prior to providing care. Care shall continue under the supervision of the attending physician.

(4) The agency staff shall determine if the patient’s needs can be met by the organization’s services and capabilities.

(5) Every person admitted for care or treatment to any agency covered by these rules shall be under the supervision of a physician as defined in this chapter who holds a license in good standing. The name of the patient’s attending physician shall be recorded in the patient’s medical record.

(6) The agency staff shall obtain the patient’s written consent for hospice services.

(7) The signed consent form shall be included with the patient’s individual clinical record.

(8) A diagnosis must be entered in the admission records of the agency for every person admitted for care or treatment.

(9) No medication or treatment shall be provided to any patient of an agency except on the order of a physician or dentist lawfully authorized to give such an order.

(10) A medical record shall be developed and maintained for each patient admitted.

(11) No patient shall be involuntarily discharged without a written order from the attending physician or the medical director stating the patient does not meet hospice criteria, or through other legal processes, and timely notification of next of kin and/or the authorized representative.

(12) When a patient is discharged, a summary of the significant findings and events of the patient’s care, the patient’s condition on discharge and the recommendation and arrangement for future care, if any, is required.

(13) The agency shall ensure that no person on the grounds of race, color, national origin or handicap, will be excluded from participation in, be denied benefits of, or otherwise subjected to discrimination in the provision of any care or service of the agency. The agency shall protect the civil rights of patients under the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, and 68-11-209.
Administrative History: Original rule filed April 17, 2000; effective July 1, 2000. Amendment filed December 23, 2009; effective March 23, 2010. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.06 BASIC AGENCY FUNCTIONS

(1) An organization providing hospice services must ensure that substantially all core services are routinely provided directly by hospice employees. The hospice services program may contract for physician services. The hospice services program may use contracted staff for nursing services, medical social services, and counseling services if necessary to supplement hospice employees in order to meet the needs of patients during periods of peak patient loads or under extraordinary circumstances. If contracting is used, the hospice services program must maintain professional, financial, and administrative responsibility for the services and must assure that the qualifications of the individuals and services meet the requirements specified in this rule.

(a) Nursing services. The hospice service program must provide nursing care and services by or under the supervision of a registered nurse (R.N.) at all times.

Nursing services must be directed and staffed to assure the nursing needs of patients are met.
Patient care responsibilities of nursing personnel must be specified.
Hospice services must be provided in accordance with recognized standards of practice.
A registered nurse may make the actual determination and pronouncement of death under the following circumstances:

(i) The deceased was receiving the services of a licensed home care organization providing Medicare-certified hospice services;

(ii) Death was anticipated, and the attending physician and/or the hospice medical director has agreed in writing to sign the death certificate. Such agreement must be present with the deceased at the place of death;

(iii) The nurse is licensed by the state; and, (iv) The nurse is employed by the home care organization providing hospice services to the deceased.

(b) Medical Social Services. Medical Social Services must be provided by a qualified social worker under the direction of a physician.

(c) Physician Services. In addition to palliation and management of terminal illness and related conditions, physician employees of the hospice service program, including the physician member(s) of the interdisciplinary group, must also meet the general medical needs of the patients to the extent these needs are not met by the attending physician.

(d) Counseling Services. Counseling services must be made available to both the patient and the family. Counseling includes bereavement counseling, provided both prior to and after the patient’s death, as well as dietary, therapeutic, spiritual and any other counseling services identified in the Plan of Care for the patient and family.

Bereavement counseling. There must be an organized program for the provision of bereavement services under the supervision of a qualified professional. The plan of care for these services should reflect family needs, services to be provided and the frequency of services.
Dietary counseling. Dietary counseling, when required, must be provided by a qualified individual.
Spiritual counseling. Spiritual counseling must include notice as to the availability of clergy.
Additional counseling. Counseling may be provided by other members of the interdisciplinary group as well as by other qualified professionals as determined by the hospice program.

(2) Plan of Care. A written plan of care must be established and maintained for each patient admitted to a hospice program and the care provided must be in accordance with the plan.

(a) Establishment of plan. The plan must be established by the attending physician, the medical director or the physician’s designee and the interdisciplinary group prior to providing care.

(b) Review of Plan. The plan must be reviewed and updated as the patient’s condition changes, but at intervals of no more than fifteen (15) days, by the attending physician, the medical director or the physician’s designee and interdisciplinary group. These reviews must be documented.

(c) Content of plan. The plan must include an assessment of the individual’s needs and identification of the hospice services required, including the management of discomfort and symptom relief. It must state in detail the scope and frequency of services needed to meet the patient’s and family’s needs.

(3) Interdisciplinary Group. The organization providing hospice services must designate an interdisciplinary group(s) composed of individuals who provide or supervise the care and services offered by the hospice program:

(a) Composition of Group. The hospice service program must have an interdisciplinary group or groups that include at least the following individuals who are employees of the hospice service program:

A doctor of medicine or osteopathy;
A registered nurse;
A social worker; and 4. A pastoral or other counselor.

(b) Role of Group. The interdisciplinary group is responsible for:

Participation in the establishment of the plan of care;
Provision or supervision of hospice care and services;
Periodic review and updating of the plan of care for each individual receiving hospice care; and 4. Establishment of policies governing the day-to-day provision of hospice care and services.

(c) If a hospice service program has more than one interdisciplinary group, it must designate in advance the group it chooses to execute the functions described in part (b) of this paragraph.

(4) Coordinator. The hospice service program must designate a registered nurse to coordinate the implementation of the plan of care of each patient.

(5) Volunteers. The hospice service program may use volunteers, in defined roles, under the supervision of a designated hospice program employee.

(a) Training. The hospice program must provide appropriate orientation and training that is consistent with acceptable standards of hospice practice.

(b) Role. Volunteers may be used in administrative or direct patient care roles.

Recruiting and retaining. The hospice must document active and ongoing efforts to recruit and train volunteers.
Availability of clergy. The hospice service program must make reasonable efforts to arrange for visits of clergy and other members of religious organizations in the community to patients who request such visits and must advise patients of this opportunity.

(6) Continuation of Care. An organization providing hospice services must assist in coordinating continued care should the patient be transferred or discharged from the hospice program or the organization.

(7) Short Term Inpatient Care. Short term inpatient care is available for pain control, symptom management and respite services, and if not provided directly, must be provided under a legally binding written agreement that meets the requirements of subparagraph (b) of this paragraph in a licensed nursing home, hospital, or residential hospice which meets the following minimum requirements:

(a) Whether provided directly or indirectly, the facility that provides short term inpatient care must provide twenty-four (24) hour nursing services which are sufficient to meet total nursing needs in accordance with the patient’s plan of care. Each hospice patient must receive treatments, medications, and diet as prescribed, and must be kept comfortable, clean, well-groomed and protected from accident, injury and infection.

Each shift must include a registered nurse (R.N.) who provides direct patient care.

Respite services shall be staffed in accordance with the patient’s Hospice Plan of Care.
The Hospice Plan of Care will state whether a registered nurse is required to provide direct care to the hospice patient.
Respite services may be provided in an Assisted Care Living Facility so long as the provisions of Rule 0720-28-.06(7)(b)-(g) are met.

(b) The facility must be designed and equipped for the comfort and privacy of each hospice patient and family member(s) by providing physical space for private patient/family visiting, accommodations for family members to remain with the patient throughout the night, accommodations for family privacy following a patient’s death and decor which is home-like in design and function.

(c) The hospice must furnish to the inpatient provider a copy of the patient’s plan of care and specify the inpatient services to be furnished.

(d) The inpatient provider must have established policies consistent with those of the hospice and agree to abide by the patient care protocols established by the hospice for its patients.

(e) The medical record must include a record of all inpatient services and events. A copy of the discharge summary must be provided to the hospice and, if requested, a copy of the medical record is to be provided to the hospice.

(f) The written agreement must designate the party responsible for the implementation of the provisions of the agreement.

(g) The hospice shall retain responsibility for appropriate hospice care training of the personnel who provide the care under the agreement.

(8) Drugs and treatments shall be administered by appropriately licensed agency personnel, acting within the scope of their licenses. Oral orders for drugs and treatments shall be given to appropriately licensed personnel acting within the scope of their licenses, immediately recorded, signed and dated, and countersigned and dated by the physician.

(9) Performance Improvement Program. Each agency must conduct an ongoing, comprehensive, integrated, self-assessment of the quality and appropriateness of past and present care provided, including inpatient care and contract services. The written performance improvement plan findings are to be used by the hospice to determine the appropriateness and effectiveness of the care provided and to ascertain that professional policies are followed in providing these services. The objectives of those responsible for the performance improvement program are as follows:

(a) To assist the agency in using its personnel and facilities to meet individual and community needs;

(b) To identify and correct problems and/or deficiencies which undermine quality of care and lead to waste of agency and personnel resources;

(c) To help the agency make critical judgments regarding the quality and quantity of its services through self-examination;

(d) To provide opportunities to evaluate the effectiveness of agency policies and when necessary make recommendations to the administration as to controls or changes needed to assure high standards of patient care;

(e) To provide data needed to satisfy state licensure and federal certification requirements; and (f) To establish criteria to measure the effectiveness and efficiency of the hospice services provided to patients.

(10) Infection Control.

(d) A Home Care Organization Providing Hospice Services shall have an annual influenza vaccination program which shall include at least:

The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Home Care Organization Providing Hospice Services will encourage all staff and independent practitioners to obtain an influenza vaccination;
A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider);
Education of all employees about the following:

(i) Flu vaccination, (ii) Non-vaccine control measures, and (iii) The diagnosis, transmission, and potential impact of influenza;

An annual evaluation of the influenza vaccination program and reasons for nonparticipation; and 5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee.

