Subject 6 CCR 1011-1, Chapter 18 - Psychiatric Hospitals Stakeholder Process Announcement

 

To: All Hospitals, All Hospital Units, All Psychiatric Facilities, All Rural Health Facilities, All Critical Access Hospitals, All Psychiatric Residential Treatment Facilities, All Community Mental Health Centers, All Behavioral Health Entities, All Health Facilities From: HFEMSD The Department will be convening a stakeholder engagement process to review, reorganize, and update 6 CCR 1011-1, Chapter 18 - Psychiatric Hospitals. The first stakeholder meeting will be held on Tuesday, November 3, 2026, from 1:00 p.m. - 3:00 p.m., and the first Tuesday of each following month beginning November 2026 and continuing through February 2028. This update of Chapter 18 will incorporate recent statutory changes, and coincide with the planned update to 6 CCR 1011-1 Chapter 4 – General Hospitals, and 6 CCR 1015-4 – Statewide Emergency Medical and Trauma Care System.  All interested parties are invited to attend meetings either in-person at the Department or online via Zoom. If you are interested in the stakeholder process to update Chapter 18, please sign-up to receive notice of each meeting and meeting details. Please feel free to share this link with other interested parties. Notice of each meeting will be emailed directly to interested parties and sent via the Division’s portal messaging system roughly one to two weeks before each meeting. Meeting details, including agendas and proposed rule language, will be available before each meeting in the public Google folder dedicated to this rulemaking. Meeting details for Tuesday, November 3, 2026 — 1:00 p.m. In-person meeting location: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80234 Building A, Room A2A (there will be signs and someone at the doors to let you into the area)  Remote meeting information: Join Zoom Meeting Meeting ID: 838 9979 8218  Passcode: 455980  Find your local number Stakeholder engagement is integral to the Department’s effort to align Chapter 18 with hospital facility care and requirements in Colorado and to protect the health, safety, and welfare of patients. If you have any questions or comments prior to the first meeting, please contact Ash Jackson at ash.jackson@state.co.us or Alexandra Haas at alexandra.haas@state.co.us.

6 CCR 1011-1, Chapter 18 - Psychiatric Hospitals Stakeholder Process Announcement

 

To: All Hospitals, All Hospital Units, All Psychiatric Facilities, All Rural Health Facilities, All Critical Access Hospitals, All Psychiatric Residential Treatment Facilities, All Community Mental Health Centers, All Behavioral Health Entities, All Health Facilities From: HFEMSD The Department will be convening a stakeholder engagement process to review, reorganize, and update 6 CCR 1011-1, Chapter 18 - Psychiatric Hospitals. The first stakeholder meeting will be held on Tuesday, November 3, 2026, from 1:00 p.m. - 3:00 p.m., and the first Tuesday of each following month beginning October 2026 and continuing through February 2028. This update of Chapter 18 will incorporate recent hospital-related statutory changes, and coincide with the planned update to 6 CCR 1011-1 Chapter 4 – General Hospitals, and 6 CCR 1015-4 – Statewide Emergency Medical and Trauma Care System.  All interested parties are invited to attend meetings either in-person at the Department or online via Zoom. If you are interested in the stakeholder process to update Chapter 18, please sign-up to receive notice of each meeting and meeting details. Please feel free to share this link with other interested parties. Notice of each meeting will be emailed directly to interested parties and sent via the Division’s portal messaging system roughly one to two weeks before each meeting. Meeting details, including agendas and proposed rule language, will be available before each meeting in the public Google folder dedicated to this rulemaking. Meeting details for Tuesday, November 3, 2026 — 1:00 p.m. In-person meeting location: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80234 Building A, Room A2A (there will be signs and someone at the doors to let you into the area)  Remote meeting information: Join Zoom Meeting Meeting ID: 838 9979 8218  Passcode: 455980  Find your local number Stakeholder engagement is integral to the Department’s effort to align Chapter 18 with hospital facility care and requirements in Colorado and to protect the health, safety, and welfare of patients. If you have any questions or comments prior to the first meeting, please contact Ash Jackson at ash.jackson@state.co.us or Alexandra Haas at alexandra.haas@state.co.us

Your input needed: Update List of Supplemental Healthcare Staffing Agencies

 

