Why has Life Safety Code plan review and inspections changed from the Department of Health?
Effective July 1, 2013, the authority to establish and maintain fire and life safety related codes for Health Facilities transferred from the Department of Public Health and Environment (CDPHE) to the Department of Public Safety, Division of Fire Prevention and Control (DFPC). The transfer was passed by the Colorado State Legislature under HB12-1268.
What is considered a Health Facility?
HB12-1268 defined: “Health Facility” means a General Hospital, Hospital Unit as defined in section 25-3-101(2) C.R.S., Psychiatric Hospital, Community Clinic, Rehabilitation Center, Convalescent Center, Community Mental Health Center, Acute Treatment Unit, Facility for Persons with Developmental Disabilities, Habilitation Center for Children with Brain Damage, Chiropractic Center and Hospital, Maternity Hospital, Nursing Care Facility, Rehabilitative Nursing Facility, Hospice Care Facility, Dialysis Treatment Clinic, Ambulatory Surgical Center, Birthing Center, Home Care Agency, Assisted Living Residence or other facility of a like nature; except that “Health Facility” does not include a facility at which health services are not provided to individuals.
The list generally encompasses facilities licensed by the Department of Public Health and Environment (CDPHE) which provide patient, resident, or client services on their premises. Examples of licensees we would not inspect include Home Care Agencies and Hospices which do not have any inpatient facilities. There are many other health care facilities that are not subject to licensure requirements such as certain federal clinic programs, physician’s offices, urgent cares, dentists, physical therapy, and other outpatient facilities operating under an individual doctor’s license.
What is a certified facility?
Certification for a Health Facility generally means the facility is certified to receive funding from Medicare and/or Medicaid. Health care entities interested receiving Medicare/Medicaid reimbursement must be certified. The goal of certification is to measure the provider's ability to deliver care that is safe and adequate, in accordance with state and federal law and regulations. The federal Centers for Medicare and Medicaid Services (CMS) delegates through contracts the responsibility for the inspection and/or certification of providers and suppliers to several agencies. The Department of Public Health and Environment (CDPHE), is the designated contractors for inspections in Colorado. CDPHE subcontracts Generally, CDPHE inspects entities for compliance with federal standards and then makes recommendations to CMS regarding certification. However, for entities that participate in Medicaid programs but do not serve the Medicare population, CDPHE makes the recommendation to the Colorado Department of Health Care Policy and Financing (HCPF), which in turn determines whether or not to certify the provider. For more information about licensure and certification contact CDPHE at (303) 692-2836 or visit www.HealthFacilities.info.
What is the difference between licensure and certification?
The Colorado Department of Public Health and Environment (CDPHE) regulates a number of different facility types. Different facility types may be licensed only, licensed and certified, or certified only. Some examples are; A private pay assisted living is licensed only, most Nursing Homes are licensed and certified, and Rural Health Clinics are certified only. For more information about licensure and certification contact CDPHE at (303) 692-2836 or visit www.HealthFacilities.info.
Is the Division of Fire Prevention and Control (DFPC) the State Fire Marshalls Office?
Colorado does not have a State Fire Marshall with authority to impose fire codes and regulations upon buildings or local jurisdictions in the entire state as is the case in many other states. As a general rule, local jurisdictions have authority over their jurisdiction adopting and enforcing their own building and fire codes. As a result, codes and amendments may vary from city to city or county to county. Where the Division has authority is in areas which do not have a local building or fire department conducting plan reviews and inspections and for certain facility types to which it has been determined there is a need to provide a statewide minimum safety standard. This includes public schools, and now Health Facilities. The codes and standards adopted by the division for Health Facilities do not override or take precedence over local requirements; they are to be applied concurrently. Where there are differences in the codes the most stringent applies. The Division also provides reviews and inspections of fire sprinkler systems (suppression) and technical assistance on fire alarm systems where requested by the local jurisdiction or in the absence of qualified local personnel. Further information on the rules DFPC operates under can be found in 8 CCR 1507 maintained by the Secretary of State www.sos.state.co.us.
Is the Division of Fire Prevention and Control the Authority Having Jurisdiction for my facility?
A Health Facility may be subject to the codes and standards of multiple Authorities Having Jurisdiction (AHJ)’s. All Health Facilities remain subject to the codes and standards established by the local building department and fire department in their area. The extent of the Division’s jurisdiction as determined by Articles 4 and 5 of 8 CCR 1507-31 is dependent upon the Health Facility’s intended certification status and the qualification of the local fire department and their inspectors and plan reviewers.. The Division may function as the Building Official, the Fire Code Official and/or the Life Safety Code Official or none of those.
