6 Colo. Code Regs. § 1011-1 Chapter 02, pt. 2

Current through Register Vol. 47, No. 11, June 10, 2024

Part 2 - [Effective 7/1/2024] LICENSURE PROCESS

2.1Statutory Authority and Applicability

2.1.1 The statutory authority for the promulgation of these rules is set forth in sections 25-1.5-103 and 25-3-100.5, et seq., C.R.S.

2.1.2 A facility or agency licensed by the Department shall comply with all applicable federal and state statutes and regulations including this Chapter 2. In the event of a discrepancy between the Department's regulations, the more specific standards shall apply.

2.1.3 All licenses shall expire one year from the date of issuance, unless otherwise acted upon pursuant to Part 2.11 of this Chapter.

2.2License Required

2.2.1 No person or business entity shall establish, maintain, or operate a facility or agency that is subject to section 25-3-101, C.R.S. without first having obtained a license or, in the case of governmental facilities, a certificate of compliance from the Department.

(A) A licensee that is subject to fire prevention and life safety code requirements shall not provide services in areas subject to plan review except as approved by the Department of Public Safety, Division of Fire Prevention and Control.

(B) Any person or business entity operating a facility or agency who does not have a provisional, conditional, or regular license from the Department is guilty of a misdemeanor and, upon conviction thereof, shall be punished by a fine of not less than fifty dollars ($50), nor more than five hundred dollars ($500). Each day of operation shall be considered a separate offense.

(C) No facility or agency shall create the impression that it is licensed at any location unless it meets the legal definition of the facility or agency that it purports to be.

2.2.2 A separate license shall be required for each physical location or campus of a facility or agency, except as otherwise specified in Chapter 3, Behavioral Health Entities, Chapter 4, General Hospitals, and Chapter 26, Home Care Agencies.

2.2.3 Each licensee offering services that are regulated by more than one Chapter of 6 CCR 1011-1, Standards for Hospitals and Health Facilities, shall obtain a separate license for each category of services that requires a state license.

(A) If any licensee offers services within the same building or on the same campus as another licensee, the client space of one licensee shall be separately identifiable from the client space of any other licensee.

(1) Client space shall include, but not be limited to, client bed wings, diagnostic, procedure, and operating rooms.

2.2.4 Each facility or agency that is federally certified shall have a state license for each category of services for which it is certified, if such a license category exists.

2.3Initial License Application Procedure

2.3.1 Any person or business entity seeking a license to operate a facility or agency that is subject to section 25-3-101, C.R.S. shall initially notify the Department by submitting a letter of intent upon such form and in such manner as prescribed by the Department.

2.3.2 The applicant shall provide the Department with a complete application including all information and attachments specified in the application form and any additional information requested by the Department. The appropriate non-refundable fee(s) for the license category requested shall be submitted with the application. Applications shall be submitted at least ninety (90) calendar days before the anticipated start-up date.

(A) A license application may be considered abandoned if the applicant fails to complete the application within twelve (12) months and fails to respond to the Department. The Department may administratively close the application process.

(B) After an administrative closure, the applicant may file a new license application along with the corresponding initial license fee.

2.3.3 Each applicant shall provide the following information:

(A) The legal name of the applicant and all other names used by it to provide services. The applicant has a continuing duty to submit a letter of intent to the Department for all name changes at least thirty (30) calendar days prior to the effective date of the change.

(1) Applicants for initial licensure shall submit a distinctive license name that does not mislead or confuse the public regarding the license or type of services to be provided.

(2) The name need not include the services to be provided. If, however, those services are included in the name, that inclusion shall not mislead or confuse the public.

(3) Duplication of an existing name is prohibited except between licensees that are affiliated through ownership or controlling interest.

(4) Each licensee shall be identified by this distinctive name on stationery, billing materials, and exterior signage that clearly identifies the licensed entity. Exterior signage shall conform to the applicable local zoning requirements.

(5) If the licensee has a "doing business as" name, it shall hold itself out to the public using such name, as it appears on the license.

(B) Contact information for the applicant shall include a mailing address, telephone number, and e-mail addresses. If applicable, the facility's or agency's website and facsimile number are to be provided.

(C) The identity, address, and telephone number of all persons and business entities with a controlling interest in the facility or agency, including but not limited to:

(1) A non-profit corporation shall list the governing body and officers.

