(Amendments to 6 CCR 1011-1, Standards for Hospitals and Health Facilities, Chapter VII – Assisted Living Residences, adopted by the State Board of Health on 4/16/08, effective 11/01/08.
NOTE:  Items in bold and parentheses preceding the amended sections are notes/instructions for the CCR Publisher and are not part of the Rules.)

(Instructions:  Strike existing subsection 1.102(36), Par ID 1203688, and replace with the following)
1.102(36)  "Secured environment" means, unless the context requires otherwise, any grounds, building or part thereof, method or device, other than restrictive egress alert devices used consistent with Section 1.104 (5)(m), that prohibits free egress of residents.   An environment is secured when the right of any resident thereof to move outside the environment during any hours is limited.

(Instructions:  Strike existing Section 1.104 in its entirety, Par IDs 1203823 through 1203966, and replace with the following) 
1.104  Organization and Staffing
1.104(1)  Owner
104(1)(a)  Regulatory Compliance.  The owner shall be responsible for meeting the requirements in these regulations.
104(1)(b)  Oversight of Staff.  The owner is responsible for assuring that there is adequate training and supervision for staff.
1.104(2)  Administrator
104(2)(a)  Minimum Age Requirement.  The administrator shall be at least 21 years of age.
104(2)(b)  Minimum Education, Training and Experience Requirements
(i)  	Any person commencing service as an administrator July 1, 1993, shall meet the minimum education, training, and experience requirements in one of the following ways:
(A)  	successful completion of a program approved by the Department pursuant to Section 1.103 (6); or
(B)  	documented previous job related experience or related education equivalent to successful completion of such program.   The Department may require additional training to ensure that all the required components of the training curriculum are met.
(ii)  	Any person already serving as an administrator on July 1, 1993, shall either meet subparagraph (i) above or meet the minimum education, training, and experience requirements in one of the following ways:
(A)  	successful completion of a program approved by the Department, pursuant to Section 1.103 (4) , if completed within a period of eighteen (18) months following July 1, 1993;
(B)  	submission of evidence of successful completion of such a program within the five (5) years immediately prior to July 1, 1993; or
(C)  	previous job related experience equivalent to successful completion of such a program.
(iii) 	The administrator shall be familiar with all applicable federal and state laws and regulations concerning licensure and certification.
1.104(3)  Personnel
104(3)(a)  General
(i)  	Communicable diseases
(A)  	All staff and volunteers, shall be free of communicable disease that can be readily transmitted in the workplace.
(B)  	All staff shall be required to have a tuberculin skin test prior to direct contact with the residents.   In the event of a positive reaction to the skin test, evidence of a chest x-ray and other appropriate follow-up shall be required in accordance with community standards of practice.
(ii)  	Physical/mental impairment.  Any person who is physically or mentally unable to adequately and safely perform duties that are essential functions, may not be approved as a licensee, or employed as staff member, or used as a volunteer.
(iii)  	Alcohol or substance abuse.  The facility shall not employ any person or use a volunteer who is under the influence of a controlled substance, as defined in C.R.S. Sections 18-18-203, 18-18-204, 18-18-205, 18-18-206, and 18-18-207, or who is under the influence of alcohol in the worksite.   This does not apply to employees or volunteers using controlled substances under the direction of a physician, and in accordance with their health care provider's instructions.
(iv)  	Access to policies and procedures.  All staff and all volunteers shall have access to the facility's policies, procedure manuals, and other information necessary to perform their duties and to carry out their responsibilities.
104(3)(b)  Personnel Files.  The facility shall maintain personnel files for staff members as well as for volunteers performing personal services and protective oversight under the auspices of the facility.   Files of current employees and volunteers shall be available   onsite for Department review.
