Health Facilities and Emergency Medical Services Division 

6 CCR 1011-1 

STANDARDS FOR HOSPITALS AND HEALTH FACILITIES 
CHAPTER V – LONG TERM CARE FACILITIES

THE PROPOSED AMENDMENT CONSISTS OF THE ADDITION OF SECTION 2.5 ON PAGE 2.  ONLY PART 2 OF CHAPTER V HAS BEEN INCLUDED HEREIN.

Part 2 - Administration
2.1	ADMINISTRATOR.
The administrator is responsible to the governing body for planning, organizing, developing, and controlling the operations of the facility.
2.1.1	The administrator shall be licensed in the State of Colorado.
2.1.2	The administrator's responsibilities: 1) liaison among the governing body, medical staff, and physicians whose patients reside in. the facility, 2) financial and personnel management, 3) providing for appropriate resident care; and 4) maintaining relationships with the community and with other health care facilities, organizations, and services; 5) assuring facility and staff compliance with all regulations; and 6) any responsibilities prescribed by facility policy.
2.2	ORGANIZATION.
The facility shall be organized formally to carry out its responsibilities with a plan of organization clearly defining the authority, responsibilities, and functions of each category of personnel.
2.3	POLICIES.
In consultation with the Medical Advisor and 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, medical, dental, dietary, diagnostic, emergency, and pharmaceutical care; social services; activities; rehabilitation; physical, occupational, and speech therapy; resident admission, transfer, and discharge; notification of physician and family or other responsible party of resident's incidents, accidents and changes of status; disasters; and health records and any other policies the department determines the facility needs based on its characteristics of its resident population.
2.4	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.

2.5  	+OCCURRENCE REPORTING.  
NOTWITHSTANDING ANY OTHER REPORTING REQUIRED BY STATE REGULATION, EACH FACILITY SHALL REPORT THE FOLLOWING TO THE DEPARTMENT 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.
(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.
(5)	ANY OCCURRENCE INVOLVING MISTREATMENT OF A RESIDENT THAT IS NOT COVERED BY ITEMS 1 THROUGH 4 ABOVE.