The testing shall be performed at no charge to the patient, and the test results shall be confidential.

(f) The agency and its employees shall adopt and utilize standard precautions (per CDC) for preventing transmission of infections, HIV and communicable diseases.

(11) Home Health Aide/Hospice Aide Services. Home Health Aide Services must be available and adequate in frequency to meet the needs of the patients.

(a) The home health aide shall be assigned to a particular patient by a registered nurse.

(b) The registered nurse, or appropriate professional staff member if other home health services are provided, shall make a supervisory visit to the patient’s residence at least monthly, either when the aide is present to observe and assist or when the aide is absent (preferably alternating visits), to assess the aide’s competence in providing care and determine whether goals are being met.

(c) There shall be continuing in-service programs on a regularly scheduled basis with onthe-job training during supervisor visits as issues are identified.

(12) Physical Therapy, Occupational Therapy and Speech Language Pathology Services.

Physical therapy services, occupational therapy services, and speech language pathology services must be available and when provided, offered in a manner consistent with accepted standards of practice.

(13) Speech therapy services shall be provided only by or under supervision of a qualified speech language pathologist in good standing, or by a person qualified as a Clinical Fellow subject to Tennessee Board of Communications Disorders and Sciences Rule 1370-01-.10.

(14) Medical Supplies. Medical supplies and appliances, including drugs and biologicals, must be provided as needed for the palliation and management of the terminal illness or conditions directly attributable to the terminal diagnosis.

(a) Administration. All drugs and biologicals must be administered in accordance with accepted standards of practice and only by appropriately licensed employees of the hospice.

(b) The hospice must have a policy for the disposal of controlled drugs maintained in the patient’s home or temporary place of residence when those drugs are no longer needed by the patient.

(c) Drugs and biologicals may be administered by the patient or his/her family member if the patient’s attending physician has approved.

(15) Medical Records.

(a) A medical record containing past and current findings in accordance with accepted professional standards shall be maintained for every patient receiving hospice services.

In addition to the plan of care, the record shall contain: appropriate identifying information; name of physician; all medications and treatments; and signed and dated clinical notes. Clinical notes shall be written the day on which service is rendered and incorporated no less often than weekly; copies of summary reports shall be sent to the physician; and a discharge summary shall be dated and signed within 7 days of discharge.

(b) A home care organization providing hospice services is authorized to receive and appropriately act on a written order for a plan of care for a patient concerning a home health service signed by a physician that is transmitted to the agency by electronically signed electronic mail. Such order that is transmitted by electronic mail shall be deemed to meet any requirement for written documentation imposed by this regulation.

basis.

(d) Even if the agency discontinues operations, records shall be maintained as mandated by this Chapter and the Tennessee Medical Records Act (T.C.A. § 68-11-308). If a patient is transferred to another health care facility or agency, a copy of the record or an abstract shall accompany the patient when the agency is directly involved in the transfer.

(e) Medical records information shall be safeguarded against loss or unauthorized use.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-3-511, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11- 260, and 68-11-304.
Administrative History: Original rule filed April 17, 2000; effective July 1, 2000. Amendment filed September 13, 2002; effective November 27, 2002. Amendment filed February 23, 2007; effective May 9, 2007. Amendments filed March 27, 2015; effective June 25, 2015. Amendment filed September 15, 2015; effective December 14, 2015. Amendments filed July 18, 2016; effective October 16, 2016. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.07 RESERVED

Administrative History: Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.08 RESERVED

Administrative History: Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-202, 68-11-204, and 68-11-206 through 68-11-209.
Administrative History: Original rule filed April 25, 1996; effective July 9, 1996. Repeal and new rule filed April 17, 2000; effective July 1, 2000. Amendment filed March 1, 2007; effective May 15, 2007. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.09 RESERVED

Administrative History: Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.10 INFECTIOUS AND HAZARDOUS WASTE

(2) The following waste shall be considered to be infectious waste:

(a) Waste human blood and blood products such as serum, plasma, and other blood components;

(b) All discarded sharps (including but not limited to, hypodermic needles, syringes, pasteur pipettes, broken glass and scalpel blades) used in patient care; and (c) Other waste determined to be infectious by the agency in its written policy.

(a) Contaminated sharps must be directly placed in leakproof, rigid and puncture-resistant containers which must then be tightly sealed.

(b) Infectious and hazardous waste must be secured in fastened plastic bags before placement in a garbage can with other household waste.

(6) In the event of spills, ruptured packaging, or other incidents where there is a loss of containment of waste, the agency must ensure that proper actions are immediately taken to:

(a) Isolate the area;

(b) Repackage all spilled waste and contaminated debris in accordance with the requirements of this rule; and (c) Sanitize all contaminated equipment and surfaces appropriately.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, and 68-11-209.
Administrative History: Original rule filed April 17, 2000; effective July 1, 2000. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.11 RECORDS AND REPORTS

(2) The agency providing hospice services shall report all incidents of abuse, neglect, and misappropriation to the Department of Health in accordance with T.C.A. § 68-11-211.

(3) The agency providing hospice services shall report the following incidents to the Department of Health in accordance with T.C.A. § 68-11-211.

(a) Strike by staff at the facility;

(b) External disasters impacting the facility;

(c) Disruption of any service vital to the continued safe operation of the home care organization providing hospice services or to the health and safety of its patients and personnel; and (d) Fires at the home care organization providing hospice services that disrupt the provision of patient care services or cause harm to the patients or staff, or that are reported by the facility to any entity, including but not limited to a fire department charged with preventing fires.

(4) The agency shall retain legible copies of the following records and reports for thirty-six (36) months following their issuance. They shall be maintained in a single file, and shall be made available for inspection during normal business hours to any person who requests to view them:

(a) Department licensure surveys;

(b) Federal Health Care Financing Administration surveys and inspections, if any;

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-207, 68-11-209, 68-11-210, 68-11-211, and 68- 11-213.
Administrative History: Original rule filed April 17, 2000; effective July 1, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendments filed January 3, 2012; effective April 2, 2012. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.12 PATIENT RIGHTS

(1) Each patient has at least the following rights:

(a) To privacy in treatment and personal care;

(b) To be free from mental and physical abuse. Should this right be violated, the agency must notify the Department within five (5) business days. Suspected abuse of a patient shall be reported immediately to the Tennessee Department of Human Services, Adult Protective Services as required by T.C.A. § 71-6-101 et seq.;

(d) To be involved in the decision-making of all aspects of their care;

(e) To refuse treatment. The patient must be informed of the consequences of that decision. A refusal and its reason must be reported to the physician and documented in the medical record;

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed April 17, 2000; effective July 1, 2000. Amendment filed June 18, 2002; effective September 1, 2002. Amendment filed December 2, 2005; effective February 15, 2006. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.13 POLICIES AND PROCEDURES FOR HEALTH CARE DECISION-MAKING

(1) Pursuant to this rule, each hospice agency shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a patient who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from individual patients. An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.

(8) An advance directive may include the individual’s nomination of a court-appointed guardian.

(10) No health care provider or institution shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care.

(12) A patient having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.

(13) A patient having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke.

(15) An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.

(16) Surrogates.

(a) An adult or emancipated minor may designate any individual to act as surrogate by personally informing the supervising health care provider. The designation may be oral or written.

(b) A surrogate may make a health care decision for a patient who is an adult or emancipated minor if and only if:

The patient has been determined by the designated physician to lack capacity, and 2. No agent or guardian has been appointed, or 3. The agent or guardian is not reasonably available.

(e) Consideration may be, but need not be, given in order of descending preference for service as a surrogate to:

The patient’s spouse, unless legally separated;
The patient’s adult child;
The patient’s parent;
The patient’s adult sibling;
Any other adult relative of the patient; or 6. Any other adult who satisfies the requirements of 0720-28-.13(16)(d).

(f) No person who is the subject of a protective order or other court order that directs that person to avoid contact with the patient shall be eligible to serve as the patient’s surrogate.

(g) The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:

Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the patient or in accordance with the patient’s best interests;
The proposed surrogate’s regular contact with the patient prior to and during the incapacitating illness;
The proposed surrogate’s demonstrated care and concern;
The proposed surrogate’s availability to visit the patient during his or her illness; and 5. The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.

(h) If the patient lacks capacity and none of the individuals eligible to act as a surrogate under 0720-28-.13(16)(c) through 0720-28-.13(16)(g) is reasonably available, the designated physician may make health care decisions for the patient after the designated physician either:

Consults with and obtains the recommendations of a facility’s ethics mechanism or standing committee in the facility that evaluates health care issues; or 2. Obtains concurrence from a second physician who is not directly involved in the patient’s health care, does not serve in a capacity of decision-making, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.

(j) A surrogate shall make a health care decision in accordance with the patient’s individual instructions, if any, and other wishes to the extent known to the surrogate.

(l) Except as provided in 0720-28-.13(16)(m):

Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution nor an employee of an operator of a health care institution may be designated as a surrogate; and 2. A health care provider or employee of a health care provider may not act as a surrogate if the health care provider becomes the patient’s treating health care provider.

(m) An employee of the treating health care provider or an employee of an operator of a health care institution may be designated as a surrogate if:

The employee so designated is a relative of the patient by blood, marriage, or adoption; and 2. The other requirements of this section are satisfied.

(17) Guardian.

(a) A guardian shall comply with the patient’s individual instructions and may not revoke the patient’s advance directive absent a court order to the contrary.

(b) Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.

(19) Except as provided in 0720-28-.13(20) through 0720-28-.13(22), a health care provider or institution providing care to a patient shall:

(20) A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.