To: Facility Administrators From: CDPHE, HCPF, and CDLE It’s time to update the list of Supplemental Healthcare Staffing Agencies that healthcare facilities in Colorado are using. Colorado Revised Statute (C.R.S.) § 8-4-125 requires staffing agencies providing services in Colorado to healthcare facilities that are licensed by the Department of Public Health and Environment pursuant to C.R.S. § 25-1.5-103(1)(a) to submit semi-annual reports to the Division of Labor Standards and Statistics (DLSS). DLSS shares the data submitted with the Colorado Departments of Public Health and Environment (CDPHE) and Health Care Policy and Financing (HCPF). To identify which SHSAs need to report, CDPHE and HCPF gather information about the staffing agencies they utilize from healthcare facilities. If your facility is licensed by CDPHE pursuant to C.R.S. § 25-1.5-103(1)(a), please complete the Healthcare Provider Questionnaire by October 15, 2026, including the names of any supplemental health-care staffing agencies your facility currently uses or has used during 2026. For further information, contact the DLSS Reporting and Accountability Programs by email at cdle_health_staffing@state.co.us or phone (720) 235-8291.

Apply to become a member of the Healthcare-Associated Infections Advisory Committee

 

The Colorado Department of Public Health and Environment (CDPHE) is recruiting four new members of the Healthcare-Associated Infections Advisory (HAI) Committee. Currently, the committee is requesting applicants for the following positions Medical statistician OR clinical microbiologist with an advanced degree, Representative from a health insurer, Infection control practitioner from a long-term care setting, Representative from a rural hospital. Applicants must be a resident of Colorado and must be able to contribute objectively to committee meetings from the perspective of the position. All interested and qualified individuals should apply. This position will be appointed by the Executive Director of CDPHE for a term of three years. The HAI Advisory Committee was established under Colorado Revised Statute (C.R.S.) 25-3-602 to provide oversight to CDPHE for the collection and public reporting of data on HAI infection rates from health facilities. The committee typically meets every other month on the fourth Tuesday of the month from 2 - 4 p.m. CDPHE facilitates committee meetings using video conferencing. There are 11 members who represent a variety of stakeholders. Membership is voluntary. Participation on the HAI Advisory Committee is a great way to learn about HAIs and play an important role in state public health! We appreciate a diversity of input. Membership is not labor intensive, apart from participating in committee meetings. CDPHE invites qualified persons to complete and submit the fillable application with a resume or curriculum vitae by email to cdphe_hai_ar@state.co.us. You may submit additional pages with the application if needed to answer the “additional questions.” The deadline for submission is October 31, 2025. The CDPHE Healthcare-Associated Infections and Antimicrobial Resistance Program will review applicants internally before making a recommendation to the Executive Director for appointment. For more information, please see the HAI Advisory Committee Website or contact Chris Czaja MD, DrPH at christopher.czaja@state.co.us or 303-692-2700.

Request for documentation timelines

 

Dear Licensed Healthcare Entities, The department is dedicated to improving the survey process. However, we have encountered a consistent challenge: receiving the requested documentation in a timely manner during surveys or complaint investigations. This delay prolongs the survey and extends the time surveyors need to spend on-site. To improve this process, your cooperation is crucial. Chapter 2 states: 6 CCR 1011-1, Chapter 2, part 2.10.5, the licensee is required to provide, upon request, access to or copies of the following to the Department to facilitate regulatory oversight: (A) Individual client records.   (B) Reports and information required by the Department, which may include staffing reports, census data, statistical information, and any other records specified by the Department. To ensure a smooth process, the department requests that all documentation be provided within 2 hours of the request. If any mitigating circumstances prevent you from meeting this timeline, please communicate this to the surveyors promptly. Thank you for your attention and cooperation.

Feedback on proposed changes to the Epidemic and Communicable Disease Control rule

 

To: Facility administrators, infection preventionists, and medical officers From: Communicable Disease Branch, Disease Control and Public Health Response   The Division of Disease Control and Public Health Response and Office of STI, HIV, and Viral Hepatitis at the Colorado Department of Public Health and Environment are requesting stakeholder feedback to proposed changes to 6 Code of Colorado Regulations 1009-1 (6 CCR 1009-1): Epidemic and Communicable Disease Control.    6 CCR 1009-1 names the communicable diseases that are reportable to CDPHE and local public health agencies in order to protect the public’s health. As part of this, this set of rules: Details how these conditions must be reported to CDPHE, Includes language about access to pertinent medical records and public health authority to access those records, as necessary, to perform investigations, and  Outlines public health’s authority to investigate causes of epidemic and communicable diseases to implement disease control measures. Go to CDPHE’s disease reporting web page to review the proposed changes, information on how to provide feedback about any of the rules in 6 CCR 1009-1, and for the rulemaking process and timeline.   If you have further questions about the rulemaking process, email cdphe_dcphr_planning@state.co.us. .

