Dialysis Treatment Clinic General Rule Update Stakeholder Process Reminder September 2026

 

To: Dialysis treatment clinics and all parties interested in the stakeholder process to update 6 CCR 1011-1, Chapter 15 From: HFEMSD  In June, the Department convened its final stakeholder meeting to review, reorganize, and update 6 CCR 1011-1, Chapter 15 - Dialysis Treatment Clinics. The Department may reconvene this stakeholder group at a later time if it determines additional stakeholder meetings are necessary. This is a friendly reminder that the Department will continue to take written comments until September 30, 2026. The draft rule has been updated as a result of the last meeting and is available in the public folder for this rulemaking. Please submit written comments to Nicola Koepnick at nicola.koepnick@state.co.us.  As discussed at the last stakeholder meeting, the Department will request a rulemaking hearing at the November 18, 2026, Board of Health meeting. The Board of Health does not accept public testimony during rulemaking hearing requests. However, if the Board accepts our request, a rulemaking hearing will be scheduled for January 20, 2027 and public testimony is encouraged at that time. Further information will be provided in future public notices. If you wish to receive individual notice of this process, please sign up to receive updates emailed directly to you. Feel free to share this link with other interested parties.  If you have any questions or comments, please contact Nicola Koepnick at nicola.koepnick@state.co.us Alexandra Haas at alexandra.haas@state.co.us.

Vacancy on the Assisted Living Informal Dispute Resolution (ALR IDR) Committee

To: ALR Providers From: HFEMSD There is a vacancy for an ALR provider on the ALR Informal Dispute Resolution (IDR) Committee. This 5-member committee includes 2 ALR providers, 1 representative from the ombudsman program, 1 representative from the Department of Health Care Policy and Financing, and 1 representative from the Division ALR program.   The committee meets the fourth Thursday of each month to review residence challenges to findings of deficient practice. Members have the option to attend by way of Google Meet, phone, or in person. We encourage ALR providers outside the Denver area to apply.   ALR providers generally serve a four-year term. Each member has an alternate with whom they may share voting responsibilities.   Interested residence providers may submit a resume to elaine.sabyan@state.co.us. Resumes will be collected through 8/13/2026.

 

Preparing Documentation for Health Facility Surveys

 

To: Licensed Health Facility Administrators From: The Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division The Colorado Department of Public Health and Environment (CDPHE), Health Facilities and Emergency Medical Services (HFEMS) Division, is committed to continually improving our survey processes to better serve Colorado's licensed healthcare facilities while ensuring compliance with applicable state and federal requirements. As part of a recent process improvement initiative, the Division evaluated opportunities to make the survey process more efficient for both healthcare providers and our survey staff. One area identified was the amount of time spent during surveys requesting and gathering documentation needed for review. To help streamline the survey process, we have developed standardized documentation lists based on facility type. We respectfully request that your facility prepare these materials in advance and have them readily available in a single location at the start of the survey whenever possible. While advance preparation of these documents is not a regulatory requirement, it is strongly encouraged as a best practice to help facilitate a timely, organized, and efficient survey. Our goal is to reduce the amount of time spent locating documentation during the survey, allowing both facility staff and surveyors to focus on the survey process itself. Requested Documentation Acute Care (ASC, Birth Centers, CCDOC, CCEC, FSED) Assisted Living Residences Home Care (Adult Day, HCA Class A & B, HHA, IHSS, PHS, Hospice) Nursing Facilities Intellectual & Developmental Disabilities (ICF,RCF) Having these materials organized and available at the beginning of the survey offers several benefits: Reduces time spent locating and retrieving documents throughout the survey. Allows surveyors to begin the review process more efficiently. Minimizes interruptions to facility staff during the survey. Helps shorten the amount of time surveyors need to remain onsite whenever possible. Please note that these documentation lists are intended to facilitate a more efficient survey process and represent the materials most commonly requested during a survey. Depending on observations made during the survey, staff interviews, complaint allegations, or other survey findings, surveyors may request additional documentation as necessary to complete the survey in accordance with applicable state and federal requirements. We recognize that every facility operates differently, and we appreciate your partnership in this effort. Your preparation and cooperation help us conduct surveys more efficiently while allowing both facility staff and surveyors to focus on what matters most ensuring the delivery of safe, high- quality care for Colorado residents. This initiative reflects the HFEMS Division’s commitment to being a Reliable, Efficient, Accountable, Compliant, and Helpful (REACH) partner to Colorado’s licensed healthcare providers while fulfilling our responsibility to protect the health and safety of the people we serve. Thank you for your continued partnership and commitment to quality. We appreciate your support as we implement these improvements and look forward to working with you to make the survey process as efficient and effective as possible.

