Let’s face it- inspection time is extremely stressful! No matter how much you have prepared or how long you have been in the “industry” when an inspector shows up to your community it can be a nerve-wracking experience. In the state of Tennessee, the OHCF can show up anytime they see fit to conduct an inspection of every nook and cranny of the facility. Be prepared, be cordial and be open with inspectors and you will certainly have a much better experience.
1200-08-25-.05 REGULATORY STANDARDS.
(1) A Department of Health representative shall make an unannounced inspection of every ACLF 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. An ACLF must cooperate during Department of Health conducted inspections, including allowing entry at any hour and providing all required records.
(2) Plan of Correction. When Department of Health inspectors find that an ACLF has committed a violation of this chapter, the Department of Health, as the Board’s representative, will issue a statement of deficiencies to the ACLF. Within ten (10) days of receipt of the statement of deficiencies, the ACLF 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.
(3) 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 ACLF’s license to disciplinary action.
(4) Upon a finding by the Board that an ACLF 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 impose a civil penalty, deny, suspend, or revoke its license.
(5) Civil Penalties. The Board may, in a lawful proceeding respecting licensing (as defined in the Uniform Administrative Procedures Act), in addition to or in lieu of other lawful disciplinary action, assess civil penalties for violations of statutes, rules, or orders enforceable by the Board in accordance with the following schedule:
T.C.A. § 68-11-201(4)(B) $0-$1000
(Provision of Room and Board and
Non-Medical Living Assistance Services)
T.C.A. § 68-11-201(4)(C) $0-$1000
(Provision of Medical and
other Professional Services;
Oversight of Medical Services; P
lan of Care & Assessment;
Personal and Medical Records; and, Fire Safety)
T.C.A. § 68-11-213(i)(2) $0-$3000
(Admission or Retention of
Inappropriately Placed Resident
Each resident shall constitute a separate violation. )
T.C.A. § 68-11-213(i)(1) $0-$5000
(Operating ACLF without Required License.
Each day of operation shall constitute a separate violation.)
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.
(6) Each violation of any statute, rule, or order enforceable by the Board shall constitute a separate and distinct offense and may render the ACLF committing the offense subject to a separate penalty for each violation.
(7) A licensee may appeal any disciplinary action taken against it in accordance with the Uniform Administrative Procedures Act, Tennessee Code Annotated § 4-5-101, et seq.
(8) 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.
- (2) Plan of Correction. When Department of Health inspectors find that an ACLF has committed a violation of this chapter, the Department of Health, as the Board’s representative, will issue a statement of deficiencies to the ACLF. Within ten (10) days of receipt of the statement of deficiencies, the ACLF must return a plan of correction including the following: A-D
A plan of correction is a really good tool to use to make quantitative changes to your facility operations. Ask for your team’s input as to how you can correct the deficiency, this will go a long way towards buy-in of your plan of improvement. Make sure to submit this in a timely manner to avoid further escalation.