Health Facility Licensure

Staffing Exceptions Form

ALC Staffing Exception

Please click on the staffing exception below to access the appropriate form for your facility. *

10 beds or less
11 to 16 beds
Stand-Alone Facilities – 16 beds or less
Assisted Living Centers Physically Attached To A Nursing Home Or Hospital –16 beds or less
Assisted Living Centers Physically Attached To A Nursing Home Or Hospital - 17-25 beds

Facility Information

Facility Name: *

Facility Address: *

Facility City: *

Facility State: *

Facility Zip Code: *

10 Beds or Less

Assisted Living Centers with 10 beds or less. Staff are permitted to sleep at night if the following items are met: (Please place a checkmark by each item to acknowledge compliance. This compliance must be continued throughout the licensing year unless otherwise amended.) *

The building is equipped with a fire alarm system that promptly alerts sleeping staff.
Exterior door alarms are audible in the staff bedroom.
A staff call system is available.
The staff bedroom has an egress window
Residents have an evacuation score which shows them capable of prompt evacuation, three minutes or less.
There is no resident residing here who is not capable of self-preservation.
There is no resident residing here who requires two staff for activities of daily living. ARSD 44:70:01:05 (6) restrictions on acceptance and retaining of residents.

Attach to this request fire drills for the last six months to verify the fire drill evacuation times.

11 to 16 Beds

Assisted Living Centers with 11 to 16 beds. One staff person who is awake is allowable during sleeping hours if the following items are met: (Please place a checkmark by each item to acknowledge compliance. This compliance must be continued throughout the licensing year unless otherwise amended.) *

The building is equipped with a fire alarm system that promptly alerts staff.
A staff call system is available.
Residents have an evacuation score which shows them capable of prompt evacuation, three minutes or less.
There is no resident residing here who is not capable of self-preservation.
There is no resident residing here who requires two staff for activities of daily living. ARSD 44:70:01:05 (6) restrictions on acceptance and retaining of residents.

Attach to this request fire drills for the last six months to verify the fire drill evacuation times.

Stand-Alone Facilities - 16 beds or less

Assisted Living Centers 16 beds or less. One staff person who is awake is allowable during sleeping hours if the following items are met: (Please place a checkmark by each item to acknowledge compliance. This compliance must be continued throughout the licensing year unless otherwise amended.) *

The building is equipped with a fire alarm system that promptly alerts staff.
The building is equipped with an automatic sprinkler system as defined in § 9.7, automatic sprinklers, of NFPA 101 Life Safety Code, 2012 edition.
A staff call system is available.
Residents have an evacuation score which shows them capable of evacuation in five minutes or less.
There is no resident residing here who is not capable of self-preservation.
There is no resident residing here who requires two staff for activities of daily living. ARSD 44:70:01:05 (6) restrictions on acceptance and retaining of residents.
The building is equipped with an automatic fire alarm dialer as defined in § 9.6.4, Emergency Forces Notification, of NFPA 101 Life Safety Code, 2012 edition, to summon the local fire department.

Please list the name, location, and phone number of monitoring agency referenced in the final checkbox above:

Attach to this request fire drills for the last six months to verify the fire drill evacuation times.

ALCs Physically Attached to a Nursing Home or Hospital - 16 beds or less

The building is equipped with a fire alarm system that promptly alerts staff.
The building is equipped with an automatic sprinkler system as defined in § 9.7, automatic sprinklers, of NFPA 101 Life Safety Code, 2012 edition.
A fire annunciator panel is provided at the nursing facility or hospital nurses station.
A staff call system is available.
Residents have an evacuation score which shows them capable of evacuation in eight minutes or less.
There is no resident residing here who is not capable of self-preservation.
There is no resident residing here who requires two staff for activities of daily living. ARSD 44:70:01:05 (6) restrictions on acceptance and retaining of residents.
The building is equipped with an automatic fire alarm dialer as defined in § 9.6.4, Emergency Forces Notification, of NFPA 101 Life Safety Code, 2012 edition, to summon the local fire department.

Please list the name, location, and phone number of monitoring agency referenced in the final checkbox above:

Attach to this request fire drills for the last six months to verify the fire drill evacuation times.

Signature

I declare under penalty of perjury under the law of South Dakota that the preceding is true and correct. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. *

I agree.

By selecting “I agree” using any device, means, or action, I consent to this document's legally binding terms and conditions.

Date Signed: *

Administrator Signature: *

Email Address:

To receive a copy of the information on this form.

Content last updated: July 25, 2024. For questions, contact:

Cassie Deffenbaugh
Health Facilities Licensure & Certification Administrator
600 East Capitol Avenue
Pierre, SD 57501

email: Cassandra.Deffenbaugh@state.sd.us
local: 605-773-3356

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Staffing Exceptions Form