ALR P&P Guidance Document 4.15.24

Assisted Living Residences

Policies and Procedures

Guidance Document

(READ COMPLETELY)

The Colorado Department of Public Health and Environment (CDPHE), Health Facilities and Emergency Medical Services Division (HFEMSD) created this document to assist Assisted Living Residences (ALR) applicants in the initial licensing process and to help agencies become more familiar with accessing the required information. Each policy and procedure required for the initial licensing process is outlined in the linked pages to identify the information the HFEMSD survey staff look for when completing initial on-site surveys. In order for initial licensure to be recommended, applicants must ensure each bullet outlined in this document is included in the ALR’s submitted policy and procedures.

Preceding the name of the policy and procedure is the statutory and/or rule citation for reference. When developing policies and procedures, the agency must reference the actual citation provided. Policies and procedures must reflect the agency’s organizational structure, methods of operation, and values and not simply be a copy and paste of rules and regulations, but instead describe how the agency intends to operationalize the rule and/or regulation. The agency must be able to show on an ongoing basis the date(s) the policies and procedures were developed and updated.

This document identifies the information the agency is required to provide in the policies and procedures reflective of 6 CCR 1011-1 Chapter 7, but does not include all required detail. All information is available in Colorado statutes and rules. Please refer to the statute/rule citation for specific details that are required in each policy. Please note, ALRs are also required to adhere to 6 CCR 1011-1 Chapter 2, and, in some instances, 6 CCR 1011-1 Chapter 24 as well.

This document is intended to provide technical assistance; this document does not replace the need for the agency to understand, utilize, and reference Colorado Revised Statutes and Department of Public Health and Environment regulations. It is the responsibility of the agency to ensure all policies and procedures meet requirements.

To access the Applicable Regulations:

To access the rule chapters that apply to facilities licensed by the Colorado Department of Public Health and Environment, go to the Colorado Secretary of State website and page that contains all Colorado Codes of Regulations applicable to the Health Facilities and Emergency Medical Services Division (1011, 1015 Series) which can be found here:

https://www.sos.state.co.us/CCR/NumericalCCRDocList.do?deptID=16&agencyID=144

Applicable licensing chapters for Assisted Living Residences include:

Please click on the hyperlinks below for more policy-specific information for 6 CCR 1011-1 Chapters 2 and 7. Please check when you have completed each policy:

Chapter 2

8.3 Basis for Use of Restraint or Seclusion
8.4 Duties Related to Use of Restraint or Seclusion
8.5 Staff Training Concerning the Use of Restraint and Seclusion
8.6 Documentation Requirements Related to the Use of Restraint and Seclusion
8.7 Restraint and Seclusion Review Process
8.8 Facility or Agency Policies Regarding the Use of Restraint and Seclusion

11.2 General Provisions
11.4 Requirements for All Other Licensed Facilities and Agencies that Fail to Meet Vaccination Rate

Chapter 7

Admission and discharge criteria in accordance with Parts 11 and 25, if applicable, including, but not limited to criteria for involuntary discharge as listed in Parts 11.11 through 11.12;
Resident rights;
Grievance procedure and complaint resolution, including a grievance procedure for involuntary discharge in accordance with Part 9.3;
Investigation of abuse, neglect, and exploitation allegations;
Investigation of injuries of known or unknown source/origin;
House rules;
Emergency preparedness;
Fall management;
Provision of lift assistance, first aid, obstructed airway technique, and cardiopulmonary resuscitation;
Unanticipated illness, injury, significant change of status from baseline, or death of resident;
Infection control;
Practitioner assessment;
Health information management;
Personnel policies as required in both Part 6 and Part 7 of these rules;
Staff Training;

Environmental pest control;
Medication errors and medication destruction and disposal;
Management of resident funds, if applicable;
Policies and procedures related to secure environment, if applicable;
Provision of palliative care in accordance with 6 CCR 1011-1, Chapter 2, Part 4.3, if applicable; and
Visitation in accordance with Part 9.2.

9.2 Visitation Rights
9.3 Involuntary Discharge Grievance Policy
Part 10 Emergency Policies and Procedures
11.2(I)(1) Policies regarding the use of restraint
11.6 Resident Agreement Deposit Policy
11.7 Guidance to Residents re: requesting ALR policies
11.10 Management of Resident Funds Policy
12.5 Practitioner Assessment Policy
12.15 Fall Management Policy
12.16, 12.17 et al., and 12.18 Lift Assistance Policy
13.11 Investigation of Abuse and Neglect Allegations or Injuries of Unknown Origin Policy
13.12 Investigation of Injury of Unknown Origin
14.32 Reporting Medication Errors Policy
14.44 Medication Destruction and Disposal Policy
18.3 Health Information Management System Policy
19.2 Infection Control Policies
23.1 Environmental Pest Control Policies
25.12 Staff Training in Secure Environment Policy
25.20 Delivery of Resident Care and Services Policy

Chapter 24

The policies and procedures listed above may not be inclusive of all of the policies and procedures the agency is required to develop prior to providing services. It is the agency’s responsibility to develop all operating policies and procedures for program administration and service provision as required and applicable to the services for which initial licensure is being sought.

Revised 8.27.24