When to Submit for FGI Review/Safety Risk Assessment Information

 

TO: Facility Administrators, Building Operations FROM: Marshall Cook, FGI Plan Review and Safety Services Unit Supervisor As you probably are aware, any new health care facilities applying for licensure in Colorado must undergo FGI plan review and garner subsequent approval prior to being eligible for licensure. This is also the case for any currently licensed facility that is undergoing renovations and/or adding additions to the facility. In this case, the areas within the scope of the project must also be designed in compliance with the adopted edition of FGI (currently the 2018 edition). FGI approval must be achieved before these spaces can be utilized. These formal regulatory requirements are as a result of the latest revisions made to 6 CCR 1011-1, Chapter 2 General Licensure Standards for all licensed healthcare facilities in Colorado completed in November 2019. The Chapter 2 regulations now mandate when plan documents must be submitted to the FGI team for review. This is a change from previous policies given delays and difficulties caused by late or non-submissions. Specifically, Part 3 discusses the general building and fire safety provisions in detail. The FGI requirements are located within this section of the rule. Part 3.3 is especially important as it provides facilities with information about what types of projects require FGI review.  Moreover, Part 3.3.2 also stipulates that design documents for guideline compliance review by the Department shall be submitted at the time that the facility or agency applies for the building permits from the local authority. In essence, you are required to submit your FGI-related documents to our team for review no later than when you are applying for local building permits. In areas where no building permits are required, then it is expected that you submit for review of your project prior to the start of construction or renovation. This is very important as the department reviews projects in the order in which they are received. Given that, the wait time in the queue for a project can vary greatly throughout the year (based on the number, size and complexity of projects in the queue at any given time). Thus, the Chapter 2 submittal timeline helps minimize the potential of delays for approval of the facility’s project beyond its anticipated completion date. CLARIFICATION ON SAFETY RISK ASSESSMENTS/RESIDENT SAFETY RISK ASSESSMENTS It has come to our attention that some architects have a misunderstanding about Safety Risk Assessments (SRA) and may be providing incorrect information to facility administrators. In most cases, the Safety Risk Assessment (Resident Safety Risk Assessment in residential environments) is a required document to be submitted with the facility plan documents when requesting an FGI compliance review. Some facility administrators have been advised by their architects that the SRA is only required when conducting renovations or additions to currently licensed and occupied facilities. This is not fully accurate information. Guidance for SRAs can be found within the FGI documents themselves, just as it is for all other required documents such as the Functional Program and Equipment List. In the Hospital and Outpatient volumes, the SRA can be located within Section 1.2-4 and at 1.2-3 within the Residential Facility volume. The table located at the end of Section 1.2 delineates for what types of projects a Safety Risk Assessment is required as well as which elements are to be included. Lastly, the FGI team email address is fgireview@state.co.us . All plan review documents should be submitted to this standardized address. It is also appropriate to email any plan review-related questions to this email address throughout the process. Thank you for your time and attention.