Regulation text
1
DEPARTMENT OF HUMAN SERVICES
Behavioral Health
BEHAVIORAL HEALTH
2 CCR 502-1
[Editor’s Notes follow the text of the rules at the end of this CCR Document.]
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Statement of Basis and Purpose, Fiscal Impact/Regulatory Analysis and Specific Statutory
Authority
Rules regarding the Care and Treatment of the Mentally Ill were originally adopted on 3/21/1977, and
subsequently amended through April 20, 1993 (effective May 30, 1993), by the Department of Institutions.
The purpose of the 1991 revision of these rules is to make the regulations easier to locate within the
document, easier to read and to understand; to incorporate policy statement formerly contained in the
Division of Mental Health's Procedures Manual; and to add several changes recommended to the
Department of Institutions by the Mental Health Advisory Board for Service Standards and Regulations.
These rules were proposed pursuant to Notice of Public Hearing published on November 10, 1991, and
after proper notice, a public hearing was conducted on Thursday, December 5, 1991. Written and oral
testimony presented to the Department of Institutions was considered in the determination to adopt these
rules. The record of the rule-making proceeding demonstrates the need for these regulations; the
regulations have been clearly and simply stated; and the regulations do not conflict with other provisions
of law. The effective date for these rules is March 1, 1992.
Sections 103.2.A.2 and 103.2.A.3, which were adopted after January 1, 1992 and before January 1,
1993, were not extended by H.B. 93-1131 and therefore expired effective June 1, 1993.
The entire re-write of these rules were adopted following publication at the 4/2/2004 State Board of
Human Services meeting, with an effective date of 6/1/2004 (Rule-making #03-5-14-1). Statement of
Basis and Purpose, fiscal impact, and specific statutory authority for these revisions were incorporated by
reference into the rule. These materials are available for review by the public during normal working hours
at the Colorado Department of Human Services, Office of Performance Improvement, Boards and
Commissions Division, State Board Administration.
Addition of r ules concerning Acute Treatment Units, Sections 19.500 through 19.568.2 were adopted
following publication at the 9/7/2007 State Board of Human Services meeting, with an effective date of
11/1/2007 (Rule-making #07-3-22-2). Statement of Basis and Purpose, fiscal impact, and specific
statutory authority for these revisions were incorporated by reference into the rule. These materials are
available for review by the public during normal working hours at the Colorado Department of Human
Services, Office of Performance Improvement, Boards and Commissions Division, State Board
Administration.
Revision of Section 19.421.3 was adopted following publication at the 7/12/2013 State Board of Human
Services meeting, with an effective date of 9/1/2013 (Rule-making# 13-5-14-1). Statement of Basis and
Purpose, fiscal impact, and specific statutory authority for these revisions were incorporated by reference
into the rule. These materials are available for review by the public during normal working hours at the
Colorado Department of Human Services, Office of Enterprise Partnerships, Division of Boards and
Commissions, State Board Administration.
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Rules regarding care and treatment of the mentally ill, as originally found in 2 CCR 502-1 (Rule Vol. 19),
are repealed in their entirety and rewritten as a consolidation of Behavioral Health rules in 2 CCR 502-1
(Rule Vol. 21) as adopted following publication at the 9/6/2013 State Board of Human Services meeting,
with an effective date of 11/1/2013 (Rule-making# 13-3-4-1). Statement of Basis and Purpose, fiscal
impact, and specific statutory authority for these revisions were incorporated by reference into the rule.
These materials are available for review by the public during normal working hours at the Colorado
Department of Human Services, Office of Enterprise Partnerships, Division of Boards and Commissions,
State Board Administration.
Revisions to Sections 21.900 through 21.950 were adopted on an emergency basis at the 11/6/2015
State Board of Human Services meeting, with an effective date of 11/6/2015 (Rule-making# 15-10-20-1).
Statement of Basis and Purpose, fiscal impact, and specific statutory authority for these revisions were
incorporated by reference into the rule. These materials are available for review by the public during
normal working hours at the Colorado Department of Human Services, Office of Strategic
Communications and Legislative Relations, State Board Administration.
Revisions to S ections 21.900 through 21.950 were adopted as final (permanent) at the 12/4/2015 State
Board of Human Services meeting, with an effective date of 2/1/2016 (Rule-making# 15-10-20-1).
Statement of Basis and Purpose, fiscal impact, and specific statutory authority for these revisions were
incorporated by reference into the rule. These materials are available for review by the public during
normal working hours at the Colorado Department of Human Services, Office of Strategic
Communications and Legislative Relations, State Board Administration.
Revisions to Sections 21.000 through 21.330 were adopted at the 3/4/2016 State Board of Human
Services meeting, with an effective date of 5/1/2016 (Rule-making# 15-08-26-1). Statement of Basis and
Purpose, fiscal impact, and specific statutory authority for these revisions were incorporated by reference
into the rule. These materials are available for review by the public during normal working hours at the
Colorado Department of Human Services, Office of Strategic Communications and Legislative Relations,
State Board Administration.
Revisions to Sections 21.120.3 and 21.120.31 were adopted at the 9/9/2016 State Board of Human
Services meeting, with an effective date of 11/1/2016 (Rule-making# 16-5-11-1). Statement of Basis and
Purpose, fiscal impact, and specific statutory authority for these revisions were incorporated by reference
into rule. These materials are available for review by the public during normal working hours at the
Colorado Department of Human Services, Office of Strategic Communications and Legislative Relation,
State Board Administrator.
Addition of r ules concerning the Behavioral Health Crisis Response System, Sections 21.400 through
21.400.6 were adopted at the 9/9/2016 State Board of Human Services meeting, with an effective date of
11/1/2016 (Rule-making# 16-5-11-1). Statement of Basis and Purpose, fiscal impact, and specific
statutory authority for these additions were incorporated by reference into rule. These materials are
available for review by the public during normal working hours at the Colorado Department of Human
Services, Office of Strategic Communications and Legislative Relation, State Board Administrator.
