Licensure Terms

Assisted Living Residence

General Approach

The Department of Public Health and Environment licenses assisted living residences (ALRs). The state licenses all adult foster homes as assisted living facilities (ALFs); residential treatment facilities for persons with mental illness are also licensed under assisted living rules.1 Residences that provide services to individuals who might not be safe outside the residence must have a secured environment.

Residences that are certified to receive Medicaid reimbursement, called alternative care facilities, must meet additional requirements. Facilities are eligible for reduced licensing fees if 35 percent or more of the licensed beds are occupied by Medicaid enrollees for at least 9 months in a fiscal year.

This profile includes summaries of selected regulatory provisions for ALRs and Medicaid requirements for these settings if they differ. The complete regulations can be viewed online using the links provided at the end.

Definitions

Assisted living residence means a residential facility for three or more adults not related to the owner of such facility that provides room and board and protective oversight, personal services, social care needed because of impaired capacity to live independently, and regular supervision on a 24-hour basis (24-hour medical or nursing care is not required).

A residential treatment facility for the mentally ill is an ALR that has received program approval from the Department of Human Services to serve no more than 16 mentally ill individuals who are not related to the licensee and are provided treatment commensurate with their psychiatric needs.

Resident Agreements

A copy of the resident agreement must be provided upon move-in. The agreement must provide information about a range of topics, including: charges, refunds, and deposit policies; services included in the rates and charges and optional services that require an additional, specified charge; types of services provided by the facility, services that are not provided, and services that the facility will assist the resident in obtaining; bed hold fees; transportation services; the availability of therapeutic diets; and whether the facility will be responsible for providing bed and linens, furnishings and supplies.

Disclosure Provisions

Facilities must disclose the following information: policies and procedures; method of determining staffing levels; whether the facility has awake staff 24 hours daily; whether certified or licensed health professionals are available on-site; whether an automatic sprinkler system is installed; whether the facility uses restrictive egress alert devices; the on-site availability of first-aid-certified staff; and the facility policy on cardiopulmonary resuscitation and lifting assistance.

Facilities must disclose if they operate a secured environment and provide information about the type of residents they serve (e.g., based on diagnosis or presence of specific behaviors) and for which staff are trained.

Admission and Retention Policy

Facilities may not admit or retain residents who are consistently, uncontrollably incontinent, unless the resident or staff are able to prevent it from becoming a health hazard; are totally bedridden with limited potential for improvement; are in need of 24- hour nursing or medical service; are in need of restraints; have a communicable disease; or have an acute substance abuse problem.

A facility may keep residents who become bedridden if: (1) a physician describes the services needed to meet specified health needs; (2) a licensed home health agency or hospice service ensures that physical, mental, and psychological needs are met; and (3) adequate staff are trained in the needs of bedridden residents. 

Residents may be allowed to receive hospice care if they are long-term residents, the facility can continue to meet the needs of the other residents, and staff are trained to provide hospice care that is not outside their scope of practice. Individuals requiring hospice care upon application for residency must not be admitted.

 Residents must not be admitted to a secured environment unless legal authority for admitting them has been established. However, a resident may be voluntarily admitted or may remain in a secured environment if his or her egress is not restricted and his or her needs can be met by the facility as determined by an assessment.

Alternative care facilities (facilities with a Medicaid contract). These facilities may not admit, or retain past 30 days, any resident who: (1) needs skilled services on more than an intermittent basis; (2) is incapable of self-administering medication, and the facility does not administer medications; (3) is consistently unwilling to take prescribed medication; (4) is diagnosed with a substance abuse disorder and refuses appropriate treatment; (5) has an acute physical illness that cannot be managed through medications or prescribed therapy; (6) has an uncontrolled seizure disorder; (7) exhibits specified disruptive behaviors; or (8) has physical limitations that require tray food service on a continuous basis.

Services

Facilities must provide protective oversight and a physically safe and sanitary environment; personal services (i.e., assistance with activities of daily living, instrumental activities of daily living, individualized social supervision, and transportation); and social and recreational services, both within the facility and in the local community, based on residents’ interests. 

