(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.