(21) A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:

(23) A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 0720-28-.13(20) through 0720-28-.13(22) shall:

(a) Promptly so inform the patient, if possible, and any person then authorized to make health care decisions for the patient;

(b) Provide continuing care to the patient until a transfer can be effected or until the determination has been made that transfer cannot be effected;

(a) Complying with a health care decision of a person apparently having authority to make a health care decision for a patient, including a decision to withhold or withdraw health care;

(26) An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.

(27) A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for such identification made in good faith.

(28) A copy of a written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.

(30) Physician Orders for Scope of Treatment (POST).

(a) Physician Orders for Scope of Treatment (POST) may be issued by a physician for a patient with whom the physician has a bona fide physician-patient relationship, but only:

With the informed consent of the patient;
If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or 3. If the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act, is not reasonably available, if the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.

No physician, who has a bona fide physician-patient relationship with the patient, is present and available for discussion with the patient (or if the patient is a minor or is otherwise incapable of making an informed decision, with the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act);
Such authority to issue is contained in the physician assistant’s, nurse practitioner’s or clinical nurse specialist’s protocols;
Either:

(i) With the informed consent of the patient;

(d) A POST issued in accordance with this section shall remain valid and in effect until revoked. In accordance with this rule and applicable regulations, qualified emergency medical services personnel; and licensed health care practitioners in any facility, program, or organization operated or licensed by the Board for Licensing Health Care Facilities, the Department of Mental Health and Substance Abuse Services, or the Department of Intellectual and Developmental Disabilities, or operated, licensed, or owned by another state agency, shall follow a POST that is available to such persons in a form approved by the Board for Licensing Health Care Facilities.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, 68-11-224, and 68- 11-1801 through 68-11-1815.
Administrative History: Original rule filed April 17, 2000; effective July 1, 2000. Amendment filed April 28, 2003; effective July 12, 2003. Repeal and new rule filed December 2, 2005; effective February 15, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendments filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-28-.14 DISASTER PREPAREDNESS

(1) Disaster Preparedness Policies and Procedures.

Contain the information needed to ensure compliance with the local comprehensive emergency plan;
Address contingency plans to address service interruptions and provisions for the continued operation or alternative arrangements for power-dependent medical equipment in the patient’s home.

(b) Branch offices shall follow the policies and procedures established by the licensed home health agency of which they are a part.

(2) Emergency Planning Coordination With Local Government Authorities.

(d) A file of documents demonstrating communications and cooperation with the local agency must be maintained.

History

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209.
Administrative History: Original rule filed April 17, 2000; effective July 1, 2000. Transferred from chapter 1200-08-27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.

Tenn. Comp. R. & Regs. 0720-28-.15 APPENDIX I

(1) Physician Orders for Scope of Treatment (POST) Form.

A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED

Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”)

This is a Physician Order Sheet based on the medical conditions and wishes of the person identified at right (“patient”). Any section not completed indicates full treatment for that section. When need occurs, first follow these orders, then contact physician.

Patient’s Last Name First Name/Middle Initial Date of Birth

Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Section B Check One Box Only MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.  Comfort Measures Only. Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.  Limited Additional Interventions. In addition to care described in Comfort Measures Only above, use medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. Treatment Plan: Basic medical treatments.  Full Treatment. In addition to care described in Comfort Measures Only and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including in the intensive care unit.

Other Instructions:

Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify)

The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other)

Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge)

MD/NP/CNS/PA Phone Number:

Name (print) Signature Relationship (write “self” if patient)

Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel.

Photocopies/faxes of signed POST forms are legal and valid.

Using POST Any incomplete section of POST implies full treatment for that section.

No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.”

Oral fluids and nutrition must always be offered if medically feasible.

IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”

A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.

Reviewing POST This POST should be reviewed if:

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.

(2) Advance Directive for Health Care Form.

ADVANCE DIRECTIVE FOR HEALTH CARE*

(Tennessee)

Instructions: Parts 1 and 2 may be used together or independently. Please mark out/void any unused part(s).

Part 5, Block A or Block B must be completed for all uses.

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

Name: Relation: Home Phone: Work Phone:

Address: Mobile Phone: Other Phone:

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.

Indicate Your Wishes for Treatment: If my quality of life becomes unacceptable to me (as indicated by one or more of the conditions marked “no” above) and my condition is irreversible (that is, it will not improve), I direct that medically appropriate treatment be provided as follows. By marking “yes” below, I have indicated treatment I want. By marking “no” below, I have indicated treatment I do not want.   Yes No CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it has stopped. Usually this involves electric shock, chest compressions, and breathing assistance.   Yes No Life Support/Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys, and other organs to continue to work.   Yes No Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a new condition but will not help the main illness.   Tube feeding/IV fluids: Use of tubes to deliver food and water to a patient’s stomach or use of IV Yes No fluids into a vein, which would include artificially delivered nutrition and hydration.

Part 3 Other instructions, such as hospice care, burial arrangements, etc.:

(Attach additional pages if necessary)

Part 5 Your signature must either be witnessed by two competent adults (“Block A”) or by a notary public (“Block B”).

Signature: _______________________________________ Date: ____________________ (Patient)

Block A Neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.

Witnesses:

I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form.

Signature of witness number 2 Block B You may choose to have your signature witnessed by a notary public instead of the witnesses described in Block A.

STATE OF TENNESSEE

COUNTY OF

My commission expires:

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-209, 68-11-224, and 68-11-1805.
Administrative History: Original rule filed February 16, 2007; effective May 2, 2007. Repeal and new rule filed August 28, 2012; effective November 26, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendments filed February 8, 2017; effective May 9, 2017. Transferred from chapter 1200-08- 27 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Chapter 0720-29 Standards for HIV Supportive Living Centers (Transferred from 1200-08-28)

Tenn. Comp. R. & Regs. 0720-29-.01 DEFINITIONS

(1) Abuse. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

(2) Administrator. An individual appointed by a governing body who is responsible for the day to day management of the HIV Supportive Living Facility.

(3) Adult. An individual who has capacity and is at least 18 years of age.

(5) Agent. An individual designated in an advance directive for health care to make a health care decision for the individual granting the power.

(6) Bereavement Counseling. Counseling services provided to the individual’s family and/or significant other both prior to and after the individual’s death.

(8) Board. The Tennessee Board for Licensing Health Care Facilities.

Any person who challenges the capacity of a resident shall have the burden of proving lack of capacity.

(10) Cardiopulmonary Resuscitation (CPR). The administering of any means or device to support cardiopulmonary functions in a resident, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilations or respirations, defibrillation, the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a resident where cardiac or respiratory arrest has occurred or is believed to be imminent.

(11) Certified Master Social Worker. A person currently certified as such by the Tennessee Board of Social Worker Certification and Licensure.

(13) Clinical Note. A written and dated notation containing a resident assessment, responses to medications, treatments and services and/or any changes in condition signed by a health professional who made contact with the resident, family or significant other.

(14) Commissioner. The Commissioner of the Tennessee Department of Health or his or her authorized representative.

(15) Competent. A resident who has capacity.

(16) Core Services. Services consisting of nursing, medical social services, physician services and counseling services.

(17) Department. The Tennessee Department of Health.

(19) Dietitian. A person currently licensed as such by the Tennessee Board of Dietitian/Nutritionist Examiners.

(20) Do-Not-Resuscitate Order (DNR). A written order, other than a POST, not to resuscitate a patient in cardiac or respiratory arrest in accordance with accepted medical practices.

(21) Emancipated Minor. Any minor who is or has been married or has by court order or otherwise been freed from the care, custody and control of the minor’s parents.

(23) Guardian. A judicially appointed guardian or conservator having authority to make a health care decision for an individual.

(24) Hazardous Waste. Materials whose handling, use, storage, and disposal are governed by local, state, or federal regulations.

(26) Health Care Decision. Consent, refusal of consent or withdrawal of consent to health care.

(27) Health Care Decision-Maker. In the case of a resident who lacks capacity, the resident’s health care decision-maker is one of the following: the resident’s health care agent as specified in an advance directive, the resident’s court-appointed guardian or conservator with health care decision-making authority, the resident’s surrogate as determined pursuant to

Rule 0720-29-.13 or T.C.A. § 33-3-220, the designated physician pursuant to these rules or in the case of a minor child, the person having custody or legal guardianship.

(28) Health Care Institution. A health care institution as defined in T.C.A. § 68-11-1602.

(30) Home Care Organization. As defined by T.C.A. § 68-11-201 “home care organizations” provides home health services, home medical equipment services or hospice services to residents on an outpatient basis in either their regular or temporary place of residence.

(31) Hospice Services. As defined by T.C.A. § 68-11-201, “hospice services” means a coordinated program of care, under the direction of an identifiable hospice administrator, providing palliative and supportive medical and other services to hospice patients and their families in the patient’s regular or temporary place of residence. Hospice services shall be provided twenty-four (24) hours a day, seven (7) days a week.

(32) Incompetent. A resident who has been adjudicated incompetent by a court of competent jurisdiction and has not been restored to legal capacity.

(33) Individual Instruction. An individual’s direction concerning a health care decision for the individual.

(35) Involuntary Transfer. The movement of a resident without the consent of the resident, the resident’s legal guardian, next of kin or representative, with required notification to the appropriate agencies.

(36) Licensed Clinical Social Worker. A person currently licensed as such by the Tennessee Board of Social Workers.

(37) Licensed Practical Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(38) Licensed Psychologist. A person currently licensed as such by the Tennessee Board of Examiners in Psychology.

(39) Licensee. The person or entity to whom the license is issued. The licensee is held responsible for compliance with all rules and regulations.

(40) Life Threatening or Serious Injury. Injury requiring the patient to undergo significant additional diagnostic or treatment measures.

