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.

2025 HAI Annual Report is now available

 

To: Facility administrators and infection preventionists From: Healthcare-Associated Infections and Antimicrobial Resistance Program The 2025 Healthcare-Associated Infections (HAI) Annual Report from the Colorado Department of Public Health and Environment is now available. New in 2025: There is a new dashboard of HAIs in Colorado. The dashboard allows users to quickly view and compare HAIs in reporting health care facilities. It supplements the written HAI annual report. Review the HAI annual report and HAI dashboard, and share them with your stakeholders. We have a communications toolkit with social media and graphics you can share with your health care providers or patients. Email cdphe_hai_ar@state.co.us with questions.

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.

Summary of Findings for all reportable occurrences, effective 2/1/25

 

To: Facility Administrators/Managers From: HFEMSD, HFEQ, Occurrences Program  Dear Providers,  The Department has updated the format of its Summary of Findings for all reportable occurrences, effective 2/1/25. You may notice that the information included in these summaries has been abbreviated, however will still contain the necessary statutory and regulatory requirements for public posting. For your purposes, the occurrence reporting requirements and reporting process remain the same.  Thank you for your attention to this matter.  If you have any questions, please contact our Occurrence Line at 303-692-2900.

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. .

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 .

Reminder to report health care worker influenza immunization by May 15 2023

 

To: Facility administrators   From: HFEMSD Current health facility rules (6 CCR 1011-1, Chapter 2, 11.2.3) require the reporting of influenza vaccination rates:  “Facilities and agencies shall ensure that ninety percent (90%) of employees and direct contractors have received the influenza vaccine during a given influenza season. In order to demonstrate that the ninety percent (90%) rate has been met, facilities and agencies shall: (A) By May 15th of every year, report to the Department, in the form and manner specified by the Department, the vaccination rate for employees and direct contracts for the most recent influenza season.” The timeframe to count employees and direct contractors to be included in your annual reporting is October 1, 2022 – March 31, 2023. This count includes employees who have worked at least one or more days during this reporting period. There are two ways to report data for the 2022-2023 influenza season: National Healthcare Safety Network: If your facility already reports other data to NHSN, you can submit your annual influenza data through NHSN by May 15, 2023. Health Facilities Portal: To report healthcare worker influenza vaccination data by May 15, 2023, please go to: https://www.cohfi.colorado.gov/COHFI/Account/Login. From there, go to the top black bar and hover over “Vaccination Reporting” and click on “Flu Vaccination Reporting” to complete the questions about your staff flu vaccination status for the 2022-23 influenza season. Once you have completed the questions, click the button on the bottom left that says “Send Vaccination Report.” You will receive a pop-up message confirming your submission and Colorado Health Facilities Interactive (COHFI) users who can submit vaccination reports at your facility will receive a copy of the submission for your records. If you need portal support, email ​cohfi.support@state.co.us. 

March 2, 2023— Stakeholder Meeting Concerning The House Bill 1294 & House Bill 22- 1401

 