(2) A for-profit corporation shall list the names of the officers and stockholders who directly or indirectly own or control five percent or more of the shares of the corporation.

(3) A partnership shall list the names of all partners.

(4) The chief executive officer of the facility or agency.

(5) If the addresses and telephone numbers provided above are the same as the contact information for the facility or agency itself, the applicant shall also provide an alternate address and telephone number for at least one individual for use in the event of an emergency or closure of the facility or agency.

(D) Proof of professional liability insurance obtained and held in the name of the applicant as required by the Colorado Health Care Availability Act, section 13-64-301, et seq., C.R.S., with the Department identified as a certificate holder. Such coverage shall be maintained for the duration of the license term and the Department shall be notified of any change in the amount, type, or provider of professional liability insurance coverage during the license term. Insurance policies that cover multiple entities must delineate the per-incident and aggregate indemnity amounts specific to the licensee, and such amounts must meet the requirements established by law.

(E) Articles of incorporation, articles of organization, partnership agreement, or other organizing documents required by the Secretary of State to conduct business in Colorado; and by-laws or equivalent documents that govern the rights, duties, and capital contributions of the business entity.

(F) The address(es) of the physical location where services are delivered, as well as, if different, where records are stored for Department review.

(G) A map for each floor of the applicant's buildings indicating room layout, services to be provided in each of the rooms, the proposed physical extent of the license within each building, and all occupancies contiguous to the applicant regardless if services are being delivered under the terms of the license.

(1) If services are delivered in multiple buildings located on a campus, a street map of the campus shall be submitted that indicates which buildings and floors are occupied as part of the license.

(2) Maps shall be submitted in the format prescribed by the Department.

(H) A copy of any management agreement pertaining to operation of the entity that sets forth the financial and administrative responsibilities of each party.

(I) If an applicant leases one or more building(s) to operate under the license, a copy of the lease shall be filed with the license application and show clearly in its context which party to the agreement is to be held responsible for the physical condition of the property.

(J) A statement, on the applicant's letterhead, if available, signed and dated, submitted with the application stating whether any of the following actions have occurred, regardless of whether the action has been stayed in a judicial appeal or otherwise settled between the parties. The actions are to be reported if they occurred within ten (10) years preceding the date of the application. For initial licensure, the Department may, based upon information received in the statement, request additional information from the applicant beyond the ten-year time frame.

(1) For initial licensure of the facility or agency, whether one or more individuals or entities identified in the response to section 2.3.3 has a controlling or ownership interest in any type of health facility and has been the subject or party to any of the following:

(a) A conviction of a felony or misdemeanor involving moral turpitude under the laws of any state or of the United States. A guilty verdict, a plea of guilty, or a plea of nolo contendere (no contest) accepted by the court is considered a conviction.

(b) A civil judgment or criminal conviction resulting from conduct or an offense in the operation, management or ownership of a facility or agency or other entity related to substandard care or health care fraud. A guilty verdict, a plea of guilty, or a plea of nolo contendere (no contest) accepted by the court is considered a conviction.

(c) A disciplinary action imposed upon the applicant by an agency in another jurisdiction that registers or licenses facilities or agencies including but not limited to, a sanction, probation, civil penalty, or a denial, suspension, revocation, or modification of a license or registration.

(d) Limitation, denial, revocation, or suspension by any federal, state, or local authorities of any health care related license.

(e) The refusal to grant or renew a license for operation of a facility or agency, or contract for participation or certification for Medicaid, Medicare, or other public health or social services payment program.

(2) For a change of ownership of a facility or agency, whether any of the new owners have been the subject of, or a party to, one of more of the following events:

(a) A conviction of a felony or misdemeanor involving moral turpitude under the laws of any state or of the United States. A guilty verdict, a plea of guilty, or a plea of nolo contendere (no contest) accepted by the court is considered a conviction,

(b) A civil judgment or a criminal conviction in a case brought by the federal, state, or local authorities that resulted from the operation, management, or ownership of a facility or agency or other entity related to substandard care or health care fraud.

(c) Limitation, denial, revocation, or suspension of a state license or federal certification by another jurisdiction.

(K) Any statement regarding the information requested in paragraph (J) shall include the following, as applicable:

(1) If the event is an action by a governmental agency, as described in 2.3.3(J)(2): the name of the agency, its jurisdiction, the case name, and the docket proceeding or case number by which the event is designated, and a copy of the consent decree, order, or decision.

