Tenn. Comp. R. & Regs. 1200-08-37-.04 - REGULATORY STANDARDS

(1) A Department of Health representative shall make an unannounced inspection of every TBI residential home 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 completed prior to the first annual license renewal. A TBI residential home 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 TBI residential home upon the receipt of an oral or written complaint; any time the Board has cause to believe that a TBI residential home 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 complaints within timeframes established in applicable statutes or regulations, or as expeditiously as necessary to ensure the health, safety and welfare of TBI residential home 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 TBI residential 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 TBI residential home provider against whom the complaint is filed; the date 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 a TBI residential home 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 TBI residential home. Within ten (10) days of receipt of the statement of deficiencies, the TBI residential home 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 TBI residential home's license to disciplinary action.
(6) Upon a finding by the Board that a TBI residential home has violated any provision of the Health Facilities and Resources Act, Part 2-Regulation of Health and Related Facilities (T.C.A. §§ 68-11-201, 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 adequate staffing. $ 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. regulations $ 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 a TBI residential home 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 TBI residential home committing the offense subject to a separate penalty for each violation.
(9) A TBI residential home provider 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. 1200-08-37-.04
Original rule filed October 28, 2015; effective 1/26/2016.

Authority: T.C.A. §§ 68-11-202, 68-11-207, 68-11-209, 68-11-210, 68-11-213, and 68-11-273.

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