New Assisted Living Regulations Under Discussion


The Chapter 7 revisions work continued recently at the CDPHE AL Advisory meeting. The definition and responsibilities of an AL Administrator were discussed. There is clearly sentiment that the administrators roll needs clarification and additional detail of expectations. The revised regulations will likely require that a designee to be named when the administrator is not available for questions or concerns.

The group will discuss administrator qualifications and certification training requirements at the next meeting on March 24, 2016.


Regs Under Discussion

Administrator:  Definitions, Qualifications, Responsibilities

1.103 (8)

1.104 (2)

Below are recommendations from the previous committee.  Unless otherwise indicated, the language below is new content.  Department is considering moving 1.103 (8) to 1.104 Organization and Staffing

Administrator Definition

1.102(2)  The “Administrator” is the person who is responsible for decision making, quality of resident care, consumer satisfaction, personnel, regulatory compliance and reports to owner(ship) or management.

Qualified Substitute/Designee

“Qualified designee” (alternate administrator) means a person designated by the owner or administrator of a facility,  who  meets the requirements under section _______, that will be responsible for the administrative responsibilities as described in section ______, in the absence of the designated administrator.

Responsibilities (Currently, only reference is in definition.)

—  The administrator shall assume authority for the operation of the facility’s services, including but not limited to:

(1) Organizing and directing the facility’s ongoing functions;consider adding maintenance of facility]

(2) Employing qualified personnel and ensure appropriate ongoing education and supervision of personnel and volunteers;

(3) Ensuring the accuracy of public information and marketing materials; duplication, see number 9 below

(4) Implementing a budgeting and accounting system; and

(5) Designating in writing a qualified alternative administrator to act in the administrator’s absence.

New section

— The administrator shall have the overall responsibility to ensure the following:

(1) The facility’s services, environment and knowledge of and the ability to conform with applicable federal, state and local laws, duplication, see number 10 below

(2) The completion, maintenance and submission of such reports and records as required by the department,

(3) A current organizational chart to ensure clear lines of responsibility and adequate supervision, including the resident level.

(5) The management of the business affairs and the overall operation of the facility.

(6) Maintenance of appropriate personnel records, financial and administrative records and all policies and procedures of the facility,

(7)  Recruit, orient and train qualified staff and ensure ongoing, continual education.

(8) Availability of the administrator or qualified designee at all hours, 24 hours a day, seven days a week.

(9) Marketing, advertising and promotional information accurately represents the facility and addresses the care, treatment and services that the facility can provide.

(10)  The administrator shall be familiar with all applicable federal and state laws and regulations concerning licensure and certification. (from 104.2 Owner/administrator)


The administrator shall

(1) Be at least 21 years of age, (existing language104.2)

(2) Be a high school graduate or equivalent,

(3) Have at least two years administration experience with at least one year of supervisory experience in assisted living or a closely related health program. (No consensus by CC 1/15)

(4) Have sufficient skill and ability to read and comprehend all facility documents including, but not limited to, resident records, policies and medication administration physician orders and records.

Curriculum – increase from 30 to 40 hrs

The curriculum will include at least forty (40) actual hours of training. If an existing administrator does not successfully complete the competency evaluation within the time limits established in this section (recommend required training occur prior to appointment as an administrator), the facility shall immediately cancel that individual’s administration responsibility and so notify the department.  The curriculum includes at least forty (40) actual hours.

Revocation of Certification

The Department reserves the right to suspend or revoke administrator certification, should the Department determine that an administrator….(need to take this from QMAP..) thoughts? (CDPHE does not regulate or certify individuals) ____

Competency Testing Every 5 Years

Any person already serving as an administrator on _______ , will be required to meet the requirements in section ___________, and will be required to take the competency test by __(five years)___________.  Potential administrators in possession of a nursing home administrator’s license for the State of Colorado, will be waived from the requirements in section ____________.  Potential administrators in possession of a ________degree in (ongoing discussion), will be waived from the requirements in section ___________ and will be required to take the competency test, as described in section __________.  All administrators will be required to take the administrator training course every five years, following the conclusion of the initial training.


The personnel file of the administrator will contain evidence of the passage of administrator training course and competency evaluation.

Training Components


Laws and Regulations

103(8)(b) Eight hours shall comprise of a discussion of Laws and Regulations governing Assisted Living residences, including Chapters II, VII, 24 (Medication administration regulations) and Volume 8-Alternative Care Facility regulations.

Medication administration

_____hours shall comprise of a discussion of Medication administration, including compliance with physician orders, communication with pharmacists and physicians, drug interactions, psychotropic medications, medication reminder boxes and controlled substances, and maintenance of an accurate medication administration record.

Resident physical needs

_____hours shall comprise of a discussion of the Physical Needs of residents, including nutrition, assistance with ADLs, health conditions, aging process, individual health care needs, sexuality in the aging adult and nutritional support.

Resident pyscho/social needs

_____ hours shall comprise of a discussion of the Psychological/Social needs of residents, including the identification of the characteristics and special needs of residents, mental health issues, family involvement, participation and dynamics, bereavement and stress issues, and activities.

Memory care

____ hours shall comprise of a discussion of Alzheimer’s Disease and Dementia, including an overview of Alzheimer’s disease and dementia, , non-pharmacologic approaches  to dementia-related behaviors, communication, personal care, medications, resident to resident abuse,  environment/physical plant and activities appropriate for individuals with dementia.


Operations: resident services

___ hours shall comprise of a discussion of Admission, ongoing assessment and retention of residents, including services provided in an assisted living setting, written agreements, pre-admission assessment and admission policies, care planning (initial, revision and implementation), progress notes, discharge policy and planning, and , resident satisfaction.

Operations:  management/supervision

___ hours shall comprise of a discussion of the Management/Supervision of Staff, including staffing requirements and ratios, hiring practices as they pertain to background checks, use of volunteers, EEO, job descriptions and Federal/State requirements.  Performance evaluations, personnel policies and records requirements, staff training and requirements, including First Aid, QMAP certification, and influenza policies.

Operations:  business

___ hours shall comprise of a discussion of Business Operations, including liability issues, budget, funding sources, overview of labor laws, marketing, cost of services, external agencies (IRS, EDO and INS), contract compliance, accounting and tax filing requirements and fundraising.


Cultural competency

_____ hours shall comprise of a discussion of Cultural Competency, including (—-need to discuss- CA regs address LGBT….

Coordination with external services

____ hours shall comprise of a discussion of Community and Support Services, including case management, referral agencies, mental health resources, ombudsman, and adult protective services, hospice services.

Person centered care

___ hours shall comprise of a discussion of person centered care including resident rights, reporting of abuse, (question: should we define “person centered care.”)  chemical restraints and non-pharmacological interventions, and the potential for adverse side effects of psychotropic medications.

Categories: Assisted Living, CDPHE