Tenn. Comp. R. & Regs. 1200-08-36-.05 - ADMINISTRATION

(1) Each ACH shall meet the following staffing standards:
(a) The adult care home provider shall reside in the ACH or employ a resident manager to reside in the ACH.
(b) Each ACH provider may employ a resident manager who shall meet the education, experience and training requirements of a Level 2 ACH provider required by the Board.
(c) Each ACH shall designate in writing a substitute caregiver who shall meet the education, experience and training requirements required by the Board. The substitute caregiver shall reside in the ACH during such time the substitute caregiver oversees the day-to-day operation of the ACH.
(d) The ACH shall provide staffing coverage that is adequate to meet the needs of residents, both medical, and non-medical assistance with activities of daily living. Such staffing may include certified nurse assistants.
(e) ACH staff shall:
1. Be awake and available to meet the routine and emergency service needs of the residents twenty-four (24) hours a day;
2. Demonstrate documented competency in providing care for residents requiring specialized services;
3. Evacuate all residents within five (5) minutes or less;
4. Know how to operate the generator without assistance and be able to demonstrate its operation upon request.
5. Coordinate with primary care physicians, specialists, and other health care professionals as appropriate.
(f) In addition to meeting the requirements found in Rule 1200-08-36-.05(1)(e), Level 2 ACHs serving ventilator dependent patients shall have a physician, nurse practitioner, registered nurse, respiratory therapist or licensed practical nurse awake and on duty at all times.
(g) An ACH shall employ a qualified dietitian, full time, part-time, or on a consultant basis.
(h) An ACH shall not employ an individual listed on the Abuse Registry maintained by the Department of Health.
(2) Each ACH shall meet the following procedural standards:
(a) Policies and Procedures:
1. An ACH shall have a written statement of policies and procedures outlining the ACH's responsibilities to its residents, any obligations residents have to the facility, and methods by which residents may file grievances and complaints.
2. An ACH shall develop and implement an effective facility-wide performance improvement plan that addresses plans for improvement for self-identified deficiencies and documents the outcome of remedial action.
3. An ACH shall develop a written policy, plan or procedure concerning a subject and adhere to its provisions whenever required to do so by these rules. An ACH that violates its own policy established as required by these rules and regulations also violates the rules and regulations establishing the requirement.
4. An ACH shall develop a written policy and procedure governing smoking practices of residents.
(i) Residents of the facility are exempt from the smoking prohibition, with the exception of residents of Level 2 ACHs providing care to ventilator dependent residents.
(ii) Smoke from permissible smoking areas shall not infiltrate into areas where smoking is prohibited.
5. An ACH shall develop a concise statement of its charity care policies and shall post such statement in a place accessible to the public.
(b) Resident grievances:
1. The ACH provider shall inform each resident verbally and in writing of the resident's right to file a complaint with the state at any time, the process for filing a complaint, and contact information for filing a complaint. Verbal and written communication to the resident shall indicate, at a minimum that:
(i) Complaints regarding suspected abuse, neglect or exploitation shall be reported to Adult Protective Services;
(ii) Complaints regarding licensure shall be reported to the Board; and
(iii) All other complaints shall be reported to the appropriate state designated oversight entity.
2. The ACH provider shall advise residents of the availability of a long-term care ombudsman, and how to contact such ombudsman for assistance.
3. The ACH shall forward all complaints to the appropriate state oversight entity.
4. The ACH provider shall not prohibit or discourage the filing of complaints or use intimidation against any person for filing a complaint.
5. The ACH provider shall not retaliate against the resident or the person acting on behalf of the resident in any way.
6. Persons acting in good faith in filing a complaint are immune from any liability, civil or criminal.
(c) Allegations of abuse, neglect, misappropriation or exploitation: An ACH provider shall place a resident manager, substitute caregiver, or employee against whom an allegation of abuse, neglect, misappropriation or exploitation has been made on administrative leave of absence until the investigation conducted by the appropriate state entity is complete.
(d) An ACH shall keep a written up-to-date log of all residents that can be produced in the event of an emergency.
(e) An ACH shall allow pets in the ACH only when they are not a nuisance and do not pose a health hazard. Plans for pet management must be approved by the Department. Proof of rabies vaccinations and any other vaccinations that are required for the pet by a licensed veterinarian must be maintained on the premises.
