6 Colo. Code Regs. § 1011-1-5-4

Current through Register Vol. 47, No. 11, June 10, 2024

Section 6 CCR 1011-1-5-4 - FACILITY ADMINISTRATION

4.1 ADMINISTRATOR

The facility shall employ an administrator who is responsible to the governing body for planning, organizing, developing and controlling the operations of the facility.

A) The administrator shall have an active Colorado nursing home administrator license issued pursuant to 3 CCR 717-1.

B) The administrator shall be responsible for, at a minimum, the following duties:

1) Acting as a liaison among the governing body, medical staff and practitioners whose patients reside in the facility;

2) Managing facility personnel and finances;

3) Providing for appropriate resident care;

4) Maintaining relationships with the community and with other health care facilities, organizations and services;

5) Ensuring facility and staff compliance with all regulations; and

6) Any other responsibilities required by facility policy or the governing body.

4.2 ORGANIZATION

The facility shall have a written plan of organization clearly defining the authority, responsibilities and functions of each category of personnel.

4.3 POLICIES

In consultation with the medical director, one or more registered nurses and other related health care professionals, the administrator shall develop and at least annually review written resident care policies and procedures that govern resident care in the following areas: nursing; housekeeping; maintenance; sanitation; infection control; medical, dental, dietary, diagnostic, emergency and pharmaceutical care; social services; activities; rehabilitation; physical, occupational, and speech therapy; resident admission, transfer, and discharge; notifying practitioner and resident representative of resident's incidents, accidents and changes of status; disasters; and health information records; along with any other policies the Department determines the facility needs based on characteristics of its resident population.

4.4 Policies and Procedures Regarding Visitation Rights

A) Each skilled nursing facility shall have written policies and procedures regarding the visitation rights detailed in Section 25-3-125 (3)(a), C.R.S. Such policies and procedures shall:

1) Set forth the visitation rights of the resident, consistent with 42 CFR 482.13(h); 42 U.S.C. 1396r(c)(3)(C); 42 U.S.C. 1395i(c)(3)(C); 42 CFR 483.10(a), (b), and (f); and Section 25-27-104, C.R.S., as applicable to the facility type;

2) Describe any restriction or limitation necessary to ensure the health and safety of residents, staff, or visitors and the reasons for such restriction or limitation;

3) Be available for inspection at the request of the Department; and

4) Be provided to residents and/or family members upon request.

4.5 FACILITY STAFFING PLAN

The facility shall have a master staffing plan for providing staffing in compliance with these regulations; distribution of personnel; replacement of personnel and forecasting future personnel needs.

4.6 POSTING DEFICIENCIES

The facility shall post conspicuously in public view either the statement of deficiencies following its most recent survey or a notice stating the location and times at which the statement can be reviewed.

4.7 WAIVERS

A facility may request waivers to these regulations pursuant to 6 CCR 1011-1, Chapter 2, General Licensure Standards, Part 5, Waiver of Regulations for Facilities and Agencies.

4.8 MANDATORY REPORTING

A) Facility personnel engaged in the admission, care or treatment of at-risk elders shall report suspected physical or sexual abuse, exploitation and caretaker neglect to law enforcement within 24 hours of observation or discovery pursuant to Section 18-6.5-108(1)(b)(v), C.R.S.

B) Facilities shall comply with all occurrence and mandatory reporting required by state and federal law including, but not limited to, notifying the Department of the following items within 24 hours of discovery by the facility.

1) Any occurrence involving neglect of a resident by failure to provide goods and services necessary to avoid the resident's physical harm or mental anguish,

2) Any occurrence involving abuse of a resident by the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish,

3) Any occurrence involving an injury of unknown source where the source of the injury could not be explained and the injury is suspicious because of the extent or location of the injury, or

4) Any occurrence involving misappropriation of a resident's property including the deliberate misplacement, exploitation or wrongful use of a resident's belongings or money without the resident's consent.

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6 CCR 1011-1-5-4

46 CR 24, December 25, 2023, effective 1/14/2024