(1) The Assisted Living Facility Governing Authority.
(a) An assisted living facility shall have an identified sole proprietorship, corporation, partnership,
limited partnership, or other business entity that is its governing authority, or it shall have a designated
individual or group of designated individuals who serve as its governing authority. A facility must give complete
information to the Department identifying:
1. Each person who has an ownership interest of 10 percent or more of the governing authority.
2. Each person or entity who has an ownership interest of 10 percent or more in the real property or
building used by the assisted living facility to offer its services.
3. Each officer and each director of the corporation if the governing authority is a corporation.
4. Each partner, including any limited partners, if the governing authority is a partnership.
(b) The governing authority shall submit any changes to the information listed above to the Department
within 15 days of the change.
(c) Responsibility of Staff to Governing Authority. The administrator, medical staff, facility
personnel, and all auxiliary organizations shall be directly or indirectly responsible to the governing
authority. For the purposes of these rules, auxiliary organizations include but are not limited to licensed or
certified outside providers, consultants, management companies that are not the facility license holder.
(d) The governing authority is responsible for appointing and supervising the administrator who is
responsible for overall management and the day-to-day operation of the facility. Under no circumstances shall
the facility operate without a licensed administrator for greater than 45 days.
(e) Policies. The governing authority shall be responsible for establishing and implementing written
policies for the management and operation of the facility and shall be responsible for development of, and adherence
to, procedures implementing those policies. The policies and procedures shall be made available to residents, any
guardians, next of kin, sponsoring agency(ies), or representative payee(s). All residents shall be informed of
new policies or changes in existing policies that may have bearing on the residents. All residents shall be provided a
copy of such policies at least 30 days prior to the policies taking effect. Policies shall cover the following:
(i) Facility responsibility to protect all residents from abuse, neglect, and exploitation.
(ii) How allegations of abuse, neglect, and exploitation will be handled by the facility.
(iii) Resident confidentiality.
(iv) Admission and continued stay criteria.
(v) Discharge criteria and notification procedures for residents and sponsors.
(vi) Facility responsibility when a resident’s personal belongings are lost.
(vii) What services the facility is capable and not capable of providing.
(viii) Medication management.
(ix) Infection control.
(x) Meal service, timing, menus and food preparation, storage, and handling.
(xi) Fire safety and emergency plan, fire drills, fire alarm system, sprinkler and fire extinguisher checks,
and disaster preparedness.
(xii) Staffing and conduct of staff while on duty.
(xiii) Oxygen administration and storage if used in the facility.
(xiv) Dietary Policies. The dietitian, with the approval of the administrator, shall develop written
policies and procedures for the guidance of all personnel handling food as outlined by the most current Food and Drug Administration Food Code published by the U.S. Department of Health and Human Services. The facility shall develop and implement dietary policies and procedures to meet the needs of the residents in the facility. In addition to other matters deemed necessary by the facility, dietary policies shall address:
(I) Sanitation of dishes, utensils, and service equipment, and sanitary food preparation and handling.
(II) The attire and cleanliness of staff members who prepare, handle, or serve food.
(III) A schedule of meals, which shall include between-meal nourishment or snacks, and fluids.
(IV) Food substitutions or alternatives.
(V) Method to ensure an adequate dietary plan is implemented for any resident with a therapeutic diet or
special dietary needs.
(VI) Procedure to be followed if a resident is nutritionally compromised or is not eating adequate quantities of food.
(VII) Provision of necessary services to any resident requiring adaptive devices to eat.
(VIII) Procedure for the handling of potentially hazardous foods such as meat, milk, ice, and eggs.
(IX) Storage of food.
(X) Procedure for food service in the event of a disaster. Disaster menus shall be developed. The policy
shall address how food will be obtained and maintained at safe temperatures if electricity is not available.
(2) The Administrator.
1. The administrator shall be a direct representative of the governing authority in the management
of the assisted living facility and shall be responsible to the governing authority for the proper performance of his
or her duties.
2. Any individual employed as an administrator shall be properly licensed.
3. Any individual employed as an administrator shall meet all applicable statutory requirements.
4. There must be an individual with experience in the day-to-day operation of the facility, who is authorized in writing, to act for the administrator during absences.
5. The administrator and any individual authorized to act as a substitute shall be at least 19
years of age.
6. The administrator and any individual authorized to act as a substitute shall be of reputable and
7. The administrator shall ensure that adequate personnel are employed and on duty to meet the care needs
of all residents 24 hours a day, 7 days a week.
8. The administrator shall manage and direct staff activities in a manner that results in maintenance
of a neat, clean, orderly, and safe environment and adequate care being provided at all times. If a facility
has an adequate number of staff members on duty to meet the care and safety needs of all residents, but adequate
care and safety is not being provided, then the facility does not meet this administration and management
9. The facility administrator is responsible for ensuring that required training is provided to all
10. The administrator shall ensure that residents who have health or safety needs beyond the
capability of the facility will be safely transferred or discharged to an appropriate setting.
11. The administrator shall ensure that facility staff members observe each resident for changes in health
and physical abilities and obtain appropriate medical attention when needed.
12. The administrator shall ensure that plans of care for all residents are current and appropriate. This
shall include the prearranged discharge plan.
13. The administrator shall ensure that all deficient practices cited by the Department are corrected
in a timely manner and that corrections are maintained.
(b) In family and group assisted living facilities, the governing authority and the administrator
may be the same individual.
(c) Department Notification.
1. The licensee of an assisted living facility shall provide written notification of voluntary closure of
the facility to the State Board of Health at least 30 days prior to the expected closure date.
2. The State Board of Health shall be provided written notification not later than 15 days after any
change in administrator.
3. The State Board of Health shall be provided written notification not later than 15 days after any
change in management company.
1. An assisted living facility must meet the applicable provisions of federal law and regulations
pertaining to nondiscrimination on the basis of race, color, gender, religion, or national origin;
nondiscrimination on the basis of handicap; nondiscrimination on the basis of age; protection of human
subjects of research; and protection from fraud and abuse. Although federal law and regulations are not normally
surveyed and enforced by the State Board of Health in assisted living facilities, serious violations of these
provisions of law may nevertheless constitute grounds for adverse licensure action.
2. An assisted living facility shall obey all applicable federal, state, and local laws, ordinances, and
3. Licensing of Staff. Staff of the facility shall be currently licensed, certified, or registered in
accordance with applicable laws.
4. Compliance with Other Laws. An assisted living facility shall comply with laws relating to fire and
life safety, sanitation, and communicable and reportable diseases.