This chapter establishes life safety and fire code requirements for all facilities licensed by the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS). It classifies facilities into occupancy types—Health Care, Business, and Residential Board and Care/One- and Two-Family Dwellings—and specifies applicable National Fire Protection Association Life Safety Code standards for each. Covered facility types explicitly named include mental health hospital facilities, crisis stabilization facilities, mental health outpatient facilities, alcohol and drug non-residential and residential facilities, methadone non-residential facilities, outpatient detoxification facilities, psychosocial facilities, day treatment facilities, and mental health residential facilities. Operators must comply with fire safety requirements including egress standards, smoke detectors, fire extinguishers, fire drills, and self-preservation assessments for service recipients.
View official sourceMay, 2026 (Revised) 1 RULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES OFFICE OF LICENSURE CHAPTER 0940-05-04 LIFE SAFETY LICENSURE RULES TABLE OF CONTENTS 0940-05-04-.01 Life Safety Requirements 0940-05-04-.02 Health Care Occupancies 0940-05-04-.03 Educational Occupancies 0940-05-04-.04 Business Occupancies 0940-05-04-.05 Repealed 0940-05-04-.06 Residential Occupancies - Board and Care 0940-05-04-.07 Residential Occupancies - One- and Two-Family Dwellings (Two or Three Service Recipients) 0940-05-04-.08 Personal Care Defined 0940-05-04-.09 Mobile Non-Ambulatory Rule 0940-05-04-.10 Capable of Self-Preservation Rule 0940-05-04-.11 Repealed 0940-05-04-.01 LIFE SAFETY REQUIREMENTS. For purposes of life safety, facilities licensed by the Tennessee Department of Mental Health and Substance Abuse Services are required to meet adopted Code standards currently in use by the Office of the State Fire Marshal as set forth in Chapter 0780-02-02 of the rules of the Department of Commerce and Insurance. The Office of Licensure will give adequate notice of any proposed changes in Rule 0780- 02-02-.01 to all licensees and applicants. Authority: T.C.A. §§ 4-4-103, 33- 1-302, 33- 1-305, 33- 1-309, and 33- 2-404. Administrative History: Original rule filed November 16, 1978; effective January 1, 1979. Amendment filed May 22, 1979; effective July 10, 1979. Repeal and new rule filed June 30, 1986; effective July 30, 1986. 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. 0940-05-04-.02 HEALTH CARE OCCUPANCIES. (1) Definition. Health Care Occupancies are those used for purposes such as medical or other treatment or care of persons suffering from physical or mental illness, disease, or infirmity; and for the care of infants, convalescent s, or infirm aged persons. Health Care Occupancies provide sleeping facilities for the occupants or are occupied by persons who are mostly incapable of self -preservation because of age, physical or mental disability, or because of security measures not under the occupants’ control. Examples of facilities required to meet health care occupancy standards are the following: (a) Mental Health Hospital Facility (b) Crisis Stabilization Facility (c) Any residential facility serving four (4) or more persons who are not capable of self - preservation and any non- residential facility serving four (4) or more persons six (6) years of age or older who are not capable of self -preservation (as defined at 0940- 05- 04-.10). For the purposes of occupancy rating, minor individuals residing with parents shall not count towards persons who are not capable of self-preservation. (2) Criteria. For the purpose of life safety, facilities required to meet Health Care Occupancies must comply with the applicable standards of the Life Safety Code of the National Fire Protection Association, 1985 Edition, Health Care Occupancies, Chapter 12 (new) or Chapter LIFE SAFETY LICENSURE RULES CHAPTER 0940-05-04 (Rule 0940-05-04-.02, continued) May, 2026 (Revised) 2 13 (existing) or equivalent standards hereafter adopted by the Office of the State Fire Marshal. Authority: T.C.A. §§ 4-4-103, 33- 1-302, 33- 1-305, 33- 1-309, and 33- 2-404. Administrative History: Original rule filed November 16, 1978; effective January 1, 1979. Amendment filed February 1, 1979; effective March 17, 1979. Amendment filed May 22, 1979; effective July 10, 1979. Repeal and new rule filed June 30, 1986; effective July 30, 1986. Amendment filed October 14, 1986; effective November 28, 1986. Amendment filed March 19, 1996; effective June 2, 1996. Amendments filed February 24, 2026; effective May 25, 2026. 