6 Colo. Code Regs. § 1011-1 Chapter 08 Part 4

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

Part 4 - Governing Body

4.1 The facility shall have a governing body that is responsible for the management and oversight of the facility, including: policy, budget, and operational direction.

(A) The governing body shall establish a policy that defines its composition and authority.

(B) The governing body may oversee more than one facility, in which case it shall maintain separate documentation concerning the oversight of each facility, recognizing the unique characteristics of each location.

4.2 The governing body shall develop written policies, including, but not limited to, those required in other parts of these rules:

(A) Admission and discharge policies that fully comply with state and federal law and that meet the requirements of Part 8.1 of these rules, including that the facility shall only admit those individuals whose needs can be met within the accommodations and services the facility provides.

(B) Policies regarding the hiring or continued service of any administrator, staff, or volunteer whose criminal history records include a conviction or plea, or otherwise demonstrate conduct that could pose a risk to the health, safety, or welfare of the resident. At a minimum, the policies shall require consideration of:

(1) The history of convictions and pleas of guilty or no contest;

(2) The nature and seriousness of the crime(s);

(3) The time that has elapsed since the convictions or pleas;

(4) Whether there are any mitigating or aggravating factors; and

(5) The nature of the position to which the individual will be assigned.

(C) Personnel policies, as required by Part 6.

(D) Resident rights policies, in compliance with Part 9.1.

(E) Resident funds policies, as required by Part 10.1.

(F) Policies that ensure the appropriate procurement, storage, administration, and disposal of medications, in accordance with Part 14.6.

(G) Policies for medical services and therapeutic services, as required by Part 15.1. (H) A policy for monitoring residents' weights, in accordance with Part 15.6.

(I) Policies for the provision of nursing services, in accordance with Part 16.1.

4.3 The governing body shall establish a system for monitoring and reviewing the physical, behavioral, and social needs and care of the residents receiving services at the facility.

4.4 The governing body shall ensure compliance with the requirements in Part 19 - Emergency Management Plan and Procedures.

4.5 The governing body shall appoint an administrator who meets the minimum administrator requirements at Part 5.2, to whom the governing body shall delegate authority to implement the facility policies and procedures, and is responsible for the day-to-day management of the facility.

4.6 The governing body shall ensure that a name-based criminal history record check is performed for the administrator prior to their employment, as follows:

(A) If the administrator has lived in Colorado for more than three (3) years at the time of application, the facility shall obtain a name-based criminal history record check conducted by the Colorado Bureau of Investigation.

(B) If the administrator has lived in Colorado for three (3) years or less at the time of application, the facility shall obtain a name-based criminal history record check for each state in which the applicant has lived during the past three years, conducted by the respective state's bureau of investigation or equivalent state-level law enforcement agency or other name-based report, as determined by the Department.

(C) If the criminal history record check reveals any convictions or pleas, the information shall be considered in accordance with the policies developed by the governing body in accordance with Part 4.2(B) of these rules.

(D) If the governing body becomes aware of information that indicates the administrator could pose a risk to the health, safety, and/or welfare of the residents, the governing body shall request an updated criminal history record check from the Colorado Bureau of Investigation and/or other relevant law enforcement agency.

6 CCR 1011-1 Chapter 08 Part 4