(i)  	General.  Files shall include documentation required in these Chapter VII regulations, evidencing:
(A)  	training, including copies of current first aid certification, if applicable;
(B)  	TB testing, if applicable;
(C)  	background checks;
(D)  	date of hire;
(E)  	If a Qualified Medication Administration Person (QMAP), also:
(I)  	a copy of the certificate of completion of the medication training course required by these regulations for QMAPs, and
(II)  	for those QMAPs filling medication reminder boxes, a signed disclosure that they have not had a professional medical, nursing, or pharmacy license revoked.
104(3)(c)  Background Checks - Owner and Administrator
(i)  	The owner and administrator of a facility shall be of good, moral, and responsible character. As part of this determination, the owner and the administrator shall undergo a state fingerprint check with notification of future arrests from a criminal justice agency designated by the Department.   The information, upon such request and subject to any restrictions imposed by such agency, shall be forwarded by the criminal justice agency directly to the Department.
(ii)  	Background checks shall be conducted for all of the following:
(A)  	owners and administrators for initial licensure, as part of the application process.
(B)  	existing owners and administrators who have not undergone a state fingerprint check with notification of future arrests.
(C)  	new owners in a change a ownership, as part of the application process.
(D)  	new administrators in a change of administrators.
(iii)  	No license shall be issued or renewed by the Department if the owner of the assisted living facility has been convicted of a felony or of a misdemeanor, which felony or misdemeanor involves moral turpitude, as defined by law, or involves conduct that the Department determines could pose a risk to the health, safety, and welfare of residents of the assisted living residence.
(iv)  	The owner shall ascertain whether the administrator has been convicted of a felony or a misdemeanor that could pose a risk to the health, safety, and welfare of the residents, when making employment decisions.
(v)  	Cost of background checks   All costs of obtaining a criminal history record pursuant to this requirement shall be borne by the facility, the contract staff agency, or the individual who is the subject of the criminal history record, as appropriate.
104(3)(d)  Background Checks - Other Staff and Volunteers
(i)  	When a background check shall be conducted.  The staff who has direct personal contact with the residents of a facility and any volunteer performing personal services or protective oversight, under the auspices of the facility for residents of such facility, shall be of good, moral, and responsible character.   In making such a determination, the owner or licensee of a facility shall obtain, prior to such staff or volunteer performing duties, any criminal history record information from a criminal agency, subject to any restrictions imposed by such agency, for any person responsible for the care and welfare or residents of such facility.   If the individual is contract staff, the facility shall ensure that a background check has been conducted on such individual within 12 months prior to the date of hire by the facility.   The facility shall have documentation of such background checks.
(ii)  	Use of information by the facility.  The facility shall ascertain whether prospective staff or volunteers have been convicted of a felony or a misdemeanor that could pose a risk to the health, safety, and welfare of the residents, when making employment decisions.
(iii)  	Costs of background checks.  All costs of obtaining a criminal history record from a criminal justice agency shall be borne by the facility, the contract staff agency, or the individual who is the subject of the criminal history record, as appropriate.
104(3)(e)  Qualifications
(i)  	General.  All staff and all volunteers shall have sufficient skill and ability to perform their respective duties, services, and functions.
(ii)  	Licensed and certified staff.  Licensed or certified staff shall perform duties in accordance with applicable statutes and regulations.   Staff and volunteers shall not perform duties that they are not licensed or certified to provide.
(iii)  	Qualified Medication Administration Persons
(A)  	To be a qualified medication administration person, an individual shall have completed a medication training course given by a licensed nurse, physician, physician's assistant, or pharmacist, and approved by the Department and/or shall have passed an approved Department competency test for assisting with medications in accordance with 25-1.5-301, et seq. and the regulations promulgated thereto.
(B)  	Every qualified medication administration staff member who administers medications, whether prescribed or non-prescribed, shall be able to read and understand the information and directions printed or written on the label.
(iv)  	Current First Aid Certification
	(A)	There shall be one staff member onsite at all times who has current certification in first aid specific to adults.
	(B)	The first aid certification shall show that it meets the standards of either the American Red Cross or the American Heart Association. 