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The following Chapters 1 - 11 apply to all agencies that apply for, receive, or renew a Behavioral Health
Entity license or 27-65 designation on or after January 1, 2024.
Chapter 1: General Statutory Authority and Definitions
1.1 Authority and Applicability
A. The statutory authority for the promulgation of these regulations is set forth in Sections 27-50-
106, C.R.S., 27-50-107 (3), C.R.S., 27-50-301(5), C.R.S., 27-50-502, C.R.S., 27-65-118, C.R.S.
and 27-65-128, C.R.S. This regulation is intended to be consistent with the requirements of the
State Administrative Procedures Act (the “APA”), Section 24-4-101 through -109, C.R.S.
B. Chapters 1-10 of these rules may be applicable to holders of the following license types or
designation following approval of an application for a Behavioral Health Entity license or renewal
of a designation:
1. Behavioral Health Entity license by the Colorado Department of Public Health and
Environment;
2. Approval or designation by the Office of Behavioral Health, as it existed before the
effective date of Section 27-60-203(5), C.R.S., or the BHA pursuant to Article 50 of Title
27, C.R.S. or Article 65 and 66 of Title 27 C.R.S.
C. On an annual basis, the BHA will review the effectiveness of these rules and produce a written
report of the results of this review to the State Board of Human Services. This review will include
engagement with stakeholders and may include, but is not limited to, analysis of grievance data
and trends in enforcement actions taken by the BHA. The BHA will provide this report annually to
State Board of Human Services (SBHS) by September 1 starting September 1, 2024. The BHA
will present information in the report to SBHS at the board's next session following submission of
the written report unless the board and the BHA agree that presentation of the report occur at a
different session of the board. If it is determined based on this review that changes to these rules
are advised, the BHA shall propose these changes to the State Board of Human Services for
promulgation in accordance with Section 26-1-107, C.R.S.
1.2 General Definitions
“27-65 Designated Facility” means an agency that has applied for and been approved by the Behavioral
Health Administration (BHA) under these rules to provide mental health services governed by Article 65 of
Title 27, C.R.S.
“42 C.F.R. Part 2” means the federal regulations issued by the United States Secretary of Health and
Human Services found at 42 C.F.R. Part 2 (Jan. 2023), which are hereby incorporated by reference. No
later editions or amendments are incorporated. These regulations are available at no cost from the U.S.
Department of Health & Human Services, Substance Abuse & Mental Health Services Administration,
Office of Communications, 5600 Fishers Lane, Rockville, MD 20857 or at
https://www.ecfr.gov/current/Title-42. These regulations are also available for public inspection and
copying at the Behavioral Health Administration, 710 S. Ash Street, Unit C140, Denver, CO 80246, during
regular business hours.
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“42 C.F.R. Part 441” means the federal regulations issued by the United States Secretary of Health and
Human Services found at 42 C.F.R. Part 441.151 (Feb.2023), which are hereby incorporated by
reference. No later editions or amendments are incorporated. These regulations are available at no cost
from the U.S. Department of Health & Human Services, Substance Abuse & Mental Health Services
Administration, Office of Communications, 5600 Fishers Lane, Rockville, MD20857 or at
https://www.ecfr.gov/current/Title-42. These regulations are also available for public inspection and
copying at the Behavioral Health Administration, 710 S. Ash Street, Unit C140, Denver, CO 80246, during
regular business hours.
“72-hour Emergency Rule” means the regulation issued by the Drug Enforcement Administration (DEA)
found at 21 C.F.R. § 1306.07 (Apr.2022), which is hereby incorporated by reference. No later editions or
amendments are incorporated. This regulation is available at no cost from the DEA at 8701 Morrissette
Drive Springfield, VA 22152 or at https://www.ecfr.gov/current/Title-21. This regulation is also available for
public inspection and copying at the Behavioral Health Administration (BHA), 710 S. Ash Street, Unit
C140, Denver, CO 80246, during regular business hours.
“988” means the National Suicide Prevention Lifeline (The Lifeline).
“Activities of Daily Living (ADLs)” means activities that are oriented toward taking care of one’s own body,
such as bathing, showering, bowel and bladder management, dressing, eating, feeding, functional
mobility, personal device care, personal hygiene and grooming, sexual activity, sleep, rest, and toilet
hygiene.
“Acute Treatment Unit” (ATU) means an agency or a distinct part of an agency, with an endorsement as
outlined in Chapter 6 for short-term psychiatric care, which may include treatment for substance use
disorders, that provides a twenty-four-hour, therapeutically planned and professionally staffed
environment for individuals who do not require inpatient hospitalization but need more intense and
individualized services than are available on an outpatient basis, such as crisis management and
stabilization services.
“ADDS” means the “Alcohol and Drug Driving Safety” program, established under Section 42-4-1301.3,
C.R.S., the Judicial Department administers an alcohol and drug driving safety program in each judicial
district that provides pre-sentence and post-sentence alcohol and drug evaluations on individuals
convicted of DUI, DUI per se, or DWAI.
“A dministration ” means (a) assisting a person in the ingestion, application, inhalation, or, using universal
precautions, rectal or vaginal insertion of medication, including prescription drugs, (b) doing so in
accordance with the legibly written or printed directions of the attending physician or other authorized
practitioner or as written on the prescription label and (c) making a written record thereof with regard to
each medication administered, including the time and the amount taken, but “administration” does not
include judgment, evaluation, or assessments. Nor does it include the injection of medication, the
monitoring of medication, or the self-administration of medication, including prescription drugs and
including the self-injection of medication by a person.
“Admission” means that point in an individual’s relationship with an organized treatment service when the
intake process has been completed and the individual is eligible to receive the services.
“Admission Summary” means a brief review of assessments and other relevant intake data, including
screenings, which summarizes an individual’s current status and provides a basis for individualized
service planning.