(41) Medical Director. A licensed physician employed by the HIV supportive living facility to be responsible for medical care in the facility.

(42) Medical Emergency. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the resident’s health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

(43) Medically Inappropriate Treatment. Resuscitation efforts that cannot be expected either to restore cardiac or respiratory function to the resident or other medical or surgical treatments to achieve the expressed goals of the informed resident. In the case of the incompetent resident, the resident’s representative expresses the goals of the resident.

(44) Medical Social Services. When provided, shall be given by a certified master social worker, a licensed clinical social worker, or by a social worker or social work assistant employed by a home care organization or by contract with the facility and under the supervision of a certified master social worker or licensed clinical social worker, and in accordance with the plan of care. The medical social services provider shall assist the physician and other team members in understanding the significant social and emotional factors related to the health problems, participate in the development of the plan of care, prepare clinical and progress notes, work with the family, utilize appropriate community resources, participate in discharge planning and inservice programs, and act as a consultant to other organization personnel.

(45) Misappropriation of Patient/Resident Property. The deliberate misplacement, exploitation or wrongful, temporary or permanent use of an individual’s belongings or money without the individual’s consent.

(46) Neglect. The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; however, the withholding of authorization for or provision of medical care to any terminally ill person who has executed an irrevocable living will in accordance with the Tennessee Right to Natural Death Law, or other applicable state law, if the provision of such medical care would conflict with the terms of the living will, shall not be deemed “neglect” for purposes of these rules.

(47) N.F.P.A. The National Fire Protection Association.

(48) Occupational Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(49) Occupational Therapy Assistant. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(50) Palliative. The reduction or abatement of pain or troubling symptoms by appropriate coordination of all elements of the health care team to achieve needed relief of distress.

(51) Person. An individual, corporation, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency, or instrumentality, or any other legal or commercial entity.

(52) Personal Care Aide. A nursing assistant or a person who can demonstrate through other education or experience that he or she is qualified to provide assistance with basic care services, including simple procedures such as feeding, personal grooming, ambulating, socializing, medication prompting, exercising and other household services essential to health care.

(53) Personally Informing. A communication by any effective means from the resident directly to a health care provider.

(54) Pharmacist. A person currently licensed as such by the Tennessee Board of Pharmacy.

(55) Physical Therapist. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(56) Physical Therapist Assistant. A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners.

(57) Physician. An individual authorized to practice medicine or osteopathy under Tennessee Code Annotated, Title 63, Chapters 6 or 9.

(58) Physician Assistant. A person who has graduated from a physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant, has passed the Physician Assistant National Certifying Examination, and is currently licensed in Tennessee as a physician assistant under Title 63, Chapter 19.

(59) Physician Orders for Scope of Treatment or POST. Written orders that:

(a) Are on a form approved by the Board for Licensing Health Care Facilities;

Specify other medical interventions that are to be provided or withheld; or 3. Specify both 1. and 2.

(60) Power of Attorney for Health Care. The designation of an agent to make health care decisions for the individual granting the power under T.C.A. Title 34, Chapter 6, Part 2.

(61) Qualified Emergency Medical Service Personnel. Includes, but shall not be limited to, emergency medical technicians, paramedics, or other emergency services personnel, providers, or entities acting within the usual course of their professions, and other emergency responders.

(62) Reasonably Available. Readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the resident’s health care needs. Such availability shall include, but not be limited to, availability by telephone.

(63) Registered Nurse. A person currently licensed as such by the Tennessee Board of Nursing.

(64) Resident. An individual who has been diagnosed with symptomatic HIV (human immunodeficiency virus) disease, who has a physician who acts as the primary care provider, and who has voluntarily requested admission to, and been accepted by a licensed residential facility.

(65) Resident File. Medical histories, records, reports, clinical notes, summaries, diagnoses, prognoses, records of treatment and medication ordered and given, entries, and other written electronics, or graphic data prepared, kept, made or maintained in the facility that pertains to confinement or services rendered to residents.

(66) Respiratory Therapist. A person currently licensed as such by the Tennessee Board of Respiratory Care.

(67) Respiratory Therapy Technician. A person currently licensed as such by the Tennessee Board of Respiratory Care.

(68) Respite Care. A short-term period of inpatient care provided to a hospice patient only when necessary to relieve the family members or other persons caring for the patient.

(69) Secured Unit. A facility or distinct part of a facility where the residents are intentionally denied egress by any means.

(70) Shall or Must. Compliance is mandatory.

(71) Social Worker. An individual who has at least a bachelor’s degree from a school accredited or approved by the Council on Social Work Education and has one (1) year of social work experience in a health care setting.

(72) Social Work Assistant. A person who has a baccalaureate degree in social work, psychology, sociology, or other field related to social work, and has at least one (1) year of social work experience in a health care setting. Social work related fields include bachelor/masters degrees in psychology, sociology, human services (behavioral sciences, not human resources), masters degree in counseling fields (psychological guidance and guidance counseling) and degrees in gerontology.

(73) Speech Language Pathologist. As defined in T.C.A. § 63-17-103, a person currently licensed as such by the Tennessee Board of Communications Disorders and Sciences.

(74) Spiritual Counselor. A person who has met the requirements of a religious organization to serve the constituency of that organization.

(75) State. A state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States.

(76) Student. A person currently enrolled in an accredited course of study that is approved by the appropriate licensing board or equivalent body.

(77) Supervising Health Care Provider. The designated physician or, if there is no designated physician or the designated physician is not reasonably available, the health care provider who has undertaken primary responsibility for an individual’s health care.

(78) Supervision. Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity with initial direction and periodic inspection of the actual act of accomplishing the function or activity. Periodic supervision must be provided if the person is not a licensed or certified assistant, unless otherwise provided in accordance with these regulations.

(79) Surrogate. An individual, other than a resident’s agent or guardian, authorized to make a health care decision for the resident.

(80) Terminally Ill. An individual with a medical prognosis that his or her life expectancy is six (6) months or less if the illness runs its normal course.

(81) Transfer. The movement of a resident at the direction of a physician or other qualified or certified professionals when a physician is not readily available, but does not include such movement of a resident who leaves the facility against medical advice.

(82) Treating Health Care Provider. A health care provider who at the time is directly or indirectly involved in providing health care to the resident.

(83) Volunteer. An individual who agrees to provide services to a resident, staff, significant other and/or family member(s), without monetary compensation, with appropriate supervision by the facility.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 39-11-106, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11- 209, 68-11-210, 68-11-211, 68-11-213, 68-11-216, 68-11-224, and 68-11-1802.
Administrative History: Original rule filed July 27, 2000; effective October 10, 2000. Amendment filed April 11, 2003; effective June 25, 2003. Amendment filed April 28, 2003; effective July 12, 2003. Amendments filed December 15, 2005; effective February 28, 2006. Amendment filed February 7, 2007; effective April 23, 2007. Amendment filed January 3, 2012; effective April 2, 2012. Amendment filed March 27, 2015; effective June 25, 2015. Amendment filed September 15, 2015; effective December 14, 2015. Transferred from chapter 1200-08-28 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-29-.02 LICENSING PROCEDURES

A license shall be issued to the person or persons named and for the premises listed in the application for licensure at the time of the original licensing. The name of the HIV supportive living center shall not be changed without first notifying the department in writing. Licenses are not transferable or assignable and shall expire and become invalid annually on the anniversary date of their original issuance. The license shall be conspicuously posted in the HIV supportive living center.

(2) In order to make application for a license:

(a) The applicant shall submit an application on a form prepared by the department.

(b) Each applicant for a license shall pay an annual license fee based on the number of beds as follows:

Less than 25 beds $1,040.00 2. 25 to 49 beds, inclusive $1,300.00 3. 50 to 74 beds, inclusive $1,560.00 4. 75 to 99 beds, inclusive $1,820.00 5. 100 to 124 beds, inclusive $2,080.00 6. 125 to 149 beds, inclusive $2,340.00 7. 150 to 174 beds, inclusive $2,600.00 8. 175 to 199 beds, inclusive $2,860.00 For HIV supportive living facilities of two hundred (200) beds or more the fee shall be two thousand eight hundred and sixty dollars ($2,860.00) plus two hundred dollars ($200.00) for each twenty-five (25) beds or fraction thereof in excess of one hundred ninety-nine (199) beds. The fee shall be submitted with the application or renewal and is not refundable.

(c) The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the department.

Residents shall not be admitted to the HIV supportive living facility until a license has been issued. Applicants shall not hold themselves out to the public as being a HIV supportive living facility until the license has been issued. A license shall not be issued until the facility is in substantial compliance with these rules, including submission of all information required by T.C.A. § 68-11-206(1) or as later amended, and all information required by the Commissioner.

(d) The applicant must prove the ability to meet the financial needs of the HIV supportive living facility.

(e) The applicant shall answer each question provided in the application fully and truthfully, shall not supply false or misleading information and shall not use any deceptive means to obtain a license, such as filing for a license through a second party when an individual has been denied a license or has had a license disciplined or has attempted to avoid inspection and Review process.

(f) The applicant shall allow the HIV supportive living facility to be inspected by a Department surveyor. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action to the Board that must be accepted by the Board.

Once the deficiencies have been corrected, then the Board shall consider the application for licensure.

(a) For the purposes of licensing, the licensee of a HIV supportive living facility has the ultimate responsibility for the operation of the HIV supportive living facility, including the final authority to make or control operational decisions and legal responsibility for the business management. A change of ownership occurs whenever this ultimate legal

authority for the responsibility of the HIV supportive living facility’s operation is transferred.

(b) A change of ownership occurs whenever there is a change in the legal structure by which the HIV supportive living facility is owned and operated.