104(3)(f)  Training.  The facility shall document the evaluation of previous related experience for volunteers, as applicable, and for staff and that these personnel have all of the training, including on-the-job training, required in this section.
(i)  	On-the-job training/Evaluation of experience.  All staff and all volunteers shall be given on-the-job training or have related experience in the job assigned to them and shall be supervised until they have completed on-the-job training appropriate to their duties and responsibilities or had previous related experience evaluated.
(ii)  	Training requirements.  Staff shall receive the following training, as appropriate.   Volunteers providing direct care shall receive training appropriate to their duties and responsibilities.
(A)  	Prior to providing direct care, the facility shall provide an orientation of the physical plant and adequate training on each of the following topics:
(I)  	training specific to the particular needs of the populations served (e.g., residents in secured environments, mentally ill, frail elderly, AIDS, Alzheimer's, diabetics, dietary restrictions and bedfast);
(II)  	resident rights;
(III)  	first aid and injury response including the procedures for lift assistance;
(IV) 	 the care and services for the current residents; 
(V)   	certified first aid training as necessary to ensure compliance with section 1.104(3)(e)(iv) of this chapter.
(VI) 	the facility's medication administration program.
(B)  	Emergency and Fire Escape Plan
(I)  	Within three (3) days of date of hire or commencement of volunteer service, the facility shall provide adequate training in emergency and fire escape plan procedures.
(II)  	Every two (2) months, there shall be a review of all components of the emergency plan, including each individual employee's responsibilities under the plan, with the staff of each shift.
(C)  	Within one month of the date of hire, the facility shall provide adequate training for staff on each of the following topics:
(I)  	assessment skills;
(II)  	infection control;
(III)  	identifying and dealing with difficult situations and behaviors;
(IV)  	residents rights, unless previously covered through other training; and
(V)  	health emergency response, unless previously covered through other training.
1.104(4)  Staffing Requirements
104(4)(a)  Staffing
(i)  	General.  The owner shall employ sufficient staff to ensure the provision of services necessary to meet the needs of the residents.
(ii)  	Staffing levels.  In determining staffing, the facility shall give consideration to factors including but not limited to:
(A)  	services to meet the residents' needs,
(B)  	services to be provided under the care plan, and
(C)  	services to be provided under the resident agreement.
(iii)  	Minimum Staffing.  Each facility shall ensure that at least one staff member who has the qualifications and training listed under Sections 1.104 (3)(e) and (f), and who shall be at least 18 years of age, is present in the facility when one or more residents is present.
104(4)(b)  Use of Residents.  Residents may participate voluntarily in performing housekeeping duties and other tasks suited to the resident's needs and abilities. However, residents who provide services for the facility on a regular basis, or on an exchange or fee-for-service basis may not be included in the facility's staffing plan in lieu of facility employees except for trained, tested, and supervised residents in those facilities which are licensed to provide services specifically for the mentally ill.
104(4)(c)  Use of Volunteers.  Volunteers may be utilized in the facility but may not be included in the facility's staffing plan in lieu of facility employees.
1.104 (5)  Policies and Procedures.   Unless otherwise indicated in this Section 1.104 (5), all facilities shall develop, adopt, and follow written policies and procedures that include the requirements listed below and shall comply with all applicable state and federal statutes and regulations.   Required disclosures to residents or their legal representatives, as appropriate, regarding the policies and procedures shall be documented in the resident record.   
104(5)(a)  Admissions.  The facility's criteria for admission shall be based upon its ability to meet all the identified care needs of residents.   The facility shall consider at least all of the following in making its admission decision:  the facility's physical plant, financial resources, and availability of adequately trained staff.
104(5)(b)  Emergency Plan and Fire Escape Procedures
(i)  	Emergency plan.  The emergency plan shall include planned responses to fire, gas explosion, bomb threat, power outages, and tornado.   Such plan shall include provisions for alternate housing in the event evacuation is necessary.
(ii)  	Fire escape procedures.  The fire escape procedures shall include a diagram developed with local fire department officials which shall be posted in a conspicuous place.
