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Health Care Facilities

Health Care Facilities: Federal Programs

Civil Rights Compliance

Civil Rights Compliance is monitored by the Office of Health Care Facilities. Compliance with Title VI of the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973 provides for the protection of the civil rights of Tennesseans receiving services from health care facilities.

The goal in monitoring civil right compliance is to improve access to health care facilities and assess discriminatory practices and behavior based on race, creed and national origin in health care facilities licensed by the Board.

The Office is responsible for disseminating information to health care facilities, conducting on-site reviews, interpreting state and federal regulations to staff and the public, and preparing periodic investigative reports. Self-evaluation surveys are conducted by every provider receiving any federal funds on a periodic basis.

The Board for Licensing Health Care Facilities may deny, suspend, or revoke a facility's license if found in non-compliance with these laws.

Clinical Laboratory Improvement Act (CLIA)

The Office of Health Care Facilities administers the certification of laboratory programs within Tennessee in accordance with the Clinical Laboratory Improvement Act of 1988 (CLIA). This program is regulated for compliance under guidelines set forth in Federal Regulations 42 CFR Parts 493.1 through 493.1850.

(Click here to view or copy regulations)

For information or assistance contact a CLIA certification representative:

Division of Health Licensure and Regulation
Office of Health Care Facilities, CLIA Certification
665 Mainstream Drive, 2nd Floor
Nashville, TN  37243
Phone: (615) 741-7023
Fax: (615) 532-2700

Please submit all CLIA payments to:
CLIA Laboratory Program
P.O. Box 530882
Atlanta, GA 30353-0882

Medicare/Medicaid Federal Certification Program

The Office of Health Care Facilities administers the Medicare and Medicaid certification programs in Tennessee for the federal government. The Office certifies the following provider types: home health agencies; hospices; nursing homes; hospitals; ambulatory surgical centers; end stage renal disease centers; rural health clinics; rehabilitation centers; comprehensive outpatient rehabilitation facilities, intermediate care facilities for the mentally retarded; and portable x-ray units. These programs are regulated in accordance with federal regulations 42 CFR Parts 400 to 1007.

Click here to access Centers for Medicare and Medicaid Services regulations

Click here to access Centers for Medicare and Medicaid Services Survey and Certification (S&C) Transmittal Letters

Click here to access Centers for Medicare and Medicaid Services Survey and Certification State Operations Manual

For information or assistance, contact the office's certification section:

Division of Health Licensure and Regulation
Office of Health Care Facilities
Medicare/Medicaid Certification Section
665 Mainstream Drive, 2nd Floor
Nashville, TN 37243
Phone: (615) 741-7221
Fax: (615) 741-7051

MDS Automation System

The Tennessee Minimum Data Set (MDS) System Administration Section is located at:

Tennessee Department of Health
Division of Health Licensure and Regulation
Office of Health Care Facilities
MDS System Administration Section
665 Mainstream Drive
Nashville, TN 37243

The federal Minimum Data Set (MDS) National Automation Project’s purpose is to provide computerized storage, access, and analysis of patient care data on patients across the United States. The MDS System creates a standard, nationwide system for connecting long term care facilities to their respective State agencies for the purpose of electronic interchange of data, reports and billing information. The MDS System consists of several inter-related components including data communication and the Data Repository. The MDS System currently serves/or will serve the following functions:

  • Receipt of electronically transmitted MDS patient care records from facilities by the state survey agency;
  • Authentication and validation by the state survey agency of MDS records received from facilities;
  • Provision of feedback to facilities submitting MDS data to the standard MDS System, indicating acknowledgment of data transmission and specifying the status of record validation;
  • Storage of MDS records in the database repository within the state survey agency;
  • Transmission of collected data to the National Data Repository; and,
  • Communication of information, such as reports, documents, and notices, between the State agencies and LTC facilities without requiring additional hardware or software.

For more information on Rules and Regulations involving the MDS 2.0 Long Term Care Resident Assessment Instrument (RAI) and clinical data information please click on the following:
State MDS Coordinator (or telephone 615-741-8002)

For more information concerning the MDS System technical support and computer systems questions call  615-741-6511.

The Tennessee MDS System Administration Section fax number is 865-594-5739.

For further information about MDS 2.0 and the MDS National Automation Project on the Health Care Financing Administration’s MDS web site.

OASIS Automation System

The Tennessee OASIS System Administration Section is located at:

Tennessee Department of Health
Office of Health Care Facilities
OASIS System Administration Section
665 Mainstream Drive, 2nd Floor
Nashville, TN 37243

The Outcome and Assessment Information Set is a group of 79 standardized medical, nursing and rehabilitation data elements that represent core items of a comprehensive assessment for an adult home care patient. These data items are collected, at specific time frames, encoded and electronically transmitted to the state agency.

Like the MDS System, OASIS is a computerized system that links state agencies to the national repository with capabilities to store, access, and provide billing information and analysis of patient data.
This system forms the basis for measuring patient outcomes for the purposes of outcome-based quality improvement, enhancing the state survey process, and for analyzing results for reimbursement under the prospective payment system.

Under current HCFA requirements, all Medicare certified home health agencies have been collecting, encoding and transmitting data on all Medicare and Medicaid skilled patients since August 24, 1999.

For more information on the OASIS rules and regulations or the OASIS System, please click on:
http://www.cms.hhs.gov/OASIS/

Or the State OASIS Educational Coordinator  (or telephone 615-741-7534)

Or the State Systems Support (or telephone 615-741-6511)

The Tennessee OASIS System Administration Section fax number is 865-594-5739.

Quality Indicator Survey (QIS) for Nursing Homes

The Centers for Medicare and Medicaid Services (CMS) is implementing the Quality indicator Survey (QIS) which is a computer-assisted long-term care survey process used by the CMS designated State Survey Agencies and CMS to determine if Medicare and Medicaid certified nursing homes meet federal requirements. Tennessee Surveyor training on the new survey program will be conducted until QIS is fully implemented statewide and all nursing home surveys are completed using the QIS program. Please see the following links to additional information on the QIS program, with other links to added as required:

CMS QIS website: https://www.qtso.com/qisdownload.html (Click on horizontal menu tabs to access information under each tab.)

CMS Survey and Certification (S&C) transmittal letter 08-21 and QIS brochure: https://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter08-21.pdf

CMS S&C transmittal letter 09-50 National Implementation in States: https://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09_50.pdf