Transfer of the HIV supportive living facility’s legal title;
Lease of the HIV supportive living facility’s operations;
Dissolution of any partnership that owns, or owns a controlling interest in, the HIV supportive living facility;
One partnership is replaced by another through the removal, addition or substitution of a partner;
Removal of the general partner or general partners, if the HIV supportive living facility is owned by a limited partnership;
Merger of a HIV supportive living facility owner (a corporation) into another corporation where, after the merger, the owner’s shares of capital stock are canceled;
The consolidation of a corporate HIV supportive living facility owner with one or more corporations; or, 8. Transfers between levels of government.

(d) Transactions which do not constitute a change of ownership include, but are not limited to, the following:

Changes in the membership of a corporate board of directors for board of trustees;
Two (2) or more corporations merge and the originally licensed corporation survives;
Changes in the membership of a non-profit corporation;
Transfers between departments of the same level of government; or, 5. Corporate stock transfers or sales, even when a controlling interest.

(e) Management agreements are generally not changes of ownership if the owner continues to retain ultimate authority for the operation of the HIV supportive living facility. However, if the ultimate authority is surrendered and transferred from the owner to a new manager, then a change of ownership has occurred.

(f) Sale/lease-back agreements shall not be treated as changes in ownership if the lease involves the HIV supportive living facility’s entire real and personal property and if the identity of the leasee, who shall continue the operation, retains the exact same legal form as the former owner.

(4) Renewal.

(a) In order to renew a license, each HIV supportive living facility shall submit to periodic inspections by Department surveyors for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action and shall remedy the deficiencies. In addition, each licensee shall submit a renewal form approved by the board and applicable renewal fee prior to the expiration date of the license.

(b) If a licensee fails to renew its license prior to the date of its expiration but submits the renewal form and fee within sixty (60) days thereafter, the licensee may renew late by paying, in addition to the renewal fee, a late penalty of one hundred dollars ($100) per month for each month or fraction of a month that renewal is late; provided that the late penalty shall not exceed twice the renewal fee.

A completed application for licensure; and 2. The license fee provided in Rule 0720-29-.02(2)(b).

(d) Upon reapplication, the licensee shall submit to an inspection of the facility by Department of Health surveyors.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-206(a)(5), 68-11-209, 68-11-209(a)(1), 68-11-210, and 68-11-216 and Chapter 846 of the Public Acts of 2008, § 1.
Administrative History: Original rule filed July 27, 2000; effective October 10, 2000. Amendment filed November 19, 2003; effective February 2, 2004. Amendment filed January 19, 2007; effective April 4, 2007. Public necessity rules filed April 29, 2009; effective through October 11, 2009. Emergency rules filed October 9, 2009; effective through April 7, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendment filed December 16, 2013; effective March 16, 2014. Amendments filed March 26, 2019; effective June 24, 2019. Transferred from chapter 1200-08-28 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-29-.03 DISCIPLINARY PROCEDURES

(1) The board may suspend or revoke a license for:

(a) Violation of federal or state statutes;

(b) Violation of the rules set forth in this chapter;

(d) Conduct or practice found by the board to be detrimental to the health, safety, or welfare of the residents of the HIV supportive living facility; or (e) Failure to renew the license.

(2) The board may consider all factors which it deems relevant, including but not limited to the following when determining sanctions:

(a) The degree of sanctions necessary to ensure immediate and continued compliance;

(b) The character and degree of impact of the violation on the health, safety and welfare of the residents in the HIV supportive living facility;

(c) The conduct of the HIV supportive living facility in taking all feasible steps or procedures necessary or appropriate to comply or correct the violation; and, (d) Any prior violations by the HIV supportive living facility of statutes, regulations or orders of the board.

(a) How the deficiency will be corrected;

(b) The date upon which each deficiency will be corrected;

(c) What measures or systematic changes will be put in place to ensure that the deficient practice does not recur; and (d) How the corrective action will be monitored to ensure that the deficient practice does not recur.

(4) Either the failure to submit a plan of correction in a timely manner or a finding by the department that the plan of correction is unacceptable shall subject the facility license to possible disciplinary action.

(5) Any licensee or applicant for a license aggrieved by a decision or action of the department or board pursuant to this chapter may request a hearing before the board. The proceedings and judicial Review of the board’s decision shall be in accordance with the Uniform Administrative Procedures Act, T.C.A. §§ 4-5-101, et seq.

(6) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to Rule

Tenn. Comp. R. & Regs. 0720-29-.04 ADMINISTRATION

(1) The HIV supportive living facility shall have a full-time (working at least 32 hours per week) administrator. Any change of administrators shall be reported in writing to the department within fifteen (15) days. The administrator shall designate in writing an individual to act in his/her absence in order to provide the HIV supportive living facility with administrative direction at all times. The administrator shall assure the provision of appropriate fiscal resources and personnel required to meet the needs of the residents.

(2) The HIV supportive living facility must organize, manage, and administer its HIV care services to attain and maintain the highest obtainable quality of life for each resident in a manner consistent with acceptable standards of practice.

(3) The HIV supportive living facility shall ensure a framework for addressing issues related to care at the end of life.

(4) The HIV supportive living facility 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 HIV 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 HIV diagnosis.

(7) An HIV supportive living facility may contract for another individual or entity to furnish services, other than core services, to the HIV supportive living facility’s residents. If services are provided under agreement or contract, the HIV supportive living facility must meet the following standards:

(a) Continuity of care. The HIV supportive living facility assures the continuity of resident and family care.

(b) Written agreement. The HIV supportive living facility has a legally binding written agreement for the provision of contracted HIV care services. The agreement must include at least the following:

Identification of the services to be provided.
A stipulation that services may be provided only with the express authorization of the HIV supportive living facility.
The manner in which the contracted services are coordinated, supervised, and evaluated by the HIV supportive living facility.
The delineation of the role(s) of the HIV supportive living facility and the contractor in the admission process, resident and family assessment, and the interdisciplinary group care conferences.
Requirements for documenting that services are furnished in accordance with the agreement.
The qualifications of the personnel providing the services.

(c) Professional management responsibility. The HIV supportive living facility 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 part, and in accordance with the resident’s plan of care and the other requirements of this part.

(d) Financial responsibility. The HIV supportive living facility retains responsibility for payment for services.

(8) The facility shall make reasonable efforts to safeguard personal property and promptly investigate complaints of such loss. A record shall be prepared of all clothing, personal possessions, and money brought by the resident to the HIV supportive living facility. One copy of the record shall be given to the resident or the resident’s representative and the original shall be maintained in the HIV supportive living facility record. This record shall be updated as additional personal property is brought to the facility.

(9) If the facility keeps resident funds, such funds shall be kept in an account separate from the facility’s funds. Resident funds shall not be used by the facility. The facility shall maintain and allow each resident access to a written record of all financial arrangements and transactions involving the individual resident’s funds. The facility shall provide each resident or his/her representative with a written itemized statement at least quarterly of all financial transactions involving the resident’s funds.

(10) Within thirty (30) days of a resident’s death, the facility shall provide an accounting of the resident’s funds held by the facility and an inventory of the resident’s personal property held by the facility to the resident’s executor, administrator or other person authorized by law to receive the decedent’s property. The facility shall obtain a signed receipt from any person to whom the decedent’s property is transferred.

(11) Upon the sale of the facility, the seller shall provide written verification that all the resident’s funds and property have been transferred and shall obtain a signed receipt from the new owner. Upon receipt, the buyer shall provide, to the residents, an accounting of funds and property held on their behalf.

(12) When licensure is applicable for a particular job, verification 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 or volunteer. Documentation that references were verified shall be on file. Adequate medical screenings to exclude communicable disease shall be required of each employee.

(13) 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. A HIV supportive living facility which violates a required policy also violates the rule and regulation establishing the requirement.

(14) Policies and procedures shall be consistent with professionally recognized standards of practice.

(15) No HIV supportive living facility 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, the long term care ombudsman, the Comptroller of the State Treasury, or any government agency. A HIV supportive living facility 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.

(16) Each HIV supportive living facility shall adopt safety policies for the protection of residents from accident and injury.

(17) A record pertaining to the payment agreement between the HIV supportive living facility and the resident shall be accomplished prior to admission. A copy of the agreement record shall be given to the resident and the original shall be maintained in the facility’s records.

(18) 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;

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.

History

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, 68-11-268, and 71-6-121.
Administrative History: Original rule filed July 27, 2000; effective October 10, 2000. Amendment filed June 18, 2002; 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. Transferred from chapter 1200-08-28 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-29-.05 ADMISSIONS, DISCHARGES, AND TRANSFERS

(1) The HIV supportive living facility shall have a policy to admit only residents who meet the following criteria:

(a) Has been diagnosed with symptomatic HIV disease;

(b) Has a physician who acts as the primary care provider; and (c) Has voluntarily requested admission to, and been accepted by, a licensed HIV supportive living facility.

(2) Residents shall be admitted to receive HIV care supportive living services, on the basis of a reasonable expectation that the resident’s medical, nursing and psychosocial needs can be met adequately by the HIV supportive living facility.

(4) The HIV supportive living facility staff shall determine that the resident’s needs can be met by the facility’s services and capabilities.

(5) Every person admitted for care or treatment to any HIV supportive living facility covered by these rules shall be under the supervision of a physician who holds a license in good standing to practice in Tennessee. The name of the resident’s attending physician shall be recorded in the resident’s file.

(6) The HIV supportive living facility staff shall obtain the resident’s written consent for HIV care services.

(7) The signed consent form shall be included with the resident’s individual file.

(8) A diagnosis must be entered in the admission records of the HIV supportive living facility for every person admitted for care or treatment.

(9) Any admission in excess of the licensed bed capacity is prohibited except when an emergency admission is approved by the department.