(iii)  	Disclosure to residents.  Within three (3) days of admission, the plan and diagram shall be explained to each resident or legal representative, as appropriate.
104(5)(c)  Serious Illness, Serious Injury, or Death of the Resident
(i)  	The policy shall describe the procedures to be followed by the facility in the event of serious illness, serious injury, or death of a resident.
(ii)  	The policy shall include a requirement that the facility notify an emergency contact when the resident's injury or illness warrants medical treatment or face-to-face medical evaluation.   In the case of an emergency room visit or unscheduled hospitalization, a facility must notify an emergency contact immediately, or as soon as practicable.
104(5)(d)  CPR Directive
(i)	At the time of admission, the facility shall inform residents or their legal representatives regarding the resident’s right to receive CPR or have a written CPR directive refusing CPR.   At least annually or upon a significant change in health condition, the facility shall review the CPR options with each resident or that resident’s legal representative
(ii)	Upon admission and at each subsequent review, the facility and the resident or the resident’s legal representative shall sign and date documentation acknowledging that the resident’s CPR options were reviewed and understood.  Such documentation shall be maintained in each resident’s record.
 (iii)	The facility shall ensure that staff are aware of or know where to immediately locate each resident’s CPR directive. 
104(5)(e)  Lift Assistance
(i)	The facility shall describe in writing the procedure for determining when it is appropriate for staff to assist a resident who has fallen and when the local emergency medical responder should be contacted.  
(ii)	The facility’s lift assistance procedure shall be made available to its local emergency medical responder.
104(5)(f)  Physician Assessment.  The facility shall identify when a physician's assessment will be required, based upon at least the following indicators:
(i)  	a significant change in the resident's condition;
(ii)  	evidence of possible infection (open sores, etc.);
(iii) 	 injury or accident sustained by the resident which might cause a change in the resident's condition;
(iv)  	known exposure of the resident to a communicable disease;
(v)  	development of any condition which would have initially precluded admission to the facility.
104(5)(g)  Resident Rights
(i)  	General.  The policy shall incorporate the provisions under Section 1.106 (1). This policy shall not exclude, take precedence over, or in any way abrogate legal and constitutional rights enjoyed by all adult citizens.
(ii)  	Posting.  The policy on resident's rights shall be posted in a conspicuous place.
(iii)  	Disclosure to residents.  Upon admission, the facility shall document the resident or legal representative, as appropriate, has read or had explained the policy on residents' rights.
104(5)(h) Smoking
(i)  	General.  The policy shall address residents, staff, volunteers and visitors.
(ii)  	Disclosure to residents/staff.  Prior to admission or employment, residents and staff shall be informed of any prohibitions.
104(5)(i) Discharge
(i)  	General.  The policy shall include all of the following:
(A)  	circumstances and conditions under which the facility may require the resident to be involuntarily transferred, discharged or evicted;
(B)  	an explanation of the notice requirements;
(C)  	a description of the relocation assistance offered by the facility; and
(D)  	the right to call advocates, such as the state ombudsman or the designated local ombudsman and the adult protection services of the appropriate county Department of Social Services, for assistance.
(ii)  	Disclosure to residents.  Upon admission, the facility shall document that the resident or legal representative, as appropriate, has read or had explained the policy on discharge.
104(5)(j) Management of Resident Funds/Property.  The policy shall address the procedures for managing resident funds or property, if the facility provides this service to residents.
104(5)(k) Internal Grievance Process
(i)  	General.  The policy shall establish a process for routine and prompt handling of grievances brought by residents and their families.   Such policy shall also indicate that residents and their families may contact any of the following agencies and shall provide the telephone number and address of each of the following:
(A)  	The state and local Long Term Care Ombudsman;
(B)  	The Adult Protection Services of the appropriate county Departments of Social Services;
(C)  	The Advocacy Services of the Area's Agency on Aging;
(D)  	The Colorado Department of Public Health and Environment; and
(E)  	The Colorado Department of Human Services in those cases where the facility is licensed to provide services specifically for the mentally ill.
