NHSN Office Hours 08/20 at 1 pm

 

To: Acute Care Hospitals, Ambulatory Surgery Centers, Critical Access Hospitals, Outpatient Hemodialysis Centers, Inpatient Rehabilitation Facilities, Long-Term Acute Care Hospitals, Pediatric Hospitals From: The Healthcare-Associated Infections (HAI) and Antimicrobial Resistance (AR) Program at the Colorado Department of Public Health and Environment (CDPHE) The CDPHE HAI AR program provides quarterly National Healthcare Safety Network (NHSN) office hours. These are held in conjunction with the NHSN Antimicrobial Use and Resistance Module (AUR) office hours. These are a great way to connect with the HAI/AR program at CDPHE, and get your questions answered regarding antimicrobial stewardship, HAIs, or NHSN reporting.  The next NHSN office hours will be held on August 20, 2025 from 1pm-1:45pm MT via Zoom. You can register here. We will discuss updates to the HAI Annual Report and AUR updates from the NHSN Annual Training. There will also be a Q&A section, so bring any questions you might have. Zoom link for office hours registration For further information please contact the CDPHE HAI AR program, cdphe_hai_ar@state.co.us.

Agency for Healthcare Research and Quality (AHRQ) is offering a free CLABSI Program for Acute Care Hospitals.

 

To: Acute Care Hospitals, Critical Access Hospitals, and Long term-Acute Care Hospitals From: CDPHE HAI/AR Program on behalf of the Agency for Healthcare Research and Quality (AHRQ). AHRQ is currently recruiting acute care hospital units for a free 9-month program to implement and improve evidence-based practices for prevention of central line-associated bloodstream infections (CLABSI). Units will receive training and one-on-one expert coaching to implement sustainable improvements to their infection prevention practices. To learn if your hospital is eligible, attend one of our informational webinars and view our flyer! The Webinars will be held on the following dates and times: Webinars are in Eastern Time (ET) Click on the links below each date and time to register. Thurs, June 5, 2025 10:30-11 a.m. Wed, June 11, 2025 1:30-2 p.m. To learn more about the program, sign up for an informational webinar, or apply for the program please visit: safetyprogram4hai-prevention.ahrq.gov

May 21, 2025 Board of Health Rulemaking Hearing Regarding SB24-121 - CAH Licensure

 

To: Critical Access Hospitals and all parties interested in SB24-121 From: HFEMSD Thank you to those of you who participated in the stakeholder process to implement SB24-121, concerning the creation of a separate health facility license for critical access hospitals. Through meetings held from July 2024 through September 2024, the Department created a draft critical access hospital licensing chapter, 6 CCR 1011-1, Chapter 16, in conjunction with stakeholders. After our last meeting in September 2024, the Department continued to receive feedback from stakeholders via written comment only. Written comments indicated that no changes were necessary to the proposed language, so the Department went forward with a request for rulemaking in March, as discussed at our last meeting. The Board of Health has granted our request for rulemaking and will be holding a public rulemaking hearing on May 21, 2025 at 10:00am to consider the proposed Chapter 16 - Critical Access Hospitals. Notice of the hearing is hereby given pursuant to the provisions of Section 24-4-103, C.R.S. You may provide your comments to the Board in advance of the May rulemaking hearing for their consideration. To submit written comments to the Board, please email cdphe.bohrequests@state.co.us. The Board also welcomes oral testimony regarding rulemakings and the stakeholder process at the hearing. To provide oral testimony, you must sign up before 5:00 pm on May 20, 2024. The time for giving oral testimony may be limited to 3 minutes or less. For further details about providing feedback at the Board of Health meeting, please visit Participate in the Board of Health.  The agenda for the public meeting and other meeting documents can be accessed at Board of Health meetings. To access the Zoom link on the day of the meeting, please visit Board of Health meetings.