(10) A resident file shall be developed and maintained for each resident admitted.

(11) No resident shall be discharged without a written order from the attending physician or the medical director stating the resident does not meet HIV care criteria, or through other legal processes, and timely notification of next of kin and/or the authorized representative.

(12) When a resident is discharged, a summary of the significant findings and events of the resident’s care, the resident’s condition on discharge and the recommendation and arrangement for future care, if any, is required.

(13) When a resident is transferred, a summary of treatment given at the HIV supportive living facility, condition of the resident at time of transfer and date and place to which he or she is transferred shall be entered in the file. If the transfer is due to an emergency, this information will be recorded, within forty-eight (48) hours, otherwise, it will precede the transfer of the resident.

(14) When a resident is transferred, a copy of the clinical summary shall, with consent of the resident, be sent to the facility that will continue the care of the resident.

(15) Except when the Board has revoked or suspended the license, a HIV supportive living facility which intends to close, cease doing business, or reduce its licensed bed capacity by ten percent (10%) or more shall notify both the Department and the area long term care ombudsman at the earliest moment of the decision, but not later than thirty (30) days before the action is to be implemented. The facility shall establish a protocol, subject -to the Department’s approval, for the transfer or discharge of the residents. Should the HIV supportive living facility violate the provisions of this subsection, the department shall request the Attorney General of the State of Tennessee to intervene to protect the residents, as is provided by T.C.A. § 68-11-213(a).

(16) The HIV supportive living facility shall ensure that no person on the grounds of race, color, national origin, or handicap, will be excluded from participation in, be denied benefits of, or otherwise subjected to discrimination in the provision of any care or service of the HIV supportive living facility. The HIV supportive living facility shall protect the civil fights of residents under the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

(17) Facilities utilizing secured units must be able to provide survey staff with twelve (12) months of the following performance information specific to the secured unit and its residents:

(a) Documentation that each secured resident has been evaluated by an interdisciplinary team consisting of at least a physician, a social worker, a registered nurse, and a family member and/or significant other (or resident care advocate) prior to admittance to the unit;

(b) Ongoing and up-to-date documentation of quarterly review by each resident’s interdisciplinary team as to the appropriateness of placement in the secured unit;

(d) A current listing of all unusual incidents and/or complications on the unit;

(e) An up-to-date staffing pattern and staff ratios for the unit that is recorded on a daily

(f) A formulated calendar of daily group activities scheduled including a resident attendance record for the previous three (3) months;

Basic facts about the causes, progression and management of HIV and related disorders;
Dealing with dysfunctional behavior and catastrophic reactions in the residents;
Identifying and alleviating safety risks to the resident;
Providing assistance in the activities of daily living for the resident; and, 5. Communicating with families and other persons interested in the resident.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-201, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 71- 6-121.
Administrative History: Original rule filed July 27, 2000; effective October 10, 2000. Amendment filed April 20, 2006; effective July 4, 2006. Transferred from chapter 1200-08-28 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-29-.06 BASIC HIV SUPPORTIVE LIVING FACILITY FUNCTIONS

(1) A HIV supportive living facility must ensure that substantially all core services are routinely provided directly by HIV supportive living facility employees. A HIV supportive living facility may use contracted staff if necessary to supplement HIV supportive living facility employees in order to meet the needs of residents.

(a) Nursing services. The HIV supportive living facility must provide nursing care and services by, or under the supervision of, a registered nurse (R.N.) at all times.

Nursing services must be directed and staffed to assure the nursing needs of residents are met.
Resident care responsibilities of nursing personnel must be specified.
HIV care services must be provided in accordance with recognized standards of practice.

(b) Medical Social Services. Medical Social Services must be provided by a qualified social worker under the direction of a physician.

(c) Physician Services. In addition to palliation and management of HIV care, physician employees of the HIV supportive living facility including the physician member(s) of the interdisciplinary group, must also meet the general medical needs of the residents to the extent these needs are not met by the attending physician.

(d) Counseling Services. Counseling services must be made available to the individual, the individual’s family and/or significant other, and staff. Counseling includes bereavement counseling, provided both prior to and after the resident’s death, as well as dietary, therapeutic, spiritual and any other counseling services identified in the plan of care for the individual and family and/or significant other while the individual is a resident of the HIV supportive living facility.

Bereavement counseling. There must be an organized program for the provision of bereavement services under the supervision of a qualified professional. The plan of care for these services should reflect family/significant other needs, services to be provided, and the frequency of services.
Dietary counseling. Dietary counseling, when required, must be provided by a qualified individual.
Spiritual counseling. Spiritual counseling must include notice to residents as to the availability of clergy.
Additional counseling. Counseling may be provided by other members of the interdisciplinary group as well as by other qualified professionals as determined by the HIV supportive living facility.

(2) Plan of Care. A written plan of care must be established and maintained for each individual admitted to a HIV supportive living facility, and the care provided to an individual must be in accordance with the plan.

(a) Establishment of plan. The plan must be established by the attending physician, the medical director or the physician’s designee and the interdisciplinary group prior to providing care.

(b) Review of plan. The plan must be reviewed and updated as the resident’s condition changes, but at intervals of no more than (14) days, by the attending physician, the medical director or the physician’s designee and the interdisciplinary group. These reviews must be documented.

(c) Content of plan. The plan must include an assessment of the individual’s needs and identification of the HIV care services required including the management of discomfort and symptom relief It must state in detail the scope and frequency of services needed to meet the resident’s and family’s/significant other’s needs.

(d) Coordinator. The HIV supportive living facility must designate a licensed professional nurse to coordinate the implementation of the plan of care of each resident.

(e) Volunteers. The HIV supportive living facility may use volunteers, in defined roles, under the supervision of a designated HIV supportive living facility employee.

Training. The HIV supportive living facility must provide appropriate orientation and training that is consistent with acceptable standards of HIV supportive living facility practice.
Role. Volunteers shall be used in administrative or direct resident care roles.
Recruiting and retaining. The HIV supportive living facility must document active and ongoing efforts to recruit and train volunteers.
Availability of clergy. The HIV supportive living facility must make reasonable efforts to arrange for visits of clergy and other members of religious organizations in the community to residents who request such visits and must advise residents of this opportunity.

(3) Continuation of Care. A HIV supportive living facility must assist in coordinating continued care should the resident be transferred or discharged from the HIV supportive living facility.

(4) Drugs and treatments shall be administered by appropriately licensed facility personnel acting within the scope of their license. Oral orders for drugs and treatments shall be given to appropriately licensed personnel acting within the scope of their licenses, immediately recorded, signed and dated, and countersigned and dated by the physician within ten (10) days of issuance of the oral order.

(5) Performance Improvement Program. The HIV supportive living facility must ensure that there is an effective facility-wide performance improvement program to evaluate resident care and performance of the organization. The administrator shall assure that a Performance Improvement Committee, composed of a physician, a licensed professional nurse, a social worker and a pastoral or other counselor, is in place to ensure that the facility has adequate policies and procedures in place, to review performance monitoring and activities, and to provide oversight and address identified care issues within the facility. The performance improvement program must be ongoing and have a written plan of implementation which assures that:

(a) All organized services related to resident care, including services furnished by a contractor, are evaluated;

(b) Nosocomial infections and medication therapy are evaluated;

(d) The HIV supportive living facility must have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically related needs of its HIV care residents;

(e) The facility must develop and implement plans for improvement to address deficiencies identified by the performance improvement program and must document the outcome of the remedial action;

(f) Performance Improvement Program records are not disclosable except when such disclosure is required to demonstrate compliance with this section;

(g) Good faith attempts by the Performance Improvement Program Committee to identify and correct deficiencies will not be used as a basis for sanctions.

(6) Infection Control.

(a) The HIV supportive living facility must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.

(b) The administrator shall assure that an Infection Control Committee, including the medical director and members of the nursing staff and administrative staff, develops guidelines and techniques for the prevention, surveillance, control and reporting of facility infections. Duties of the committee shall include the establishment of:

Written infection control policies;
Techniques and systems for identifying, reporting, investigating and controlling infections in the facility;
Written procedures governing the use of aseptic techniques and procedures in the facility;
Written procedures concerning food handling, laundry practices, disposal of environmental and resident wastes, traffic control and visiting rules, sources of air pollution, and routine culturing of autoclaves and sterilizers;
A log of incidents related to infectious and communicable diseases;
Formal provisions to educate and orient all appropriate personnel in the practice of aseptic techniques such as handwashing, proper grooming, masking and dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of resident equipment and supplies; and 7. Continuing education for all facility personnel on the cause, effect, transmission, prevention, and elimination of infections.

The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The HIV Supportive Living Center will encourage all staff and independent practitioners to obtain an influenza vaccination;
A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider);
Education of all employees about the following:

(i) Flu vaccination, (ii) Non-vaccine control measures, and (iii) The diagnosis, transmission, and potential impact of influenza;

An annual evaluation of the influenza vaccination program and reasons for nonparticipation; and 5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee.

(d) The administrator, the medical director and a licensed professional nurse must ensure that the facility-wide performance improvement program and training programs address problems identified by the infection control program and must be responsible for the implementation of successful corrective action plans in affected problem areas.

(e) The facility shall develop policies and procedures for testing a resident’s blood for the presence of blood borne infections in the event that an employee of the facility, a student studying at the facility, or other health care provider rendering services at the facility is exposed to a resident’s blood or other body fluid. The testing shall be performed at no charge to the resident, and the test results shall be confidential.

(f) The facility and its employees shall adopt appropriate policies to evaluate staff for exposure to blood-borne pathogens, and utilize standard or universal precautions for preventing transmission of infections, HIV, and communicable diseases.

