**Information Disclaimer: Please be advised that the alerts contained in the links that follow were transmitted to the Tennessee Department of Health, Division for Licensing Health Care Facilities by the agency listed under which the link is located. The enclosed information is being provided to you/your facility for its use as received and the Department of Health takes no legal responsibility for the information contained therein.**
Effective May 27, 2009, the Health Data Reporting Act of 2002 was amended by Public Chapter 318. The new law provides that all licensed health care facilities are no longer required to report "unusual events" as the term was defined in the 2002 Act, but that each facility, except for those facilities required to report abuse, neglect or misappropriation pursuant to federal laws and rules (42 CFR §483.13), shall only report incidents of abuse, neglect, and misappropriation that occur at the facility to the Department. The facility is required to make the report within seven (7) business days from the date that the facility identifies the incident. The new law removes the requirement that the facility shall submit a corrective action report to the Department. Although reporting requirements for facilities have been changed, the Department is still required to investigate the incidents of abuse, neglect or misappropriation reported to the Department as complaints for certification purposes.
The new law did not change the requirements contained in the 2002 Act that require all licensed health care facilities to report the following to the Department: strike by the staff at the facility; external disaster impacting the facility; disruption of any services vital to the continued safe operation of the facility or to the health and safety of its patients and personnel; and fires at the facility that disrupt the provisions 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. These incidents must be reported to the Department of Health within seven (7) business days after the facility becomes aware of the incident. Public Acts of 2009, Chapter 318.
Amendments to the Hospital and Nursing Home Rules and Regulations became effective October 1, 2007 which include new requirements regarding influenza vaccination and declination documentation, hand hygiene practices, and central line insertion practices. These amended rules and regulations can be accessed from this website by selecting Rules and Regulations on the left menu, then State Rules, and the appropriate chapter.
Please note that documentation of influenza vaccination or declination is required for both facility types. Under those amended regulations, hospitals and nursing homes are also required to calculate influenza vaccination coverage rates among their healthcare workers as of December 31 each year. This requirement applies to all facility staff, including licensed independent contractors.
Below are links to sample forms that can be downloaded and used/modified as needed by your facility to document this required information. Other health care providers or individuals may also use these forms to document receipt of an influenza vaccination at another health care facility, physician office, clinic or pharmacy. Such facility forms are to be maintained in the facility and should not be sent to the Division.
Effective July 1, 2007, all health care facilities licensed by the State of Tennessee Board for Licensing Health Care Facilities shall post a sign that must be at least eight and one-half inches (8-1/2”) in width and fourteen inches (14”) in height in the main public entrance of the facility containing the following information:
In addition, all nursing homes, assisted living facilities and any other residential facility licensed by the Board for Licensing Health Care Facilities are required to provide upon admission to each resident the Division of Adult Protective Services’ statewide toll-free number. Nursing homes which comply with the requirements of Tennessee Code Annotated 68-11-254 are exempt from the posting requirements in 1 and 2 above.
Toll-Free Hotline Numbers Example Sign: If you wish to have a copy of this statement mailed to you, please contact the State of Tennessee Board for Licensing Health Care Facilities toll-free at 1-800-778-4504 or 1-615-741-7221 to request the Toll-Free Hotline Numbers Notice and Example Sign.
The Division of Health Care Facilities is responsible for licensing health care facilities and for certifying providers for participation in federal Medicare and/or Medicaid Programs. The Division monitors facility compliance with state minimum standards and federal regulations through the conducting of facility surveys, patient care inspections and complaint investigations. This division also provides administrative support to the Board for Licensing Health Care Facilities.