(2) If the event is a felony conviction or misdemeanor involving moral turpitude: the court, its jurisdiction, the case name, the case number, a description of the matter or a copy of the indictment or charges, and any plea or verdict entered by the court.

(3) If the event concerns a civil action or arbitration proceeding: the court or arbiter, the jurisdiction, the case name, the case number, a description of the matter or a copy of the complaint, and a copy of the verdict of the court or arbitration decision.

2.3.4 Each application shall be signed under penalty of perjury by an authorized corporate officer, general partner, or sole proprietor of the applicant as appropriate.

2.3.5 The Department shall conduct a preliminary assessment of the application and notify the applicant of any application defects.

(A) The applicant shall respond within fourteen (14) calendar days to written notice of any application defect.

2.3.6. Applicants must show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements as set forth in section 26-3.1-111, C.R.S.

2.4Provisional License

2.4.1 Where an applicant fails to fully conform to the applicable statutes and regulations but the Department determines the applicant is making a substantial good faith attempt to comply, the Department may refuse to issue an initial license and instead grant the applicant a provisional license upon payment of the non-refundable provisional license fee.

(A) A provisional license shall be valid for ninety (90) days.

(B) Except for Assisted Living Residences, a second provisional license may be issued if the Department determines that substantial progress continues to be made and it is likely compliance can be achieved by the date of expiration of the second provisional license.

(C) The second provisional license shall be issued for the same duration as the first upon payment of a second non-refundable provisional license fee. The Department may not issue a third or subsequent provisional license to the entity, and in no event shall an entity be provisionally licensed for a period to exceed one hundred eighty (180) calendar days.

(D) During the term of the provisional license, the Department shall conduct any review it deems necessary to determine if the applicant meets the requirements for a regular license.

(E) If the Department determines, prior to expiration of the provisional license, that the applicant has achieved reasonable compliance, it shall issue a regular license upon payment of the applicable initial license fee. The regular license shall be valid for one year from the date of issuance of the regular license, unless otherwise acted upon pursuant to Part 2.11 of this Chapter.

2.5Renewal License Application Procedure

2.5.1 Except for those renewal applicants described in (A) below, a licensee seeking renewal shall provide the Department with a license application, signed under penalty of perjury by an authorized corporate officer, general partner, or sole proprietor of the applicant, as appropriate, and the appropriate fee at least sixty (60) calendar days prior to the expiration of the existing license. Renewal applications shall contain the information required in Part 2.3.3, above, unless the information has been previously submitted and no changes have been made to the information currently held by the Department.

(A) In order to comply with Colorado Division of Insurance Rule 2-1-1, a licensee that has an insurance policy with any portion of self-insured retention or alternate form of security shall submit its license application and fee to the Department at least ninety (90) calendar days prior to the expiration of the existing license.

2.5.2 Failure to submit a complete renewal application and appropriate fees to the Department by the license expiration date will result in the following late fees:

(A) Six (6) to twenty-nine (29) calendar days after expiration, a late fee of ten percent (10%) of the renewal fee is due in addition to the renewal fee,

(B) Thirty (30) to fifty-nine (59) calendar days after expiration, a late fee of fifty percent (50%) of the renewal fee is due in addition to the renewal fee,

(C) Sixty (60) to eighty-nine (89) calendar days after expiration, a late fee of seventy-five percent (75%) of the renewal fee is due in addition to the renewal fee.

2.5.3 If a license renewal application and appropriate fees are not received by the Department by day ninety (90) following the expiration of the license, the licensee shall cease operation and submit an initial application and associated initial fees to the Department in accordance with Part 2.3, above.

2.5.4 The Department shall conduct a preliminary assessment of the renewal application and notify the licensee of any application defects.

(A) The applicant shall respond within fourteen (14) calendar days to written notice of any application defect.

(B) Licensees must show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements set forth in section 26-3.1-111, C.R.S.

2.5.5 [Emergency rule expired 08/08/2020]

2.5.6 [Emergency rule expired 08/08/2020]

2.6Change of Ownership/Management

2.6.1 When a currently licensed facility or agency anticipates a change of ownership, the current licensee shall submit a letter of intent to the Department within the specified time frame, and the prospective new licensee shall submit an application and supporting documentation for change of ownership along with the requisite fees within the same time frame. The time frame for submittal of the letter of intent and the application and supporting documentation shall be at least ninety (90) calendar days before a change of ownership involving any facility or agency except those specifically enumerated in (A) below.