(ii)  	Posting.  The internal grievance policy and procedure shall be posted in a conspicuous place.
(iii)  	Disclosure to residents.  Upon admission, the facility shall document that the resident or the resident's representative, as appropriate, has read or had the policy for the internal grievance process explained.
104(5)(l) Investigation of Abuse and Neglect Allegations.  The facility shall investigate all allegations of abuse and neglect involving residents in accordance with its written policy, which shall include but not be limited to:
(i)  	reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services and to the facility administrator;
(ii)  	a requirement that the facility notify an emergency contact about the allegation within 24 hours of the facility becoming aware of the allegation;
(iii)  	the process for investigating such allegations;
(iv)  	how the facility will document the investigation process to evidence the required reporting and that a thorough investigation was conducted;
(v)  	a requirement that the resident shall be protected from potential future abuse and neglect while the investigation is being conducted;
(vi)  	a requirement that if the alleged neglect or abuse is verified, the facility shall take appropriate corrective action; and
(vii)  	a requirement that a report with the investigation findings will be available for review by the Department not later than five working days of the allegation being lodged with a staff member of the facility.
104(5)(m) Restrictive Egress Alert Devices   Facilities that use restrictive egress alert devices, shall have policy addressing at minimum, the following:
(i)  	How the device will be used to protect the resident from elopement, including but not limited to, which door alarms will be triggered by the device.
(ii)  	Evidence in the resident's record that the facility has:
(A)  	established the legal authority by guardianship, court order, medical durable power of attorney, health care proxy, or other means allowed by Colorado law, for the use of such device;
(B)  	conducted an assessment, prior to use, that evaluates the appropriateness of the device and reassessment(s) within 3 calendar days of a significant change in the resident's condition that warrants intervention or different care needs.  The assessment and reassessment shall include written findings and their basis.  The assessment and reassessment(s) shall be completed by a qualified professional, such as the resident's physician, a social worker, physician's assistant or nurse practitioner.  If the qualified professional is a member of the facility staff or has been hired by the facility to conduct the evaluation, the qualified professional shall consult with the resident's physician or other independent person qualified to review the care needs of the resident.
(iii)  	How the facility will respond to prevent elopement when an alarm is triggered, including but not limited to:
(A)  	the system that will be used to alert staff regarding which door(s) have been breached;
(B)  	the staff member(s) responsible for responding to the alarm and for conducting the behavior management intervention; and
(C)  	how staff will continue providing protective oversight for other residents while the behavior management intervention, such as redirection, is taking place.
(iv)  	How the facility will provide access to a secure outdoor area, consistent with Section 108 (9)(c) (i) and (ii).
(v)  	Monthly testing to ensure that the devices are functioning properly and written evidence of such testing.
104 (5)(n) Accepting Donated Medications for Redispensing by a Pharmacist.   A policy under this subsection (l) is required only if the facility accepts unused donated medications in accordance with state law, including section 12-22-133, C.R.S. (2005).   The policy shall address at minimum the following:  
(i)  	documented evidence that the resident or the resident’s next of kin donated the medications;  
(ii)  	the name(s) and contact information of the pharmacist(s) who have agreed to accept donated medications from the facility and the types of medication that such pharmacist(s) will accept;  
(iii)  	inventory control, including but not limited to, documentation of the date the medication was donated, type and quantity of medication, and the date the pharmacist received the medication evidenced by signature of the pharmacist or his/her representative;  
(iv)  	secure storage of the medication, including but not limited to ensuring that donated medications will not be intermingled with other medications, and prevention of diversion; and  
(v)  	adequate disposal of donated medications either not accepted by the pharmacist or in the facility inventory for longer than 90 days after the date of the donation.  

