Updated Chapter 2 General Licensing Regulations

To: All Licensed Health Facilities

From: Health Facilities & Emergency Medical Services Division

Pursuant to Section 24-4-103.3, C.R.S., and Department policy, the Department must review its rules every five to seven years to ensure the rules continue to be efficient, effective, and essential. Accordingly, in 2018 and 2019 the Department reviewed the existing 6 CCR 1011-1, Standards for Hospitals and Health Facilities, Chapter 2 General Licensure Standards. The proposed draft regulations were adopted by the State Board of Health in November 2019 and were made effective on January 14, 2020. They can be found on the Colorado Secretary of States webpage or at this link: Secretary of State, Code of Colorado Regulations .

Summary of Changes:

During the course of the rule review, the Department identified areas where technical changes should be made and where substantive regulatory additions were necessary. Areas of technical changes included the consolidation and movement of the definitions, which were previously throughout the Chapter, to Part 1. This change ensured consistency in the use of terms throughout the Chapter and enables readers to more easily find definitions. Parts within the Chapter were also relocated to provide better clarity, and duplication of information was removed as much as possible. Terminology was also updated to remove the total focus on health care facilities and services to recognize that not all facilities and agencies licensed by the Department are medical in nature.

While the statutory authority for licensing facilities and agencies has not been significantly changed in a number of years, statutes that inform Chapter 2 have been. Therefore, Part 8, Protection of Clients from Involuntary Restraint or Seclusion, was updated to align with changes made to Section 26-20-108, C.R.S. Nomenclature was also changed to align with Section 25-3-607, C.R.S, from "hospital-acquired" infection reporting to "health-care-acquired" infection reporting.

The major substantive change to the Chapter is the addition of Part 3, General Building and Fire Safety Provisions. The changes update the Facilities Guidelines Institute (FGI) standard from the 2010 edition to the 2018 edition, which previously existed within each of the individual licensing chapters, and also create a process, in regulation for the first time, as to how the FGI compliance review will take place. In placing the incorporation of FGI in Chapter 2, the Department also made conforming amendments to all other chapters within 6 CCR 1011-1 to remove the FGI references, expect for Chapter 7 Assisted Living Residences. Chapter 7 had already been updated to reference the 2018 edition of FGI.

Other substantive changes to the Chapter include the removal of language that an applicant shall pay a 100% late fee if a license renewal is not submitted 30 days in advance, which is now replaced with a tiered late fee based on receipt of the renewal application after expiration of a license; clarification as to the time period over which a transfer of ownership that equals 50% interest takes place; clarification as to when the Department considers that a non-profit transfer of ownership has taken place; and a process for facilities and agencies to cease operations.

Due to the nature of Chapter 2 being a reference for all other chapters within 6 CCR 1011-1, the Department also completed any necessary conforming amendments to those chapters. The conforming amendments removed the references to FGI as mentioned above, as well as updated references to Chapter 2 to accurately reflect the proposed structure.