(f) No person associated with the licensee or ACH shall act as a court-appointed guardian, trustee, or conservator for any resident of the ACH or any of such resident's property or funds, except as provided by rule 1200-08-36-.15(1)(i).
(3) An ACH shall post the following at the main public entrance or other equally prominent place in the ACH:
(a) A statement that a person of advanced age who may be the victim of abuse, neglect, or exploitation may seek assistance or file a complaint with the Division of Adult Protective Services. The statement shall include the statewide toll-free number for the Division and the telephone number for the local district attorney's office. The posting shall be on a sign no smaller than eleven inches by seventeen inches (11" x 17"). (This same information shall be provided to each resident in writing upon admission to any facility);
(b) A statement that any person, regardless of age, who may be the victim of domestic violence may call the nationwide domestic violence hotline for immediate assistance, with that number printed in boldface type, and posted on a sign no smaller than eight and one-half inches (8½") in width and eleven inches (11") in height;
(c) A statement that the ACH has liability insurance, the identity of the primary insurance carrier, and if self-insured, the corporate entity responsible for payment of any claims. It shall be posted on a sign no smaller than eleven inches (11") in width and seventeen inches (17") in height;
(d) "No Smoking" signs or the international "No Smoking" symbol, consisting of a pictorial representation of a burning cigarette enclosed in a red circle with a red bar across it, shall be clearly and conspicuously posted at every entrance;
(e) A statement that any person who has experienced a problem with a specific licensed ACH may file a complaint with the Division of Health Care Facilities. The posting shall include the statewide toll-free telephone number for the Division's centralized complaint intake unit; and
(f) A copy of the resident's rights.
(4) Infection Control.
(a) An ACH shall ensure that neither a resident nor an employee of the ACH with a reportable communicable disease shall reside or work in the ACH unless the ACH has a written protocol approved by the Board's administrative office.
(b) An Adult Care Home shall have an annual influenza vaccination program which shall include at least:
1. The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Adult Care Home will encourage all staff and independent practitioners to obtain an influenza vaccination;
2. A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider);
3. Education of all employees about the following:
(i) Flu vaccination;
(ii) Non-vaccine control measures; and
(iii) The diagnosis, transmission, and potential impact of influenza;
4. An annual evaluation of the influenza vaccination program and reasons for non-participation; and
5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner's designee.
(c) An ACH and its employees shall adopt and utilize standard precautions in accordance with guidelines established by the Centers for Disease Control and Prevention (CDC) for preventing transmission of infections, HIV, and communicable diseases, including adherence to a hand hygiene program which shall include:
1. Use of alcohol-based hand rubs or use of non-antimicrobial or antimicrobial soap and water before and after each resident contact if hands are not visibly soiled;
2. Use of gloves during each resident contact with blood or where other potentially infectious materials, mucous membranes, and non-intact skin could occur and gloves shall be changed before and after each resident contact;
3. Use of either a non-antimicrobial soap and water or an antimicrobial soap and water for visibly soiled hands; and
4. Health care worker education programs which may include:
(i) Types of resident care activities that can result in hand contamination;
(ii) Advantages and disadvantages of various methods used to clean hands;
(iii) Potential risks of health care workers' colonization or infection caused by organisms acquired from residents; and
(iv) Morbidity, mortality, and costs associated with health care associated infections.
(d) An ACH shall develop and implement a system for measuring improvements in adherence to the hand hygiene program and influenza vaccination program.
(5) An ACH shall ensure that no person will be excluded from participation in, be denied benefits of, or be otherwise subjected to discrimination in the provision of any care or service of the ACH on the grounds of race, color, national origin, or handicap. An ACH shall protect the civil rights of residents under the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.


Tenn. Comp. R. & Regs. 1200-08-36-.05
Emergency rule filed November 2, 2010; effective through May 1, 2011. New rule filed January 28, 2011; effective April 28, 2011. Amendments filed July 18, 2016; effective 10/16/2016.

Authority: T.C.A. §§ 39-17-1804, 68-11-202, 68-11-206, 68-11-207, 68-11-209, 68-11-268, 68-11-270 and 71-6-121.

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