Section 0720-37-.04 - REGULATORY STANDARDS(1) A Department of Health representative shall make an unannounced inspection of every ACH holding a license granted by the Board for its compliance with applicable state law and regulations within fifteen (15) months following the date of its last inspection, and as necessary, to protect the public's health, safety and welfare, with the first unannounced inspection to be completed prior to the first annual license renewal. An ACH must cooperate during Department of Health conducted inspections, including allowing entry at any hour and providing all required records.(2) A Department of Health investigator, as the Board's representative, shall be permitted access to enter and inspect any ACH upon the receipt of an oral or written complaint, any time the Board has cause to believe that an ACH is operating without a license, or any time there exists a threat to the health, safety or welfare of any resident.(3) A Department of Health investigator, as the Board's representative, shall investigate all allegations of complaints within timeframes established in applicable statutes or regulations, or as expeditiously as necessary to ensure the health, safety and welfare of ACH residents. (a) The investigation findings shall be reported to the Board in an anonymous probable cause presentation.(b) Once the Board determines the appropriate discipline, the adult care home provider shall be informed by written correspondence.(c) The Board shall notify the complainant of the complaint's resolution.(d) The Board shall maintain a file of reported complaints which includes the name of the adult care home provider against whom the complaint is filed, the date of the complaint is filed, the action taken by the Board on the complaint and date of action taken.(4) Plan of Correction. When Department of Health inspectors find that an ACH has committed a violation of this chapter, including a violation(s) resulting in a suspension of admissions, the Department of Health, as the Board's representative, will issue a statement of deficiencies to the ACH. Within no more than ten (10) days of receipt of the statement of deficiencies, the ACH must return a plan of correction including the following:(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.(5) Either failure to submit a plan of correction in a timely manner or a finding by the Department of Health that the plan of correction is unacceptable may subject the ACH's license to disciplinary action.(6) Upon a finding by the Board that an ACH has violated any provision of the Health Facilities and Resources Act, Part 2-Regulation of Health and Related Facilities (T.C.A. §§ 68-11201, et seq.) or the rules promulgated pursuant thereto, action may be taken, upon proper notice to the licensee to deny, suspend, revoke or place the facility's license on probation in accordance with T.C.A. § 68-11-207(f).(7) Civil Penalties. The Board may, in a lawful proceeding respecting licensing (as defined in the Uniform Administrative Procedures Act, T.C.A. §§ 4-5-101, et seq.), in addition to or in lieu of other lawful disciplinary action, assess civil penalties for serious violations of statutes, rules or orders resulting in endangerment to the health, safety and welfare of residents enforceable by the Board in accordance with the following schedule: Violation | Penalty |
Failure to have either a qualified adult care home provider, resident manager or substitute caregiver on duty 24 hours per day. | $500-$5000 |
Failure to maintain personal and medical records. | $0-$1000 |
Failure to provide appropriate medical and other professional services. | $0-$1000 |
Failure to provide appropriate non-medical living assistance services (assistance with ADLs). | $0-$1000 |
Failure to create and/or maintain a plan of care. | $0-$1000 |
Failure to conduct an admission assessment. | $0-$1000 |
Failure to abide by applicable fire safety regulation | $0-$1000 |
Admitting residents over the licensed capacity. | $500-$1000 |
Admission or retention of inappropriately placed resident. T.C.A. § 68-11-213(i)(2). (Each resident shall constitute a separate violation.) | $0-$3000 |
Operating an ACH without required license. T.C.A. § 68-11-213(i)(1). (Each day of operation shall constitute a separate violation.) | $1000-$5000 |
In determining the amount of any civil penalty to be assessed pursuant to this rule the Board may consider such factors as the following:
(a) Willfulness of the violation.(b) Repetitiveness of the violation.(c) Magnitude of the risk of harm caused by the violation.(8) Each violation of any statute, rule or order enforceable by the Board shall constitute a separate and distinct offense and may render the ACH committing the offense subject to a separate penalty for each violation.(9) A licensee may appeal any disciplinary action taken against it in accordance with the Uniform Administrative Procedures Act, T.C.A. §§ 4-5-101, et seq.(10) Reconsideration and Stays. The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized pursuant to rule 1360-04-01-.18 regarding petitions for reconsiderations and stays in that case.Tenn. Comp. R. & Regs. 0720-37-.04
Emergency rule filed November 2, 2010; effective through May 1, 2011. New rule filed January 28, 2011; effective April 28, 2011. Transferred from chapter 1200-08-36 pursuant to Public Chapter 1119 of 2022 effective 7/1/2022.Authority: T.C.A. §§ 68-11-207, 68-11-209, 68-11-210, and 68-11-213.