“Adverse Childhood Experiences (ACES)” means traumatic events that occur before the age of eighteen
(18) years old. Aces can include but are not limited to:
A. A buse, which can be emotional, verbal, physical or sexual;
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B. Neglect, either physical or emotional;
C. Witnessing or experiencing domestic violence;
D. Substance misuse by a member of the household;
E. Divorce or separation of parents and/or caregivers or parental abandonment;
F. Mental illness of a member of the household;
G. Loss of a member of the household;
H. Attempted, or death by, suicide of a member of the household; and,
I. Incarceration of a member of the household.
“Affidavit of Enrollment” means the document approved by the Department of Revenue, Division of Motor
Vehicles pursuant to Section 42-2-132(2)(II)(c), C.R.S. indicating proof of an individual’s current
enrollment in a Level II Alcohol and Drug Education and Treatment program.
“Agency” means a behavioral health provider licensed, designated, or approved by the BHA.
“Aggrieved” means having suffered actual loss or injury or being exposed to potential loss or injury to
legitimate interests as defined in Section 24-4-102(3.5), C.R.S.
“Alcohol and Drug Evaluation Specialists” or “ADES,” means persons within the Judicial Department,
qualified to conduct pre- and post-sentence evaluations on, and provide supervision for, individuals
convicted of DUI/DWAI.
“Americans with Disabilities Act”, or “ADA,” means the Federal Americans with Disabilities Act of 1990,
pub. L. No. 101-336 (1990), codified at 42 U.S.C. § 12101 et seq. (Jan 2017).
“AS AM Criteria” means the publication from the American Society of Addiction Medicine by Mee-lee, D.,
Shulman, G.D., Fishman, M.J., Gastfriend, D.R., Miller, M.M., eds Titled the ASAM Criteria: Treatment
Criteria for Addictive, Substance-related, and Co-occurring Conditions, 3rd ed. Carson City, NV: The
Change Companies®; 2013, which is hereby incorporated by reference. No later editions or amendments
are incorporated. The ASAM Criteria is available for a reasonable charge at www.asam.org. It is also
available for public inspection at the Behavioral Health Administration, 710 S. Ash Street, Unit C140,
Denver, CO 80246, during regular business hours.
“Assent” means to agree or approve of something (such as an idea or suggestion) especially after
thoughtful consideration.
“Assessment” means a formal and continuous process of collecting and evaluating information about an
individual for service planning, treatment, and referral. Assessments establish justification for services.
“Auxiliary Aids or Services” means an aid or service that is used to provide information to an individual
with a cognitive, developmental, intellectual, neurological, or physical disability, and is available in a
format or manner that allows the individual to better understand the information.
“Behavioral Health” has the same meaning as provided in Section 27-50-101(1), C.R.S.
“Behavioral H ealth Administration” or “BHA” has the same meaning as provided in 27-50-101(2), C.R.S.
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“Behavioral Health Administration DUI/DWAI legal supplement”, or “legal supplement,” means the
document available to BHEs providing DUI/DWAI programming, incorporating information about recent
legal updates to legislation impacting DUI/DWAI-involved individuals (2023 version), which is
incorporated by reference. No later editions or amendments are incorporated. The legal supplement is
available for inspection on the BHA website at https://bha.Colorado.gov/behavioral-health/DUI-services
and at the Behavioral Health Administration headquarters, 710 South Ash Street, Unit C140, Denver, CO
80246, during regular business hours.
"Behavioral Health Crisis” means a significant disruption in a person’s mental or emotional stability or
functioning resulting in an urgent need for immediate assessment and treatment to prevent a serious
deterioration in the person’s mental or physical health.
"Behavioral Health Disorder" has the same meaning as provided in Section 27-50-101(3), C.R.S.
"Behavioral Health Entity" has the same meaning as provided in Section 27-50-101(4), C.R.S.
“Behavioral Health Provider” has the same meaning as provided in Section 27-50-101(6), C.R.S.
"Behavioral Health Safety Net Provider" has the same meaning as provided in Section 27-50-101(7),
C.R.S.
“Best Practices” are professional procedures, interventions, techniques, and treatment approaches that
have some quantitative data showing positive treatment outcomes over a period of time but may not have
enough research or replication to be considered an evidence-based approach.
“Breath or Blood Testing” has the same meaning as provided in Section 42-4-1301.1(2)(a)(I), C.R.S.
“Brief Therapeutic Interventions” means interactions that are intended to induce a change in a behavioral
health-related behavior(s).
“Care Coordination” means services that support individuals and families and initiate care and navigating
crisis supports, mental health and substance use disorder assistance, and services that address the
social determinants of health, and preventive care services.
“C ertificate of Compliance” means an official document issued by the Department of Public Safety,
Division of Fire Prevention and Control for a building or structure as evidence that materials and products
meet specified codes and standards, that work has been performed in compliance with approved
construction documents, and that the provisions of applicable fire and life safety codes and standards
continue to be appropriately maintained.
“Chemical Restraint” has the same meaning as provided in 26-20-102(2), C.R.S.
“Child/Children” means a person under eighteen (18) years of age.
“Clearance Practice” means the process of identifying specific health needs and conditions that may
require specialty management in a higher level of care, such as a crisis stabilization unit or an inpatient
psychiatric hospital. Accepting agencies may have varying requirements prior to accepting a referral.
“Clinically Managed” means services that are directed by clinical personnel, which may include but are
not required to be, medical personnel. These services involve on-site behavioral health support to
address problems related to emotional, behavioral, or cognitive concerns, readiness to change, relapse,
or recovery environment.
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“Clinically Monitored” means that behavioral health services are accessed in the community, and not
provided directly on-site by the agency. The agency is responsible for monitoring of the individual’s
engagement in services and coordinating care, as needed.
“Colorado Crisis Services” means the statewide behavioral health crisis response system offering
individuals mental health, substance use, or emotional crisis help, information and referrals.
“Commissioner” has the same meaning as provided in Section 27-50-101(9), C.R.S.
“Community-Based” has the same meaning as provided in Section 27-50-101(10), C.R.S.
