Springs Ranch Memory Care Community

“QMP/Occ/Pall QMP PART 4. QUALITY MANAGEMENT PROGRAM, OCCURRENCE REPORTING, PALLIATIVE CARE 4.1 Quality Management Program, Occurrence Reporting, Palliative Care 4.1.1 Every facility or agency shall have a quality management program (QMP) designed to improve client safety and well-being. The client safety component of the program shall implement improvements in response to patterns and trends associated with service delivery errors and potential for error. The client well-being component of the program shall implement improvements that are not necessarily tied to errors or potential for error but instead to the continuous quality improvement principle that opportunities always exist to enhance service delivery.”

This is the rule that was cited, not the inspector’s specific finding.

“Prsnl-Stf/Vol Ornt/Trng Init Gen 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 7 - PERSONNEL - Staff and Volunteer Orientation and Training 7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (A) The assisted living residence shall ensure each staff member or volunteer completes an initial orientation prior to providing any care or services to a resident. Such orientation shall include, at a minimum, all of the following topics: (1) The care and services provided by the assisted living residence; (2) Assignment of duties and responsibilities, specific to the staff member or volunteer; (3) Hand Hygiene and infection control; (4) Emergency response policies and procedures, including: (a) Recognizing emergencies, (b) Relevant emergency contact numbers, (c) Fire response, including facility evacuation procedures (d) Basic first aid, (e) Automated external defibrillator (AED) use, if applicable, (f) Practitioner assessment, and (g) Serious illness injury, and/or death of a resident. (5) Reporting requirements, including occurrence reporting procedures within the facility; (6) Resident rights; (7) House rules; (8) Where to immediately locate a resident's advance directive; and (9) An overview of the assisted living residence's policies and procedures and how to access them for reference.”

This is the rule that was cited, not the inspector’s specific finding.

“Prsnl-Prsnl Files Rq 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 7 - PERSONNEL - Personnel Files 7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following items: (A) A description of the employee or volunteer duties; (B) Date of hire or acceptance of volunteer service and date duties commenced; (C) Orientation and training, including first aid and CPR certification, if applicable; (D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable; (E) Results of background checks and follow up, as applicable; and (F) Tuberculin test results, if applicable. (G) Documentation of initial dementia training and continuing education for direct-care staff members: (1) The residence shall maintain documentation of each employee's completion of initial dementia training and continuing education. Such records shall be available for inspection by representatives of the Department. (2) Completion shall be demonstrated by a certificate, attendance roster, or other documentation. (3) Documentation shall include the number of hours of training, the date on which it was received, and the name of the instructor and/or training entity. (4) Documentation of the satisfactory completion of an equivalent training as defined in sub-part 7.8(B)(2)(b) and as required in the criteria for an exception discussed in sub-part 7.8(B)(4), shall include the information required in this sub-part 7.12 (G)(2) and (3). (5) After the completion of training and upon request, such documentation shall be provided to the staff member for the purpose of employment at another covered facility. For the purpose of dementia training documentation, covered facilities shall include assisted living residences, nursing care facilities, and adult day care facilities as defined in Section 25.5-6-303(1), C.R.S.”

This is the rule that was cited, not the inspector’s specific finding.

“Sec Env-Re As 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 25 - SECURE ENVIRONMENT - Re-Assessment 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident's condition changes from baseline status. (A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident's attending practitioner, family, and/or resident's representative and review service documentation dating back to the most recent comprehensive assessment.”

This is the rule that was cited, not the inspector’s specific finding.

“Sec Env-Stff Tr Wrk Indep 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 25 - SECURE ENVIRONMENT - Staff Training 25.14 Before a staff member is allowed to work independently in the secure environment, the assisted living residence shall provide each staff member with training and education on the provision of care and services for the specific population in the assisted living residence. (A) At a minimum, the individual shall be trained on the care plan for each resident to which the individual could provide care given the staff member's assigned duties and responsibilities. Such training shall be documented.”

This is the rule that was cited, not the inspector’s specific finding.

“Sec Env-Stff Tr CP 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 25 - SECURE ENVIRONMENT - Staff Training 25.16 The assisted living residence shall ensure that each staff member assigned to the secure environment is trained on the care plan for each new resident that is part of the individual's assigned duties and responsibilities.”

This is the rule that was cited, not the inspector’s specific finding.