(A) The letter of intent and the application and supporting documentation regarding the change of ownership of an assisted living residence; home care agency; facility for persons with developmental disabilities; outpatient mental health care facility, including but not limited to, a community mental health center or clinic; and any extended care facility or hospice with sixteen (16) or fewer inpatient beds, including but not limited to, nursing homes or rehabilitation facilities, shall be submitted to the Department at least thirty (30) calendar days before the change of ownership.

2.6.2 The Department shall consider the following criteria in determining whether there is a change of ownership of a facility or agency that requires a new license. The transfer of fifty percent (50%) of the ownership interest referred to in this Part 2.6.2 may occur during the course of one transaction or during a series of transactions occurring over a five year period.

(A) Sole proprietors:

(1) The transfer of at least fifty percent (50%) of the ownership interest in a facility or agency from a sole proprietor to another individual, whether or not the transaction affects the title to real property, shall be considered a change of ownership.

(2) Change of ownership does not include forming a corporation from the sole proprietorship with the proprietor as the sole shareholder.

(B) Partnerships:

(1) Dissolution of the partnership and conversion into any other legal structure shall be considered a change of ownership if the conversion also includes a transfer of at least fifty percent (50%) of the direct or indirect ownership to one or more new owners.

(2) Change of ownership does not include dissolution of the partnership to form a corporation with the same persons retaining the same shares of ownership in the new corporation.

(C) Corporations:

(1) Consolidation of two or more corporations resulting in the creation of a new corporate entity shall be considered a change of ownership if the consolidation includes a transfer of at least fifty percent (50%) of the direct or indirect ownership to one or more new owners.

(2) Formation of a corporation from a partnership, a sole proprietorship, or a limited liability company shall be considered a change of ownership if the change includes a transfer of at least fifty percent (50%) of the direct or indirect ownership to one or more new owners.

(3) The transfer, purchase, or sale of shares in the corporation such that at least fifty percent (50%) of the direct or indirect ownership of the corporation is shifted to one or more new owners shall be considered a change of ownership.

(D) Limited Liability Companies:

(1) The transfer of at least fifty percent (50%) of the direct or indirect ownership interest in the company shall be considered a change of ownership.

(2) The termination or dissolution of the company and the conversion thereof into any other entity shall be considered a change of ownership if the conversion also includes a transfer of at least fifty percent (50%) of the direct or indirect ownership to one or more new owners.

(3) Change of ownership does not include transfers of ownership interest between existing members if the transaction does not involve the acquisition of ownership interest by a new member. For the purposes of this Part, "member" means a person or entity with an ownership interest in the limited liability company.

(E) Non-Profits:

(1) The transfer of at least fifty percent (50%) of the controlling interest in the nonprofit is considered a change of ownership.

(F) Management contracts, leases, or other operational arrangements:

(1) If the licensee enters into a lease arrangement or management agreement whereby the owner retains no authority or responsibility for the operation and management of the facility or agency, the action shall be considered a change of ownership that requires a new license.

(G) Legal Structures:

(1) The conversion of a licensee's legal structure, or the legal structure of a business entity that has a direct or indirect ownership interest in the licensee is a change of ownership if the conversion also includes a transfer of at least fifty percent (50%) of the facility's or agency's direct or indirect ownership interest to one or more new owners.

2.6.3 Each applicant for a change of ownership shall submit an application as prescribed in 2.3.2 through 2.3.6 of this Chapter.

2.6.4 The existing licensee shall be responsible for correcting all rule violations and deficiencies in any current plan of correction before the change of ownership becomes effective. In the event that such corrections cannot be accomplished in the time frame specified, the prospective licensee shall be responsible for all uncorrected rule violations and deficiencies including any current plan of correction submitted by the previous licensee unless the prospective licensee submits a revised plan of correction, approved by the Department, before the change of ownership becomes effective.

2.6.5 When the Department issues a license to the new owner, the previous owner shall return its license to the Department within five (5) calendar days of the new owner's receipt of its license.

2.7Fitness Review Process

2.7.1 The Department shall review the applicant's fitness to conduct or maintain a licensed operation. The Department shall determine by on-site inspection or other appropriate investigation the applicant's compliance with applicable statutes and regulations. The Department shall consider the information contained in an entity's application and may request access to and consider other information including but not limited to, the following:

(A) Whether the applicant has legal status to provide the services for which the license is sought as conferred by articles of incorporation, statute, or other governmental declaration.