0940-05-04-.03 EDUCATIONAL OCCUPANCIES. (1) Any and all references to Chapter 0940- 05 that pertain to Section 0940- 05-04-.03, Educational Occupancies, shall be construed to refer to Section 0940- 05-04-.04, Business Occupancies. Authority: T.C.A. § § 4-4-103, 33- 1-302, 33- 1-305, 33- 1-309, and 33- 2-404. Administrative History: Original rule filed November 16, 1978; effective January 1, 1979. Repeal and new rule filed June 30, 1986; effective July 30, 1986. Amendments filed February 24, 2026; effective May 25, 2026. 0940-05-04-.04 BUSINESS OCCUPANCIES. (1) Definition. Business Occupancies are those used for the transaction of business (other than that covered under Mercantile), for the keeping of accounts and records, and similar purpose. Examples of facilities required to meet business occupancy standards are the following: (a) Mental Health Outpatient Facility (b) Alcohol and Drug Abuse Non-Residential Facility (c) Methadone Non-Residential Facility (d) Alcohol and Drug Outpatient Detoxification Facility (e) Psychosocial Facility (f) Day Treatment Facility (2) Criteria. For the purpose of life safety, facilities required to meet Business Occupancies must comply with the applicable standards of the Life Safety Code of the National Fire Protection Association, 1985 Edition, Business Occupancies, Chapter 26 (new) or Chapter 27 (existing) or equivalent standards hereafter adopted by the Office of the State Fire Marshal. Authority: T.C.A. §§ 4 -4-103, 33- 1-302, 33- 1-305, 33- 1-309, and 33- 2-404. Administrative History: Original rule filed November 16, 1978; effective January 1, 1979. Amendment filed February 1, 1979; effective March 17, 1979. Amendment filed May 22, 1979; effective July 10, 1979. Repeal and new rule filed June 30, 1986; effective July 30, 1986. Amendments fil ed February 24, 2026; effective May 25, 2026. 0940-05-04-.05 REPEALED. Authority: T.C.A. §§ 33-1-302, 33-1-303, 33-1-305, and 33-2-504. Administrative History: Original rule filed November 16, 1978; effective January 1, 1979. Amendment filed May 22, 1979; effective July 10, 1979. Repeal and new rule filed June 30, 1986; effective July 30, 1986. Repeal filed November 25, 2024; effective February 23, 2025. LIFE SAFETY LICENSURE RULES CHAPTER 0940-05-04 May, 2026 (Revised) 3 0940-05-04-.06 RESIDENTIAL OCCUPANCIES - BOARD AND CARE. (1) Definition. Board and Care facilities include a building or part thereof that is used for the lodging and boarding of four (4) or more residents, not related by blood or marriage to the owner or operator, to provide care services. Examples of facilities required to meet board and care occupancy standards are the following: (a) Mental Health Residential Facility (b) Alcohol and Drug Residential Facility (2) Criteria. For the purpose of life safety, facilities required to meet Board and Care occupancy must comply with the following: (a) Applicable standards of the Life Safety Code of the National Fire Protection Association, 1985 Edition, Residential Board and Care Occupancies, Chapter 21, or equivalent standards hereafter adopted by the Office of the State Fire Marshal, and 1. Provide at least two hundred (200) square feet, gross, of occupiable space per service recipient, (i) A minor residing with their parent or guardian at the facility does not meet the definition of a service recipient. 2. Provide at least: (i) Eighty (80) square feet per service recipient bedroom space for single occupancy, or (I) A minor residing with their parent or guardian at the facility does not meet the definition of a service recipient. (ii) Sixty (60) square feet per service recipient bedroom space for multiple occupancy, 3. Not allow multiple occupancy which exceeds four (4) service recipients per bedroom, and (i) A minor residing with their parent or guardian at the facility does not meet the definition of a service recipient. 4. Equip any stairways with emergency lighting, 5. Provide emergency lighting in any corridors as means of egress, 6. Not use unvented gas heaters, 7. Use portable electric space heaters only in emergency situations, and as appropriate under fire code standards, 8. Allow the use of fireplaces only under the following conditions: (i) For recreation or therapy only, (ii) Not used as a primary source of heat, LIFE SAFETY LICENSURE RULES CHAPTER 0940-05-04 (Rule 0940-05-04-.06, continued) May, 2026 (Revised) 4 (iii) Used in activity or living rooms, (iv) Under proper supervision and in accordance with specific written fire safety procedures, and (v) Fireplaces may be installed and used only in areas other than service recipient sleeping areas, provided the fireplace is equipped with a heat - tempered glass fireplace enclosure guaranteed against breakage up to a temperature of 650 degrees Fahrenheit. 