EVS Infection Prevention & Control Workshops

 

To: Healthcare Professionals From: CDPHE’s HAI Project Firstline Team Project Firstline provides infection control training for frontline healthcare workers on how to recognize and stop infection risks. CDPHE’s Project Firstline team has developed training specific to the role of our EVS professionals.   EVS-specific infection prevention and control training will be covered over the course of three sessions. Topics include the concept of infection control, environmental cleaning and disinfection, linen and laundry, and medical waste.   To accommodate various schedules, we have created four “tracks” that include three separate sessions to cover the curriculum in half hour sessions. Dates for each session are listed for each track below. Register in advance.   Track 1: July 16, July 23, and July 30 at 8:00 am Track 2: July 17, July 24, and July 31 at 10:00 am   Track 3: July 18, July 25, and August 1 at 2:00 pm  *Spanish* Track: August 13, August 20, and August 27 at 8:00 am     If you have questions, email cdphe_project_firstline@state.co.us. .

Changes to the approach to public health surveillance for healthcare-associated invasive Group A Streptococcus infections

 

Key points Starting May/June 2024, the Colorado Department of Public Health and Environment’s (CDPHE) Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program will only routinely review medical records of reported cases of invasive Group A Streptococcus (iGAS) infection in patients 55 years and older to identify healthcare exposures. CDPHE will no longer review medical records for patients younger than 55 years old for this purpose. This approach will allow CDPHE to identify and respond to 95% of long-term facility cases of iGAS, as well as allow for more efficient use of public health resources to respond to healthcare-associated iGAS infection in people at greatest risk of severe disease. The Vaccine Preventable and Invasive Disease Program will continue laboratory-based surveillance for iGAS in the five-county Denver metro area without changes. Background Healthcare-associated iGAS can cause severe disease and death. A single case of iGAS in a healthcare setting can be an indicator of an outbreak. Most healthcare-associated iGAS outbreaks occur in long-term care facilities, frequently skilled nursing facilities. Approximately 30% of cases of iGAS in residents of long-term care facilities reported to CDPHE from 2020-2023 were associated with an outbreak. Long-term care facility staff may not be aware of an iGAS outbreak because iGAS infection may be diagnosed in a hospital and cases may occur weeks or months apart. In contrast to long-term care facility outbreaks of iGAS, postpartum and postsurgical infections are less common and more readily identified by hospital providers.  CDPHE’s HAI/AR Program conducts active surveillance for iGAS in healthcare settings. GAS identified from a normally sterile site or from a non-sterile site in the presence of streptococcal toxic shock syndrome or necrotizing fasciitis is a four-day laboratory-reportable condition for patients residing in Arapahoe, Adams, Denver, Douglas, and Jefferson counties as part of CDC’s Emerging Infections Program - Active Bacterial Core Surveillance project. Currently, the HAI/AR Program reviews the medical records associated with all reported cases in order to identify healthcare exposures, including recent surgery, delivery, and long-term care facility residency. The HAI/AR Program investigates single cases and clusters of cases with healthcare exposures, in order to identify and respond to outbreaks and prevent additional cases of iGAS in healthcare settings. Between 2020 and 2023, reports of iGAS in the catchment area increased from fewer than 500 to greater than 1,000 per year. The proportion of iGAS reports with long-term care facility exposure was 1% among patients aged 0-54 years and 15% among patients aged 55 years and older. Medical record review for reports in patients 55 years and older will capture 95% of long-term facility cases of iGAS while reducing the volume of medical record review by 50%. Passive surveillance through provider reports will capture the remaining 5% of long-term care facility-associated cases, cases of iGAS in younger postpartum and post-surgical patients, and healthcare-associated cases outside the Denver metro area.  Health care providers statewide should contact the HAI/AR Program for technical assistance with the evaluation and management of single cases of iGAS in healthcare settings. Outbreaks of any kind, including suspected outbreaks of iGAS in healthcare settings, are immediately reportable. Contact the HAI/AR Program at 303-692-2700 or (cdphe_hai_ar@state.co.us). .

