(a)

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Terms Used In Tennessee Code 68-11-310

  • Department: means the department of health. See Tennessee Code 68-11-302
  • Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
  • Hospital: means any institution, place, building or agency that has been licensed by the board, as defined in §. See Tennessee Code 68-11-302
  • Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105
(1) All hospitals licensed by the health facilities commission or by the department of mental health and substance abuse services shall, within one hundred fifty (150) days after the end of each individual hospital’s fiscal year, submit to the department of health a joint annual report of the statistical particulars relative to their patients for the fiscal year.
(2)If a hospital changes ownership during the fiscal year, the owner of the hospital at the beginning of the fiscal year shall either:

(A) File a joint annual report with the department of health within one hundred five (105) days of the sale for the period of time that the hospital was owned or operated; or
(B) Provide a notarized statement to the department of health within one hundred five (105) days of the sale indicating that the required data for the period of time that the hospital was owned or operated has been provided to the purchaser who shall submit a report for the full year.
(3) If the department of health determines that there are errors in the joint annual report, the hospital shall be notified of the errors and shall be required to provide corrections to the department of health within fifteen (15) business days of notification.
(4) A hospital that submits a joint annual report to the department of health pursuant to this section shall also submit to the department 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 must also be attested to by the chief executive officer of the hospital. This notarized statement validates that the hospital has submitted accurate and complete data such that the department of health is not required to independently audit the hospital’s internal processes.
(5)All hospitals shall submit accurate and complete data. The department of health is not responsible for validating hospitals’ internal data as reported in accordance with this section.
(b) The commissioner shall determine, through the promulgation of rules and regulations, the contents of the report, but may request early completion of the report, portions of the report or special reports when requested to do so by the office of the comptroller or at other times, but only after consultation with the Tennessee Hospital Association. In no event shall the department of health authorize the reporting of a hospital’s statistics for less than a full twelve-month period, unless the hospital was not open during the entire twelve-month period. Any hospital that is open for less than the full twelve-month period shall report for the entire period of its operation.
(c)

(1) Hospitals that fail to file their joint annual report in a timely manner, as referenced in § 68-1-109, 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 department’s editing, shall receive a deficiency from the department. Within fifteen (15) business days from receipt of the deficiency, the hospital shall be required to return a plan of correction indicating:

(A) How the deficiency will be corrected;
(B) The date upon which each deficiency will be corrected;
(C) What measures or systemic changes will be put in place to ensure that the deficient practice does not recur; and
(D) How the corrective action will be monitored to ensure that the deficient practice does not recur.
(2) Either failure to submit a plan of correction in a timely manner or a finding by the department that the plan of correction is unacceptable shall subject the hospital’s license to possible disciplinary action.
(d) The department of health shall compile, finalize and make available to the public an electronic compilation of the statistics reported by the hospitals for the fiscal years ending during a calendar year by November 30 of the following year.
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