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 STANDARDS FOR HOSPITALS CHAPTER 0720-14 (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 STANDARDS FOR HOSPITALS CHAPTER 0720-14 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; (c) Fire marshal reports; (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.