“Community-Based Respite Care Services” means services of a temporary or short-term nature provided
to an individual to temporarily relieve the family or other home providers from the care and maintenance
of such individual.
“Comorbid” means the simultaneous presence of two or more diseases or medical conditions in an
individual.
“C ompetent to Proceed” has the same meaning as provided in Section 16-8.5-101(5), C.R.S.
“Comprehensive Community Behavioral Health Provider” has the same meaning as provided in Section
27-50-101(11), C.R.S.
“Continuum of Care” or "Behavioral Health Continuum of Care'' is a model of care that guides and tracks
patient outcomes through a comprehensive array of health services that include strategies for prevention,
early intervention, treatment, and recovery from mental health problems and disorders with the goal of
supporting the individual’s ability to live productively in the community.
“C ontrolled Substance” has the same meaning as provided in Section 18-18-102(5), C.R.S.
“Co-occurring” disorders may include any combination of two or more substance use disorders and
mental disorders identified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5-TR).
“Crisis Assessment” means a standardized assessment form created by the Behavioral Health
Administration, available on the BHA website.
“Crisis Stabilization Services” means services provided in a crisis stabilization unit (CSU).
“Crisis Stabilization Unit” (CSU) means an agency, endorsed for behavioral health crisis and emergency
services per Chapter 6 and that provides short-term, bed-based crisis stabilization services in a twenty-
four-hour environment for individuals who cannot be served in a less restrictive environment.
“Critical Incident” means a significant event or condition, which may be of public concern, which
jeopardizes the health, safety, and/or welfare of personnel and/or individuals.
“Culturally and Linguistically Appropriate Services (CLAS)” means services that are respectful of and
responsive to individual cultural health beliefs, practices, preferred languages, health literacy levels and
communication needs.
"Danger to the Person’s Self or Others" means:
A. A person poses a substantial risk of physical harm to the person’s self as manifested by evidence
of recent threats of or attempts at suicide or serious bodily harm to the person’s self; or
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B. A person poses a substantial risk of physical harm to another person or persons, as manifested
by evidence of recent homicidal or other violent behavior by the person in question, or by
evidence that others are placed in reasonable fear of violent behavior and serious physical harm
to them, as evidenced by a recent overt act, attempt, or threat to do serious physical harm by the
person in question.
“Deficiency” means a failure to fully comply with any statutory and/or regulatory requirements applicable
to an agency.
“Designated Representative” means a designated representative of an individual or service provider who
is a person so authorized in writing or by court order to act on behalf of the individual or service provider.
In the case of a deceased individual, the personal representative, as defined at Section 15-10-201(39),
C.R.S., or, if none has been appointed, heirs shall be deemed to be designated representatives of the
individual.
“Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision,” or “DSM-5-TR,” is
published by the American Psychiatric Association (2022), which is hereby incorporated by reference. No
later editions or amendments are incorporated. A copy may be purchased directly from the American
Psychiatric Association at https://www.psychiatry.org and/or inspected at the American Psychiatric
Association, 1000 Wilson boulevard, Arlington, VA 22209-3901. A copy may also be inspected at the
Behavioral Health Administration, 710 S. Ash Street, Unit C140, Denver, CO 80246, during regular
business hours.
“D isaster ” means the occurrence or imminent threat of widespread or severe damage, injury, or loss of life
or property resulting from any natural cause or cause of human origin, including but not limited to fire,
flood, earthquake, wind, storm, wave action, hazardous substance incident, oil spill or other water
contamination requiring emergency action to avert danger or damage, volcanic activity, epidemic, air
pollution, blight, drought, infestation, explosion, civil disturbance, hostile military or paramilitary action, or
a condition of riot, insurrection, or invasion existing in the state or in any county, city, town, or district in
the state as defined in Section 24-33.5-703(3), C.R.S.
“Discharge” means the termination of treatment obligations and/or services between an individual and the
agency. For agencies that provide concurrent behavioral health services to an individual, “discharge” is
specific to the discontinued treatment obligation or service and does not impact or apply to an individual’s
concurrent, active behavioral health service(s).
“Dispense” means to interpret, evaluate, and implement a prescription drug order or chart order, including
the preparation of a drug for an individual in a suitable container appropriately labeled for subsequent
administration or use by an individual.
“Dispute” means a verbal or written expression of dissatisfaction to a BHE about the care or services
received or not received by an individual, that cannot be resolved to the satisfaction of the person
expressing the dispute at the time of submission to BHE personnel. Disputes may be submitted by the
individual or a personal representative on behalf of the individual.
“D ivert Status” means the period of time in which an agency is unable to accommodate new admissions
for timely services. This status may be necessary for reasons including but not limited to, the maximum
number of individuals the agency is able to serve is exhausted, unexpected personnel concerns, and
safety or environmental concerns.
“DUI/DWAI” for purposes of this Chapter 10, includes the following impaired offenses:
A. “ driving under the influence” as defined in Section 42-4-1301(1)(f), C.R.S.;
B. “ driving while ability impaired” as defined in Section 42-4-1301(1)(g), C.R.S.;
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C. “ DUI per se” as defined in Section 42-4-1301(2)(a), C.R.S.;
D. Operating an aircraft under the influence as defined in Section 41-2-102, C.R.S.;
E. Operating a vessel while under the influence as defined in Section 33-13-108.1, C.R.S.; and
F. Underage Drinking and Driving (UDD) as defined in Sections 42-1-102(109.7) C.R.S. and 42-4-
1301, C.R.S.
1. For the purpose of this section, UDD applies to individuals that are under twenty-one (21)
years of age.
2. Agencies providing UDD services to individuals under eighteen (18) years of age shall
comply with Chapter 8 of these rules.
“DUI/DWAI Reporting System” or “DRS” is the official document generated from data entered by
endorsed DUI/DWAI programs into the Treatment Management System (TMS). This document reflects at
minimum an individual’s education and treatment enrollment, attendance, compliance, and discharge
status.