Assisted Living Residences Informal Dispute Resolution (ALR IDR) Committee meeting

 

To: Assisted Living Residences Providers From: HFEMSD The ALR IDR Committee will not meet on July 23, 2026. No requests have been received for committee review. The next scheduled meeting is August 27, 2026, at 10:00 a.m.   For more information please contact Elaine Sabyan

CDPHE Request to White List (Accept) Email Addresses (correction and update)

 

To: Technical support/providers From: Department of Public Health and Environment, Office of the State Registrar of Vital Statistics We send monthly email information with reminders or new announcements to facilities and providers regarding birth, death and fetal death record submission. The email address we send from is cdphe.vitalrecords411@state.co.us.  The email with the underscore, cdphe_vitalrecords411@state.co.us, is no longer in use.  Please allow emails from cdphe.vitalrecords411@state.co.us.  Below is a reminder about a different email address notice/request that was sent very recently, on or about May 29, 2026. There was an extra letter in the address, in the previous communication. Apologies for the error. Below is the correct address. We are requesting technical support/providers in facilities allow receiving (white listing) of emails from this address: cdphe.coves.notification@state.co.us. These emails are received by physicians, physician assistants, advance practice nurses, medical support staff, administrative staff, birthing facility staff, midwives and midwifery staff involved in the entry of data for birth, death and fetal death records. These emails are necessary login MFA receipt and/or notices for successful and timely compliance with vital statistics reporting requirements.   If you have questions or concerns, you may contact us at the above email. The email address is now in use.

HOSPICE IDR Committee Meeting May 19 2026

 

To: HOSPICE providers From: HFEMSD The HOSPICE IDR Committee will not meet May 19, 2026. The committee has not received requests for review. for more information please contact Elaine Sabyan

HHA IDR Committee Meeting May 19 2026

 

To: HHA providers From: HFEMSD The HHA IDR Committee will not meet May 19, 2026. The Division has not received requests for committee review. for more information please contact Elaine Sabyan

Immediate Jeopardy

 

This message is being sent out to all Program Approved Service Agencies (PASA) providers. CDPHE, in collaboration with Health Care Policy and Financing (HCPF), would like to emphasize the importance of “Immediate Jeopardy” situations found during surveys conducted by CDPHE. Immediate Jeopardy is defined as a situation in which noncompliance by providers (referred to as "entities") has caused, or is likely to cause, serious injury, harm, impairment, or death to an individual member. The following definitions may be used during an immediate jeopardy investigation: IJ Template: Standardized form completed by surveyors to document the basis for an IJ determination, and to formally notify the provider agency of the IJ determination. Likely/Likelihood: the nature and/or extent of the identified noncompliance creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death will occur if not corrected. Recipient at Risk: a member who, as a result of noncompliance, and in consideration of the recipient’s physical, mental, psychosocial or health needs, and/or vulnerabilities, is likely to experience a serious adverse outcome. Noncompliance: failure to meet one or more federal or state health, safety, and/or quality regulations. Serious injury, serious harm, serious impairment or death: adverse outcomes which result in, or are likely to result in: death; or a significant decline in physical, mental, or psychosocial functioning (that is not solely due to the normal progression of a disease or aging process); or loss of limb, or disfigurement; or avoidable pain that is excruciating, and more than transient; or other serious harm that creates life-threatening complications/conditions. *NOTE: IJ does not require serious injury, harm, impairment or death to occur. It is sufficient that non-compliance makes serious injury, harm, impairment or death likely to occur to one or more members IJ Removal Plan: A written, time-limited plan from the agency identifying immediate actions taken to remove the immediate jeopardy. Plan of Correction (POC): A separate plan from the IJ Removal Plan that addresses all cited deficiencies, which may include long-term preventive actions. Agency Responsibilities After Declaration of an Immediate Jeopardy The agency must immediately begin corrective actions and submit an IJ Removal Plan within the timeframe established by CDPHE (typically within 45 minutes). Written IJ Removal Plan Must Include: Affected [Member(s)]: Identify who has suffered or may suffer serious harm. Immediate Correction: Step-by-step actions to resolve the issue and protect health, safety, and welfare. System/Process Fix: Actions to prevent recurrence, including completion dates. Responsible Staff: Provide the title of staff accountable for each action. Investigation: Method for determining the cause of the noncompliance. Staff Training: Trainer title, content, and completion dates. Documentation: How actions will be recorded and implemented. Ongoing Monitoring: Monitoring steps, frequency, and staff responsible to prevent future issues. Submission Instructions: The plan must be on the agency letterhead, or have agency name and contact information listed at the top of the removal document.  Must be signed and dated by the administrator or designee. Provide the plan to the surveyor who sent the IJ template and the IDD supervisors at cdphe_hfems_idd_sups@state.co.us CDPHE will review the plan and request revisions as needed. Final acceptance requires supervisory approval. The agency's plan must address all immediate actions outlined in the IJ Template’s “Need for Immediate Action” section.