Service Planning

Written care plans, reviewed at least annually, are required for each resident.

Plans must be based on a comprehensive assessment of physical, health, behavioral, and social needs; preferences; capacity for self-care; whether medication is self- administered or administered by staff; dietary restrictions; and any physical or mental limitations or activity restrictions.

Residents whose ability to move safely outside the environment is limited, must be assessed by a qualified professional who can evaluate the need for a secured environment. Reassessments must be completed within 10 days of a significant change to determine whether placement is appropriate.

Third-Party Providers

Personal services and protective oversight services may be provided to a resident by persons who are not employees, contractors, or volunteers of the facility. The term “external services providers” is used to describe home health, hospice, private pay caregivers, and family members.

Medication Provisions

The rules specify how drugs that are used to affect or modify behavior may be administered and how staff may assist residents who use oxygen. Staff may assist with medications used on an as-needed (PRN) basis if the resident is capable of requesting the medication and a licensed medical professional has documented instructions for appropriate use.

A “qualified medication administration person” (QMAP) is an employee who has passed a Department-approved medication training course given by a licensed nurse, physician, physician’s assistant, or pharmacist, and/or has passed an approved competency test for assisting with medications. QMAPs may administer prescribed and non-prescribed medications but may not prepare, draw, or administer medication in a syringe for injection into the blood stream or skin, including insulin pen type devices.

The Department maintains a current list of persons certified as QMAPs. Facility managers must keep a copy of the QMAP certificate in employee records. A QMAP must complete a competency evaluation every 5 years.

ALRs are encouraged to develop and disclose policies and procedures for residents’ use of medical marijuana. Alternative care facilities may not have policies for medical marijuana use because they receive federal funds.

Food Service and Dietary Provisions

Three nutritionally balanced meals, using a variety of foods from the basic food groups, and between meal snacks of nourishing quality must be provided. Therapeutic diets may be provided if prescribed by a physician. Meals cannot be routinely provided in residents’ rooms unless indicated on the care plan. Residents are encouraged to participate in meal planning and to make suggestions regarding menus. Facilities must reasonably respond to residents’ suggestions regarding meals and must provide access to a food preparation area for heating or reheating food or making hot beverages, subject to the facility’s rules.

Alternative care facilities must provide access to food at all times.

Staffing Requirements

Type of Staff. Facilities must have a full-time administrator and sufficient staff to provide care. A qualified medication administration person and at least one staff member with current certification in adult first-aid, which meets the standards of the American Red Cross or American Heart Association, must be on site at all times.

Staff Ratios. No minimum ratios. Facilities must have a method for determining staffing levels, including whether or not the facility has awake staff available 24 hours a day. Sufficient staff must be present at all times to ensure the provision of services necessary to meet residents’ needs, including services provided under the care plan and services provided under the resident agreement. 

Alternative care facilities must maintain a 1:10 staff-to-participant ratio during the day and a 1:16 ratio during the night unless a lower ratio that does not jeopardize the health and safety of residents is documented. Facilities that provide a secured environment must have a 1:6 ratio and at least one staff member must be awake during the night.

Training Requirements

Administrators must complete a 30-hour training program approved by the Department. Fifteen hours of the training must cover the following topics: residents’ rights; environment and fire safety; emergency procedures and first-aid; assessment skills; identifying and addressing difficult situations and behaviors; and nutrition.

An additional 15 hours of training must include the following required topic: meeting the personal, social, and emotional needs of the resident population served (for example, the elderly, persons with dementia, or persons with severe and persistent mental illness); and can include medication management; management of residents’ finances; oxygen use; chronic illnesses, such as diabetes, depression, mental illness, and dementia; legal and ethical issues; activity or care planning; confidentiality; end of life care; and use of community resources.

