Tennessee assisted-care living facility (ACLF) license: rules, fees and steps

What Tennessee means by an assisted-care living facility

Rule 0720-26-.02 defines an ACLF as “a building, establishment, complex or distinct part thereof that accepts primarily aged persons for domiciliary care and services.”⁠¹ The rule sets no minimum bed count. Two definitions limit who you can serve:

• Primarily aged. At least 51% of the people living in the facility must be 62 or older.⁠¹ The rest may be younger adults, but the 51% test applies to the whole facility.
• Resident mobility. An ACLF resident is primarily an aged person who needs domiciliary care. If the resident is not ambulatory, they must be able at admission to transfer from bed to a wheelchair or similar device and propel it without help.⁠¹ “Ambulatory” means able to bear weight, pivot and walk safely, with a cane or walker if needed. The resident must also be “physically and mentally capable of self-preservation by evacuating in response to an emergency.”⁠¹

Within those limits, a resident may receive room and board, non-medical help with activities of daily living, administration of typically self-administered medications, and medical services allowed by the rule.⁠¹ Every ACLF must provide at least protective care, safety while in the facility, daily awareness of each resident’s whereabouts, readiness to intervene in a crisis, room and board, and non-medical help with daily living.⁠¹

The rules moved to the HFC from the Department of Health under Public Chapter 1119 of 2022, effective July 1, 2022. The old rule number was 1200-08-25.⁠¹ The March 2026 rule text still refers to “the Board” and to “Department of Health” inspectors. In practice, you file with the HFC and its regional offices schedule your surveys.⁠²

ACLF or home for the aged?

The neighboring license is the Home for the Aged, sometimes called a residential home for the aged (RHA), under rule chapter 0720-21. It covers room, board and personal services for four or more unrelated people, at least 51% of them aged. Its personal services “do not include nursing or medical care.”⁠⁷ An ACLF may provide medical services within the limits described below.⁠¹

The fees are different too. A home for the aged with fewer than 6 beds pays $390 a year.⁠⁷ The smallest ACLF tier, under 25 beds, pays $1,040.⁠¹ If you plan a small house with no nursing services, read our Tennessee home for the aged guide first. The HFC uses one administrator certification for both facility types.⁠⁴

No certificate of need

The HFC’s certificate-of-need page lists the healthcare institutions that need a CON before they open, including hospitals, nursing homes and home care organizations. Assisted-care living facilities are not on the list, and the page expressly excludes the home for the aged.⁠⁶ You do need a CON to provide home health or hospice services.⁠⁶ This matters if you plan to run a home care organization next to the ACLF; see our Tennessee home care organization guide.

Who you can admit, keep and must discharge

Admission limits are set in rule 0720-26-.08, and rule 0720-26-.05 lets the Board impose a civil penalty of up to $3,000 for each resident admitted or kept inappropriately.⁠¹

You may not admit or keep anyone who:⁠¹

• needs treatment for stage III or IV decubitus ulcers, or has exfoliative dermatitis
• needs continuous nursing care
• has an active, reportable infectious disease that requires contact isolation
• shows verbal or physical aggression that poses an imminent physical threat, judged “based on behavior, not diagnosis”
• needs physical or chemical restraints (psychotropic medication for a manageable mental disorder is not counted as a restraint)
• has needs the facility cannot meet safely and effectively

You may admit and keep someone who meets the level of care for a nursing facility in two cases. The treating physician must certify in writing that the ACLF can meet the person’s needs safely, and you must be able to assure timely evacuation in a fire or emergency.⁠¹

Some treatments block new admissions but not continued stays. You may not admit a resident who needs nasopharyngeal or tracheotomy aspiration, nasogastric or gastrostomy feedings, or IV therapy. A current resident may get these treatments intermittently for up to three 21-day periods. The physician must certify the last two periods.⁠¹ The treatments may continue indefinitely in three cases: the resident is on hospice, the resident does not qualify for nursing facility care and the Board grants a waiver, or the resident manages the treatment without help.⁠¹ Hospice residents may stay when their physician certifies that care can be given in the ACLF. The hospice and the ACLF share responsibility for the plan of care.⁠¹