“Early Intervention Services” means:
A. Services provided to an individual who is at risk of developing a mental health, substance use, or
co-occurring disorder which may include screening, brief intervention, referral(s) to treatment
(SBIRT), and/or education-only services;
B. Services provided to an individual who is currently diagnosed with a mental health, substance
use, or co-occurring disorder and is undergoing screening, brief intervention, referral(s) to
treatment (SBIRT), and/or education-only services.
“E gress Alert Device” means a device that is affixed to a structure or worn by an individual that triggers a
visual or auditory alarm when an individual leaves the building or grounds. An egress alert device is
considered restrictive when the device is used to prevent the elopement of an individual.
“Emergency” means an unexpected event that places life or property in danger and requires an
immediate response through the use of state and community resources and procedures per Section 24-
33.5-703(3.5), C.R.S.
“Emergency Services” means the public organizations that respond to emergencies when they occur.
This includes, but is not limited to, police, ambulance, and firefighting services. It may also include
emergency behavioral health services accessed during times of crisis, such as Colorado Crisis Services.
“Endorsement” means approval for an agency approved, licensed, or designated by the BHA to provide a
specific service.
“Essential Behavioral Health Safety Net Provider” has the same meaning as defined in Section 27-50-
101(13), C.R.S.
“Evidence-Based” means practices, principles, and programming that uses interventions, techniques, and
treatment methods that have been tested using scientific methodology and proven to be effective in
improving outcomes for a specific population.
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“External Services” means personal services and protective oversight services provided to an individual
by family members, or health care professionals who are not personnel of the agency. External service
providers include, but are not limited to, home health providers, hospice, private pay caregivers, friends,
and family members.
“Facility,” as used in the definition of BHE set forth above in part 1.2 of these rules, means a Behavioral
Health Entity licensed by the Department of Public Health and Environment; a public or private “treatment
facility” required to meet the approval standards established under Section 27-81-106, C.R.S.; an entity
providing emergency or crisis behavioral health services; an entity providing behavioral health residential
services; or an entity providing withdrawal management services.
"Family Member" means a spouse, partner in a civil union, as defined in Section 14-15-103 (5), C.R.S.,
parent, adult child, or adult sibling of a person with a mental health disorder.
“Federally Qualified Health Center” has the same meaning as defined in the federal “Social Security Act”,
42 U.S.C. Sec. 1395x(aa)(4)(2022).
“Fentanyl Education” means the fentanyl education program developed by the BHA pursuant to Section
27-80-1287, C.R.S. This program is accessible publicly and will be required for those individuals that
have a court order to complete the program as a condition of probation or parole.
“F ollow -Up Services” means services that may include interactions after the initial early intervention
session and are intended to reassess an individual’s behavioral health status and progress, promote, or
sustain reduction in symptomology and risk factors for a behavioral health disorder, as defined by the
DSM-5-TR, and assess an individual’s need for additional referral(s) to services.
“Full Time Equivalent” (FTE) means the scheduled working hours for personnel divided by the number of
hours in a full-time workweek for the entity. For example, if the entity considers forty hours to be a full-
time workweek, then personnel working twenty hours per week would have an FTE of 0.5.
“Gender Identity” means a person’s innate sense of the person’s own gender, which may or may not
correspond with the person’s sex assigned at birth. Gender identity does not include sexual orientation or
gender non-conforming expressions.
“Good Standing” means that a license, certification, registration, or enrollment has not been revoked or
suspended and against which there are no outstanding disciplinary or adverse actions.
“Governing Body” means the board of trustees, directors, or other governing body in whom the ultimate
authority and responsibility for the conduct of the agency is vested.
“G rievance” means an expression of dissatisfaction made to the BHA about the care or services received
or not received by an individual, that could not be resolved to the satisfaction of the person expressing the
grievance at the time of submission to BHE personnel. Grievances may be submitted by an individual or
entity, including but not limited to, recipients of service, family members of recipients of service,
authorized representatives of recipients of service, licensed facilities, state departments and members of
the general public.
“Harm Reduction” means an approach that emphasizes engaging directly with individuals whose actions
or behaviors place them at risk for a variety of adverse mental health, substance use disorder or physical
health outcomes. Harm reduction is a set of practical strategies and ideas aimed at reducing potential
negative consequences associated with a variety of actions or behaviors. These strategies and
approaches may include but are not limited to safer drug use, overdose prevention, safer sex, medication
adherence, managed drug use, abstinence, and addressing environmental conditions along with the
actions or behaviors themselves.
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“Health-Related Social Needs (HRSN)” means an individual’s unmet, adverse social conditions (e.g.,
housing instability, homelessness, nutrition insecurity) that contribute to poor health and are a result of
underlying social determinants of health.
“HIPAA” means the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110
Stat. 1936 (1996), codified at 42 U.S.C. § 300gg (2012) and 29 U.S.C. § 1181 et seq. (2012) and 42
U.S.C. § 1320d et seq. (2012) and the federal regulations issued by the U.S. Department of Health &
Human Services found at 45 C.F.R. part 160 (2017); 45 C.F.R. part 162 (2017); and, 45 C.F.R. part 164
(2017), which are hereby incorporated by reference. No later editions or amendments are incorporated.
These regulations are available at no cost from the U.S. Department of Health & Human Services, Office
of Civil Rights, 200 Independence Avenue, SW, Room 509f, HHH building, Washington, D.C. 20201 or at
https://www.ecfr.gov/. These regulations are also available for public inspection and copying at the
Behavioral Health Administration, 710 S. Ash Street, Unit C140, Denver, CO 80246 during regular
business hours.
"Hospitalization" means twenty-four (24) hour out-of-home placement for treatment in a facility for a
person with a mental health disorder.
“I ncompetent to Proceed” has the same meaning as defined in Section 16-8.5-101(12), C.R.S. for adults
and in Section 19-2.5-102(25), C.R.S. for youth.
“Individual” means a person seeking or receiving behavioral health services and includes a respondent,
as defined by Section 27-65-102(29), C.R.S.