Critical Access Hospital Licensure - SB24-121 - Comment Reminder

 

To: CAHs, hospitals, and all stakeholders interested in SB24-121 From: HFEMSD Thank you to everyone who participated in stakeholder meetings related to SB24-121 concerning the licensure of Critical Access Hospitals (CAHs). Through meetings held from July 2024 through September 2024, the Department created a draft critical access hospital licensing chapter, 6 CCR 1011-1, Chapter 16, in conjunction with stakeholders.  The Department continues to take written comment on the draft rules. Comments may be submitted via the comment form or sent via email to Ash Jackson at ash.jackson@state.co.us. The draft Chapter 16 is available on the Division’s public google folder for this project. All comments and questions regarding the new licensing chapter to implement SB24-121 are welcome. The Department encourages stakeholders to review the draft of Chapter 16 and submit any and all feedback. Feedback from stakeholders is critical to the success of any stakeholder process and we deeply value your input. The written comment form will be available until April 16, 2025, when the Department anticipates that it will request a rulemaking hearing with the Board of Health. If you would like to receive future communication regarding the critical access hospital licensure stakeholder process, please sign-up for the interested parties list to receive email notifications directly to your inbox.  If you have any questions or comments, feel free to contact Ash Jackson at ash.jackson@state.co.us, or Alexandra Haas, at alexandra.haas@state.co.us

September 25, 2024 Stakeholder Meeting: Critical Access Hospital Licensure - SB24-121

 

To: CAHs, hospitals, and all stakeholders interested in SB24-121 From: HFEMSD You are invited to participate in the stakeholder process to create a new license category for critical access hospitals as required by SB24-121, a law passed by the Colorado Legislature during the 2024 session. Starting on January 1, 2026, federally-designated critical access hospitals subject to 42 CFR 485, Subpart F will no longer hold general hospital licenses to operate. Instead, these hospitals will be required to hold a new critical access hospital license. The federal requirements for critical access designation remain the same. The goal of this stakeholder process is to create a separate licensing chapter and license category for critical access hospitals.  The third and final stakeholder meeting will be on September 25, 2024 from 1:00 - 3:00 pm. As discussed at last month’s meeting, this stakeholder process will be abbreviated as a result of stakeholder feedback thus far. The September meeting will be our last scheduled meeting and the Department will continue to take written comments only after the final meeting. Written comment may be submitted via the comment form or sent to Ash Jackson at ash.jackson@state.co.us. The Department may decide to reconvene this stakeholder group at a later time.  In order to foster robust discussion, the Department encourages stakeholders to prepare for meetings by reviewing materials in advance and identifying questions, potential inconsistencies, and concerns. Please bring your comments to the next stakeholder meeting and be prepared to discuss the proposed rules in a meaningful way. Active participation from stakeholders is critical to the success of any stakeholder process. All stakeholder meetings are open to the public and all are welcome to attend. Meetings will be held in hybrid format with an option to attend either in-person, or remotely, via Zoom, to ensure equal access for participation regardless of geographic location of the attendee.  The in-person meeting will be at the Colorado Department of Public Health and Environment main campus, 4300 Cherry Creek S Drive, Denver, CO 80246, in Building A, Room Snow. This meeting room is located on the first floor of Building A, down the hall from the main entrance. Zoom meeting information:  Join Zoom Meeting Meeting ID: 830 3112 6573 Details regarding the stakeholder process, including meeting documents, agendas, proposed rule language, presentations, etc., will be available in the public meeting folder. Agendas and proposed rule language will be posted no later than a week in advance of each meeting. If you would like to receive communication regarding the critical access licensure stakeholder process, please sign-up for the interested parties list to receive email notifications directly to your inbox.  If you have any questions or comments prior to the meeting, feel free to contact Ash Jackson at ash.jackson@state.co.us, or Alexandra Haas, at alexandra.haas@state.co.us. .