What medical care the facility may give

An ACLF may give medical services that a private citizen could receive at home. Examples include part-time or intermittent nursing, therapies, podiatry, medical social services, durable medical equipment and hospice.⁠¹ IV medications are limited to existing residents who receive them intermittently and to hospice residents.⁠¹ These services may come from your own licensed staff, contractors, a licensed home care organization, another licensed entity, or nursing home staff. Medicare-reimbursable services must come from a certified Medicare provider.⁠¹

Medication rules:⁠¹

• A licensed or certified health care professional must administer medication, within the scope of their license.
• A medication aide who is administering medications may not be given other duties, except to respond to an emergency.
• All medications must be locked or closed away, out of sight of other residents.
• Staff may not repackage medication.
• You need a medication disposal policy written to FDA or DEA guidelines. Residents or their representatives get a copy before admission.

Admission paperwork the rule requires

Before admission or before a care contract is signed, whichever comes first, you must disclose in writing:⁠¹

• whether you carry liability insurance and who the primary carrier is (or which entity pays claims if you self-insure)
• your medication disposal policy

You also need:⁠¹

• a written admission agreement that covers transfers and discharges
• an accurate written statement of fees and services
• a 30-day notice to all residents before any fee change
• a signed copy of resident rights for each resident
• an assessment by a direct care staff member within 72 hours of admission
• a plan of care within 5 days, reviewed at least every six months
• documented influenza vaccination for each resident each year, plus pneumococcal vaccination for residents 65 and older, unless refused or medically contraindicated

The building: plans review before construction

In Tennessee, the building usually takes longer to approve than the paperwork. Rule 0720-26-.09 has you submit construction plans after you file the application and license fee.⁠¹ No new ACLF may be built, and no major alteration made, without approved plans.⁠¹ The HFC’s procedure sheet says this applies to existing buildings too: “If it is an existing building, you will need to make any renovations that the plans reviewer has indicated.”⁠²

The plans must:⁠¹

• be prepared by or under a Tennessee-licensed architect or engineer
• be submitted as two complete sets, drawn at least at 1/8 inch = 1 foot
• include architectural, structural, mechanical, electrical and sprinkler drawings

The design must meet:⁠¹

• the International Building Code, excluding Chapters 1 and 11
• NFPA 101 Life Safety Code
• the FGI Guidelines for Design and Construction of Health Care Facilities
• the U.S. Public Health Service Food Code
• the ADA Standards for Accessible Design

Where these conflict with local codes, the strictest rule applies. The code editions in effect when you submit plans govern the whole project.⁠¹ The 2025 submittal form, PH-4096, asks for the occupancy type under the 2021 edition of NFPA 101 and the construction type under the 2021 edition of the IBC.⁠⁵

Source: ⁠⁵. Round the construction cost up to the next $1,000. The fee must be paid before review.⁠⁵

If construction starts within 180 days of approval, the HFC’s written notice of satisfactory review stands as your plan approval.⁠¹ Before the final inspection, you submit the final approved plans on a CD in TIF or PDF format, including shop drawings and sprinkler calculations.⁠¹ The Tennessee Department of Environment and Conservation must approve the water supply before the building is used.⁠¹

Room sizes and fixtures

Rule 0720-26-.09(18) sets these minimums:⁠¹

• at least 80 square feet of bedroom space per resident
• no more than two beds in a bedroom, with privacy screens or curtains on request
• living and dining areas big enough for all residents, with at least 15 square feet per resident per dining area
• no more than six people per toilet, sink, bath or shower, with grab bars and non-slip surfaces at tubs and showers
• hot water at showers, baths and hand-washing sinks between 105°F and 115°F

Fire alarms, and generators if you have them, must be monitored 24 hours a day.⁠¹

The 13-minute evacuation line

When you submit plans, you must state your residents’ evacuation capability as defined by NFPA. “This declaration will determine the design and construction requirements of the facility.”⁠¹ Rule 0720-26-.08(8) then sets a hard limit: you may not keep a resident who cannot evacuate within 13 minutes. The exception is a building that meets Chapter 19 of the 2006 NFPA Life Safety Code and the Institutional Unrestrained Occupancy of the 2006 International Building Code.⁠¹

If you expect residents to become frailer over time, decide on the construction standard before the architect starts. Otherwise you may have to discharge residents later.