If the facility is CMS certified or intends to seek CMS certification then CMS is also an AHJ which contracts the inspection duties to the Colorado Department of Public Health and Environment which then contracts them with the Division. The Division also is an AHJ for licensure as well by the requirement for issuance of a Certificate of Compliance. There may also be other AHJ’s involved as well such as for Elevators, Commercial Cooking and others systems within a building.
What building codes and standards have been adopted for the construction and maintenance of health facilities?
The codes adopted by the Division for Health Facilities can be found in Article 3 of 8 CCR 1507-31. The specific categories of codes applicable to a Health Facility, Building, Fire, Life Safety/Health Facility is dependent upon the extent of the Division’s jurisdiction as previously determined by the Health Facility’s intended certification status and the qualification of the local fire department and their inspectors and plan reviewers. If the facility is CMS certified the facility must also meet the requirements of CMS. CMS has currently adopted the 2000 edition of the 101 Life Safety Code. CMS also has issued a number of Survey and Certification letters (Policy & Memos to States and Regions) which are applicable as well. These requirements can be found at:
It is anticipated than CMS intends to adopt the 2012 edition of the 101 Life Safety Code sometime within the next two years.
Why do I need a Certificate of Compliance?
As part of HB12-1268 the Certificate of Compliance was created as the mechanism for CDPHE to verify a building providing licensed services meets minimum fire safety standards as they no longer conduct those inspections themselves. To issue or renew a license for a Health Facility from CDPHE the facility must have a valid and current Certificate of Compliance issued by DFPC. This requirement is detailed in the Standards for Hospitals and Health Facilities, 6 CCR 1011-1, Chapter 2, General Licensure Standards. Even though DFPC will always be the one issuing the Certificate of Compliance there are provisions where DFPC may not be conducting the inspections for issuing the certificate. The Divisions rules regarding issuance of Certificates of Compliance can be found in Article 8 of 8 CCR 1507-31.
Does my project require permit from DFPC?
The requirement for a permit from the Division is dependent upon the extent of the Division’s jurisdiction as previously determined by the Health Facility’s intended certification status and the qualification of the local fire department and their inspectors and plan reviewers. See the table below.
WHEN DFPC PERMITS ARE REQUIRED
Certified or Seeking Certification
Local Building Department
Reviews plans, issues permits, conducts inspections and issue Certificates of Occupancy
Local Building Permit
Local Building Permit
Local Building Department
DFPC Building Permit
DFPC Building Permit
Local Fire Department
Local Fire Permit
Local Fire Permit and DFPC Life Safety Permit
Local Fire Department
DFPC Fire/Life Safety Permit
DFPC Fire/Life Safety Permit
Does a remodel project in an existing facility require a permit from DFPC?
The requirement for a remodeling project is dependent on the same certification status and local qualifications as indicated above. The specific requirements for the types of projects which require permits are detailed in the International Building Code Section 105 (except 105.1.1 and 105.1.2) and the International Fire Code Section 105.7. As a general rule, any construction, alteration, repair, move, demolition or change of occupancy regulated by the applicable adopted codes requires a permit. Certain small projects and maintenance work may qualify for a Limited Scope Project Permit. If in doubt if your project requires a permit it is best to submit a complete permit application
My facility/project does not require a permit from DFPC, do I need to submit anything?
If a facility has determined that they are private pay, non-certified, or that they have qualified local inspectors, and a permit is not required from the Division there are still some notification requirements which must be met. Any project submitted to a local building department or any private pay non-certified facility intending to license an existing building or space shall submit notification and plans to the Division in accordance with Section 6.1 of 8 CCR 1507-31 prior to beginning construction. This is for our records, verification of local qualifications, and to speed up processing of the Certificate of Compliance if required at completion of the project. Forms are available as detailed in the Application Instructions available on the webpage to cover the items required for notification.
What is a Limited Scope Project Permit?
Limited Scope Project Permits are intended for certain qualifying small projects, repairs and inspection corrections where it has been determined by the Division a full permit is not required. The Division maintains a list of qualifying projects on the webpage which may be periodically updated. Once a facility applies for a Limited Scope Project Permit the permit covers any items listed as a qualifying project for the duration of the permit. The permit holder must record and document all projects and inspections done under the permit. Limited Scope Project Permits expire concurrently with the facility’s Certificate of Compliance, meaning a permit may be valid up to 3-5 years depending on the facility type. The rules applicable can be found in Section 6.7 of 8 CCR 1507-31.
My project will be completed in Phases, do I need separate permits?
A project which is to be completed in multiple phases should be submitted as separate permit applications. Each application must detail the specific scope of work to be included under that individual permit application. Fees must be calculated separately for each application. If a project were to be submitted and reviewed as a single phase under one permit, partial inspections will be assessed additional fees in accordance with Article 13 of 8 CCR 1507-31 and there may be restrictions on occupying spaces and/or providing patient/resident/client services in spaces completed prior to completion of the entire project.