All Stakeholders interested in regulations related to “Patients’ Right to Know” Act, or HB23-1218

 

To: All Stakeholders interested in regulations related to the “Patients’ Right to Know” Act, or HB23-1218 From: HFEMSD The “Patients’ Right to Know” Act, or HB23-1218 is a law passed by the Colorado Legislature in the 2023 session. This new law requires hospitals, rehabilitation hospitals, freestanding emergency departments, and licensed community clinics to make publicly available a list of the health care services that are generally available or subject to significant restriction specifically relating to health care in three areas: Reproductive health-care services; LGBTQ healthcare services; and End-of-life healthcare services. In response to the new law, the Division will develop, in collaboration with stakeholders, a “Service Availability Form.” Once the form itself is developed, the Division will work to establish rules which bring the law into the pertinent health facility licensing chapters. Once the form is finalized and published, the affected health facilities will be required to provide this form to patients, members of the public, and the Department for public display. For more information, please see the whitepaper here.    The Division intends to engage a robust stakeholder process to bring together the many different populations affected by this new law. This will occur via monthly online meetings, beginning September 2023 and concluding April 2024.  Participating in this stakeholder process will involve attending these monthly meetings, and providing any feedback relevant to your organization. The first monthly meeting will be Tuesday, September 26th, 2023, from 12:30 pm to 3:30 pm, and on the fourth Tuesday of the month thereafter until the process concludes in spring 2024. Notice of each meeting will be provided to facilities through the Division’s portal messaging system roughly two weeks in advance of each meeting. Notice will also be emailed directly to all individuals who sign up to receive such messages. Please sign up here. Please feel free to share this link with other interested parties. All who are interested are welcome to attend and participate. Meeting documents, including agendas, proposed rule language, presentations, etc., will be posted to the public meeting drive no later than a week before each meeting.  If you have any questions or comments prior to the meeting, feel free to contact Ash Jackson at ash.jackson@state.co.us, or Alexandra Haas, at alexandra.haas@state.co.us. 

Infection Control in Critical Access Hospitals

 

To: Critical Access Hospitals From: Pamela Fricke  CDPHE HAI/AR Program My name is Pamela Fricke, and I am the Field Infection Preventionist (IP) in the Healthcare Associated Infection and Antimicrobial Resistance (HAI/AR) Program at Colorado Department of Public Health and Environment (CDPHE). I am writing to you to let you know about a new infection prevention initiative we are launching for critical access hospitals.  I am reaching out today to introduce myself and the HAI/AR Program. The HAI/AR Program exists to prevent healthcare-associated infections and control the spread of emerging antimicrobial-resistant threats in all healthcare settings in Colorado through surveillance, containment and response, infection prevention, and antimicrobial stewardship. We serve as subject matter experts (SMEs), using best practices and evidence-based recommendations to guide mitigation and prevention efforts, provide education, and respond to current HAI/AR events. Our work often includes consultation and on-site infection control assessments in order to better understand facility processes, transmission threats, and guide mitigation.  Starting September 1st, 2023, we will conduct proactive infection prevention assessments in critical access hospitals. The purpose of the assessments will be to support best practices for infection prevention as part of a statewide quality improvement initiative. Proactive infection control assessments are distinct from response-driven assessments. Prevention-based infection control assessments are intended to provide feedback on infection control policies and practices before a problem is identified to help improve healthcare programs. These assessments are known as ICARs (Infection Control Assessment and Response surveys) and will require direct in-person observation and the use of a structured form for data collection Infection Control Assessment Tools | HAI | CDC.  The infection prevention assessments will focus on core infection prevention practices. Depending on the setting, we will assess practices for sterile instrument reprocessing, injection safety, and prevention of catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), and ventilator-associated events (VAE). We will prioritize assistance to facilities that offer on-site hemodialysis. Assessments will generally consist of a six-hour visit (at minimum) that will be scheduled ahead of time at the convenience of the facility. An infection preventionist from the HAI/AR Program will accompany facility staff to conduct an in-depth review that will include direct observation of infection prevention practices related to patient care. At the end of the assessment, we will discuss our immediate findings with facility staff. Following the visit, we will provide a written summary of findings with recommendations for improvement and additional resources to guide quality improvement and priorities for mitigation. Participation is voluntary and highly encouraged. The site visit is not a regulatory visit and the purpose is not punitive. Rather, the purpose is to support and improve infection control practices and to guide education and training. The HAI/AR Program supports efforts aimed at improving healthcare practices in Colorado. Either myself or a team member will be reaching out to facilities individually for participation. When contacted, we encourage facilities to take advantage of this opportunity. In the meantime, I’d like to share some great resources specific to infection prevention and control (IPC): CDC/STRIVE Infection Control Training: Provides training courses, including those specific to core IPC practices (hand hygiene, PPE, environmental cleaning, etc.) and high-risk care activities (e.g., CAUTI, CLABSI, etc.). Additional IPC Training for Healthcare Professionals can be found here. CDCs Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings: Guidance that is similarly separated by topic/care activity, providing healthcare facilities with current evidence-based recommendations.  Continuing education and IPC training specific to setting types can be found here. Project First Line: CDC’s National Training Collaborative for Healthcare Infection Control. More information on Infection Control can be found here. Should you have any questions, want to schedule your assessment in advance, or need other HAI/AR support, please email me directly at pamela.fricke@state.co.us. We look forward to collaborating with you and your facility. You can view the full letter here.