Ongoing fire safety rules in 0720-26-.10:⁠¹

• Each sleeping unit door opens to the outside or to a corridor leading directly to an exit, and the resident can always unlock it.
• No open flames or portable space heaters.
• Electrically powered smoke detectors with battery backup in sleeping units, day rooms, corridors, laundry and hazardous areas.
• A fire drill for each work shift in each building at least quarterly, and one drill each quarter during sleeping hours.

The administrator certificate

Every ACLF needs an administrator certified by the HFC. The only exception is an administrator who holds a Tennessee nursing home administrator license.⁠¹ To be certified, an applicant must:⁠¹

• be at least 21
• hold a high school diploma or GED
• submit criminal background check results
• show no conviction for abuse or intentional neglect of an elderly or vulnerable person

The application (HF-3203) must be notarized. Attach proof of education, proof of birth and a basic criminal background check. Send it with the $180 nonrefundable fee by check or money order payable to the Health Facilities Commission.⁠⁴ The form says certification takes effect on the date the HFC receives it, and the certificate should arrive within 5 to 7 business days.⁠⁴

The first certification period lasts at least 1½ and at most 2½ years and ends on June 30.⁠⁴ After that, the certificate renews every two years on June 30.⁠¹ Each renewal requires 24 classroom hours of continuing education in the past two years. The courses must be approved in advance and cover these topics:⁠¹

• state ACLF rules
• health care management
• nutrition and food service
• financial management
• healthy lifestyles

Courses from the National Association of Boards of Examiners for Nursing Home Administrators (NAB) and geriatric-focused association courses count as approved.⁠¹ If the administrator leaves because of serious illness, incapacity, death or resignation, you must notify the HFC immediately.⁠¹

Staffing the facility

Tennessee sets no numeric staff-to-resident ratio for an ACLF’s general population. Rule 0720-26-.06 requires the following instead:⁠¹

• A responsible attendant who is “alert and awake at all times,” plus enough staff to meet residents’ needs, including prescribed medical services. Attendants and direct care staff must be at least 18.
• A licensed nurse available as needed.
• A qualified dietitian, full-time, part-time or as a consultant, and an employee who directs food service. The facility must serve at least three meals a day, with no more than 14 hours between the evening meal and breakfast. Menus are planned one week ahead.
• No one on the Abuse Registry may be employed.
• A named substitute. The licensee designates in writing a responsible person who acts for the licensee in their absence.

If the licensee is an individual, they must be at least 18, of reputable character, and have enough money and income to meet residents’ needs.⁠¹ Each year you must offer influenza vaccination to staff and run a hand hygiene program that follows CDC standard precautions.⁠¹ Every employee must also receive disaster-plan training each year, recorded in a signed log.⁠¹

Secured (memory care) units

Tennessee has no separate memory care license. An ACLF may operate a “secured unit,” a distinct part of the facility where residents are deliberately denied exit except as life safety codes require.⁠¹ The initial application asks whether you will have one and how many secured beds.⁠² At each annual survey, you must show 12 months of records for the unit:⁠¹

• Before admission, a team of at least a physician, a registered nurse and a family member or advocate evaluated each resident.
• The team reviews each resident’s placement every quarter.
• Deaths and hospitalizations, with diagnoses.
• Unusual incidents.
• Decubitus and infection incidents.
• An activity calendar and three months of attendance records.
• A daily staffing record showing at least one awake attendant on the unit 24 hours a day, 7 days a week.
• Annual in-service training for 100% of unit staff on Alzheimer’s disease and related disorders, behaviors, safety, daily living help and family communication.