ALR IDR Committee Meeting 4/23/26

 

The ALR IDR Committee will meet on April 23rd at 10:00 a.m. The meeting will be held remotely unless an in-person meeting is requested via email to Elaine Sabyan by close of business on April 20, 2026. You may access the meeting remotely by way of Google Meet or by phone: (US) 1 402-751-0128 PIN: 991 536 862# For more information, please contact: Elaine Sabyan

April 23, 2026 - House Bill 1294 Stakeholder Forum - Extended Survey, Branch Updates & Meeting Date Updates

 

To: All Stakeholders  From: HFEMSD  You are invited to participate in the 1294 Stakeholder Forum. House Bill 1294 Stakeholder Forum is an opportunity to promote dialogue and transparency for issues of interest and concern to all licensed healthcare facilities. 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. At this meeting, the department will present:  Branch updates Introduction to the extended survey criteria DATES: This meeting is scheduled for Thursday, April 23, 2026, from 2:00pm-3:00pm.  After this meeting, the Division will begin a series of ongoing 1294 meetings which will be held for 90 minutes beginning in May to continue discussions regarding the extended survey criteria. Thursday May 21, 2026 at 1pm-2:30pm Thursday June 18, 2026 at 1pm-2:30pm Thursday July 16, 2026 at 1pm-2:30pm To participate, we have a number of resource links below.   HB 1294 Stakeholder Forum Website (includes meeting information and invite/communication sign-up)  Agenda Item Request Form   REMINDER: Official meeting minutes are available from the department upon request. Attendees may use artificial intelligence (AI) note-taking tools; however, notes taken in this manner do not constitute the official record of the meeting. If you have any further questions or comments before the meeting, please contact Rachel Bader at rachel.bader@state.co.us

Memorandum: ALAC Meeting Update April 2026 Reschedule & Revised Quarterly Schedule

 

To: Assisted Living Advisory Committee Members  From: Marcie Schweitzer, ALR Community Services Section Manager The upcoming Assisted Living Advisory Committee (ALAC) quarterly meeting scheduled for April 23 is being rescheduled due to a conflict with the HB 12-1294 Stakeholder Forum occurring at the same time (2:00 p.m. to 3:00 p.m.). This adjustment ensures members and interested parties have the opportunity to participate in the stakeholder forum. Going forward, ALAC quarterly meetings will be held on the first Thursday of each quarter from 1:30 p.m. to 3:30 p.m. The first meeting under this updated schedule will take place on May 7. The division's Assisted Living Advisory Committee webpage will be updated to reflect this revised schedule. Meeting information and the agenda for the upcoming meeting will be posted closer to the meeting date.

