Inspections — Reports — Federal Accreditation Exemption
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Unless exempt under subdivision (c)(5), every facility licensed under this part as an adult care home, ambulatory surgical treatment center, assisted care living facility, home for the aged, hospice, hospital, nursing home, residential hospice, or traumatic brain injury residential home shall be inspected within fifteen (15) months following the date of the last inspection. All other facilities for which a license has been issued shall be inspected within three (3) years following the date of the last inspection. All inspections shall be conducted by a duly appointed representative of the department under the rules promulgated under this part.
Inspection reports shall be prepared on forms prescribed by the department.
No institutions or agencies licensed pursuant to this part shall be required to be inspected or licensed under the laws of this state relative to hotels, restaurants, lodging houses, boardinghouses and places of refreshment.
Adult care homes are subject to the following inspection standards:
The board shall inspect an adult care home prior to issuing an initial license.
The board shall conduct an unannounced inspection of an adult care home in accordance with subdivision (a)(1).
The board shall be permitted access to enter and inspect any adult care home upon the receipt of an oral or written complaint, any time the board has cause to believe that an adult care home is operating without a license, or any time there exists a perceived threat to the health, safety or welfare of any resident.
Traumatic brain injury residential homes are subject to the following inspection standards:
The board shall inspect a traumatic brain injury residential home prior to issuing an initial license;
The board shall conduct an unannounced inspection of a traumatic brain injury residential home in accordance with subdivision (a)(1); and
The board shall be permitted access to enter and inspect any traumatic brain injury residential home upon the receipt of an oral or written complaint, any time the board has cause to believe that a traumatic brain injury residential home is operating without a license, or any time there exists a perceived threat to the health, safety or welfare of any resident.
Each facility licensed pursuant to this title and performing more than fifty (50) surgical abortions in a year shall conduct a mandatory interim assessment of the facility's compliance with quality measures as specified by the board, in addition to regular inspections conducted pursuant to this section.
Such mandatory interim compliance assessment shall include contents prescribed by the board.
The facility shall develop a plan of correction with appropriate time for correction of any deficiency discovered in connection with an interim assessment and shall submit the plan of correction to the department.
The department is authorized to accept the plan or timeline for correction or to request changes in the plan of correction or the timeline for compliance.
Each facility licensed pursuant to this title and performing more than fifty (50) surgical abortions in a year shall report sentinel events.
The board shall provide interpretive guidelines to facilities regarding the meaning of sentinel event.
The department is authorized to require the facility to provide a plan of correction for preventing future occurrence of the reported sentinel event.
In addition to reporting sentinel events, each facility in which a surgical abortion is performed shall make and maintain a record of the disposition of the aborted fetus or aborted fetal tissue as required in § 68-3-505(a) and shall produce such records at the time of an inspection of the facility and upon request from the department.
Failure to comply with this subsection (b) shall be grounds for discipline by the board pursuant to this chapter.
The purpose of this subsection (c) is to require that state agencies, including the department of human services or the department of children's services, the department of health, and those agencies with which each contracts, who perform surveys, inspections and investigations of health care facilities, do not duplicate their procedures or subject such health care facilities to duplicate rules and regulations.
For the purposes of this subsection (c), unless the context otherwise requires:
“Health care facility” includes hospital, recuperation center, nursing home, birthing center, prescribed child care center, home for the aged, residential HIV supportive living facility, assisted-care living facility, adult care home and traumatic brain injury residential home, as defined in this part; and
“Inspection” means all surveys, inspections, investigations and other procedures necessary for a state agency, or a division or unit of a state agency, to perform in order to carry out various obligations imposed on such agency by applicable state and federal law and regulations.
State agencies shall make, or cause to be made, only such inspections necessary to carry out the various obligations imposed on such agencies by applicable state and federal law and regulations.
Any on-site inspection by a state agency, division licensing board, or unit thereof, that substantially complies with the inspection requirements of any other state agency, other division licensing boards, or unit of the inspecting agency charged with making similar inspections shall be accepted as an equivalent inspection, instead of an on-site inspection by such agency, division licensing board, or unit of the inspecting agency.
The governor shall be authorized to coordinate the inspections of health care facilities by state agencies required to conduct such inspections.
Notwithstanding this section or any other law to the contrary, the department shall conduct such on-site inspections and investigations as may be necessary to safeguard and ensure, at all times, the public's health, safety and welfare.
