Tenn. Comp. R. & Regs. 1200-08-25-.10 - LIFE SAFETY

(1) The department will consider any ACLF that complies with the required applicable building and fire safety regulations at the time the Board adopts new codes or regulations, so long as such compliance is maintained (either with or without waivers of specific provisions), to be in compliance with the requirements of the new codes or regulations.
(2) An ACLF shall ensure fire protection for residents by doing at least the following:
(a) Eliminate fire hazards;
(b) Install necessary fire fighting equipment;
(c) Adopt a written fire control plan;
(d) Ensure that each resident sleeping unit shall have a door that opens directly to the outside or to a corridor which leads directly to an exit door and that is always capable of being unlocked by the resident;
(e) Ensure that louvers shall not be present in doors to residents' sleeping units;
(f) Keep corridors and exit doors clear of equipment, furniture and other obstacles at all times. Passage to exit doors leading to a safe area shall be clear at all times;
(g) Prohibit use of combustible finishes and furnishings;
(h) Prohibit open flame and portable space heaters;
(i) Ensure that upon entering the ACLF, the resident or his or her responsible party is asked if they wish to have a cooking appliance that is appropriate for their level of cognition. If the facility chooses to provide a requested cooking appliance, it shall be used in accordance with the facility's policies. If the resident or his or her responsible party wishes to provide their own cooking appliance, it shall meet the facility's policies and safety standards. The cooking appliances shall be designed so that they can be disconnected and removed for resident safety or if the resident chooses not to have cooking capability within his or her apartment. The cooking appliances shall have an automatic timer;
(j) Ensure that all heaters shall be guarded and spaced to prevent ignition of combustible material and accidental burns. The guard shall not have a surface temperature greater than 120°F;
(k) Allow use of fireplaces and/or fireplace inserts only if the ACLF ensures that they have guards or screens which are secured in place;
(l) Inspect and clean fireplaces and chimneys annually and maintain documentation that such inspection has occurred;
(m) Ensure that there are electrically-operated smoke detectors with battery back-up power operating at all times in, at least, resident sleeping units, day rooms, corridors, laundry room, and any other hazardous areas; and
(n) Provide and mount fire extinguishers and maintain travel distance between fire extinguishers, complying with NFPA 10, so they are accessible to all residents in the kitchen, laundries and at all exits.
(3) An ACLF shall conduct fire drills in accordance with the following:
(a) Fire drills shall be held for each ACLF work shift in each separate ACLF building at least quarterly;
(b) There shall be one (1) fire drill per quarter during sleeping hours;
(c) An ACLF shall prepare a written report documenting the evaluation of each drill that includes the action that is recommended or taken to correct any deficiencies found; and,
(d) An ACLF shall maintain records that document and evaluate these drills for at least three (3) years.
(4) An ACLF shall take the following action should a fire occur:
(a) An ACLF shall report all fires which result in a response by the local fire department to the department within seven (7) days of its occurrence.
(b) An ACLF's report to the department shall contain the following:
1. Sufficient information to ascertain the nature and location of the fire;
2. Sufficient information to ascertain the probable cause of the fire; and
3. A list and description of any injuries to any person or persons as a result of the fire.
4. An ACLF may omit the name(s) of resident(s) and parties involved in initial reports. Should the department later find the identities of such persons to be necessary to an investigation, the ACLF shall provide such information.
(5) An ACLF shall take the following precautions regarding electrical equipment to ensure the safety of residents:
(a) Provide lighted corridors at all times, to a minimum of one foot candle;
(b) Provide general and night lighting for each resident and equip night lighting with emergency power;
(c) Maintain all electrical equipment in good repair and safe operating condition;
(d) Ensure that electrical cords shall not run under rugs or carpets;
(e) Ensure that electrical systems shall not be overloaded;
(f) Ensure that power strips are equipped with circuit breakers; and
(g) Prohibit use of extension cords.
(6) If an ACLF allows residents to smoke, it shall ensure the following:
(a) Permit smoking and smoking materials only in designated areas under supervision;
(b) Provide ashtrays wherever smoking is permitted;
(c) Smoking in bed is prohibited;
(d) Written policies and procedures for smoking within the ACLF shall designate a room or rooms to be used exclusively for residents who smoke. The designated smoking room or rooms shall not be the dining room, the activity room, or an individual resident sleeping unit, and;
(e) Post no smoking signs in areas where oxygen is used or stored.
(7) An ACLF shall not allow trash and other combustible waste to accumulate within and around the ACLF. It shall store trash in appropriate containers with tight-fitting lids. An ACLF shall furnish resident sleeping units with an UL approved trash container.
(8) An ACLF shall ensure that:
(a) The ACLF maintains all safety equipment in good repair and in a safe operating condition;
(b) The ACLF stores janitorial supplies away from the kitchen, food storage area, dining area or other resident accessible areas;
(c) The ACLF stores flammable liquids in approved containers and away from the facility living areas; and
(d) The ACLF cleans floor and dryer vents as frequently as needed to prevent accumulation of lint, soil and dirt.
(9) An ACLF shall post emergency telephone numbers near a telephone accessible to the residents.
(10) An ACLF shall maintain its physical environment in a safe, clean and sanitary manner by doing at least the following:
(a) Prohibit any condition on the ACLF site conducive to the harboring or breeding of insects, rodents or other vermin;
(b) Properly identify chemical substances of a poisonous nature used to control or eliminate vermin and store such substances away from food or medications;
(c) Ensure that the building shall not become overcrowded with a combination of the ACLF's residents and other occupants;
(d) Ensure that each resident sleeping unit shall contain a chair, bed, mattress, springs, linens, chest of drawers and wardrobe or closet space, either provided by the ACLF or by the resident if the resident prefers. All furniture provided by the resident must meet NFPA standards;
(e) Maintain all residents' clothing in good repair and ensure that it is suitable for the use of elderly persons;
(f) Maintain the building and its heating, cooling, plumbing and electrical systems in good repair and in clean condition at all times; and
(g) Maintain temperatures in resident sleeping units and common areas at not less than 65°F and no more than 85°F.


Tenn. Comp. R. & Regs. 1200-08-25-.10
Original rule filed February 9, 1998; effective April 25, 1998. Amendment filed April 11, 2003; effective June 25, 2003. Public necessity rule filed May 13, 2009; effective through October 25, 2009. Emergency rule filed October 22, 2009; effective through April 20, 2010. Amendment filed September 24, 2009; effective December 23, 2009. Amendments filed July 10, 2018; effective 10/8/2018.

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, 68-11-207, 68-11-209, 68-11-210, 68-11-211, and 68-11-213.

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