HOSPICE IDR Committee Meeting 4/21/26

 

To: HOSPICE providers From: HFEMSD The HOSPICE IDR Committee will not meet on April 21, 2026. The committee has not received requests for review.  For more information, please contact: Elaine Sabyan

Understanding Dementia, A Course for Caregivers, 4-hour Basic Dementia Training

 

In 2022, the Colorado legislature passed SB 22-079, CRS section 25-1.5-118, requiring all direct-care staff who work in Assisted Living facilities to complete at least 4 hours of basic Dementia training and 2 hours of continuing education every 2 years. Facilities are responsible for making the required training available to direct-care staff at no cost.  The Department is pleased to announce a new 4-hour basic Dementia e-learning course, titled Understanding Dementia, A Course for Caregivers, that is now available to all direct-care staff throughout the state. The course, developed in partnership with an outside vendor, satisfies the requirements for initial dementia training and is available for free in both English and Spanish. To access the training, staff must log in or register for a CoTrain account.  CoTrain Website How to register:  To register for CoTrain, please create an account and then create your Train Profile.   How to create an account How to complete your CoTrain profile How to access the training: Once you’ve set up your CoTrain account, Please log in and search for Course ID 1134696 to access the dementia learning series in English. For the dementia learning series in Spanish it is Course ID 1134697. Next, click the green “Register” button at the top right of the screen. Didn’t receive a verification code after setting up your CoTrain Account? Check your spam folder. If the email is not in your spam folder, the email may be blocked by your agency, and you will need to speak with your IT department. The dementia course is listed as a 4-hour course, but once I register, the complete list of modules shows a total of seven hours. Which is correct? The course is approximately four hours long. However, because it is a learning series, each module had to be listed separately with a minimum time of one hour. Please note, this is a self-paced course, and the length to complete the course is dependent on the individual. The dementia course is a series of modules. You will need to follow these directions to access the next lesson after completing each module: After completing a lesson, select the "Exit Module" button in the upper right-hand corner of the screen. You will be taken back to the module homepage. Select the back arrow on the upper left side (under the title) to go back to the course menu. Select the next module to complete the course.  Select the green "Launch" button, and begin the next module. Continue to follow the directions to complete the series. If you have any questions regarding the training, please reach out to Dr. Steve Cox, Branch Chief, Home and Community Facilities at steve.cox@state.co.us. For assistance with setting up your CoTrain Account, please review the Tutorials or contact cdphe.co.train@state.co.us. If you continue to have issues, please reach out to Tonie Miller at tonie.miller@state.co.us.

Changes to the Colorado HAI Reportable Conditions & NHSN Annual Data Freeze

 

To: Infection Preventionists and Facility Administrators From: CDPHE Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program  Changes to Colorado HAI Reportable Conditions On Jan. 27, 2026, the Colorado Healthcare-Associated Infections (HAI) Advisory Committee voted to remove the following conditions from the HAI reportable conditions list in Colorado: Surgical site infections (SSIs) following outpatient colon surgery in acute care hospitals (ACHs) Central line-associated bloodstream infections (CLABSIs) in critical access hospitals (CAHs) SSIs following the following procedures in CAHs: Inpatient and outpatient breast surgery Outpatient colon surgery Inpatient and outpatient hysterectomy The committee removed these conditions because the low volume of HAI data made the results statistically unactionable and required suppression in the HAI Annual Report. Effective immediately, the conditions above are no longer reportable in Colorado. Please review the updated list of HAI reportable conditions and confer rights to the appropriate CDPHE National Healthcare Safety Network group for these conditions to ensure you continue to meet all other Colorado HAI reporting requirements. Changes to this list do not alter Centers for Medicare and Medicaid Services reporting requirements or the Colorado State Board of Health requirements for reporting communicable diseases and conditions.  Annual NHSN Data Freeze April 15, 2026 The reporting deadline for NHSN healthcare-associated infections (HAI) data is April 15, 2026. Please be sure to finish all HAI data reporting by April 15th to be included in the annual report. The HAI/AR Program pulls reportable HAI data from the National Healthcare Safety Network (NHSN) on April 16 for publication in the Annual Report on September 15. Review HAI Reportable Conditions.pdf for details on Colorado’s reportable conditions. NHSN includes data quality checks that can be found in the data quality folder within the supplemental reports. Please run these reports to ensure the quality of your data before submitting. The CDC NHSN Data Quality website provides additional information on data quality.