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. STANDARDS FOR HOSPITALS CHAPTER 0720-14 (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; (c) Be provided when identified as a need by the patient, a person acting on the patient’s behalf, or by the physician; (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. STANDARDS FOR HOSPITALS CHAPTER 0720-14 (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; (c) Stabilizing and splinting the spine or fractures; (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: 1. The medical necessity of the movement; 2. The availability of appropriate medical services at both the transferring and receiving hospitals; 3. 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, STANDARDS FOR HOSPITALS CHAPTER 0720-14 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: 1. The hospital’s administrator must make written notification to the Commission within forty-eight (48) hours of exceeding its licensed bed capacity. 2. 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.; STANDARDS FOR HOSPITALS CHAPTER 0720-14 (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. 3. 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. 4. 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. 5. 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. 1. 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. 2. 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: STANDARDS FOR HOSPITALS CHAPTER 0720-14 1. Was born within the preceding forty-five-day period, as determined within a reasonable degree of medical certainty; 2. 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. 1. 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. 2. The hospital shall document the designated caregiver in the patient record and include contact information; and STANDARDS FOR HOSPITALS CHAPTER 0720-14 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: 1. The name and contact information of the designated caregiver and relation to the patient; 2. 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: 1. 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.