APIC - Critical Access Hospital Scholarship Opportunity

 

To: Critical Access Hospitals From: CDPHEs HAI/AR Program APIC - Critical Access Hospital Scholarship August 15, 2023 The Healthcare-Associated Infections (HAI) and Antimicrobial Resistance (AR) program at the Colorado Department of Public Health and Environment (CDPHE) wants to share an exciting opportunity for critical access hospitals. The Association for Professionals in Infection Control and Epidemiology (APIC) and its subsidiary organizations, APIC Consulting Services, and the Certification Board of Infection Control and Epidemiology (CBIC), joined together to launch the APIC Health Equity Fund. The APIC Health Equity Fund will help underwrite the cost of infection prevention and control tools and resources for underserved U.S. communities.  The focus of the fund for the first three years is a scholarship program for critical access hospitals (CAH). The Critical Access Hospital Scholarship is a capacity-building award for under-resourced critical access hospitals that offer vital healthcare to people living in rural areas throughout Colorado and the United States. Scholarship details, the application process (including an application link), and sponsorship details are available on APIC’s website. Applications are available August-September 2023. If you have any questions, email Scholarships@apic.org. CDPHE’s HAI/AR program is sending the message as a means to bring awareness to Colorado’s CAH partners and are not otherwise affiliated with or able to answer questions related to this opportunity.

Switchback Team Resilience, Recovery and Development Training Program

 

To: Local Public Health Agencies or Medical Organizations (e.g. critical access hospitals, clinical practices, FQHC) without financial resources necessary to pay for similar experiences. From: CO-CARES Team (Colorado Alliance for Resilient & Equitable Systems) & Switchback Institute Switchback Institute serves those who serve others. It is dedicated to individuals, teams, and organizations doing high-impact, high-stakes work. Switchback champions individuals, teams, and organizational leadership in engineering environments that promote individual and team resilience, connectedness, and effectiveness. Workshops are designed to be interactive, and participant-centered. They are customized to meet the needs of individuals and achieve agency-identified outcomes. Group sessions are no-fault, strengths-based, collaborative, and fun! The Team Resilience, Recovery, and Development Training Program includes participation in a recovery retreat, an assessment of team intelligence leading to a team development plan, and team coaching to achieve self-identified goals. By the end of our time together you will have the tools needed to sustain consistent professional growth and resilience both individually and collectively. Most importantly, we want your teams to be reunited with the passion that took them into the healthcare field. The Team Resilience, Recovery, and Development Training Program aims to provide resources, training, and coaching to individuals/teams from the public health and medical care workforce to respond to and grow from the challenges faced currently and over the last 3 years. We will accomplish this in partnership with selected teams through the following activities: Retreat 1: A day-long Resilience and Recovery retreat focused on understanding challenges, and providing support as well as tools to process and grow as individuals and as a team. Inter-stage period: 2-3 virtual team coaching sessions to support ongoing agendas set by team. Completing Team Emotional and Social Intelligence (TESI) assessment that describes a team’s current effectiveness in 7 domains: team identity, motivation, communication, positive mood, stress tolerance, social awareness, and conflict management. Retreat 2: A half-day retreat to debrief TESI assessment, prioritize areas for development, and identify ongoing activities to meet development goals. Inter-stage period: 2-3 virtual team coaching sessions to support ongoing development agendas.  Closing Retreat 3: To celebrate accomplishments and commit to the ongoing development. Visit the CO-CARES page at Switchback Institute to learn more and submit your letter of interest for the program.