9. Allow the use of portable cooking devices in the kitchen only, 10. Document fire safety drills which shall be conducted: (i) Monthly at unexpected times and under varying conditions, and (ii) Under direct staff supervision; 11. Provide a functioning UL rated battery-operated smoke detector in each bedroom occupied by the resident and document that all smoke- detection devices are tested monthly and that batteries are changed when no longer operating, but at least yearly; 12. Provide operable 2A -10B, C multi -purpose fire extinguishers in a fixed location and readily accessible for use in the facility, and document that all fire extinguishers are properly maintained and serviced. The facility shall consult with the fire authority of jurisdiction on the number of fire extinguishers required in a particular facility and document the recommendation. 13. Document instructions to staff upon employment and service recipients upon enrollment in fire evacuation procedures; 14. Adopt and post a policy on smoking in specified areas, except that no smoking shall be allowed within residential bedrooms; 15. Suspended unit electric heaters may be used, except in means of egress and service recipient sleeping areas, provided such heaters are located high enough to be out of the reach of persons using the area and provided the heaters are equipped with appropriate safety devices and as acceptable by fire code. 16. Use extension cords only on a limited basis and under the conditions acceptable to the Office of Licensure of the department. 17. In facilities where minors are residing with parents or guardians, only the parent or guardian shall be assigned to the room where the minor resides. Facilities shall request licensure approval via waiver request for multiple occupancy if they believe their arrangement justifies such a scenario. (b) Serve only persons who require no greater level of care than personal care (as defined at 0940-05-04-.08). (c) Facilities shall maintain proper storage and safeguards for all flammable materials. Authority: T.C.A. § § 4-4-103, 33- 1-302, 33- 1-305, 33- 1-309, and 33- 2-404. Administrative History: Original rule filed November 16, 1978; effective January 1, 1979. Amendment filed May 22, 1979; effective July 10, 1979. Repeal and new rule filed June 30, 1986; effective July 30, 1986. Amendment LIFE SAFETY LICENSURE RULES CHAPTER 0940-05-04 (Rule 0940-05-04-.06, continued) May, 2026 (Revised) 5 filed October 14, 1986; effective November 28, 1986. Amendments filed February 24, 2026; effective May 25, 2026. 0940-05-04-.07 RESIDENTIAL OCCUPANCIES - ONE- AND TWO -FAMILY DWELLINGS (TWO OR THREE SERVICE RECIPIENTS). (1) Definitions. One- and Two- Family Dwellings (Two or Three Service Recipients) includes buildings in which each living unit is occupied by members of a single family or facility staff with no more than three outsiders. Examples of facilities required to meet one- and two-family dwelling occupancy standards are the following: (a) Mental Health Residential Facility (b) Alcohol and Drug Residential Facility (2) Criteria. For the purpose of life safety, facilities required to meet one- and two-family dwelling occupancy must comply with the following: (a) Applicable standards of the Life Safety Code of the National Fire Protection Association, 1985 Edition, One and Two- Family Dwellings, Chapter 22, or equivalent standards hereafter adopted by the Office of the State Fire Marshal, and 1. Provide at least two hundred (200) square feet, gross, of occupiable space per service recipient, (i) A minor residing with their parent or guardian at the facility does not meet the definition of a service recipient. 2. Provide at least: (i) Eighty (80) square feet per service recipient bedroom space for single occupancy, or (I) A minor residing with their parent or guardian at the facility does not meet the definition of a service recipient. (ii) Sixty (60) square feet per service recipient bedroom space for multiple occupancy, 3. Not allow multiple occupancy which exceeds four (4) service recipients per bedroom, and (i) A minor residing with their parent or guardian at the facility does not meet the definition of a service recipient. 