Staff must be given on-the-job training or have related experience in the job assigned to them. Before staff can furnish direct care services, the facility must provide adequate training on residents’ rights; first-aid and injury response; procedures for providing care and services for the current residents; the facility’s medication administration program; and specific needs of the population served (e.g., frail elderly, diabetics, residents in secured environments, those who are severely and persistently mentally ill, or have AIDS, dementia, or are bedfast).

Within 1 month of hire, the facility must provide adequate training on assessment skills, infection control, identifying and dealing with difficult situations and behaviors, and health emergency response.

Provisions for Apartments and Private Units

Apartment-style units are not required. No more than two people can share a room in facilities built after July 1, 1986. One full bathroom is required for every six residents. Cooking may be allowed in facilities that provide apartments rather than bedrooms.

Cooking is not allowed in bedrooms, and facilities must provide access to a food preparation area for heating or reheating food or making hot beverages, subject to the facility’s rules. Only residents who are capable of cooking safely are allowed to do so.

Alternative care facilities must accommodate requests regarding roommate choice, within reason.

Provisions for Serving Persons with Dementia

Dementia Care Staff. Staffing must be appropriate to meet residents’ needs.

Dementia Staff Training. Staff and the owner/operator must have appropriate training to address the needs of residents in secured environments. At least 75 percent of staff must have a minimum of 8 hours of annual training about Alzheimer’s specific care techniques. The Colorado Alzheimer’s Association training program is recognized by the Department.

Dementia Facility Requirements. Facilities must provide a safe and secure outdoor area for residents’ use year round. Fencing or other enclosures may be installed around secure areas and residents must be able to access the secure areas. Requirements for the use of restrictive egress alert devices are specified.

Background Checks

Owners and administrators must undergo a fingerprint background check. Owners are responsible for obtaining a criminal background check of administrators to determine whether they have been convicted of a felony or a misdemeanor that could pose a risk to residents’ health, safety, and welfare. A criminal background check is also required for all staff, volunteers, and contract staff. The owner or licensee must obtain any criminal history record information from relevant agencies for all persons responsible for residents’ care and welfare.

Inspection and Monitoring

Inspections, both announced and unannounced, are conducted periodically by the Department. A license is valid for 1 year from the date of issuance. Facilities meeting the following criteria are eligible for an extended survey cycle: licensed for at least 3 years, and, within that prior 3 years, have had no enforcement activity, no pattern of deficient practice, and no significant deficiency cited in response to a complaint that negatively affected the life, health, or safety of residents.

Public Financing

The state provides services in ALRs–which are called alternative care facilities– under two Medicaid 1915(c) waiver programs that serve older adults, adults with physical disabilities, adults with HIV/AIDs, and people with mental illness: the Home and Community-Based Services Waiver for Community Mental Health Supports and the Elderly, Blind, and Disabled Waiver.

Room and Board Policy

In 2015, room and board charges for Medicaid beneficiaries residing in alternate care facilities are capped at $675 a month and residents are permitted to retain a personal needs allowance (PNA) of the difference between the cap and their income. For federal Supplemental Security Income (SSI) beneficiaries, the difference is $58.

In 2011, the state paid an optional state supplement of $551 to SSI recipients residing in ALFs. 

In 2009, family supplementation was allowed to pay for items not covered by the Medicaid waiver program.

Location of Licensing, Certification, or Other Requirements

Code of Colorado Regulations, Title 6, Chapter 7: Assisted Living Residences. [various effective dates between November 1, 2008 and July 15, 2014] http://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=5803&fileName=6%20CC R%201011-1%20Chap%2007

Colorado Department of Health Care Policy and Financing website: Alternative Care Facilities, with links to provider information and regulations. https://www.colorado.gov/pacific/hcpf/alternative-care-facilities

Information Sources

Ann Kokish
Colorado Health Care Association

Dee Reda
Colorado Department of Health

Michele Craig
Colorado Department of Health Care Policy and Financing

Caitlin Phillips
Alternative Care Facility Specialist
Long-Term Services and Supports Division Department of Health Care Policy and Financing