To: All Stakeholders  From: HFEMSD  The next House Bill (HB) 1294 Stakeholder Forum Meeting is scheduled for March 2, 2023, from 2:00 to 3:00pm. For this meeting, we will continue our conversation regarding rule changes in 6 CCR 1011-1, Chapter 2 as it relates to the passage of House Bill 22-1401- Hospital Nurse Staffing Standards. We will focus on the Stakeholder process for reviewing the proposed updated rule language.   The rule changes for 6 CCR 1011-1 Chapter 2 – General Licensure Standards have two parts. The first part affects all licensed health facilities, and brings into rule the requirement from Public Health Order 20-20 that facilities maintain an infectious disease, vaccine, and mitigation plan. The second part affects the following residential care facility types: All facilities licensed under 6 CCR 1011-1 Chapter 7, e.g. Assisted Living Residences All facilities licensed under 6 CCR 1011-1 Chapter 5, e.g. Skilled Nursing Facilities All facilities licensed under 6 CCR 1011-1 Chapter 8, e.g. Facilities for Persons with Intellectual and Developmental Disabilities, Group Homes, and Intermediate Care Facilities This second part brings into rule the requirement from Public Health Order 20-20 that requires those facilities to appoint an infection control officer, and that appointee’s duties related to infection control and the mitigation of infectious diseases. To participate, we have a number of resource links below.  HB 22-1401 Meeting Folder (includes meeting information  and invite/communication sign-up)  HB 1294 Stakeholder Forum Website (includes meeting information  and invite/communication sign-up)  Agenda Item Request Form   When:  Thursday, March 2, 2023, from 2:00- 3:00 p.m.  Where: This meeting will be held remotely via Zoom Join Zoom Meeting  https://us02web.zoom.us/j/83216415362 Meeting ID: 832 1641 5362 One tap mobile +17193594580,,83216415362# US +16694449171,,83216415362# US Find your local number: https://us02web.zoom.us/u/k9HAnr6w5 If you have any further questions or comments prior to the meeting please contact Tonie Miller at tonie.miller@state.co.us For more information on the purpose and function of the HB 1294 Stakeholder Forum:  The House Bill 1294 Stakeholder Forum is an opportunity to promote dialogue and transparency for all licensed healthcare facilities' issues of interest and concern. This forum is statutorily required for such purpose and had been postponed since the onset of the COVID pandemic.  During this time a smaller, Subject Matter Expert (SME) group members wishing to have ongoing discussions with the department about policy-level questions, issues regarding the financial impact of the pandemic, reimbursement rates for Medicaid providers, long-term planning to deal with healthcare worker shortages, and how to bring more people into the workforce was established.  Members of this group are encouraged to continue these discussions through the re-establishment of the HB 12-1294 Stakeholder Forum. Additionally, pursuant to C.R.S 25-3-113, the Stakeholder Forum consists of representatives from various types of provider facilities licensed by the department along with consumers, consumer advocates, ombudsmen, and other interested parties which meet at least four times each year for the Department to discuss and take into consideration the concerns and issues of interest to the forum members and other attendees regarding the development and implementation of rules and other matters that affect all licensed health care facilities.  Meetings are generally held virtually monthly, on the 1st Thursday of each month.

CMS Revised Emergency Preparedness Guidance For In-Patient and Out-Patient Providers Related to Exercise Exemption based on A Facility's Activation of their Emergency Plan

 

Message to: Administrators, Executive Directors   From: Melanie Roth Lawson, Trainer and Emergency Response Coordinator     Re: CMS Provides Guidance and Clarifications on Emergency Preparedness Exercise Exemptions for Inpatient and Outpatient Providers Due to Ongoing COVID-19 Public Health Emergency (PHE)   Note: The updated guidance only applies if your facility is still currently operating under its activated emergency plan or reactivated its emergency plan for COVID-19 in 2021 or 2022.   CMS recognizes many facilities are still operating under an activated emergency plan during the COVID-19 Public Health Emergency. For those facilities, they are providing more guidance for inpatient and outpatient providers/suppliers, consistent with the exercise exemption authorized by the EP regulations.   To view the document, go here (URL https://www.cms.gov/files/document/qso-20-41-all-revised-05262022.pdf)   All of the changes are in RED.   This exemption states that during or after an actual emergency, the regulations allow for a one-year exemption from the requirement that the facility perform testing exercises. This exemption applies to the next required full-scale exercise only, not the exercise of choice, based on your facility's 12-month exercise cycle.   Please see the attached CMS guidance document. If you have any questions, please contact Melanie.Roth-Lawson@state.co.us or call 720-291-5929.

FDA alerts customers to voluntary recall of compounded drugs due to sterility issues by Drug Depot, LLC, dba APS Pharmacy

 

FDA is alerting patients, health care professionals, veterinarians, and animal owners/caretakers about a voluntary recall by Drug Depot, LLC, doing business as APS Pharmacy, of certain unexpired compounded drugs due to a lack of sterility assurance. Administration of a non-sterile drug intended to be sterile may result in serious and potentially life-threatening infections. See the FDA alert for details of the recalled drugs, reported adverse events, and guidance for health care professionals and consumers: https://www.fda.gov/drugs/drug-safety-and-availability/fda-alerts-customers-voluntary-recall-compounded-drugs-due-sterility-issues-drug-depot-llc-dba-aps?utm_medium=email&utm_source=govdelivery.  Contact the Healthcare-Associated Infections & Antimicrobial Resistance (HAI/AR) Program at CDPHE if you suspect infections related to the recalled products: 303-692-2700 (303-370-9395 after hours).

