1. (1) The administration of every facility shall have in effect and available for all supervisory personnel and staff, written copies of the following required disaster plans for the protection of all persons in the event of fire and other emergencies for evacuation to areas of refuge and/or evacuation from the building. A detailed log with staff signatures of training received shall be maintained. All employees shall be trained annually as required in the following plans and shall be kept informed with respect to their duties under the plans. A copy of the plans and the specific emergency numbers related to that type of disaster shall be readily available at all times. Each of the following plans shall be exercised annually:

   1. (a) Fire Safety Procedures Plan shall include:

      1. 1. Minor fires;
      2. 2. Major fires;
      3. 3. Fighting the fire;
      4. 4. Evacuation procedures;
      5. 5. Staff functions.

   2. (b) Tornado/Severe Weather Procedures Plan shall include:

      1. 1. Staff duties;
      2. 2. Evacuation procedures.

   3. (c) Flood Procedure Plan, if applicable:

      1. 1. Staff duties;
      2. 2. Evacuation procedures;
      3. 3. Safety procedures following the flood.

   4. (d) Earthquake Disaster Procedures Plan:

      1. 1. Staff duties;
      2. 2. Evacuation procedures;
      3. 3. Safety procedures;
      4. 4. Emergency services.

2. (2) Emergency Planning with Local Government Authorities.

   1. (a) All facilities shall establish and maintain communications with the county Emergency Management Agency. This includes the provision of the information and procedures that are needed for the local comprehensive emergency plan. The facility shall cooperate, to the extent possible, in area disaster drills and local emergency situations. CENTERS
   2. (b) Each facility shall conduct both the physical facility and community emergency drills as required in these regulations, even if the local Emergency Management Agency is unable to participate.
   3. (c) A file of documents demonstrating communications and cooperation with the local agency must be maintained.

3. (3) The emergency power system shall:

   1. (a) Use either propane, gasoline or diesel fuel. The generator shall be designed to meet the facility’s HVAC and essential needs and shall have a minimum of twenty-four (24) hours of fuel designed to operate at its rated load. The fuel quantity shall be based on its expected or known connected load consumption during power interruptions.
   2. (b) Automatically transfer within ten (10) seconds in ASTC’s conducting invasive surgical procedures.
   3. (c) Be inspected monthly and exercised at the actual load and operating temperature conditions and not on dual power for at least thirty (30) minutes each month, including automatic and manual transfer of equipment. A log shall be maintained for all inspections and tests and kept on file for a minimum of three (3) years. The facility shall have trained staff familiar with the generator’s operation.
   4. (d) Emergency generators are not required if the facility does not utilize anesthesia that renders the patient incapable of self preservation. However, the facility shall have an emergency power source able to produce adequate power to run required equipment for a minimum of two (2) hours.
4. (4) Emergency electrical power connections shall be through a switch which shall automatically transfer the circuits to the emergency power source in case of power failure. (It is recognized that some equipment may not sustain automatic transfer and provisions will have to be made to manually change these items from a non-emergency powered outlet to an emergency powered outlet or other power source.)
5. (5) In the event of natural disaster or electrical power failure, no new surgical procedures shall be begun, and surgical procedures in progress shall be brought to conclusion as soon as possible.

Authority: T.C.A. §§ 68-11-202, 68-11-204, 68-11-206, and 68-11-209. Administrative History: Original rule filed November 22, 1996; effective August 27, 1997. Repeal and new rule filed March 21, 2000; effective June 4, 2000. Amendment filed June 16, 2003; effective August 30, 2003. Transferred from chapter 1200-08-10 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed December 18, 2025; effective March 18, 2026.