(B) Whether the applicant's financial resources and sources of revenue appear adequate to provide staff, services, and the physical environment sufficient to comply with the applicable state statutes and regulations; including, if warranted, review of an applicant's credit report,

(C) The applicant's previous compliance history,

(D) Review of the applicant's policies and procedures,

(E) Review of the applicant's quality improvement plans, other quality improvement documentation as may be appropriate, and accreditation reports,

(F) Physical inspection of the entity,

(G) Credentials of staff,

(H) Interviews with staff, and

(I) Other documents deemed appropriate by the Department.

2.7.2 The Department may conduct a fitness review of an existing owner of a licensed facility or agency that has submitted an application for a change of ownership only when the Department has new information not previously available or disclosed that bears on the fitness of the existing owner to operate or maintain a license.

2.8Issuance of License

2.8.1 No license shall be issued until the applicant conforms to all applicable statutes and regulations.

(A) The Department shall not issue or renew any license unless it has received a Department of Public Safety Certificate of Compliance certifying that the building or structure of the facility or agency is in conformity with the standards adopted by the Director of the Division of Fire Prevention and Control. This requirement does not apply to out-patient hospice or home care agency licenses because they do not provide services on their own premises.

2.8.2 Each license shall contain the name of the facility or agency, license category, term of license, holder of license, and the licensed capacity.

(A) Each dialysis treatment clinic and ambulatory surgical center shall be licensed for its maximum operational capacity as determined by the Department.

(B) Except as specified below, no licensee shall admit a client if such admission would exceed the licensed capacity.

(1) If the facility or agency has the physical space and staff capacity to meet the needs of one additional client, the licensee may request from the Department a thirty (30) day exception from the licensed capacity if the client requires immediate admission and the Department determines that there is no convenient appropriate alternative source of admission.

(2) In the event of an emergency involving multiple ill or injured persons, hospitals and other licensees providing essential emergent or continued care services may admit clients that exceed their maximum bed capacity. The length of stay may be for up to thirty (30) consecutive days. One or more extensions of up to thirty (30) consecutive days may be requested based upon extenuating circumstances. Any licensee implementing the emergency bed increase shall provide the Department with verbal notice at the time of implementation and a written report within fourteen (14) calendar days after implementation explaining the emergent situation and the actions taken by the licensee.

(3) If a licensee exceeds its licensed capacity, it shall continue to provide services that meet the health and safety needs of the clients, including but not limited to, life safety code requirements, staffing requirements, and an existing emergency disaster plan.

2.8.3 The Department may impose conditions upon a license prior to issuing an initial or renewal license or during an existing license term. If the Department imposes conditions on a license, the licensee shall immediately comply with all conditions until and unless said conditions are overturned or stayed on appeal.

(A) If conditions are imposed at the same time as an initial or renewal license, the applicant shall pay the applicable initial or renewal license fee plus the conditional fee.

(B) If conditions are imposed during the license term, the licensee shall pay the conditional fee and the conditions shall run concurrently with the existing license term.

(C) If the conditions are renewed in whole or in part for the next license term, the licensee shall pay the applicable renewal fee along with the conditional fee in effect at the time of renewal.

(D) If the Department imposes conditions of continuing duration that require only minimal administrative oversight, it may waive the conditional fee after the licensee has complied with the conditions for a full license term.

(E) If a licensee holds a conditional license, it shall post a clearly legible copy of the license conditions in a conspicuous public place in the facility or agency.

2.9Continuing Obligations of Licensee

2.9.1 Each licensee shall have and maintain electronic business communication tools, including but not limited to, internet access and a valid e-mail address. The licensee shall use these tools to receive and submit information, as required by the Department.

2.9.2 The license shall be displayed in a conspicuous place readily visible to clients who enter at the address that appears on the license.

2.9.3 The license is only valid while in the possession of the licensee to whom it is issued and shall not be subject to sale, assignment, or other transfer, voluntary or involuntary, nor shall a license be valid for any premises other than those for which it was originally issued.

2.9.4 The licensee shall provide accurate and truthful information to the Department during inspections, investigations, and licensing activities.

2.9.5 Where a facility or agency is subject to inspection, certification, or review by other agencies, accrediting organizations, or inspecting companies, the licensee shall provide and/or release to the Department, upon request, any correspondence, reports, or recommendations concerning the licensee that were prepared by such organizations.