(g) Precautions shall be taken to prevent the contamination of sterile supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents, decontamination and preparation areas shall be separated.

(h) Space and facilities for housekeeping equipment and supply storage shall be provided in each service area. Storage for bulk supplies and equipment shall be located away from resident care areas. The building shall be kept in good repair, clean, sanitary and safe at all times.

(i) The facility shall appoint a housekeeping supervisor who shall be responsible for:

Organizing and coordinating the facility’s housekeeping service;
Acquiring and storing sufficient housekeeping supplies and equipment for facility maintenance; and, 3. Assuring the clean and sanitary condition of the facility to provide a safe hygienic environment for residents and staff. Cleaning shall be accomplished in accordance with the infection control rules and regulations herein and facility policy.

(j) Laundry facilities located in the HIV supportive living facility shall:

Be equipped with an area for receiving, processing, storing and distributing clean linen;
Be located in an area that does not require transportation for storage of soiled or contaminated linen through food preparation, storage or dining areas;
Provide space for storage of clean linen and for bulk storage within clean areas of the facility; and 4. Provide carts, bags or other acceptable containers appropriately marked to identify those used for soiled linen and those used for clean linen to prevent dual utilization of the equipment and cross contamination.

(k) The facility shall name an individual who is responsible for laundry service. This individual shall be responsible for:

Establishing a laundry service, either within the HIV supportive living facility or by contract, that provides the facility with sufficient clean, sanitary linen at all times;
Knowing and enforcing infection control rules and regulations for the laundry service;
Assuring the collection, packaging, transportation and storage of soiled, contaminated, and clean linen is in accordance with all applicable infection control rules, regulations and procedures; and, 4. Assuring that a contract laundry service complies with all applicable infection control rules, regulations and procedures.

(7) Personal Care Services. Aide services must be available and adequate in frequency to meet the needs of the residents.

(a) The personal care aide shall be assigned to a particular resident by a licensed professional nurse. Written instructions for resident care shall be prepared by a registered nurse or therapist as appropriate. Duties may include the performance of simple procedures to assist residents with basic care services, including simple procedures such as feeding, personal grooming, ambulating, socializing, medication prompting, reporting changes in the resident’s condition and needs, completing appropriate records, exercising and other household services essential to health care.

(b) The registered nurse shall monitor and assess the aide’s competence in providing care and determine whether goals are being met.

(8) Physical therapy, occupational therapy, respiratory therapy and speech language pathology.

Physical therapy services, occupational therapy services, respiratory therapy services and speech-language pathology services must be available, and when provided, offered in a manner consistent with accepted standards of practice.

(9) Speech therapy services shall be provided only by or under supervision of a qualified speech language pathologist in good standing, or by a person qualified as a Clinical Fellow subject to Tennessee Board of Communications Disorders and Sciences Rule 1370-01-.10.

(10) Medical supplies. Medical supplies and appliances including drugs and biologicals, must be provided as needed for the palliation and management of HIV or conditions directly attributable to the HIV diagnosis.

(a) Administration. All drugs and biologicals must be administered in accordance with accepted standards of practice and only by appropriately licensed employees of the HIV supportive living facility.

(b) The HIV supportive living facility must have a policy for the disposal of controlled drugs when those drugs are no longer needed by the resident.

(c) Drugs and biologicals may be administered by the resident or a family member or significant other if the resident’s attending physician has approved.

(11) Resident File.

(a) A resident file containing past and current findings in accordance with accepted professional standards shall be maintained for every HIV care resident. The record must be complete, promptly and accurately documented, readily accessible and systematically organized to facilitate retrieval. Each file is a comprehensive compilation of information. Entries are made for all services provided. Entries are made and signed by the person providing the services. The record includes all services whether furnished directly or under arrangements made by the HIV supportive living facility.

Each individual’s record must contain:

The initial and subsequent assessments;
The plan of care;
Identification data;
Consent and authorization and election forms;
Pertinent medical history; and 6. Complete documentation of all services, volunteers and events (including evaluations, treatments, progress notes, etc.).

(b) All resident records, either written, electronic, graphic or otherwise acceptable form, must be retained in their original or legally reproduced form for a minimum period of at least (10) years after which such records may be destroyed. However, in cases of residents under mental disability or minority, their complete HIV supportive living facility records shall be retained for the period of minority or known mental disability, plus one (1) year, or ten (10) years following the discharge of the resident, whichever is longer.

Records destruction shall be accomplished by burning, shredding or other effective method in keeping with the confidential nature of the contents. The destruction of records must be made in the ordinary course of business, must be documented and in accordance with the HIV supportive living facility’s policies and procedures, and no record may be destroyed on an individual basis.

(c) Even if the HIV supportive living facility discontinues operations, records shall be maintained as mandated by these rules and the Tennessee Medical Records Act (see T.C.A. § 68-11-308). If a resident is transferred to another health care facility or agency, a copy of the record or an abstract shall accompany the resident when the HIV supportive living facility is directly involved in the transfer.

(d) The HIV supportive living facility must have a procedure for ensuring the confidentiality of resident records. Information from, or copies of, records may be released only to authorized individuals, and the facility must ensure that unauthorized, individuals cannot gain access to, or alter, resident records. Original resident records must be released by the facility only in accordance with federal and state laws.

(f) All entries must be legible, complete, dated and authenticated according to facility policy.

(12) Pharmaceutical Services.

(a) The HIV supportive living facility shall have pharmaceutical services that meet the needs of the residents and are in accordance with the Tennessee Board of Pharmacy statutes and regulations. The facility is responsible for developing policies and procedures that minimize drug errors.

(b) All internal and external medications and preparations intended for human use shall be stored separately. They shall be properly stored in medicine compartments, including cabinets on wheels, or drug rooms. Such cabinets or drug rooms shall be kept securely locked when not in use and the key must be in the possession of the supervising nurse or other authorized persons. Poisons or external medications shall not be stored in the same compartment and shall be labeled as such.

(c) Schedule II drugs must be stored behind two (2) separately locked doors at all times and accessible only to persons in charge of administering medication.

(d) Every HIV supportive living facility shall comply with all state and federal regulations governing Schedule II drugs.

(f) All oral orders shall be immediately recorded, designated as such and signed by the person receiving them and countersigned by the physician within ten (10) days.

Accepted only by personnel that are authorized to do so by the medical staff policies and procedures, consistent with federal and state law; and, 2. Signed or initialed by the prescribing practitioner according to HIV supportive living facility policy.

(i) Medication administration records (MAR) shall be checked against the physician’s orders. Each dose shall be properly recorded in the clinical record after it has been administered.

(j) Preparation of doses for more than one scheduled administration time shall not be permitted.

(k) Medication shall be administered only by licensed medical or licensed nursing personnel or other licensed health professionals acting within the scope of their license.

(m) Legend drugs shall be dispensed by a licensed pharmacist.

(n) Any unused portions of prescriptions shall be turned over to the resident only on a written order by the physician. A notation of drugs released to the resident shall be entered into the medical record. All unused prescriptions left in a HIV supportive living facility must by destroyed on the premises and recorded by a pharmacist. Such record shall be kept in the HIV supportive living facility.

(13) Laboratory Services. The HIV supportive living facility must maintain or have available, either directly or through a contractual agreement, adequate laboratory services to meet the needs of the residents. The HIV supportive living facility must ensure that all laboratory services provided to its residents are performed in a facility licensed in accordance with the Tennessee Medical Laboratory Act (TMLA). All technical laboratory staff shall be licensed in accordance with the TMLA and shall be qualified by education, training and experience for the type of services rendered.

(14) Food and Dietetic Services.

(a) The HIV supportive living facility must designate a person, either directly or by contractual agreement, to serve as the food and dietetic services director with responsibility for the daily management of the dietary services.

(b) There must be a qualified dietitian, full-time, part-time, or on a consultant basis who is responsible for the development and implementation of a nutrition care process to meet the needs of residents for health maintenance, disease prevention and, when necessary, medical nutrition therapy to treat an illness, injury or condition.

Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the residents and must be prepared and served as prescribed.
Special diets shall be prepared and served as ordered.
Nutritional needs must be met in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the residents.
A current therapeutic diet manual approved by the dietitian and medical director must be readily available to all medical, nursing, and food service personnel.

(d) Education programs, including orientation, on-the-job training, inservice education, and continuing education shall be offered to dietetic services personnel on a regular basis.

Programs shall include instruction in the use of equipment, personal hygiene, proper inspection, and the handling, preparing and serving of food.

(e) A minimum of three (3) meals in each twenty-four (24) hour period shall be offered. A supplemental night meal shall be offered if more than fourteen (14) hours lapse between supper and breakfast. Additional nourishment shall be provided to residents with special dietary needs. A minimum of three (3) days supply of food shall be on hand.

(f) Food shall be protected from dust, flies, rodents, unnecessary handling, droplet infection, overhead leakage and other sources of contamination0 whether in storage or while being prepared and served and/or transported through hallways.

(g) Perishable food shall not be allowed to stand at room temperature except during necessary periods of preparation or serving. Prepared foods shall be kept hot (140ºF or above) or cold (45ºF or less). Appropriate equipment for temperature maintenance, such as hot and cold serving units or insulated containers, shall be used.

(h) Dishwashing machines shall be used according to manufacturer specifications.

(i) All dishes, glassware and utensils used in the preparation and serving of food and drink shall be cleaned and sanitized after each use.

(j) The cleaning and sanitizing of handwashed dishes shall be accomplished by using a three-compartment sink according to the current U.S. Public Health Service Sanitation Manual.

(k) The kitchen shall contain sufficient refrigeration equipment and space for the storage of perishable foods.

