6 Colo. Code Regs. § 1011-1-2.1

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

Section 6 CCR 1011-1-2.1 - Licensure and Department Oversight

2.1.1 The licensee shall ensure compliance with the following:

(A) The BHE shall only provide services for which it holds an endorsement as part of its license.

(B) The licensee shall ensure all BHE operations, locations, and services, including contracted services or personnel, comply with laws, regulations, and standards as required by Chapter 2, General Licensure Standards, and this Chapter 3, Behavioral Health Entities.

(C) The BHE shall meet the requirements in Parts 1 and 2 of these rules, regardless of endorsements included as part of its BHE license.

(D) The BHE shall meet endorsement-specific requirements, as applicable to the endorsements included as part of the BHE's license.

(E) The BHE shall have at least one endorsement and shall provide at least one type of service for each endorsement held, as listed below:

(1) Part 3. Outpatient Endorsement

(a) Outpatient treatment services

(b) Walk-in services

(2) Part 4. 24-Hour/Overnight Endorsement

(a) Crisis Stabilization Services

(b) Acute Treatment Services

2.1.2 Applicants for an initial or renewal license, or a change in ownership, shall follow the licensure procedures and comply with the requirements outlined in 6 CCR 1011-1, Chapter 2, Parts 2.1 through 2.9, with the following additions or exceptions:

(A) The timeline for implementation and transition to the Behavioral Health Entity license shall be:

(1) During the time period of July 1, 2021 through June 30, 2022, facilities or agencies holding a current license from the Department as an ATU, CSU, community mental health center, or community mental health clinic shall apply to become licensed as a BHE in lieu of applying for renewal of the current license at the time that the current license is due to be renewed.

(a) Entities holding more than one ATU, CSU, community mental health center, or community mental health clinic license shall apply to become licensed as a BHE at the earliest renewal date of all licenses held.

(i) The application shall include all of the existing licenses held.

(ii) The BHE will be issued a single license that lists all endorsements and physical locations included in the license.

(iii) Upon issuance of the BHE license, the prior licenses shall be invalid.

(b) If an entity holding a current license from the Department as an ATU, CSU, community mental health center, or community clinic is unable to meet the standards contained within this Chapter 3, the entity may be issued a provisional or conditional license with expected timeframes for compliance.

(c) During the transition period from July 1, 2021 through June 30, 2022, an entity holding a license as an ATU, CSU, community mental health center, or community mental health clinic shall continue to meet the requirements of its existing license until such time as the entity receives a BHE license.

(2) Beginning July 1, 2022, no entity previously licensed as an ATU, CSU, community mental health center, or community mental health clinic shall provide BHE services unless it has been issued a BHE license by the Department.

(3) Effective July 1, 2021, any entity that was not previously licensed by the Department and meets the definition of a BHE shall seek an initial license.

(B) A BHE shall be issued a single entity-wide license which identifies all physical locations included in the license and endorsements for services the BHE is licensed to provide and shall display the license, or a copy thereof, in a manner readily visible to clients at each physical location included in the license.

(C) Each physical location of the BHE shall meet the standards adopted by the Director of the Division of Fire Prevention and Control, as applicable to the services provided in that location, in accordance with 6 CCR 1011-1, Chapter 2, Part 2.2.

(D) A BHE shall only provide services for which it holds an endorsement, and at locations as are authorized by its license.

(1) A BHE shall submit a letter of intent in accordance with the process at 6 CCR 1011-1, Chapter 2, Part 2.9.6, prior to a change in the operation of the BHE, including adding or discontinuing use of physical locations, adding or discontinuing an endorsement, or moving services for which it has an endorsement from one location already included in the license to another location.

(a) Changes to the endorsement(s) and/or physical location(s) used for the operation of a BHE shall not be implemented without prior approval of the Department.

(b) The addition of a physical location requires a Certificate of Compliance prior to approval.

(c) Modifying the services provided in a physical location may require a new Certificate of Compliance, or other appropriate acknowledgement from the Division of Fire Prevention and Control that the space meets the standards for the provision of those services, prior to approval.

