Section 0720-24-.02 - REQUIREMENTS FOR CIVIL RIGHTS COMPLIANCEThe Board for Licensing Health Care Facilities may deny, suspend, or revoke a facility's license, or otherwise discipline the facility for violations of the following requirements pursuant to T.C.A. §§ 68-11-207 and 68-1-113. Licensed health care facilities must comply with the following:
(1) Shall not directly or through licensing, contractual or other arrangements, utilize criteria or methods of administering services which have the effect of subjecting individuals to discrimination on the basis of race, color, national original or handicapped condition.(2) Admission policies and procedures shall include measures to admit patients/residents to the facility without regard to race, color, national origin or handicapping condition.(3) Shall include in their operational policies and procedures manuals measures to provide all services in a nondiscriminatory manner (i.e. medical, dental, nursing, laboratory, pharmacy, skilled rehabilitative, social, volunteer, dietary and housekeeping).(4) Physical facilities including lounges, dining facilities, beauty and barber shops shall not be used in a segregated or discriminatory manner.(5) Shall include in their operational policies and procedures manuals that patients/residents are assigned to rooms, wards, floors, sections, buildings, and other areas without regard to race; color; national origin; or handicapping conditions if medically indicated,(6) Shall include in their operational policies and procedures manuals that a aspects of all their training programs -those operated by the facility, and those operated by other institutions within their facility for which the facility provides clinical training are conducted without discrimination, on the basis of race, color, national origin or handicapping condition.(7) Shall use all reasonable efforts to recruit minority and handicapped persons to training programs offered by the facility.(8) Shall inform all patients/residents, potential patients/residents, and the general public that admissions and services are provided on a non-discriminatory basis. This shall be accomplished by:(a) If a facility publishes or uses brochures, pamphlets and newsletters which are designed to acquaint potential patients/residents and members of the general public with the facility's programs and services, a statement of the facility's commitment and compliance to Title VI and Section 504 must be included. All efforts to communicate to the public should convey the message that services are provided in a nondiscriminatory manner.(b) Including a statement of the facility's commitment and compliance to Title VI and Section 504 on all application forms for admission and employment.(c) Notifying all customary referral sources and the minority community within the service area that the facility's services and benefits are provided in a non-discriminatory manner.(d) Displaying in prominent places in the facility notices indicating the Title VI and Section 504 compliance and commitment.(9) Shall be responsible for conveying to all staff their non-discriminatory policy and how to file a complaint under Title VI or Section 504. This shall be accomplished by providing, as part of new employee's orientation and periodic retraining of permanent employees, information regarding the obligation, intent, and meaning of Title VI and Section 504 compliance.(10) Those facilities with fifteen or more employees shall designate a responsible employee (Section 504 Coordinator) to coordinate its efforts to comply with Section 504 regulations.(11) Shall establish and adhere to an internal procedure for handling patient/resident and employee grievances. The grievance procedure shall include: (a) Complainant's right to due process.(b) Time frames for the review, resolution and/or findings process.(12) Shall ensure that the opportunity to participate as members of planning, advisory, and policy boards whose membership is opened to the public, is available in a non-discriminatory manner.(13) Shall develop procedures for monitoring all aspects of its operation to ensure that no policy or practice is, or has the effect of discriminating against applicants, patients/residents, employees or other participants on the basis of race, color, national origin, or handicapping condition. Each facility shall establish a system to review annually all new and existing policies to determine compliance with such policies with Title VI and Section 504.(14) Shall maintain and make available to the OCRC for the purpose of demonstrating compliance and upon request, all data and information necessary to determine the facility's compliance with Title VI of the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973. Such statistical data shall include racial and ethnic data showing the extent to which minority and handicapped individuals participate in the facility's services and programs.(15) All recruitment and employment practices shall not discriminate on the basis of race, color, national origin, handicapping condition, or have an adverse effect on the provision of services, privileges, or advantages offered to the facility's patients/residents.(16) Shall include in their operational policies and procedures manuals a procedure for effective communication with handicapped persons and persons with limited English proficiency for the purpose of giving notice concerning benefits, services, waiver of rights, and consent to treatment, including emergency treatment.(17) Shall provide appropriate auxiliary aids to persons with impaired sensory, manual, or speaking skills, where necessary to afford such persons an equal opportunity to benefit from services provided by the facility. Auxiliary aids may include information in braille, taped material and interpreters.(18) Shall include in assurance of compliance with Title VI and Section 504 in all contracts with service agencies, health care providers and other health care facilities, eg. "services will be provided in a non-discriminatory manner without regard to race, color, national origin or handicapped condition."Tenn. Comp. R. & Regs. 0720-24-.02
Original rule filed November 21, 1990; effective January 5, 1991. Transferred from chapter 1200-08-16 pursuant to Public Chapter 1119 of 2022 effective 7/1/2022.Authority: T.C.A. §§ 4-5-202, 68-1-113, 68-11-102, and 68-11-203; 45 C.F.R., Part 80; and 45 C.F.R., Part 84.