Applying: the order the HFC uses

The HFC’s procedure sheet for a new ACLF (HF-3501, rev. 10/2025) sets this sequence:⁠²

1. File the notarized application and fee

   Include a financial statement prepared by a certified public accountant, your local business license if your city or county requires one, and documents showing the owner’s legal status. A corporation or LLC also needs a certificate of good standing.⁠¹⁠²

2. Get plans approved, then build or renovate

   Plans go to the HFC Plans Review Section, signed and sealed by an architect or a Tennessee-licensed engineer.⁠²

3. Request the life safety and health surveys

   When construction is finished, send the request to the HFC regional office for your area. Under Public Chapter 1019 (2024), the life safety inspection must be completed within 10 days of receiving the request.⁠²

4. Pass the health survey

   It follows within 30 to 45 days of the life safety survey. Have your policies ready: the HFC warns that if you are not ready, rescheduling will “most likely be thirty (30) days or more.”⁠²

5. Get the surveyor’s recommendation

   The surveyor sends occupancy forms to the Regional Director and then to the Central Office Licensure Unit in Nashville.⁠²

6. Wait for the initial approval letter

   “Residents cannot be admitted to your facility until you have received an initial approval letter.”⁠²

7. Commission ratification

   The application goes to the next regular Commission meeting. After ratification, the license should arrive in 7 to 10 days. If the Commission does not ratify, your authorization ends and the HFC sends a letter explaining review options.⁠²

The application form also asks about:⁠²

• bed capacity, secured beds, adult day care beds and pet therapy
• any criminal convictions of the administrator
• who owns the building
• parent and holding companies, and any management contract
• for owners and any other health facilities they own: license denials, exclusions, Medicare or Medicaid terminations, fraud settlements, corporate integrity agreements, bankruptcies, and civil money penalties of $250,000 or more

A license covers only the named licensee and location. A separate license is needed for each facility, and you may not admit more residents than your licensed bed count.⁠¹ The rule also bars “subterfuge,” such as filing through a second party after a denial.⁠¹

Policies and postings the surveyors check

Before the health survey, have these written policies:⁠¹

• residents’ responsibilities and the facility’s, with a grievance procedure
• a facility-wide performance improvement plan
• a smoking policy for residents
• a charity care statement, posted where the public can see it
• policies on advance directives, living wills, do-not-resuscitate orders and health care powers of attorney
• disaster plans for fire, tornado and severe weather, bomb threats, flooding if applicable, severe heat and cold, and earthquakes; each plan is exercised every year
• a resident log you can produce in an emergency

At the main public entrance, post:⁠¹

• an Adult Protective Services notice on a sign at least 11 by 17 inches
• the national domestic violence hotline on a sign at least 8½ by 11 inches
• a liability insurance statement on a sign at least 11 by 17 inches
• “No Smoking” signs at every entrance
• the complaint line for licensed facilities

You must also keep up communication with the county Emergency Management Agency.⁠¹

Fees as published

Sources: ⁠¹⁠². Facilities run by the United States or the State of Tennessee are exempt. You pay the fee with each application and renewal, and it is not refundable.⁠¹ Add the $180 administrator certification fee and the plans review fee shown above.⁠¹⁠⁵

Getting paid through TennCare CHOICES

TennCare’s CHOICES program covers “Assisted Care Living Facility (ACLF) Services.” These are community-based residential alternatives to nursing facility care: meals, personal care, homemaker and supportive services, and health care including medication oversight. Coverage “shall not include the costs of Room and Board.”⁠⁸ Residents or their families pay the room-and-board share. Several CHOICES services, including attendant care, companion care, home-delivered meals and personal emergency response systems, cannot be provided to members living in an ACLF.⁠⁸

To be credentialed as a TennCare provider, an ACLF must comply with the federal Home and Community Based Services (HCBS) Settings Rule. ACLFs that do not comply cannot be credentialed for Medicaid payment.⁠² Neither the HFC procedure sheet nor TennCare rule 1200-13-01 sets out how an ACLF contracts with a TennCare managed care organization or what rate it is paid for ACLF services. Before you build a business plan around CHOICES, ask TennCare and each MCO for the credentialing steps and the current ACLF rate.