“Informed Consent” means an informed assent that is freely given. It is always preceded by the following:
A. An explanation of the nature and purpose of the recommended treatment or procedure in
layman's terms and in a form of communication understood by the individual or the individual’s
designated representative;
B. An explanation of the risks and benefits of a treatment or procedure, the probability of success,
mortality risks, and serious side effects;
C. An explanation of the alternatives with the risks and benefits of these alternatives;
D. An explanation of the risks and benefits if no treatment is pursued;
E. An explanation of the recuperative period which includes a discussion of anticipated problems;
and
F. An explanation that the individual, or the individual’s designated representative, is free to
withdraw consent and to discontinue participation in the treatment regimen at any time.
“I nitial License” means the licensing of a facility or provider organization by the BHA that is not currently
licensed by the BHA, as well as a licensure change from one type to another.
“Inpatient” refers to inpatient hospitalization as well as twenty-four (24) hour residential levels of care.
“In-Person” means services provided in the same physical location as the individual and agency
personnel. This may include on-scene crisis responses.
“Inspection” means a process of review to ensure licensed, approved, or designated entities are operating
in substantial conformity with applicable licensing, approval, and/or designation rules.
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“Integrated Care Model” means the systematic coordination of mental health, substance use, and primary
care services.
“Intensive Case Management” means community-based services provided to individuals with serious
behavioral health disorders who are at risk of needing a more intensive 24-hour placement and is
designed to provide extra support for living in the community. These services include assessment, care
plan development, multi-system referrals, assistance with wraparound and supportive living services,
monitoring and follow-up.
“Intensive Outpatient Program” or “IOP” means a service provided for individuals that require a more
structured outpatient treatment experience than can be received in standard outpatient services. Program
may be treatment for mental health, substance-related, and co-occurring disorders.
“Interlock Enhancement Counseling”, or “IEC,” means the evidence-based intervention curriculum which
combines cognitive behavioral treatment with motivational interviewing/motivational enhancement as a
treatment intervention. IEC was developed by Timken, Nandi, and Marques, for DUI/DWAI individuals
who have alcohol ignition interlock devices installed in their vehicles (July 2012), which is incorporated by
reference. No later editions or amendments are incorporated. This curriculum is available to providers of
DUI/DWAI services at no cost through the BHA. A copy of the curriculum is available for inspection at the
Behavioral Health Administration headquarters, 710 S. Ash Street, Unit C140, Denver, CO 80246, during
regular business hours.
“Lega l Guardian” is an individual appointed by the court, or by will, to make decisions concerning an
incapacitated individual's or minor's care, health, and welfare.
“Legal Representative” means one of the following acting within the scope of their authority:
A. The guardian of the individual, as defined in Section 15-14-102, C.R.S., where proof is offered
that such guardian has been duly appointed by a court of law, acting within the scope of such
guardianship;
B. An individual named as the agent in a power of attorney (POA), as defined in Section 15-14-
500.5, C.R.S., that authorizes the individual to act on the individual's behalf, as enumerated in the
POA;
C. An individual selected as a proxy decision-maker pursuant to Section 15-18.5-101 through -105,
C.R.S., to make medical treatment decisions. For the purposes of these rules, the proxy decision-
maker serves as the individual's legal representative for the purposes of medical treatment
decisions only; or
D. A conservator, where proof is offered that such conservator has been duly appointed by a court of
law, acting within the scope of such conservatorship.
“Lethal Means Restriction” means an approach to suicide prevention that reduces access to a fatal
method of suicide (e.g., firearms, medications, sharps), thus preventing or reducing the lethality of an
attempt.
“Let ter of Intent” means the notification provided to the BHA related to an application for an initial BHE
license or safety net approval.
“Level I and Level II Alcohol and Drug Education or Treatment” means a BHA endorsed ADDS education
or treatment program as defined in Section 42-4-1301.3(3)(c)(IV) C.R.S.
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“Level II Four Plus”, also referred to as “Track F” treatment, is an ADDS program, intended for an
individual who has four (4) or more alcohol and/or drug impaired driving offenses, as noted in Section 42-
4-1301.3(3)(c)(IV), C.R.S. This includes vehicular homicide and vehicular assault where alcohol or other
drugs were involved. Only programs endorsed to provide Level II Four Plus treatment may accept
referrals for this level of service.
“Level II Four Plus: competencies and phases” means the BHA-approved document available to Level II
Four Plus programs, providing additional guidance regarding competency and phase completion. It is
available on the BHA website.
“Level 3-Withdrawal Management” or “Level 3-WM” means the on-site service offered twenty-four (24)
hours per day to individuals who are intoxicated and actively withdrawing from the use of one (1) or more
substances. It includes both Level 3.2-WM and Level 3.7-WM, as defined in part 1.2 of these rules.
“Living Space Assignment” means the assigned bathroom and sleeping quarters of individuals served by
the agency.
“Managed Care Entity” has the same meaning as provided in Section 25.5-5-403(4), C.R.S.
“M edically Managed” means services that are directly provided and/or managed by licensed medical
personnel.
“Mechanical Restraint” means a physical device used to involuntarily restrict the movement of an
individual or the movement or normal function of a portion of an individual’s body.
“Medically Monitored” means services that are provided by an interdisciplinary team of personnel
including nurses, behavioral health professionals, other health care professionals and technical
personnel, under the direction of a licensed physician. Medical monitoring is provided through a mix of
direct individual contact, review of records, team meetings, twenty-four (24) hour coverage by a physician,
and quality assurance programs.
“Medication/Psychiatric - Only Services” means services dedicated solely to the management of
medications prescribed to an individual for the management of mental health, substance use, and/or co-
occurring behavioral health disorders.
“Medication-Assisted Treatment,” or “MAT” services, means the use of medications, in combination with
or without counseling and behavioral therapies, to provide a whole-person approach to the treatment of
substance use disorders. Medications used in MAT are approved by the United States Food and Drug
administration (FDA) and MAT programs are clinically driven and tailored to meet each individual’s needs.
