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9/9/2015 Survey Tag 0004 Detail for:
Monday, February 24, 2020 7:34 AM

Survey Date: 9/9/2015

Regulation Number:0004, level A scope/severity

Regulation Title: Compliance with Chapter VII ALR Regs

Regulation Description: 1.101 (2) Assisted living residences, as defined herein, shall be in compliance with all applicable federal and state statutes and regulations, including but not limited to, the following: (a) This Chapter VII.

Surveyor Findings:

Based upon record review and interview, the facility failed to comply with all applicable state statutes and regulations, including but not limited to Chapter VII., which requires that the administrator be the person who is responsible for the overall operation and daily administration of the facility; and further requires the completion of a 30-hour administrator's training which has been approved by the department. The findings:

6 C.C.R. 1011-1 Chapter VII, Section 1.102(2) reads, "Administrator" means a person who is responsible for the overall operation, and daily administration, management and maintenance of the facility.

Additionally section 1.104(2) b) (i) requires that administrators complete a 30-hour administrator training approved by the Department.

Review of the department's data base on 8/31/15, identified the former executive director, who had been moved to a regional corporate position and was no longer located at the facility, as the administrator of record.

The current executive director stated during the onsite investigation that she was responsible for day to day decisions at the facility. She said she had been responsible for day to day decisions at the facility for approximately two months prior to the onsite investigation. She further stated she had not yet completed an on-line administrator's training program, which was approved by the department.

The administrator of record stated on 9/8/15 that she was onsite at the facility "several times" but clarified "not several times a week." When asked who made day to day decisions, the administrator of record stated that the executive director did; however, that if there were "extenuating circumstances" that she was available to make decisions.

The health and wellness director stated the executive director began duties in that position on 5/18/15. When asked who made day to day decisions, the health and wellness director replied that the executive director did.

The district director of clinical services stated on 9/8/15 that the executive director was making day to day administrative decisions and also confirmed the executive director had not yet completed the required 30-hour administrator's training.

Facility Plan of Correction:

P004- Administrator on File
Current Executive Director (ED) has completed the 30 hour administrator course on 9/25/2015. The cdphe administrator on record was updated on 10/22/2015 with the current ED information at Briargate.

(1.What process improvements or system changes have or will be implemented to ensure that when administrative changes occur at the facility, that appropriate training is obtained within the required timeframes?)

The DDO will create a New Hire checklist specific to the administrator to insure training is completed within required timeframe.

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Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

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