HEALTH FACILITY CONSTRUCTION AND INSPECTION FREQUENTLY ASKED QUESTIONS

FREQUENTLY ASKED QUESTIONS

 

Abbreviations

Governmental Entities with enforcement authority for health facilities.

DFPC – Division of Fire Prevention and Control www.dfpc.state.co.us

CDPHE – Colorado Department of Public Health and Environment www.healthfacilities.info

CMS – Centers for Medicare and Medicaid Services www.cms.gov


General



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.

   

About DFPC



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:
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/index.html


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

 

Private pay,
Non-Certified

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
Does not exist or the local department does not review plans, issue permits, conduct inspections or issue Certificates of Occupancy

DFPC Building Permit

 DFPC Building Permit

Local Fire Department 
Has Qualified Fire Inspectors at the appropriate level and will conduct plan review and inspections

 Local Fire Permit

Local Fire Permit and DFPC Life Safety Permit

Local Fire Department
Does not have qualified Fire Inspectors at the appropriate level or declines to perform plan reviews or inspection

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. 

CODES, DOCUMENTS, AND STANDARDS INCORPORATED BY REFERENCE

 CODES, DOCUMENTS, AND STANDARDS INCORPORATED BY REFERENCE
3.1 The technical requirements of these rules are supported primarily by codes developed by the International Code Council and the National Fire Protection Association. These two organizations are membership associations dedicated to building safety and fire prevention. These rules establish minimum requirements where the Division is the Authority Having Jurisdiction for building systems using prescriptive and performance related provisions, which are widely used to construct residential and commercial buildings. The appropriate portions of the adopted codes (particularly in relation to classification of occupancy) will be applied as prescribed by the adopted codes themselves. Where there are differing provisions for new and existing construction, all work taking place after July 1, 2013 must meet the requirements for new construction.

3.2 The following codes and their referenced standards are adopted and promulgated as minimum standards for the construction and maintenance of all property, buildings, and structures containing a Health Facility in the State of Colorado where the Division is the Authority Having Jurisdiction

3.2.1 The following Building Codes are adopted by these regulations. Wherever these regulations refer to a Building Code, the following codes and standards will be enforced by the Division where applicable:
a) International Building Code - 2012 Edition, Second Printing: June 2011 (Copyright 2011 by International Code Council, Inc.).
b) International Mechanical Code - 2012 Edition, First Printing: April 2011 (Copyright 2011 by International Code Council, Inc.).
c) International Energy Conservation Code - 2012 Edition, First Printing: May 2011 (Copyright 2011 by International Code Council, Inc.).
d) International Existing Building Code- 2012 Edition, First Printing: April 2011 (Copyright 2011 by International Code Council, Inc.).
Code of Colorado Regulations 5
e) International Residential Code – 2012 Edition, First Printing: May 2011 (Copyright 2011 by International Code Council, Inc.).
f) All electrical work shall be conducted, inspected, and approved in accordance with the provisions of the State of Colorado's Electrical Board's rules and regulations.
g) All plumbing work shall be conducted, inspected, and approved in accordance with the provisions of the State of Colorado's Examining Board of Plumber's rules and regulations.

3.2.2 The following Fire Codes are adopted by these regulations. Wherever these regulations refer to a Fire Code, the following codes and standards will be enforced where applicable:
a) International Fire Code - 2012 Edition, First Printing: May 2011 (Copyright 2011 by International Code Council, Inc.), including Appendices B through I.
b) International Wildland-Urban Interface Code – 2012 Edition, First Printing: April 2011 (Copyright 2011 by International Code Council, Inc.).

3.2.3 The following Life Safety and Health Facility Construction Codes and Guidelines are adopted by these regulations. Wherever these regulations refer to a Life Safety Code, the following codes, standards, and guidelines will be enforced where applicable:
a) NFPA 101A Guide on Alternative Approaches to Life Safety – 2013 Edition, First Printing: June 2013 (Copyright 2013 by National Fire Protection Association).
b) NFPA 101 Life Safety Code – 2012 Edition, First Printing: September 2011 (Copyright 2011 by National Fire Protection Association).
c) NFPA 99 Health Care Facilities Code – 2012 Edition, Fourth Printing: April 2013 (Copyright 2011 by National Fire Protection Association).
d) Facilities Guidelines Institute, Inc. (FGI) - 2010 Guidelines for Design and Construction of Health Care Facilities including errata and addendums adopted by the FGI as of July 1st, 2013 (Copyright 2010 by Facilities Guidelines Institute, Inc. - Chicago, Illinois). The FGI applies to all facilities submitting applications for Fire and/or Life Safety Construction Permits to the Division after January 1, 2014.

3.3 The Fire Safety Evaluation System (FSES) as prescribed by NFPA 101A, Guide on Alternative Approaches to Life Safety, may be used as a means for establishing equivalent protection to specific provisions of the NFPA 101, the Life Safety Code for new or existing Health Facilities, or renovations of existing Health Facilities. In addition, until such time as the 2012 edition of NFPA 101 is adopted by CMS, a new Health Facility or renovation of an existing Health Facility, may be designed and evaluated in accordance with the 2012 edition of NFPA 101 if it passes an FSES for new construction under the 2001 edition of NFPA 101A.

3.4 In any facility where the evacuation capability of the facility or resident population is required to be rated, the "Procedure for Determining Evacuation Capability" published by NFPA is to be used by the facility whether the facility is evaluated utilizing the NFPA 101A, Guide on Alternative Approaches to Life Safety (2013), or NFPA Standard 101, Life Safety Code (2012). The Level of Evacuation Difficulty for each facility will be determined by the scores developed in the Worksheet for Rating Residents completed by responsible staff for each resident and the level of staffing maintained at the facility. It is the responsibility of the owner or administrator to ensure that the
Code of Colorado Regulations 6
abilities of the residents are accurately rated in accordance with the published instructions. Each new resident shall be rated utilizing the Worksheet for Rating Residents within two (2) weeks of their admission to the facility. All resident rating scores shall be reviewed at least annually, or when there are significant changes in a resident's physical or cognitive abilities. Failure to rate the evacuation capability in accordance with these provisions upon two inspections will result in a permanent "impractical" rating for the facility.

3.5 Certified Health Facilities shall meet the requirements established by CMS or the State Medicaid Agency for such certification. In the event a Certified Health Facility cannot meet the requirements of the applicable state codes, rules, and standards as well as those established by CMS, the codes, rules, and standards established by CMS will prevail for the purposes of these rules.

3.6 Certificates of Occupancy and Certificates of Compliance issued after July 1, 2013 by the Division for space not currently licensed by CDPHE will be based on compliance with the requirements for new construction within the applicable codes.

3.7 The Division shall maintain copies of the complete texts of the adopted codes for public inspection. Interested parties may inspect the referenced incorporated materials during regular business hours at the Division office located at 690 Kipling Street, Lakewood, Colorado, 80215.

3.8 In the event that a new edition of the code is adopted by the Division, the code in effect at the time of permit application will remain in effect throughout the work authorized by the permit.

3.9 This rule does not include later amendments or editions of the incorporated material.