Recall of Urology and Operating Room Kits

 

To: Infection Prevention Partners From:  CDPHE HAI/AR Program Dear IP Partners, We wanted to update you about an additional recall related to the Nurse Assist recall issued in November.   The U.S. Food and Drug Administration (FDA) issued a Safety Communication notifying that "Cardinal Health issued a medical device recall on December 5, 2023, for its Covidien and Cardinal Health™ brand urology and operating room-specific kits and trays that contain 0.9% sodium chloride irrigation USP and sterile water for irrigation USP supplied by Nurse Assist."   The Safety Communication provides a link to affected Covidien and Cardinal Health™ brand codes and lot numbers.   Please note:   Assure the timely and effective removal of these products according to the safety communication. Reports of adverse events associated with use of these recalled products can be transmitted via MedWatch. Notify CDPHE if you suspect a healthcare-associated infection or outbreak associated with recalled saline and sterile water products.    Please refer to the FDA Safety Communication for more details. To report an outbreak please email the CDPHE HAI/AR Program at cdphe_hai_ar@state.co.us or call the communicable disease line at 303-692-2700 (or 303-370-9395 after hours). For further information: Contact the CDPHE HAI/AR Program at cdphe_hai_ar@state.co.us .

Public Notice Stakeholder November 9, 2023 Behavioral Health Entity Implementation and Advisory Committee

To: All Stakeholders interested in the Behavioral Health Entity Implementation and Advisory Committee   From: HFEMSD   When:  November 9, 2023, 1:00 – 3:00 p.m.   Online: Zoom meeting Audio line: 719-359-4580, Meeting ID: 706 298 107, Password: 385375    The Behavioral Health Entity Implementation and Advisory Committee will facilitate one final meeting in November to complete the discussion of the transition of the Behavioral Health Entity License from CDPHE to the Behavioral Health Administration, and to review what regulatory authority remains with CDPHE for mental health services. Meeting documents, schedules and archived agendas are available on the department website (click on link below and then click on large font that says, “MEETING INFORMATION”):  https://www.colorado.gov/pacific/cdphe/behavioral-health-entity-implementation-and-advisory-committee  A draft agenda will be available on this site no later than one week in advance. Sign up here if interested in receiving updates and public notice correspondence:  https://docs.google.com/forms/d/e/1FAIpQLSdROO_GY8Iwl0rJLuwchy7qu9fY09QZGrq_3dDXZquNSfyySQ/viewform   If you have any questions or comments prior to the meeting, feel free to contact Jane Flournoy at Jane.Flournoy@state.co.us.

 

Public Notice Stakeholder September 14, 2023 Behavioral Health Entity Implementation and Advisory Committee

 

To: All Stakeholders interested in the Behavioral Health Entity Implementation and Advisory Committee From: HFEMSD   When:  September 14, 2023, 1:00 – 3:00 p.m.   Where:   Online: Zoom meeting Audio line: 719-359-4580, Meeting ID: 706 298 107, Password: 385375  The Behavioral Health Entity Implementation and Advisory Committee will meet in September to continue the discussion of the transition of the Behavioral Health Entity License from CDPHE to the newly-formed Behavioral Health Administration. Meeting documents, schedules and archived agendas are available on the department website (click on link below and then click on large font that says, “MEETING INFORMATION”):  https://www.colorado.gov/pacific/cdphe/behavioral-health-entity-implementation-and-advisory-committee  A draft agenda will be available on this site no later than one week in advance. Sign up here if interested in receiving updates and public notice correspondence: If you have any questions or comments prior to the meeting, feel free to contact Jane Flournoy at Jane.Flournoy@state.co.us.

Changes to Renewal Application in COHFI

 

To: All Licensed Health Facilities/Agencies and COHFI users who submit license applications   From: HFEMSD   Background: When the COHFI system launched in February 2020, CDPHE left renewal applications open and editable by COHFI license users. This was necessary to get all facility information entered into the COHFI system. Once all facilities were able to complete one renewal cycle in COHFI, HFEMSD’s intent was to lock down the sections of the renewal applications for which changes require a separate approval process. While this plan was significantly delayed, but we are now prepared to implement these changes.   Need to Know: During the COHFI maintenance window on Wednesday, August 30th, the following fields will no longer be editable on a renewal application. This change will be implemented system wide for all renewal applications Licensees must follow the established process to submit an Update Application when this information changes.   The following sections will no longer be editable on a Renewal Application:   General and Demographics Facility/Agency Name Facility/Agency Physical Address Administrator Information Director of Nursing Information Demographics Information (for some facility/agency types) Additional Locations Buildings Off-Campus Locations Branches Workstations BHE Service Locations Ownership Ownership General            -Ownership Type            -Name of Business Entity            -EIN            -Start Date of Ownership  Board of Directors  Officers Business Ownership Summary (Shareholders/Stakeholders) Management Company Management Company General             -Ownership Type             -Name of Business Entity             -EIN             -Start Date of Ownership Officers Board of Directors Management Owner Summary     For questions, or if you experience bugs or issues with this change, please contact cdphe.healthfacilities@state.co.us with your facility name, facility ID, and a description of your issues.