1. (1) The governing body must ensure that a written policies and procedures manual is maintained. The manual must include the following elements: AND FACILITIES

   1. (a) A description of each facility service provided by the licensee. The description must include the hours of operation and admission and discharge criteria and rules for service recipients, if any;
   2. (b) An organizational chart or a statement which clearly shows or describes the lines of authority between the governing body, the chief executive officer, and the staff;
   3. (c) Policies and procedures which ensure that someone is delegated the authority to act in the absence of the individual responsible for the operation of the facility;

   4. (d) A schedule of fees currently charged to the service recipient, if any, for all services provided by the licensee, including a refund policy. The schedule shall include:

      1. 1. The fee or fees for each service, including any additional charges for services not covered by the basic service fee;
      2. 2. The process by which licensee will apply any governmental or other funds or donations to the fee or fees for services. This may include, but not be limited to, use of a service recipient’s food stamps as payment for his or her meals; use of federal, state or other funds or donations to finance all or part of the service recipient’s cost for services; or payments made to the agency for a service recipient’s participation in an employment or rehabilitation program to finance the cost of services provided; and,
      3. 3. The total cost of services to the service recipient;
   5. (e) A statement of service recipient rights and the grievance procedures to be followed when a suspected violation of service recipient rights has been reported. This statement shall, at a minimum, include those service recipient rights found in Rule 0940-05-06-.06 and, if applicable, 0940-05-06-.09;

   6. (f) Policies and procedures which ensure the confidentiality of service recipient information and which include the following provisions:

      1. 1. The facility staff must comply with applicable confidentiality laws and regulations, including, but not limited to, T.C.A. § 33-3-103; the Health Insurance Portability and Accountability Act of 1996; and federal alcohol and drug regulations found at 42 C.F.R. Part 2;
      2. 2. The service recipient must not be required to make public statements which acknowledge gratitude to the licensee or for the licensee’s facility services;
      3. 3. The service recipient must not be required to perform in public gatherings; and,
      4. 4. Identifiable photographs of the service recipient must not be used without the written and signed consent of the service recipient or the service recipient’s guardian;
   7. (g) A medication administration policy and control procedures for facilities involved in the administration of medication to service recipients or facilities that supervise the self- administration of medication by the service recipient; AND FACILITIES
   8. (h) The plans and procedures to be followed in the event of fire evacuation and natural disaster emergencies, including what the duties are of the employees assigned responsibility for those individuals not capable of self-preservation;
   9. (i) The plans and procedures to be followed in the event of an emergency involving service recipient care which will provide for emergency transportation of service recipients, emergency medical care, and staff coverage in such events;

   10. (j) A policy which prohibits service recipients, except those who may be certified by the Department as peer or family support specialists and who are working at a facility in that capacity, from having any of the following responsibilities:

       1. 1. Responsibility for the care of other service recipients;
       2. 2. Responsibility for the supervision of other service recipients unless on-duty/on- site staff are present; and,
       3. 3. Responsibilities requiring access to confidential information;
   11. (k) Policies and procedures to be followed in the reporting and investigation of suspected or alleged abuse, neglect, or other critical incidents, whether perpetrated by or on the service recipient by staff, other service recipients or outside parties. The procedures must include provisions for corrective action, if any, to be taken as a result of such reporting and investigation. These procedures shall also include provisions for reporting incidents or allegations to the Department and, when necessary other appropriate state agencies and local law enforcement;
   12. (l) Policies and procedures which ensure that volunteers, if used by the facility, are in a supportive capacity and are under the supervision of appropriate designated staff members. A record should be maintained on each volunteer which shall include the volunteer’s status on the Sexual Offender Registry (Sex Offender Registry) and Tennessee’s Vulnerable Adult Abuse Registry (Abuse Registry). A volunteer included on either the Abuse Registry or the Sex Offender Registry shall not work in an agency providing services to vulnerable adults or children. It is recommended that the volunteer’s record also include a criminal background check and references.
   13. (m) Policies and procedures which govern the use of service recipient behavior- management techniques, if used by the facility;

   14. (n) A policy regarding the use of human subjects in research, if the facility is involved or planning to be involved in such research, which includes procedures for the following:

       1. 1. Identification of subjects, projects and staff;
       2. 2. Provisions to protect the personal and civil rights of the subjects;
       3. 3. Obtaining the consent of the subject involved;
       4. 4. Assurance that all research projects are conducted under the direction and supervision of professional staff qualified by education and experience to conduct research;
       5. 5. Emergency guidelines for problems that may develop during research activities; and, AND FACILITIES
       6. 6. Appointment of a facility representative to act as a coordinator of the research activities;
   15. (o) Policies and procedures for ensuring that employees and volunteers comply with procedures for detection, prevention, and, if applicable, mandatory reporting of infectious and communicable diseases to the Tennessee Department of Health;
   16. (p) Policies and procedures ensuring that employees and volunteers practice infection control procedures and standard precautions to protect the service recipient from infectious diseases;
   17. (q) Policies and procedures regarding coordination of care with the service recipient’s other health, mental health, social, educational and residential service providers;
   18. (r) Policies and procedures describing the process by which the licensee will comply with Rule 0940-05-06-.03 Financial Management of All Services and Facilities, including process by which the service recipient or service recipient’s representative may register a complaint with the licensee to address the licensee’s holding and disbursement of service recipient’s funds or property;
   19. (s) Policies and procedures that address inappropriate relationships of a business, social, professional, romantic and sexual nature between the service recipient and the licensee, its staff and/or volunteers;
   20. (t) Policies and procedures that address sanctions against an employee for violations of the licensee’s policies and procedures and a process by which a complaint or grievance may be registered with the licensee;
   21. (u) Policies and procedures, as dictated by 0940-05-06-.10, should facilities serve parent or guardian service recipients whose minor children also reside with them in the same facility;
   22. (v) Policies and procedures shall be reviewed annually for determination of needed changes if deemed necessary by the governing body. Evidence of this review and determination shall be documented in the governing body minutes of the applicable meeting.
   23. (w) Policies and procedures assigning an employee to be responsible for each individual who is not capable of self-preservation, regardless of whether the individual is a service recipient or not; and
   24. (x) Licensees shall annually review their policies and procedures and make changes to them if deemed necessary by their governing body.

Authority: T.C.A. §§ 4-4-103, 33-1-302, 33-1-305, 33-1-309, and 33-2-404. Administrative History: Original rules filed May 26, 1988; effective July 11, 1988. Amendment filed May 28, 2010; to have been effective August 26, 2010. Stay of amendment filed by the Tennessee Department of Mental Health and Substance Abuse Services on July 21, 2010; new effective date November 9, 2010. Withdrawal of amendment filed August 2, 2010. Amendment filed August 30, 2010; to have been effective January 29, 2011. Stay of amendment filed by the Tennessee Department of Mental Health and Substance Abuse Services on January 29, 2011; new effective date March 7, 2011. Withdrawal of amendment filed by the Tennessee Department of Mental Health and Substance Abuse Services on February 25, 2011. Repeal and new rules filed November 30, 2016; effective February 28, 2017. Administrative corrections made to agency names in December 2022 pursuant to Public Chapter 575 of 2012. Amendments filed February 24, 2026; effective May 25, 2026. AND FACILITIES