2.9.6 Each licensee shall submit to the Department a letter of intent of any change in the information required by Part 2.3.3 of this Chapter from what was contained in the last submitted license application.

(A) Changes to the operation of the facility or agency shall not be implemented without prior approval from the Department. A licensee shall, at least thirty (30) calendar days in advance, submit a letter of intent to the Department regarding any of the following proposed changes.

(1) Increase in licensed capacity.

(a) If a licensee requests an increase in capacity that is approved by the Department, an amended license shall be issued upon payment of the appropriate fee.

(b) The Department has the discretion to deny a requested increase in capacity if it determines that the increase poses a potential risk to the health, safety, or welfare of the licensee's clients based upon the licensee's compliance history, or because the licensee is unable to meet the required health and environmental criteria for the increased capacity.

(2) Change in a management company or proposed use of a management agreement not previously disclosed.

(3) Change in license category or classification.

(4) Change in the scope of services.

(a) For a nursing care facility, the addition or removal of a secure environment.

(b) For an assisted living residence, the addition or removal of a secure environment.

(c) For an ambulatory surgical center, the addition or removal of an operating room or procedure room.

(d) For dialysis treatment clinics, the addition or removal of a treatment modality, such as in-home peritoneal dialysis.

(e) For behavioral health entities, the addition or removal of an endorsement, a service, or a physical location.

(5) Change in service territory.

(a) For a home care agency.

(b) For a hospice.

(6) Change in legal name of the licensee and all other names used by it to provide services.

2.10Department Oversight

2.10.1 The Department and any duly authorized representatives thereof shall have the right to enter upon and into the premises of any licensee or applicant in order to determine the state of compliance with the statutes and regulations, and shall initially identify themselves to the person in charge of the facility or agency at the time.

(A) In accordance with section 25-1.5-103, C.R.S., routine unannounced onsite inspections shall be made only between the hours of 7 a.m. and 7 p.m.

2.10.2 Licensure Surveys and Tiered Inspections

For each licensee that is eligible, the Department will either extend the standard licensure survey cycle up to three (3) years or utilize a tiered licensure inspection system.

(A) In order to be eligible, the licensee shall meet all of the following criteria:

(1) Licensed for at least three (3) years;

(2) No enforcement activity within three (3) years prior to the date of the survey;

(3) No patterns of deficient practices, as documented in the inspection and survey reports issued by the Department within the three (3) years prior to the date of the inspection; and

(4) No substantiated complaint resulting in the discovery of significant deficiencies that may negatively affect the life, health, or safety of clients of the licensee within the three (3) years prior to the date of the survey.

(B) The Department may expand the scope of a tiered inspection to an extended or full survey if the Department finds deficient practice during the tiered inspection process.

(C) Nothing in this Part 2.10.2 limits the ability of the Department to conduct a periodic inspection or survey that is required to meet its obligations as a state survey agency on behalf of the Centers for Medicare and Medicaid Services or the Department of Health Care Policy and Financing to assure that the licensee meets the requirements for participation in the Medicare and Medicaid programs.

2.10.3 The Department may share information regarding an applicant's or licensee's employees or managers that it acquires in the context of a Department review with other state or federal agencies that have a statutory or regulatory interest in the applicant or licensee or applicant's or licensee's employees.

(A) The Department shall forward any responses it receives from the applicant or licensee for the matter under review to other state or federal agencies.

2.10.4 The Department may use the following measures to ensure a licensee's full compliance with the applicable statutory and regulatory criteria.

(A) Unscheduled or unannounced reviews

The Department may conduct an unscheduled or unannounced review of a current licensee based upon, but not limited to, the following criteria:

(1) Routine compliance inspection,

(2) Reasonable cause to question the licensee's continued fitness to conduct or maintain licensed operations,

(3) A complaint alleging non-compliance with license requirements,

(4) Discovery of previously undisclosed information regarding a licensee or any of its owners, officers, managers, or other employees if such information affects or has the potential to affect the licensee's provision of services, or

(5) The omission of relevant information from documents requested by the Department or indication of false information submitted to the Department.

(B) Plan of Correction

After any Departmental review, the Department may request a plan of correction from a licensee or require a licensee's compliance with a Department directed plan of correction.

