Tennessee survey readiness

What Tennessee Department of Health — Health Care Facilities can ask you for, each line cited — and the ones you can't yet produce.

The building

Tennessee requirements loaded — the rules below are Tennessee’s own.

0 of 30 ready.

29 of the outstanding items are the ones a survey opens with.

TennesseeAssisted-Care Living Facility (ACLF)

What Tennessee Department of Health — Health Care Facilities can ask for, each cited. Checked July 2026.

Must be done, on a scheduleWhen did it last happen, and was that inside the interval?

Drills at the required frequency: Fire drills at least quarterly for each work shift, for personnel in EACH SEPARATE BUILDING, with one drill per quarter held during sleeping hours. Each drill needs a written report evaluating it and naming the action recommended or taken for any deficiency found.

Tenn. Comp. R. & Regs. 1200-08-25; Tenn. Code §68-11-236 (fire safety in assisted-care living facilities) · Tennessee Department of Health — Health Care Facilities · keep: Records documenting and evaluating drills maintained for at least 3 years.

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At least once a year the facility must coordinate a fire drill with its local fire department, and the fire department observes the drill and gives the facility input on its fire safety. This is a scheduled outside inspection of your response, not just a filing.

Tenn. Comp. R. & Regs. 1200-08-25 · Tennessee Department of Health — Health Care Facilities

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Records to retainHow far back can you produce the records?

Drills at the required frequency: Fire drills at least quarterly for each work shift, for personnel in EACH SEPARATE BUILDING, with one drill per quarter held during sleeping hours. Each drill needs a written report evaluating it and naming the action recommended or taken for any deficiency found.

Tenn. Comp. R. & Regs. 1200-08-25; Tenn. Code §68-11-236 (fire safety in assisted-care living facilities) · Tennessee Department of Health — Health Care Facilities · keep: Records documenting and evaluating drills maintained for at least 3 years.

Produce this →

Records documenting and evaluating drills maintained for at least 3 years.

Tenn. Comp. R. & Regs. 1200-08-25; Tenn. Code §68-11-236 (fire safety in assisted-care living facilities) · Tennessee Department of Health — Health Care Facilities · keep: Records documenting and evaluating drills maintained for at least 3 years.

Produce this →

Life-safety systems

The code-based tests a life-safety survey opens with. These are the starred ones — the full schedule is the compliance calendar.

Test record

NFPA 72 Table 14.4.3.2 (supervisory device testing) (2022) · national · keep: Minimum 5 years

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Certificate + inspection report

NFPA 72 §14.4 (annual ITM) (2022) · national · keep: Minimum 5 years

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Test record

NFPA 25 §5.3.3 / §13.7 (2023) · national · keep: Life of system

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Static + residual pressures; compare to prior; >10% drop investigated

NFPA 25 §5.3.3 (main drain quarterly where sole supply passes through backflow preventer or PRV) (2023) · national · keep: Life of system

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Pressures vs prior year

NFPA 25 §13.2.5 (2023) · national · keep: Life of system

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Written record for AHJ

NFPA 80 §5.2.1 (annual, 13 criteria) (2022) · national · keep: 3 years

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Report

NFPA 110 §8.3.1 (2022) · national · keep: Per authority

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Damper log with location, ID, pass/fail and corrective action.

NFPA 80 §19.4 / NFPA 105 Ch. 6 (2022) · national · keep: Until the next test, minimum 3 years

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Written report listing every damper by location with pass/fail

NFPA 80 §19.4 / NFPA 105 Ch. 6 (hospital 6-year interval) (2022) · national · keep: Until the next test, minimum 3 years

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Monthly firefighter service log.

ASME A17.1 §8.6.11.1 (2019) · state-governed · keep: Minimum 3 years

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Trip test report with trip time and water delivery time.

NFPA 25 §13.4.4.2.2 (3-year full trip) (2020) · national · keep: Minimum 3 years

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Tank inspection report.

NFPA 25 §9.2.6 (interior inspection) (2020) · national · keep: Until the next interior inspection

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Smoke control test report with fan and damper positions.

NFPA 92 §8.4.2 (dedicated: semiannual) (2021) · national · keep: Minimum 3 years

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Signed drill sheet: date, time, shift, participants, evacuation time.

NFPA 101 §19.7.1 / CMS LSC (2012) · national · keep: Survey cycle

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Signed drill sheet.

NFPA 101 §19.7.1 / CMS LSC (2012) · national · keep: Survey cycle

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Signed drill sheet.

NFPA 101 §19.7.1 / CMS LSC (2012) · national · keep: Survey cycle

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After-action report and improvement plan.

42 CFR §483.73(d)(2) (—) · national · keep: Minimum 3 years

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Signed HVA.

42 CFR §483.73(a)(1) (—) · national · keep: Minimum 3 years

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Dated plan revision.

42 CFR §483.73(a) (—) · national · keep: Minimum 3 years

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Dated plan revision and team roster.

ASHRAE 188 / CMS QSO-17-30 (2018) · national · keep: Survey cycle

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Readings against control limits.

ASHRAE 188 §7 (2018) · national · keep: Survey cycle

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Receptacle test record by room.

NFPA 99 §6.3.3.2 (12-month interval applies to receptacles not listed hospital grade) (2021) · national · keep: Minimum 3 years

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Rounds log.

NFPA 101 §19.3.6 (2012) · national · keep: Survey cycle

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Barrier log with locations.

NFPA 101 §19.3.7 (2012) · national · keep: Survey cycle

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Photo of posting with date.

29 CFR §1904.32(b)(6) (—) · national · keep: 5 years

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Temperature log by unit.

FDA Food Code §3-501.16 (cold holding, as adopted by your state) (2022) · state-governed · keep: Minimum 1 year

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Inspection report and corrective-action record.

Local AHJ (—) · local · keep: Minimum 3 years

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What Tennessee requires

Assisted-Care Living Facility (ACLF)Assisted living / residential care
  • Your fire and evacuation drill records for the period. Drills at the required frequency: Fire drills at least quarterly for each work shift, for personnel in EACH SEPARATE BUILDING, with one drill per quarter held during sleeping hours. Each drill needs a written report evaluating it and naming the action recommended or taken for any deficiency found. Tenn. Comp. R. & Regs. 1200-08-25; Tenn. Code §68-11-236 (fire safety in assisted-care living facilities)
  • Records going back as far as the rule requires. Records documenting and evaluating drills maintained for at least 3 years. Tenn. Comp. R. & Regs. 1200-08-25; Tenn. Code §68-11-236 (fire safety in assisted-care living facilities)
  • The fire department watches one drill a year. At least once a year the facility must coordinate a fire drill with its local fire department, and the fire department observes the drill and gives the facility input on its fire safety. This is a scheduled outside inspection of your response, not just a filing. Tenn. Comp. R. & Regs. 1200-08-25
Tennessee Department of Health — Health Care Facilities · checked July 2026

The evidence, and where it comes from

Every item above needs something you can hand over. The Tennessee fire drill log produces the drill record at the frequency this state sets, the emergency plan builder writes the plan itself from the same research, and the compliance calendar puts the life-safety tests on dates. Anything you record against the building shows up on the checklist already ticked.

A self-assessment against published rules, not a compliance determination. CompliMaint issues nothing — Tennessee Department of Health — Health Care Facilities and your authority having jurisdiction do. Requirements we could not verify are absent rather than guessed at.