4. Equip any stairways with emergency lighting, 5. Provide emergency lighting in any corridors as means of egress, 6. Not use unvented gas heaters, 7. Use portable electric space heaters only in emergency situations with advance special permission and under conditions specified by the Office of Licensure. 8. Allow the use of fireplaces only under the following conditions: LIFE SAFETY LICENSURE RULES CHAPTER 0940-05-04 (Rule 0940-05-04-.07, continued) May, 2026 (Revised) 6 (i) For recreation or therapy only, (ii) Not used as a primary source of heat, (iii) Used in activity or living rooms, (iv) Under proper supervision and in accordance with specific written fire safety procedures; and (v) Fireplaces may be installed and used only in areas other than service recipient sleeping areas, provided the fireplace is equipped with a heat - tempered glass fireplace enclosure guaranteed against breakage up to a temperature of 650 degrees Fahrenheit. 9. Allow the use of portable cooking devices in the kitchen only, 10. Document fire safety drills which shall be conducted: (i) Monthly at unexpected times and under varying conditions, and (ii) Under direct staff supervision; 11. Provide a functioning UL rated battery-operated smoke detector in each bedroom occupied by the resident and document that all smoke- detection devices are tested monthly and that batteries are changed when no longer operating, but at least yearly; 12. Provide operable 2A -10B, C multi -purpose fire extinguishers in a fixed location and readily accessible for use in the facility, and document that all fire extinguishers are properly maintained and serviced. The Office of Licensure will determine the number of fire extinguishers required in a particular facility. 13. Document instructions to staff upon employment and service recipients upon enrollment in fire evacuation procedures; 14. Adopt and post a policy on smoking in specified areas, except that no smoking shall be allowed within residential bedrooms; 15. Suspended unit electric heaters may be used, except in means of egress and service recipients sleeping areas, provided such heaters are located high enough to be out of the reach of persons using the area and provided the heaters are equipped with appropriate safety devices and are approved for use by the Office of Licensure of the department. 16. Use extension cords only on a limited basis and under the conditions acceptable to the Office of Licensure of the department. 17. In facilities where minors reside with parents or guardians, only the parent or guardian shall be assigned to the room where the minor resides. Facilities shall request licensure approval via waiver request for multiple occupancy if they believe their arrangement justifies such a scenario. (b) Serve only persons who require no greater level of care than personal care (as defined at 0940-05-04-.08). (c) Facilities shall maintain proper storage and safeguards for all flammable materials. LIFE SAFETY LICENSURE RULES CHAPTER 0940-05-04 (Rule 0940-05-04-.07, continued) May, 2026 (Revised) 7 Authority: T.C.A. §§ 4 -4-103, 33- 1-302, 33- 1-305, 33- 1-309, and 33- 2-404. Administrative History: Original rule filed November 16, 1978; effective January 1, 1979. Amendment filed May 22, 1979; effective July 10, 1979. Repeal and new rule filed June 30, 1986; effective July 30, 1986. Amendment filed October 14, 1986; effective November 28, 1986. Amendments filed February 24, 2026; effective May 25, 2026. 0940-05-04-.08 PERSONAL CARE DEFINED. Personal care means services provided to a service recipient who does not require chronic or convalescent medical or nursing care. Personal care is the safekeeping and supervision of the service recipient’s self -administration of prescription medication along with any of the following services: (1) responsibility for the safety of the service recipient, (2) a daily awareness by the management and staff of the service recipient’s functioning, (3) knowledge of his or her whereabouts, (4) reminding a service recipient of appointments, (5) the ability and readiness to intervene if a crisis arises for a service recipient, and/or (6) supervision in the following areas for the service recipient’s major life activities, self -care, self- direction, capacity for independent living or economic self-sufficiency. Authority: T.C.A. §§ 4-4-103, 33- 1-302, 33- 1-305, 33- 1-309, and 33- 2-404. Administrative History: Original rule filed November 16, 1978; effective January 1, 1979. Amendment filed May 22, 1979; effective July 10, 1979. Repeal and new rule filed June 30, 1986; effective July 30, 1986. Amendments filed February 24, 2026; effective May 25, 2026. 