(1) The plan of correction shall be in the format prescribed by the Department and included, but not be limited to, the following:

(a) A description of how the licensee will correct each identified deficiency,

(i) If deficient practice was cited for a specific client(s), the description shall include the measures that will be put in place or systemic changes made to ensure that the deficient practice will not reoccur for the affected clients(s) and/or other clients having the potential to be affected.

(b) A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur, and

(c) A completion date that shall be no longer than thirty (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department. The completion date is the date that the entity deems it can achieve compliance.

(2) A completed plan of correction shall be:

(a) Signed by the licensee's director, administrator, or manager, and

(b) Submitted to the Department within ten (10) calendar days after the date of the Department's written notice of deficiencies.

(i) If an extension of time is needed to complete the plan of correction, the licensee shall request an extension in writing from the Department prior to the plan of correction due date. The Department may grant an extension of time.

(3) The Department has discretion to approve, impose, modify, or reject a plan of correction.

(a) If the plan of correction is accepted, the Department shall notify the licensee by issuing a written notice of acceptance.

(b) If the plan of correction is unacceptable, the Department shall notify the licensee in writing, and the licensee shall re-submit the changes within the time frame prescribed by the Department.

(c) If the licensee fails to comply with the requirements or deadlines for submission of a plan or fails to submit requested changes to the plan, the Department may reject the plan of correction and impose disciplinary sanctions as set forth below.

(d) If the licensee fails to implement the actions agreed to by the correction date in the approved plan of correction, the Department may impose disciplinary sanctions as set forth below.

2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities:

(A) Individual client records.

(B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department.

2.11Enforcement and Disciplinary Sanctions

2.11.1 License Denials

(A) The Department may deny an application for an initial or renewal license for reasons including but not limited to, the following:

(1) The applicant has not fully complied with all local, state, and federal laws and regulations applicable to that license category or classification,

(2) The application or accompanying documents contain a false statement of material fact,

(3) The applicant fails to respond in a timely manner to Departmental requests for additional information,

(4) The applicant refuses any part of an on-site or off-site inspection,

(5) The applicant fails to comply with or successfully complete an acceptable plan of correction,

(6) The results of the fitness review and/or background check reveal issues that have harmed or have the potential to harm the health or safety of the client(s) served,

(7) The applicant has failed to cooperate with the investigation of any local, state, or federal regulatory body, or

(8) The applicant is not in compliance with regulatory requirements or has a documented pattern of non-compliance that has harmed or has the potential to harm the health or safety of the client(s) served.

(B) If the Department denies an application for an initial or renewal license, it shall provide the applicant with a written notice explaining the basis for the denial and affording the applicant or licensee the opportunity to respond.

(C) Appeals of licensure denials shall be conducted in accordance with the State Administrative Procedure Act, section 24-4-101, et seq., C.R.S.

2.11.2 Revocation or Suspension of a License

(A) The Department may revoke or suspend an existing license for good cause including but not limited to, circumstances in which an owner, officer, director, manager, administrator, or other employee of the licensee:

(1) Fails or refuses to comply with the statutory and/or regulatory requirements applicable to that license type,

(2) Makes a false statement of material fact about clients served by the licensee, its staff, capacity, or other operational components verbally or in any public document or in a matter under investigation by the Department or another governmental entity,

(3) Prevents, interferes with, or attempts to impede in any way the work of a representative or agent of the Department in investigating or enforcing the applicable statutes or regulations,

(4) Falsely advertises or in any way misrepresents the licensee's ability to provide services for the clients served based on its license type or status,

(5) Fails to provide reports and documents required by regulation or statute in a timely and complete fashion,

(6) Fails to comply with or complete a plan of correction in the time or manner specified, or

(7) Falsifies records or documents.

(B) If the Department revokes or suspends a license, it shall provide the licensee with a notice explaining the basis for the action. The notice shall also inform the licensee of its right to appeal and the procedure for appealing the action.

(C) Appeals of Department revocations or suspensions shall be conducted in accordance with the State Administrative Procedure Act, section 24-4-101, et seq., C.R.S.

2.11.3 Summary Suspension of a License

(A) Notwithstanding other remedies available under state law, the Department may summarily suspend a license pending proceedings for revocation or refusal to renew a license in cases of deliberate or willful violation of applicable statutes and regulations or where the public health, safety, or welfare imperatively requires emergency action.