(l) All refrigerators and freezers shall have thermometers. Refrigerators shall be kept at a temperature not to exceed 45°F. Freezers shall be kept at a temperature not to exceed 0°F.

(m) Written policies and procedures shall be followed concerning the scope of food services in accordance with the current edition of the “U.S. Public Health Service Recommended Ordinance and Code Regulating Eating and Drinking Establishments” and the current U.S. Public Health Service Sanitation Manual should be used as a guide to food sanitation.

History

Authority: T.C.A. §§ 4-5-202, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-216.
Administrative History: Original rule filed July 27, 2000; effective October 10, 2000. Amendment filed September 15, 2015; effective December 14, 2015. Amendments filed July 18, 2016; effective October 16, 2016. Transferred from chapter 1200-08-28 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-29-.07 RESERVED

Administrative History: Transferred from chapter 1200-08-28 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-29-.08 BUILDING STANDARDS

(1) An HIV supportive living facility shall construct, arrange, and maintain the condition of the physical plant and the overall HIV supportive living facility environment in such a manner that the safety and well-being of the residents are assured.

(3) The codes in effect at the time of submittal of plans and specifications, as defined by these rules, shall be the codes to be used throughout the project.

(4) The licensed contractor shall perform all new construction and renovations to HIV supportive living facilities, other than minor alterations not affecting fire and life safety or functional issues, in accordance with the specific requirements of these regulations governing new construction in HIV supportive living facilities, including the submission of phased construction plans and the final drawings and the specifications to each.

(5) No new HIV supportive living facility shall be constructed, nor shall major alterations be made to an existing HIV supportive living facility without prior written approval of the department, and unless in accordance with plans and specifications approved in advance by the department. Before any new HIV supportive living facility is licensed or before any alteration or expansion of a licensed HIV supportive living facility can be approved, the applicant must furnish two (2) complete sets of plans and specifications to the department, together with fees and other information as required. Plans and specifications for new construction and major renovations, other than minor alterations not affecting fire and life safety or functional issues, shall be prepared by or under the direction of a licensed architect and/or a licensed engineer and in accordance with the rules of the Board of Architectural and Engineering Examiners.

(a) The project architect or engineer shall forward two (2) sets of plans to the appropriate

(b) Review of plans does not eliminate responsibility of owner and/or architect to comply with all rules and regulations.

(8) Specifications shall supplement all drawings. They shall describe the characteristics of all materials, products and devices, unless fully described and indicated on the drawings.

Specification copies should be bound in an 8½ x 11 inch folder.

(9) Drawings and specifications shall be prepared for each of the following branches of work:

Architectural, Structural, Mechanical, Electrical and Sprinkler.

(10) Architectural drawings shall include where applicable:

(a) Plot plan(s) showing property lines, finish grade, location of existing and proposed structures, roadways, walks, utilities and parking areas;

(b) Floor plan(s) showing scale drawings of typical and special rooms, indicating all fixed and movable equipment and major items of furniture;

(d) The elevation of each facade;

(e) The typical sections throughout the building;

(f) The schedule of finishes;

(g) The schedule of doors and windows;

(h) Roof plans;

(i) Details and dimensions of elevator shaft(s), car platform(s), doors, pit(s), equipment in the machine room, and the rates of car travel must be indicated for elevators; and (j) Code analysis.

(11) Structural drawings shall include where applicable:

(a) Plans of foundations, floors, roofs and intermediate levels which show a complete design with sizes, sections and the relative location of the various members;

(b) Schedules of beams, girders and columns; and (c) Design live load values for wind, roof, floor, stairs, guard, handrails, and seismic.

(12) Mechanical drawings shall include where applicable:

(a) Specifications which show the complete heating, ventilating, fire protection, medical gas systems and air conditioning systems;

(b) Water supply, sewerage and HVAC piping systems;

(d) Heating, ventilating, HVAC piping, medical gas systems and air conditioning systems with all related piping and auxiliaries to provide a satisfactory installation;

(13) Electrical drawings shall include where applicable:

(a) A seal, certifying that all electrical work and equipment is in compliance with all applicable codes and that all materials are currently listed by recognized testing laboratories;

(d) Color coding to show all items on emergency power;

(14) The electrical drawings shall not include knob and tube wiring, shall not include electrical cords that have splices, and shall not show that the electrical system is overloaded.

(15) In all new facilities or renovations to existing electrical systems, the installation must be approved by an inspector or agency authorized by the State Fire Marshal.

(16) Sprinkler drawings shall include where applicable:

(a) Shop drawings, hydraulic calculations, and manufacturer cut sheets;

(b) Site plan showing elevation of fire hydrant to building, test hydrant, and flow data (Data from within a 12 month period); and (c) Show "Point of Service" where water is used exclusively for fire protection purposes.

(17) The licensed contractor shall not install a system of water supply, plumbing, sewage, garbage or refuse disposal nor materially alter or extend any existing system until the architect or engineer submits complete plans and specifications for the installation, alteration or extension to the department demonstrating that all applicable codes have been met and the department has granted necessary approval.

(a) Before the HIV supportive living facility is used, Tennessee Department of Environment and Conservation shall approve the water supply system.

(18) It shall be demonstrated through submission of plans and specifications that in each HIV supportive living facility:

(20) In the event submitted materials do not appear to satisfactorily comply with 0720-29-.08(2), the department shall furnish a letter to the party submitting the plans which shall list the particular items in question and request further explanation and/or confirmation of necessary modifications.

(21) The licensed contractor shall execute all construction in accordance with the approved plans and specifications.

(22) If construction begins within one hundred eighty (180) days of the date of department approval, the department’s written notification of satisfactory review constitutes compliance with 0720-29-.08(2). This approval shall in no way permit and/or authorize any omission or deviation from the requirements of any restrictions, laws, regulations, ordinances, codes or rules of any responsible agency.

(24) The department requires the following alarms that shall be monitored twenty-four (24) hours per day:

(a) Fire alarms; and (b) Generators (if applicable).

(26) Each HIV supportive living facility shall ensure that an emergency keyed lock box is installed next to each bank of functioning elevators located on the main level. Such lock boxes shall be permanently mounted seventy-two inches (72") from the floor to the center of the box, be operable by a universal key no matter where such box is located, and shall contain only fire service keys and drop keys to the appropriate elevators.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-261.
Administrative History: Original rule filed July 27, 2000; effective October 10, 2000. Amendment filed February 18, 2003; effective May 4, 2003. Repeal and new rule filed December 15, 2005; effective February 28, 2006. Amendment filed February 23, 2007; effective May 9, 2007. Repeal and new rule filed December 20, 2011; effective March 19, 2012. Amendment filed January 21, 2016; effective April 20, 2016. Transferred from chapter 1200-08-28 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.

History

Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-219, 4-5-312, 4-5-316, 4-5-317, 68-11-202, 68-11-204, 68-11- 206, 68-11-207, 68-11-208, and 68-11-209.
Administrative History: Original rule filed July 27, 2000; effective October 10, 2000. Amendment filed March 1, 2007; effective May 15, 2007. Transferred from chapter 1200-08-28 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022.

Tenn. Comp. R. & Regs. 0720-29-.09 LIFE SAFETY

(1) Any HIV supportive living facility which complies with the required applicable building and fire safety regulations at the time the board adopts new codes or regulations will, so long as such compliance is maintained (either with or without waivers of specific provisions), be considered to be in compliance with the requirements of the new codes or regulations.

(2) The HIV supportive living facility shall provide fire protection by the elimination of fire hazards, by the installation of necessary fire fighting equipment and by the adoption of a written fire control plan. Fire drills shall be held at least quarterly for each work shift for new HIV supportive living facility personnel in each separate building. There shall be one fire drill per quarter during sleeping hours. There shall be a written report documenting the evaluation of each drill and the action recommended or taken for any deficiencies found. Records which document and evaluate these drills must be maintained for at least three (3) years. All fires which result in a response by the local fire department shall be reported to the department within seven (7) days. The report shall contain sufficient information to ascertain the nature and location of the fire, its probable cause and any injuries incurred by any person or persons as a result of the fire. Initial reports by the facility may omit the name(s) of resident(s) and parties involved, however, should the department find the identities of such persons to be necessary to an investigation, the facility shall provide such information.

(3) Residents who cannot evacuate within thirteen (13) minutes may be retained in the facility so long as such residents are retained in designated areas in accordance with the Standard Building Code and the National Fire Protection Code (NFPA).

(4) Each resident’s room shall have a door that opens directly to the outside or a corridor which leads directly to an exit door and must always be capable of being unlocked by the resident.

(5) Doors to residents’ rooms shall not be louvered.

(6) Corridors shall be lighted at all times, to a minimum of one foot candle.

(7) General lighting and night lighting shall be provided for each resident. Night lighting shall be equipped with emergency power.

(8) Corridors and exit doors shall be kept clear of equipment, furniture and other obstacles at all times. There shall be a clear passage at all times from the exit doors to a safe area.

(9) Combustible finishes and furnishings shall not be used.

(10) Open flame and portable space heaters shall not be permitted in the facility. Cooking appliances other than microwave ovens shall not be allowed in sleeping rooms.

(11) All heaters shall be guarded and spaced to prevent ignition of combustible material and accidental burns. The guard shall not have a surface temperature greater than 120°F.

(13) All electrical equipment shall be maintained in good repair and in safe operating condition.

(14) Electrical cords shall not be run under rugs or carpets.

(15) The electrical systems shall not be overloaded. Power strips must be equipped with circuit breakers. Extension cords shall not be used.

(16) All facilities must have electrically-operated smoke detectors with battery back-up power operating at all times in, at least, sleeping rooms, day rooms, corridors, laundry room, and any other hazardous areas.