MAT services may include Medications for Opioid Use Disorder (MOUD) services for the specialized
treatment of Opioid Use Disorder (OUD).
“Medi cation Diversion ” means the transfer of any controlled substance from a licit to an illicit channel of
distribution or use.
“Medication Formulary” means the Required Formulary Psychotropic Medications: 2018, which is
available at no cost from the Colorado Department of Human Services at
https://bha.colorado.gov/behavioral-health/medication-consistency. The medication formulary is a list of
minimum medications, established pursuant to Section 27-70-103, C.R.S., that may be used by service
providers to increase the likelihood that a broad spectrum of effective medications are available to
individuals to treat behavioral health disorders, regardless of the setting or service provider. The
medication formulary may not contain a complete list of medications, and providers may prescribe and/or
carry any additional medications they deem necessary.
“Member” means a person or entity with an ownership interest in the limited liability company.
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"Mental Health Disorder" has the same meaning as provided in Section 27-50-101(15), C.R.S.
“Mental Health Transitional Living Home” means a community-based residential agency providing
residential support to individuals who require ongoing support with daily living due to their behavioral
health diagnosis but whose needs do not rise to the level of hospitalization. There are two levels of
mental health transition living homes:
A. “ Level One Mental Health Transitional Living Homes” provide clinically monitored services as
defined in part 1.2 of these rules.
B. “ Level Two Mental Health Transitional Living Homes” provide clinically managed services as
defined in part 1.2 of these rules.
“Mental Status Examination '' means a structured assessment of the individual’s behavioral and cognitive
functioning. The specific cognitive functions of alertness, language, memory, constructional ability, and
abstract reasoning are the most clinically relevant. The mental status examination can include but is not
limited to:
A. The individual’s appearance and general behavior;
B. Level of consciousness and attentiveness;
C. Motor and speech activity;
D. Mood and affect;
E. Thought and perception;
F. Attitude and insight; and
G. Higher cognitive abilities.
“Milieu” means the shared living space of the agency and includes the living space assignments for
individuals served.
“Mi nor in Possession” (MIP) is an offense committed by an individuals aged twenty-one (21) and younger
for possession or consumption of ethyl alcohol or possession of two ounces or less or consumption of
marijuana or possession of marijuana paraphernalia. MIP may result in fines, court-ordered public
service, a substance use disorder assessment, and/or substance abuse education program per Section
18-13-122, C.R.S.
“Monitoring” means the observation, review, and documentation of results when tracking an individual’s
progress over a period of time related to an event. This may include, but is not limited to, monitoring of
medication compliance and administration, and monitoring of vital signs while actively withdrawing from
substances.
“Motivational Enhancement” means the counseling approach to initiate behavior change by helping an
individual resolve ambivalence about engaging in treatment services and reducing engagement in
harmful behavior and activities. This approach employs strategies to evoke rapid and internally motivated
change in the individual rather than guiding the individual stepwise through the recovery process.
“Multidisciplinary Team” or “MDT” means a group of personnel, acting within their professional role(s) and
respective scope(s) of practice, who are members of different professions, working together to provide
services to individuals.
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“Natural Supports” means the relationships that occur in everyday life. Natural supports typically involve
family members, friends, co-workers, neighbors, and acquaintances and are self-defined by the individual
in crisis.
“No Refusal Requirements” means the requirements found in 27-50-301(4), C.R.S. that establish the
conditions under which a behavioral health safety net provider cannot refuse to treat an individual.
“On-Site” means at the location that is licensed, designated, or approved by the BHA for the provision of
behavioral health services.
“Opioid Antagonist” has the same meaning provided in Section 17-1-113.4(4)(b), C.R.S.
“Outreach, Education, and Engagement Services” means services by an agency that have identified
priority target populations and service needs in the area the agency serves that require higher levels of
active engagement by the agency to produce positive behavioral health outcomes.
“Outpatient Competency Restoration” means a community-based program that allows adults and
juveniles in the criminal justice or juvenile justice system, who are found incompetent to proceed by the
court, to receive psychoeducation services, case management, and referrals to community-based
services and supports throughout all of Colorado with the goal of restoring competency.
“O utpatient Treatment” means behavioral health services provided to an individual in accordance with
their service plan on a regular basis in a non-overnight setting, which may include, but not be limited to,
individual, group, or family counseling, peer support professional services, case management, or
medication management.
“OWNPATH” is an online directory operated by the Colorado Behavioral Health Administration that allows
individuals to find behavioral health providers licensed, designated, or approved by the BHA in order to
access specific services or resources that best meet the individual’s behavioral health needs.
“Paired Mobile Response” means a mobile crisis response in which two personnel respond, one person
on scene and the other person on scene or via telehealth. Both members of the paired response should
be crisis professionals.
“Partial Hospitalization Program” or “PHP” means a service provided for individuals that require regularly
scheduled monitoring or management while providing clinical structure in an outpatient setting to treat
mental health, substance use, or co-occurring needs in addition to providing direct access to medical,
psychiatric, and laboratory services.
“Pass” means written permission by an agency for an individual to leave campus grounds.
“Peer Respite Home” means an agency staffed by peer support professionals that provides temporary
accommodations to prevent behavioral health-related hospitalizations.
“P eer Support” means recovery-oriented services provided by peer support professionals that promote
self-management of psychiatric symptoms, relapse prevention, treatment choices, mutual support,
enrichment, and rights protection. Peer support also provides social supports and a lifeline for individuals
who have difficulties developing and maintaining relationships.
“Persistent Drunk Driver”, or “PDD,” has the same meaning as provided in Section 42-1-102(68.5)(a),
C.R.S.
“Personal Services” means those services that an agency and its personnel provide for each individual
including, but not limited to:
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A. An environment that is sanitary and safe from physical harm;
B. Individualized social supervision;
C. Assistance with transportation; and
D. Assistance with activities of daily living.
“Person-Centered Care” means individuals participate in the development of treatment goals and services
provided to the greatest extent possible. Person-centered service planning is strength-based and focuses
on individual capacities, preferences, and goals. Individuals are core participants in the development of
the plans and goals of treatment.