(d) A BHE submitting a letter of intent to add services under a new endorsement or physical location, or move services provided under an endorsement from the current location to a new location, shall pay the appropriate fees, as listed in Part 2.1.5.

(e) The addition of an endorsement to an existing BHE license shall not extend the term of the license.

(E) Each applicant for license renewal shall annually submit, in the form and manner prescribed by the Department, information about the BHE's operations, client care, and services.

(F) As part of each initial or renewal application, or application for a change of ownership, the entity shall provide information on circumstances in which there may be a perceived conflict of interest and/or dual relationship within an agency that could negatively impact the individual receiving services, along with policies, procedures, or other mitigating efforts to reduce/eliminate such conflict. Such circumstances include, but are not limited to:

(1) The BHE has a financial interest that may have negative treatment and/or referral implications for the client.

(2) The combining of professional roles within the agency that is incompatible to the best interests of the client.

(3) The combining of professional roles and personal roles that is incompatible to the best interest of the client.

2.1.3 With the submission of an application for licensure, or within ten (10) calendar days after a change in the owner or manager, each owner or manager of a BHE shall submit a complete set of fingerprints to the Colorado Bureau of Investigation (CBI) for the purpose of conducting a state and national fingerprint-based criminal history record check with notifications of future arrests. The information shall be forwarded by the CBI directly to the Department.

(A) The cost of obtaining such information shall be borne by the individual who is the subject of the criminal history record check.

(B) The Department may acquire a name-based criminal history record check for an applicant who has twice submitted to a fingerprint-based criminal history record check and whose fingerprints are unclassifiable.

2.1.4 The Department may deny or limit an application for an initial or renewal license in accordance with 6 CCR 1011-1, Chapter 2, Part 2.11.1, with the following additions or exceptions:

(A) The Department shall not issue or renew a BHE license unless it has received a Certificate of Compliance for each physical location where services are provided.

(B) The Department may deny or limit the overall BHE license, any endorsements or physical locations, or any combination thereof.

(C) No license shall be issued or renewed by the Department if the owner or manager has been convicted of a felony or misdemeanor, if that felony or misdemeanor involves conduct that the Department determines could pose a risk to the health, safety, or welfare of clients of the BHE.

(D) The Department may deny a license for circumstances in which an owner, officer, director, manager, administrator, or other personnel of the applicant or licensee is found to have negatively impacted client treatment and/or decisions through the following, or similar, actions:

(1) The use or dissemination of misleading, deceptive, or false information.

(2) The acceptance of commissions, rebates, or other forms of remuneration for referrals or other treatment decisions.

(3) The exercise of undue influence or coercion over a client that influences client decisions or actions or for financial or personal gain. A relationship other than a professional relationship, including but not limited to a relationship of a sexual nature, between an owner, officer, director, manager, administrator, or other personnel of the applicant or licensee and a client, shall be considered exercise of undue influence or coercion.

2.1.5 License fees shall be submitted to the Department as specified below.

(A) Initial License. An applicant for an initial license as a BHE shall submit the following nonrefundable fee(s) with the application for licensure, as applicable:

(1) A base fee of $1,750, regardless of endorsements or physical locations included as part of the application for initial licensure.

(2) A fee of $700 for the Outpatient Endorsement, regardless of the number of physical locations included in the endorsement, to be paid only by BHEs that are seeking a license that includes services included under Part 3 of these rules.

(3) A fee of $900 for each physical location in which services are to be provided under the 24-hour/Overnight Endorsement in Part 4 of these rules, to be paid only by BHEs seeking such endorsement.

(B) Renewal License. An applicant for a renewal license as a BHE shall submit the following nonrefundable fees, as applicable:

(1) A base fee of $1,350, regardless of endorsements or physical locations included in the application for initial licensure.

(2) A fee of $600 for the Outpatient Endorsement, regardless of the number of renewing physical locations included in the endorsement, to be paid by BHEs renewing a license that currently includes an Outpatient Endorsement.