(B) For purposes of this Part, a deliberate and willful violation may be shown by intentional conduct or by a pattern or practice of repeated, identical, or similar violations.

(C) Summary suspension of any license shall be by order of the executive director of the Department or authorized designee and shall comply with the requirements of section 24-4-104, C.R.S.

(D) Appeals of summary suspensions shall be conducted in accordance with the State Administrative Procedure Act, section 24-4-101, et seq., C.R.S.

2.11.4 A license issued by the Department may be revoked, suspended, annulled, limited, or modified at any time during the license term because of a licensee's failure to comply with any of the applicable statutes or regulations, or to make the reports required by section 25-3-104, C.R.S.

(A) Unless consented to by the applicant, a limitation imposed prior to issuance of an initial or renewal license shall be treated as a denial.

(B) Unless consented to by the licensee, a modification of an existing license during its term shall be treated as a revocation.

2.12License Fees

Unless explicitly set forth elsewhere in 6 CCR 1011-1 or statute, the following non-refundable fees shall apply and be submitted to the Department with the corresponding application or notification. More than one fee may apply depending upon the circumstances.

Initial license	$406.36
Renewal license	$406.36
Conditional license	$1,693.13
First provisional license	$1,128.76
Second provisional license	$1,128.76
Change of ownership	$406.36
Change in licensed capacity	$406.36
Change of name	$84.65
Renewal application late fee	See Part 2.5.2, above.

2.13Performance Incentive

2.13.1 Licensee shall be eligible for a performance incentive if the Department's on-site re-licensure inspection demonstrates that:

(A) The licensee has no significant deficiencies that have negatively affected the life, safety, or health of its clients;

(B) The licensee has fully and timely cooperated with the Department during the on-site inspection;

(C) The Department has found no documented actual or potential harm to clients; and

(D) If significant deficiencies are found that do not negatively affect the life, safety, or health of clients, the licensee has submitted and the Department has accepted a plan of correction and the Department has verified that the deficient practice was corrected within the period required by the Department.

2.13.2 The incentive payment shall be calculated at ten percent (10%) of the licensee's renewal license fee and shall apply when:

(A) The inspection is completed with the full and timely cooperation of the licensee,

(B) Inspection findings do not document harm or potential harm to clients, and

(C) Correction of the deficient practice is verified by the Department on or prior to the respective due dates.

(D) The incentive payment shall be paid to the licensee within sixty (60) days following the acceptance of the validation of correction of all cited deficiencies, or within sixty (60) days of the inspection exit date if no deficiencies were cited.

2.14Facility Closure

2.14.1 Each license issued by the Department shall become invalid when the licensee fails to timely renew the license, ceases operation, or there is final agency action suspending or revoking the license. The license shall be returned to the Department within ten (10) calendar days of the event that invalidated it.

2.14.2 Temporary Closures

(A) If a licensee wants to maintain its current license during a temporary suspension of operation, the licensee shall submit a letter of intent to the Department for the Department's approval at least thirty (30) days prior to the suspension of operation. A licensee may be allowed to maintain a current license during a suspension of operation if all of the following are met:

(1) The suspension of operation will be ninety (90) days or less,

(2) The licensee will not be discharging its clients, and

(3) The licensee plans to reopen at the same location with the same services.

2.14.3 Emergency Closures

(A) In the event of an emergency affecting the physical space of the facility or agency that necessitates the removal of clients and employees or contractors from the facility or agency, a licensee shall provide the Department with verbal notice of the event at the time of removal and a written report within fourteen (14) calendar days after the removal explaining the emergent situation and the actions taken by the licensee to provide services that meet the health and safety needs of the clients. Based on the extenuating circumstances, the Department may approve the continuation of the license during the time period that it takes to make the physical space appropriate for clients and employees or contractors to return.

2.14.4 Permanent Closures

(A) Each licensee that surrenders its license shall accomplish the following with regard to any individual client records that the entity is legally obligated to maintain:

(1) Within ten (10) calendar days prior to closure, inform the Department in writing of the specific plan for storage and retrieval of individual client records,

(2) Within ten (10) calendar days of closure, inform all clients or designated representatives thereof, in writing, how and where to obtain their individual records; and

(3) Provide secure storage for any remaining client records.

6 CCR 1011-1 Chapter 02, pt. 2

47 CR 10, May 25, 2024, effective 6/14/2024

47 CR 10, May 25, 2024, effective 7/1/2024