Reminder: NHSN AUR Module Colorado Group Office Hour on 8/02/2023

 

Please join us for our National Healthcare Safety Network (NHSN) AUR Module Colorado Group Office Hour webinar on Wednesday, August 2, 2023 from 1:00 – 1:45 MST. The Colorado Department of Public Health and Environment (CDPHE), Healthcare-Associated Infections and Antimicrobial Resistance Program, offers NHSN Colorado user group office hours quarterly via webinar to provide updates and training related to the NHSN Antimicrobial Use and Resistance Module (AUR). Currently, general NHSN office hours are paused and this session will only discuss the AUR module. Staff will provide a brief presentation followed by a question and answer session. The office hours are not required but are an opportunity for your facility to ask questions about the NHSN AUR Module. If you need assistance, please help us maximize the NHSN office hours and feel free to stop by for any amount of time you like. Intended audience: Acute Care Hospitals, Critical Access Hospitals, and Long-Term Acute Care Hospitals reporting to NHSN AUR Module. Agenda for August 2nd office hour: Antimicrobial Stewardship and the NHSN Antimicrobial Use and Resistance (AUR) Module. Antibiotic Use Feedback Reports. Discussion. Please register in advance for this webinar: https://zoom.us/meeting/register/tJwufumprjwuE9FiInm0rrDbYveTEw9Not95 After registering, you will receive a confirmation email containing information about joining the webinar. Please let us know if there are any specific topics or content you would like to see in our next office hour webinar in Fall 2023. For comments or questions, please contact Lauren Biehle at lauren.biehle@state.co.us.

Switchback Team Resilience, Recovery and Development Training Program

 

To: Local Public Health Agencies or Medical Organizations (e.g. critical access hospitals, clinical practices, FQHC) without financial resources necessary to pay for similar experiences. From: CO-CARES Team (Colorado Alliance for Resilient & Equitable Systems) & Switchback Institute Switchback Institute serves those who serve others. It is dedicated to individuals, teams, and organizations doing high-impact, high-stakes work. Switchback champions individuals, teams, and organizational leadership in engineering environments that promote individual and team resilience, connectedness, and effectiveness. Workshops are designed to be interactive, and participant-centered. They are customized to meet the needs of individuals and achieve agency-identified outcomes. Group sessions are no-fault, strengths-based, collaborative, and fun! The Team Resilience, Recovery, and Development Training Program includes participation in a recovery retreat, an assessment of team intelligence leading to a team development plan, and team coaching to achieve self-identified goals. By the end of our time together you will have the tools needed to sustain consistent professional growth and resilience both individually and collectively. Most importantly, we want your teams to be reunited with the passion that took them into the healthcare field. The Team Resilience, Recovery, and Development Training Program aims to provide resources, training, and coaching to individuals/teams from the public health and medical care workforce to respond to and grow from the challenges faced currently and over the last 3 years. We will accomplish this in partnership with selected teams through the following activities: Retreat 1: A day-long Resilience and Recovery retreat focused on understanding challenges, providing support, as well as tools to process and grow as individuals and as a team. Inter-stage period: 2-3 virtual team coaching sessions to support ongoing agendas set by the team. Completing Team Emotional and Social Intelligence (TESI) assessment that describes a team’s current effectiveness in 7 domains: team identity, motivation, communication, positive mood, stress tolerance, social awareness, and conflict management. Retreat 2: A half-day retreat to debrief the TESI assessment, prioritize areas for development, and identify ongoing activities to meet development goals. Inter-stage period: 2-3 virtual team coaching sessions to support ongoing development agendas. Closing Retreat 3: To celebrate accomplishments and commit to the ongoing development. Visit the CO-CARES page at Switchback Institute to learn more and submit your letter of interest for the program.