(3) A fee of $800 for each physical location in which services are currently provided under the 24-hour/Overnight Endorsement in Part 4 of these rules.

(4) If a BHE is adding endorsements or physical locations at the time of the renewal application, the fees listed in Part 2.1.5(D), as applicable, shall be paid at the time of renewal.

(C) Change of Ownership. An applicant for a change of ownership shall submit the following nonrefundable fee(s) with the application for licensure, as applicable:

(1) A base fee of $1,750, regardless of endorsements or physical locations included as part of the application for the change of ownership.

(2) A fee of $700 for the Outpatient Endorsement, regardless of the number of physical locations included in the endorsement, to be paid only when the change of ownership application includes services included under Part 3 of these rules.

(3) A fee of $900 for each physical location under the 24-hour/Overnight Endorsement, to be paid only when the change of ownership application includes services included in Part 4 of these rules.

(D) Adding an endorsement or physical location. A BHE wishing to add an endorsement or physical location to its license, either at renewal or during the term of the license, shall pay the following fee(s), as applicable:

(1) When adding the Outpatient Endorsement under Part 3 of these rules, the fee shall be $700, regardless of the number of physical locations included in the endorsement.

(2) When adding a physical location to the Outpatient Endorsement, the fee shall be $150.

(3) When adding the 24-hour/Overnight Endorsement, the fee shall be $900 per physical location to be included as part of the endorsement.

(4) When adding physical locations to an existing 24-hour/Overnight Endorsement, the fee shall be $900 per physical location being added.

2.1.6 A BHE shall comply with the requirements in 6 CCR 1011-1, Chapter 2, Part 2.10, Department Oversight, with the following additions:

(A) Oversight and enforcement activities may include review of endorsements and/or separate physical locations as necessary for the Department to ensure the health, safety, and welfare of clients.

(B) When citing a BHE for noncompliance, the Department may consider the following:

(1) The actual or potential harm to the BHE's clients due to the noncompliance.

(2) Whether the noncompliance is isolated, a pattern, or widespread.

(3) Whether the noncompliance has occurred within an endorsement type, a physical location, or across the BHE.

(C) The BHE shall be responsible for the compliance of contractors and affiliate agencies and shall ensure the correction of any deficiencies identified during such reviews.

2.1.7 A BHE shall comply with the requirements in 6 CCR 1011-1, Chapter 2, Part 2.11, Enforcement and Disciplinary Sanctions, with the following additions:

(A) Enforcement actions may be directed to the overall BHE license, or any endorsement(s) or physical location(s) included in the license, or any combination thereof.

(B) The Department, at its discretion, may impose the following intermediate restrictions or conditions on a BHE in accordance with Section 25-27.6-110(2)(b)(I), C.R.S.:

(1) Retaining a consultant to address corrective measures including deficient practice resulting from systemic failure;

(2) Monitoring by the Department for a specific period;

(3) Providing additional training to personnel, owners, or operators of the BHE;

(4) Complying with a directed written plan to correct the violation; or

(5) Paying a civil fine not to exceed two thousand dollars ($2,000) in a calendar year.

(C) The BHE may appeal any intermediate restriction or condition to the Department through an informal review process as specified by the Department.

(D) In addition to the circumstances listed at Chapter 2, Part 2.11.2, the Department may revoke or suspend a BHE's license for circumstances in which an owner, director, manager, administrator, or other personnel is found to have negatively impacted client treatment and/or decisions through:

(1) The use or dissemination of misleading, deceptive, or false information,

(2) The acceptance of commissions, rebates, or other forms of remuneration for referrals or other treatment decisions.

(3) The exercise of undue influence or coercion over a client that influences client decisions or actions or for financial or personal gain. A relationship other than a professional relationship, including but not limited to a relationship of a sexual nature, between an owner, director, manager, administrator, or other personnel and a client, shall be considered exercise of undue influence or coercion.

6 CCR 1011-1-2.1