(Instructions: Strike existing sections 1.105(1) and 1.105(2), Par IDs 1203968 through 1203998, in their entirety, and replace with the following)  
1.105(1)  Admissions
105(1)(a)  Who May be Admitted to the Facility.  Only residents whose needs can be met by the facility within its licensure category shall be admitted.   The facility's ability to meet resident needs shall be based upon a comprehensive pre-admission assessment of the resident's physical, health and social needs; preferences; and capacity for self care.
105(1)(b)  Who May Not be Admitted to the Facility.  A facility shall not admit or keep any resident requiring a level of care or type of service which the facility does not provide or is unable to provide, and in no event shall a facility admit or keep a resident who:
(i)  	Is consistently, uncontrollably incontinent unless the resident or staff is capable of preventing such incontinence from becoming a health hazard.
(ii)  	Is totally bedridden with limited potential for improvement.   A facility may keep a resident who becomes bedridden after admission if there is documented evidence of each of the following:
(A)  	an order by a physician describing the services required to meet the health needs of the resident, including but not limited to, the frequency of assessment and monitoring by the physician or by other licensed medical professionals.
(B)  	ongoing assessment and monitoring by a licensed or Medicare/Medicaid certified home health agency or hospice service.   The assessment and monitoring shall ensure that resident's physical, mental, and psychosocial needs are being met.   The frequency of the assessment and monitoring shall be in accordance with resident needs, but shall be conducted no less frequently than weekly.
(C)  	adequate staffing, with staff who are trained in the provision of caring for bedridden residents, and provision of services to meet the needs of the resident.
(iii)  	Needs medical or nursing services, as defined herein, on a twenty-four hour basis, except for care provided by a psychiatric nurse in those facilities which are licensed to provide services specifically for the mentally ill.
(iv)  	Needs restraints, as defined herein, of any kind except as otherwise provided in 27-10-101, et seq. C.R.S. for those facilities which are licensed to provide services specifically for the mentally ill.   The placement of residents in his or her room for the night and the use of time-out, as provided for in Section 26-20,102 (6), C.R.S., shall be conducted only as part of a treatment plan developed in consultation with a physician board certified in psychiatry or an advance practice nurse with a specialty in psychiatry.   The appropriateness of these provisions in the treatment plan shall be reassessed by either one of these psychiatric clinicians every three months.
(v)  	Has a communicable disease or infection that is: 1) reportable under 6 CCR 1009 Regulation 1 and 2) potentially transmissible in a facility, unless the resident is receiving medical or drug treatment for the condition and the admission is approved by a physician; or
(vi)  	Has a substance abuse problem, unless the substance abuse is no longer acute and a physician determines it to be manageable.
1.105(2)  Resident Agreement.  A written agreement shall be executed between the facility and the resident or the resident's legal representative at the time of admission.   The parties may amend the agreement provided such amendment is evidenced by the written consent of both parties.   No agreement shall be construed to relieve the facility of any requirement or obligation imposed by law or regulation.
105(2)(a)  Content.  The written agreement shall specify the understanding between the parties regarding, at a minimum the following:
(i)  	charges, refunds and deposit policies;
(ii)  	services included in the rates and charges, including optional services for which there will be an additional, specified charge;
(iii)  	types of services provided by the facility, those services which are not provided, and those which the facility will assist the resident in obtaining;
(iv)  	the amount of any fee to hold a place for the resident in the facility while the resident is absent from the facility and the circumstances under which it will be charged;
(v)  	transportation services;
(vi)  	therapeutic diets;
(vii)  	whether the facility or the resident will be responsible for providing   bed and bath linens, as outlined in Section 110 (3)(a) or furnishings and supplies, as outlined in Section 112(3)(f); and
(viii)  	a provision that if the facility closes without giving residents thirty days notice of such closure, that security deposits shall be reimbursed.
105(2)(b)  Addenda.  The written agreement shall have as addenda:
(i)  	the care plan outlining functional capability and needs; and
(ii)  	house rules, established pursuant to Section 1.105(4).