Switchback Team Resilience, Recovery and Development Training Program

 

To: Local Public Health Agencies or Medical Organizations (e.g. critical access hospitals, clinical practices, FQHC) without financial resources necessary to pay for similar experiences. From: CO-CARES Team (Colorado Alliance for Resilient & Equitable Systems) & Switchback Institute Switchback Institute serves those who serve others. It is dedicated to individuals, teams, and organizations doing high-impact, high-stakes work. Switchback champions individuals, teams, and organizational leadership in engineering environments that promote individual and team resilience, connectedness, and effectiveness. Workshops are designed to be interactive, and participant-centered. They are customized to meet the needs of individuals and achieve agency-identified outcomes. Group sessions are no-fault, strengths-based, collaborative, and fun! The Team Resilience, Recovery, and Development Training Program includes participation in a recovery retreat, an assessment of team intelligence leading to a team development plan, and team coaching to achieve self-identified goals. By the end of our time together you will have tools needed to sustain consistent professional growth and resilience both individually and collectively. Most importantly, we want your teams to be reunited with the passion that took them into the healthcare field. The Team Resilience, Recovery, and Development Training Program aims to provide resources, training, and coaching to individuals/teams from the public health and medical care workforce to respond to and grow from the challenges faced currently and over the last 3 years. We will accomplish this in partnership with selected teams through the following activities: Retreat 1: A day-long Resilience and Recovery retreat focused on understanding challenges, and providing support as well as tools to process and grow as individuals and as a team. Inter-stage period: 2-3 virtual team coaching sessions to support ongoing agendas set by the team. Completing Team Emotional and Social Intelligence (TESI) assessment that describes a team’s current effectiveness in 7 domains: team identity, motivation, communication, positive mood, stress tolerance, social awareness, and conflict management. Retreat 2: A half-day retreat to debrief the TESI assessment, prioritize areas for development, and identify ongoing activities to meet development goals. Inter-stage period: 2-3 virtual team coaching sessions to support ongoing development agendas. Closing Retreat 3: To celebrate accomplishments and commit to the ongoing development. Visit the CO-CARES page at Switchback Institute to learn more and submit your letter of interest for the program.

New Online Tool for Submitting CMS 1135 Waiver Requests and Inquiries

 

TO: Medicare/Medicaid-Participating Providers FROM: Greg Schlosser, Branch Chief, Health Facility Education and Quality In light of the volume of 1135 waiver requests associated with COVID-19, the Centers for Medicare and Medicaid Services (CMS) has announced a new online system for providers and suppliers to request and submit inquiries related to the CMS 1135 Waivers. Effective immediately, please use this CMS PHE Emergency Web Portal (https://cmsqualitysupport.servicenowservices.com/cms_1135) for any II35 requests; it’s simple-to-use format will help expedite the review of submissions, triage request or inquiries. If you or your organization would like to request a waiver or have questions for CMS regarding a Public Health Emergency (PHE), please visit the 1135 web-based portal to submit a PHE-related Inquiry. If you or your organization would like to request an 1135 waiver during a PHE, then also visit the web-based portal to submit your request. Note: Providers or suppliers do not have to apply for an individual waiver when a blanket waiver is issued. For additional information on current blanket 1135 waivers or flexibilities, please visit https://www.cms.gov/about-cms/emergency-preparedness-response-operations/currentemergencies/coronavirus-waivers To view the policy memorandum that outlines these new changes to submitting 1135 waiver requests/inquires, go here  ((or https://drive.google.com/file/d/1KYMfI0eQxxGNQUk9F_DHfuOZ45ijxuHI/view?usp=sharing.) You will also see resources available to providers and supplies during the current COVID-19 Public Health Emergency. If you have any questions, please contact Melanie.Roth-Lawson@state.co.us.