Inspections, renewal and ownership changes

• Surveys. Inspectors make an unannounced inspection within 15 months of the last one. You must let them in at any hour and produce all records.⁠¹ After a statement of deficiencies, you have 10 days to return a plan of correction. The plan must say how and by when each deficiency will be fixed and how you will keep it from recurring.⁠¹
• Renewal. The license expires each year on the anniversary of its first issue. A late renewal within 60 days costs $100 per month or part of a month, capped at twice the renewal fee. After 60 days you must reapply and be inspected again.⁠¹ The HFC posts a separate ACLF renewal application.⁠³
• Reports. You must report abuse, neglect and misappropriation, staff strikes, external disasters, loss of vital services, and qualifying fires. You must also file the Joint Annual Report of Assisted Care Living Facilities.⁠¹
• Change of ownership. File the CHOW application at least 30 days ahead. Include the fee, a CPA financial statement, formation documents and the bill of sale or closing documents.⁠¹ The rule treats these as ownership changes: a transfer of title, a lease of operations, adding or removing a partner, and some mergers. Corporate stock sales are not ownership changes, even when control passes. Neither is a management contract under which the owner keeps ultimate authority.⁠¹
• Moving. A move needs a new license and an inspection of the new building before any resident moves in.⁠¹

Penalties

The Board may impose civil penalties under this schedule:⁠¹

• up to $1,000 for violations of the room-and-board, medical-services, care-plan, records and fire-safety provisions of T.C.A. § 68-11-201
• up to $3,000 for each resident admitted or kept inappropriately
• up to $5,000 for each day you run an ACLF without a license

Each violation is a separate offense. The Board may also deny, suspend or revoke a license. Appeals go through the Uniform Administrative Procedures Act.⁠¹

You can reach the HFC Licensure Unit at 502 Deaderick Street, Andrew Jackson Building, 9th Floor, Nashville, TN 37243, (615) 741-7221.⁠⁴ If you plan to add day services for non-residents, compare the Department of Human Services route in our Tennessee adult day services center guide. For in-home help outside the facility, see the personal support services agency guide.

Sources

1. 1
   Tennessee Secretary of State, Division of Publications, Rule chapter 0720-26, Standards for Assisted-Care Living Facilities (March 2026 revision) Checked 12 Oct 2026 · Back to text ↑
2. 2
   Tennessee Health Facilities Commission, Assisted Care Living Facilities: Procedures for Applying and Application for Initial Licensure (HF-3501, rev. 10/2025) Checked 12 Oct 2026 · Back to text ↑
3. 3
   Tennessee Health Facilities Commission, Licensure Applications Checked 12 Oct 2026 · Back to text ↑
4. 4
   Tennessee Health Facilities Commission, Home for the Aged/Assisted Care Living Facility Administrator Application (HF-3203) Checked 12 Oct 2026 · Back to text ↑
5. 5
   Tennessee Health Facilities Commission, Plans Review Submittal Form (PH-4096, rev. 10-21-2025) Checked 12 Oct 2026 · Back to text ↑
6. 6
   Tennessee Health Facilities Commission, Certificate of Need Basics Checked 12 Oct 2026 · Back to text ↑
7. 7
   Tennessee Secretary of State, Division of Publications, Rule chapter 0720-21, Standards for Homes for the Aged (March 2026 revision) Checked 12 Oct 2026 · Back to text ↑
8. 8
   Tennessee Secretary of State, Division of Publications, Rule chapter 1200-13-01, TennCare Long-Term Care Programs (October 2025 revision) Checked 12 Oct 2026 · Back to text ↑

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