1200-08-25-.06 ADMINISTRATION.

(1) Each ACLF shall meet the following staffing and procedural standards:

(a) Staffing Requirements:
1. The licensee must designate in writing a capable and responsible person to act on administrative matters and to exercise all the powers and responsibilities of
the licensee as set forth in this chapter in the absence of the licensee.
2. If the licensee is a natural person, the licensee shall be at least eighteen (18) years of age, of reputable and responsible character, able to comply with these
rules, and must maintain financial resources and income sufficient to provide for the needs of the residents, including their room, board, and personal services.
3. An ACLF shall have an identified responsible attendant who is alert and awake at all times and a sufficient number of employees to meet the residents’ needs,
including medical services as prescribed. The responsible attendant and direct care staff must be at least eighteen (18) years of age and capable of complying
with statutes and rules governing ACLFs.
4. An ACLF shall have a licensed nurse available as needed.
5. An ACLF shall employ a qualified dietitian, full-time, part-time, or on a consultant basis.
6. An ACLF may not employ an individual listed on the Abuse Registry maintained by the Department of Health.

(b) Policies and Procedures:
1. An ACLF shall have a written statement of policies and procedures outlining the facility’s responsibilities to its residents, any obligation residents have to the
the facility, and methods by which residents may file grievances and complaints.
2. An ACLF 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 ACLF shall develop a written policy, plan, or procedure concerning a subject and adhere to its provisions whenever required to do so by these rules. A
a licensee that violates its own policy established as required by these rules and regulations also violate the rules and regulations establishing the requirement.
4. An ACLF shall develop a written policy and procedure governing the smoking practices of residents.
(i) Residents of the facility are exempt from the smoking prohibition that otherwise applies to the ACLF.
(ii) Smoke from permissible smoking areas shall not infiltrate into areas where
smoking is prohibited.
5. An ACLF shall develop a concise statement of its charity care policies and shall post such a statement in a place accessible to the public.
(c) An ACLF shall keep a written up-to-date log of all residents that can be produced in the event of an emergency.
(d) An ACLF shall allow pets in the ACLF only when they are not a nuisance and do not pose a health hazard. Plans for pet management must be approved by the Department.
(e) No person associated with the licensee or ACLF shall act as a court-appointed guardian, trustee, or conservator for any resident of the ACLF or any of such resident’s
property or funds, except as provided by rule 1200-08-25-.14(1)(i).
(f) An ACLF shall not retaliate against or, in any manner, discriminate against any person because of a complaint made in good faith and without malice to the Board, the
Department, the Adult Protective Services, or the Comptroller of the State Treasury. An ACLF shall neither retaliate nor discriminate, because any person lawfully provides
information to these authorities cooperates with them or is subpoenaed to testify at a hearing involving them.
(2) In the event a resident dies at an ACLF, a registered nurse may make the actual determination and pronouncement of death under the following circumstances.
(a) Death was anticipated and the attending physician has agreed in writing to sign the death certificate. Such agreement by the attending physician must be present and with
the deceased at the place of death;
(b) The nurse is licensed by the Tennessee Board of Nursing; and
(c) The nurse is employed by the ACLF in which the deceased resided.
(3) In the event that a resident, receiving services of a Medicare-certified hospice program licensed by the state, dies at an ACLF, a registered nurse may make the actual determination and
pronouncement of death under the following circumstances:
(a) The deceased was suffering from a terminal illness;
(b) Death was anticipated and the attending physician has agreed in writing to sign the death certificate. Such agreement by the attending physician must be present and with
the deceased at the place of death;
(c) The nurse is licensed by the Tennessee Board of Nursing; and
(d) The nurse is employed by the hospice program from which the deceased had been receiving hospice services.
(4) An ACLF shall post the following at the main public entrance:
(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. (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 national 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 regarding whether it has liability insurance, the identity of their 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; and
(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 ACLF 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.
(5) Infection Control
(a) An ACLF shall ensure that neither a resident nor an employee of the ACLF with a reportable communicable disease shall reside or work in the ACLF unless the ACLF
has a written protocol approved by the Board’s administrative office.
(b) An Assisted-Care Living Facility 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 Assisted-Care Living Facility 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 nonparticipation; 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 ACLF 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 were 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 non-antimicrobial soap and water or 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 healthcare-associated infections.
(d) An ACLF shall develop and implement a system for measuring improvements in adherence to the hand hygiene program and influenza vaccination program.
(6) An ACLF 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 ACLF on the grounds of race, color, national origin, or handicap. An ACLF shall protect the civil rights of residents under the Civil Rights Act of 1964 and Section 504 of the
Rehabilitation Act of 1973.

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