The department shall conduct such inspections and investigations as may be necessary to appropriately respond to complaints received from the public and to immediately act upon any determination by the board that the public's health, safety or welfare is, or appears to be, threatened.
The department, under part 1 of this chapter, the board, under this part, the Tennessee state board of examiners for nursing home administrators, under title 63, chapter 16, and any hospital authority, under title 7, chapter 57, shall conduct one (1) joint inspection for each licensing period or shall accept the investigation of one (1) of such entities, under subdivision (c)(3), unless otherwise required by federal law or regulation.
All health care facilities licensed by the department that have obtained accreditation from a federally recognized accrediting health care organization shall be deemed to meet all applicable licensing requirements. Such facilities may be subject to an inspection by the department and shall continue to be subject to subdivisions (c)(3)(D) and (E) but may be exempt from subdivision (a)(1) so long as the facility remains accredited.
In order to be issued a license by the department, such hospitals shall be required to annually remit the statutory licensing fees and a copy of a letter of current accreditation and accompanying report from the joint commission on accreditation of hospitals.
The report shall be maintained as a confidential record pursuant to § 10-7-504.
No licensure fee shall be reduced by this subsection (c).
If a violation, citation, deficiency, or civil monetary penalty is found during the nursing home survey process, in which the violation is based upon an action or actions that are directly pursuant to a physician's order, the board of medical examiners' consultant, or the consultant's physician designee, shall be contacted for a consultation on the determination as to the medical necessity of the physician's order in question. The determination of medical necessity shall be based upon the recognized medical standards of practice and shall include, but not be limited to, a review of the physician's order, the date the order was given, the status of the patient at the time the actions occurred and the outcomes of the actions, the applicable state and federal regulations, and shall include contact between the consultant or designee and the treating physician or the facility's medical director. Any consultation between the consultant or designee and the treating physician or medical director must be completed within the time frames of the survey process. If it is determined that the violation is based upon or relates to a physician's order determined to be medically necessary, no violation, citation, deficiency, or civil monetary penalty shall be assessed against the facility and any deficiency cited in violation of this subsection (d) will be removed. The department shall report back to the board of medical examiners and the appropriate standing committees at the end of six (6) months regarding the effectiveness and the resources necessary to meet the requirements of this subsection (d).
Any nursing home that files for federal bankruptcy protection shall immediately inform the commissioner of health regarding its financial condition and the status of the legal proceedings. In overseeing a facility that has filed for federal bankruptcy protection, the department of health shall follow any existing policies or regulations pertaining to any special inspection or oversight of such a facility. The fund established by § 68-11-827 may be used for the purpose of protecting the residents of such a nursing home, if the facility's noncompliance with the conditions of continued licensure, applicable state and federal statutes, rules, regulations and contractual standards threatens the residents' continuous care, the residents' property, the nursing home's continued operation, or the nursing home's continued participation in the medical assistance program of title 71, chapter 5. The commissioner shall inform the attorney general and reporter regarding the status of the legal proceedings.
When inspecting a hospital licensed under this title, the department shall include in its inspection a determination of the hospital's compliance with the reporting requirements of subdivision (f)(2). The hospital must document its compliance with a record of its communication with local law enforcement with respect to the commitments. A hospital's failure to comply with the reporting requirements shall subject the hospital to civil penalties or other action against the hospital's license under this part.
If a patient is involuntarily committed to inpatient treatment at a hospital licensed under this title, the hospital shall report the service recipient to local law enforcement as soon as practicable, but no later than the third business day following the date of such commitment, who shall report the service recipient to the federal bureau of investigation-NICS Index and the department of safety as soon as practicable, but no later than the third business day following the date of receiving such notification, for the purposes of complying with the NICS Improvement Amendments Act of 2007, Public Law 110-180, as enacted and as may be amended in the future.
If hospital is required to report pursuant to subdivision (f)(2)(A), the hospital shall report the following information:
Complete name of the person involuntarily committed;
Date involuntary commitment was ordered;
Private or state hospital or treatment resource to which the individual was involuntarily committed;
Date of birth of the person involuntarily committed;
Race and sex of the person involuntarily committed; and
Social security number of the person involuntarily committed.
The information in subdivisions (f)(2)(B)(i)-(vi), the confidentiality of which is protected by other statutes or regulations, shall be maintained as confidential and not subject to public inspection pursuant to such statutes or regulations, except for such use as may be necessary in the conduct of any proceedings pursuant to §§ 39-17-1316, 39-17-1353, and 39-17-1354.