105   (2)(c)  Disclosures.  There shall be written evidence that the following have been disclosed, upon admission unless otherwise specified, to the resident or the resident's legal representative, as appropriate:
(i)  	the facility policies and procedures listed under Section 1.104(5).
(ii)  	the method for determining staffing levels based on resident needs, the onsite availability of first aid certified staff, and the extent to which certified or licensed health care professionals are available onsite.
(iii)  	types of daily activities, including examples of such activities, that will be provided for the residents.
(iv)  	whether or not the facility has automatic fire sprinkler systems.
(v)  	if the facility uses restrictive egress alert devices, the types of individuals exhibited by persons that need such devices.

(Instructions:  Strike existing section 1.113(2) in its entirety, Par IDs 1204340 through 1204353, and replace with the following)
1.113(2)  Compliance with National Fire Protection Association (NFPA) Life Safety Code Requirements
113(2)(a)  Chapter 32, NFPA 101 (2003).  The following facilities shall meet the requirements of   Chapter 32, New Residential Board and Care Occupancies, NFPA 101 (2003):
(i)  	Facilities which apply for licensure on or after June 1, 2004.
(ii) 	Facilities required to submit building plans for plan review, pursuant to Section 1.103 of this chapter, for additions or remodeling of more than 25 percent of the habitable floor space on or after June 1, 2004.
(iii) 	Facilities licensed on or after June 1, 2004, that met the automatic sprinkler exception requirements of Life Safety Code Section 32.2.3.5.2 that subsequently apply for a change of ownership shall meet the requirements of 32.2.3.5.1 upon change of ownership.
113(2)(b)  Chapter 33, NFPA 101 (2003).  The following facilities shall meet the requirements of     Chapter 33, Existing Residential Board and Care Occupancies, NFPA 101 (2003):
(i) 	Facilities that were constructed and that obtained a building permit for such construction on or between January 1, 1993 and May 31, 2004.   Existing life safety features that met the requirements for new buildings at the time of licensure shall be maintained and not diminished.
(ii)  	Facilities that underwent addition, remodeling or renovation to 50 percent or more of its floor area, and obtained a permit for such remodeling on or between January 1, 1993 and May 31, 2004.   Such remodeling or renovation may have been completed as part of a single project or through a series of projects over a period of time.   Existing life safety features that met the requirements for new buildings at the time of licensure shall be maintained and not diminished.
(iii)  	However, facilities with less than 17 beds that were approved by the Department for prompt and slow evacuation levels prior to June 1, 2004 based on the installation of the automatic NFPA Standard 13D or 13R, for automatic fire suppression systems may remain in compliance with this standard, without necessitating the extension of sprinkler coverage in small closets of 24 square feet or less.
113 (2)(c)  Chapter 33, NFPA 101 (2003) or NFPA 101-A Guide on Alternative Approaches to Life Safety (2004).  The following facilities shall meet the requirements of either Chapter 33, Existing Residential Board and Care Occupancies, NFPA 101 (2003) or NFPA 101-A Guide on Alternative Approaches to Life Safety (2004) 9 unless otherwise specified. 
9  For those facilities complying with NFPA 101-A, Guide on Alternative Approaches to Life Safety (2004), the requirements for existing facilities shall apply.
(i)  	Facilities with eight or less licensed beds that apply for a change of ownership, on or after June 1, 2004.  These facilities, licensed on or before June 1, 2004, are allowed one change of ownership prior to having to meet the sprinkler requirements set forth in Life Safety Code section 32.2.3.5.
(ii)  	Facilities with nine or more licensed beds that apply for a change of ownership, on or after June 1, 2004.  The new owner in a change of ownership transaction shall have three years from the date that the initial license was issued to comply with the automatic sprinkler requirements of Life Safety Code sections 32.2.3.5 or 32.3.3.5, as applicable.  Facilities with existing sprinkler systems meeting the requirements of NFPA standard 13R will continue to be acceptable.
(iii) 	any currently licensed facility not described under subsections (a) or (b) above.