0940-05-04-.09 MOBILE NON-AMBULATORY RULE. (1) Definition. Mobile non- ambulatory individual means an individual who is able, without other assistance, to transfer to and to move about only with the aid of a wheelchair, crutch, wheeled platform, or similar device. (2) Criteria. For the purpose of life safety, facilities required to meet the Mobile Non- Ambulatory Rule must comply with the following: (a) Provide that non-ambulatory individuals only be located on the level of exit discharge; (b) Provide ramps of appropriate steepness; (c) Provide corridors of at least three (3) unobstructed feet in width with passing intervals reasonably spaced that are at least sixty (60) inches minimum; (d) Provide doors that open ninety (90) degrees minimum and which measure at least thirty-two (32) inches in clear opening; and (e) Provide bathrooms adequately spaced and equipped for the accessibility of non- ambulatory individuals. Authority: T.C.A. §§ 4 -4-103, 33- 1-302, 33- 1-305, 33- 1-309, and 33- 2-404. Administrative History: Original rule filed November 16, 1978; effective January 1, 1979. Amendment filed May 22. 1979; effective July 10, 1979. Repeal and new rule filed June 30, 1986; effective July 30, 1986. Amendment filed October 14, 1986; effective November 28, 1986. Amendments filed February 24, 2026; effective May 25, 2026. 0940-05-04-.10 CAPABLE OF SELF-PRESERVATION RULE. (1) Definition. Capable of self -preservation means that a service recipient is capable of responding to an approved emergency signal, including prompting by voice, by following a pre-taught evacuation procedure within a reasonable time limitation regardless of whether the LIFE SAFETY LICENSURE RULES CHAPTER 0940-05-04 (Rule 0940-05-04-.10, continued) May, 2026 (Revised) 8 service recipient is fully aware of the reasons for the action. A service recipient is capable of self-preservation if the service recipient is able to transfer unassisted from the bed or another fixed position to an individualized means of mobility, which is continuously available, and able to demonstrate the ability to transverse a pre- defined means of egress from the facility within a reasonable time limitation. Service recipients who have imposed upon them security measures beyond their control, which prevent their egress from the facility, are not capable of self-preservation. (2) Limitation. All residential facilities serving four (4) or more service recipients who are not capable of self -preservation and all non- residential facilities serving four (4) or more service recipients six (6) years of age or older who are not capable of self -preservation are required to meet the criteria for Health Care Occupancies. (3) For the purposes of occupancy rating, minor individuals residing with parents or guardians shall not count towards persons who are not capable of self-preservation. (4) Any facility permitting any persons who are not capable of self -preservation into the facility, shall assign an employee to be responsible for those individuals not capable of self - preservation. (5) Any service recipient who is unable to respond to an approved emergency signal, including voice prompt, and evacuate the facility without physical assistance, in three (3) minutes or less, is to be considered not capable of self-preservation. (6) The facility shall fill out the Department’s Risk Assessment/Evaluation of Capability for each person it deems incapable of self-preservation. Authority: T.C.A. §§ 4 -4-103, 33- 1-302, 33- 1-305, 33- 1-309, and 33- 2-404. Administrative History: Original rule filed November 30, 1983; effective December 30, 1983. Repeal and new rule filed June 30, 1986; effective July 30, 1986. Amendment filed October 14, 1986; effective November 28, 1986. Amendment filed March 19, 1996; effective June 2, 1996. Amendments filed February 24, 2026; effective May 25, 2026. 0940-05-04-.11 REPEALED. Authority: T.C.A. §§ 4-4-103, 4- 5-202, 4- 5-204, 33- 1-302, and 33- 1-305. Administrative History: Original rule filed March 1, 2002; effective May 15, 2002. Repeal filed February 24, 2026; effective May 25, 2026.