CMS Clarifies Emergency Preparedness Exercise Exemption Due to Activation of Emergency Plan

 

To: Administrators and Directors   From: Greg Schlosser, Branch Chief, Health Facility Quality & Education Branch                                                                   CMS recognizes that as the COVID-19 Public Health Emergency continues, many facilities continue to operate under their respective activated emergency plans. The emergency preparedness rule states that facilities that activate their emergency plans are exempt from the next required full-scale community-based or individual, facility-based functional exercise. Facilities must be able to demonstrate, through written documentation, that they activated their program due to the emergency.   Now, CMS is providing further clarification to its September 28, 2020 guidance related to the exemption requirements:   The updated guidance only applies if a facility is still currently operating under its activated emergency plan. Facilities that have resumed normal operating status (not under their activated emergency plans) and were exempted from a full-scale exercise for its 2020 cycle, must conduct a full-scale exercise or an individual facility-based exercise for its next cycle. This exemption only applies to the next required full-scale exercise (not the exercise of choice), based on the facility’s 12-month exercise cycle. The cycle is determined by the facility (e.g. calendar, fiscal, or another 12-month timeframe).   For Inpatient Providers and Suppliers (§418.113(d)(2) (inpatient hospice); §441.184(d) (PRTFs), §482.15(d)(2) (hospitals); §483.73(d)(2)(LTC facilities); §483.475(d)(2)(ICFs/IID); §484.102 (HHAs); and §485.625(d)(2)(CAHs):   If the facility is still operating under its currently activated emergency plan, any currently-activated emergency plan will be recognized by surveyors as having met the full-scale exercise requirement for 2021 (even if it claimed the exemption for the 2020 full-scale exercise). If the facility claimed the full-scale exercise exemption in 2020 based on its activated emergency plan and has since resumed normal operating status, the inpatient provider/supplier is expected to complete its required full-scale exercise in 2021 unless it has reactivated its emergency plan for an actual emergency during its 12-month cycle for 2021.   For Outpatient Providers (Required 1 Annual Exercise- Alternating Full-Scale & Exercise of Choice): The outpatient providers will continue to follow the guidance issued, as the facility was either exempt from the full-scale exercise in 2020 or in 2021, depending on its cycle of testing exercises.   For Organ Procurement Organizations (OPOs) at §486.360 and Religious Nonmedical Healthcare Institutions (RNHCIs) at §403.748, we expect these organizations to continue to conduct the required paper-based, tabletop exercise or workshop at least annually.   For more specifics on these updates, we encourage you to review the CMS revised guidance and worksheet surveyors will use to determine compliance. (You may also copy and paste this link to your browser’s address bar: https://drive.google.com/file/d/17OnAa0OivmR66m__MiorsMT_vd9a4eBd/view?usp=sharing.   If you have any questions, please contact Melanie.Roth-Lawson@state.co.us.

Healthcare Worker Influenza Immunization Data Not Due Until May 15

 

To: Facility Administrators From: HFEMSD Current health facility rules require the reporting of influenza vaccination rates per 6 CCR 1011-1, Chapter 2, 11.2.3 “Facilities and agencies shall ensure that ninety percent (90%) of employees and direct contractors have received the influenza vaccine during a given influenza season. In order to demonstrate that the ninety percent (90%) rate has been met, facilities and agencies shall: (A) By May 15th of every year, report to the Department, in the form and manner specified by the Department, the vaccination rate for employees and direct contracts for the most recent influenza season.” There are two ways to report your healthcare worker influenza immunization data for the 2020-2021 Season: NHSN: If your facility already reports other data to NHSN, you submit it anytime from April 1-May 15. Health Facilities Portal: There has been a delay in the creation of the new reporting tool. Once the reporting tool is available, we will send a message letting facilities know how to access the tool. Thank you for your patience in this matter. If you have further questions, please email erica.bloom@state.eco.us.

Active Screening of personnel and visitors

 

To: Owners, Administrators, Directors, Risk Management From: HFEMSD Based on the Center for Disease Control (CDC) summary of changes to the guidance for: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, the following revised screening steps are required for ALL licensed facilities. Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19: Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days. Fever can be either measured temperature ≥100.0°F or subjective fever. People might not notice symptoms of fever at the lower temperature threshold that is used for those entering a healthcare setting, so they should be encouraged to actively take their temperature at home or have their temperature taken upon arrival. For Questions please reach out to: Acute Care Facilities: Erica Brudjar 720-347-8829 or Erica.Brudjar@state.co.us Nursing Facilities: Jo Tansey 303-692-2863 or Jo.Tansey@state.co.us Home and Community Facilities: Cheryl McMahon 303-692-2588 or Cheryl.McMahon@state.co.us Behavioral Health and Community Services: Jane Flournoy 303-910-6348 or Jane.Flournoy@state.co.us

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