“Pharmacotherapy” means the treatment by an authorized practitioner of an individual’s behavioral health
condition(s) through medicinal use of pharmaceutical products.
“Physical Management” means the physical action of placing one’s hands on an individual to gain
physical control to protect the individual or others from physical harm after all attempts to verbally direct or
de-escalate the individual have failed. Any attempts at physical management of a child is considered
restraint.
“Physical Restraint” means the use of bodily, physical force to involuntarily limit a person's freedom of
movement, except that “physical restraint” does not include the holding of a child or youth by one adult for
the purpose of calming or comforting the child.
“P lan of Action” is a description of how an agency plans to bring into compliance any standards identified
as out of compliance within a specified time period.
“Postpartum” means the period of time following the end of a pregnancy or birth of a child up to one year.
“Primary Complaint” or “Presenting Problem” means the reason, concern, or motivation which prompts an
individual to seek services or that which the individual’s referral source identifies as the issue which
requires intervention, usually in the individual’s own words.
“Priority Populations” has the same meaning as provided in Section 27-50-101(17), C.R.S.
“Protective Oversight” means guidance of an individual as required by the needs of the individual or legal
representative or as reasonably requested by the individual including the following:
A. Being aware of an individual’s general whereabouts, although the individual may travel
independently in the facility; and
B. Monitoring the activities of the individual on the premises to ensure the individual’s health, safety,
and well-being, including monitoring the individual’s needs and ensuring that they receive the
services and care necessary to protect health, safety, and well-being.
“P rosocial ” means relating to or denoting behavior which is positive (e.g., friendly, expresses empathy to
or about others, and respects rules as well as the boundaries of others), helpful, and intended to promote
social acceptance and friendship which is positive, helpful, and intended to promote social acceptance
and friendship.
“Protective Factor” means the characteristics associated with a lower likelihood of negative outcomes or
that reduce a risk factor’s impact. Protective factors are seen as positive countering events. Protective
factors may include factors such as positive self-image, self-control, or social competence.
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“Provider Organization,” as used in the definition of BHE set forth above, means a corporation,
partnership, limited liability company, business trust, association, or organized group of persons, which is
in the business of behavioral health care delivery or management and that (a) includes ten (10) or more
full time equivalent (FTE) fully licensed or certified professionals providing diagnostic, therapeutic, or
psychological services for behavioral health conditions under the providers’ Professional Practice Act.
“Psychiatric Advance Directive (PAD)” means a written instruction, created pursuant to Section 15-18.7-
202, C.R.S. concerning behavioral health treatment, medication, and alternative treatment decisions,
preferences, and history to be made on behalf of the adult who provided the instruction.
“Psychotherapy” or “psychotherapy services” has the same meaning as defined in Section 12-245-
202(14), C.R.S.
“Readiness to Change” means an individual’s emotional and cognitive awareness of and interest in the
need to change, coupled with a commitment to change.
“Real-Time” documentation means that the personnel providing a monitoring activity enters the result in
the individual’s record at the time of the monitoring activity, allowing necessary information to transition
seamlessly between shift change. If this process involves delayed entry of results into an electronic health
record or other tracking system, the documentation reflecting real-time communication must be included
in the individual’s record.
“R ecovery ” means a process of change through which individuals improve their health and wellness and
ability to live a self-directed life and strive to reach their full potential.
“Recovery Support Services Organization” (RSSO) has the same meaning as in 27-60-108(2)(c).
“Residential Child Care Facility (RCCF)” has the same meaning as described in Section 26-6-903(29),
C.R.S.
“Residential Services” means the on-site service for individuals whose mental health and/or substance
use issues and symptoms are severe enough to require a twenty-four (24)-hour per day structured
program and oversight, but that do not require hospitalization. It includes mental health transitional living
homes, but does not include residential child care facilities.
“Restraint” has the same meaning as described in Section 26-20-102(6), C.R.S.
“Risk Factors” mean the characteristics at the biological, psychological, family, community, or cultural
level that precede and are associated with a higher likelihood of negative outcomes. Risk factors on an
individual level may include an individual’s genetic predisposition to addiction or exposure to alcohol or
other potentially harmful substance(s) prenatally.
“Risk, Need, Responsivity,” or “RNR,” means the model of evaluating how to best engage an individual
involved in the criminal justice system. It incorporates the following principles:
A. C riminogenic risk: the likelihood that an individual will engage in future illegal behavior in the form
of a new crime or failure to comply with conditions of probation or parole.
B. Criminogenic need: dynamic risk factors that increase an individual’s likelihood to engage in
future illegal behavior in the form of a new crime or failure to comply with conditions of probation
or parole. This includes, but is not limited to, factors such as lack of employment or livable wages,
or the presence of a substance use disorder. These factors are malleable and responsive to
intervention.
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C. Responsivity: maximizing the potential success of treatment intervention by tailoring the
intervention to the learning style, secondary needs, motivation, and strengths of the individual.
“SAMHSA” means the Substance Abuse and Mental Health Services Administration overseen by the
United States Department of Health and Human Services.
“Screening” means a brief process used to identify current behavioral health or health needs and is
typically documented through the use of a standardized instrument. Screening is used to determine the
need for further assessment, referral, or immediate intervention services.
“Seclusion” has the same meaning as described in Section 26-20-102(7), C.R.S.
“Self-Administration” means the ability of a person to take medication independently without assistance
by administration from another person.
“Sequential Intercept Model (SIM)” means the model of how individuals with behavioral health disorders
come into contact with and move through the criminal justice system.
“Service Plan” means a written description of the services to be provided by the agency to meet an
individual's treatment needs.
“Session” means a face-to-face, telehealth, or audio-only interaction of the individual and personnel.
Session may include but is not limited to individual therapy, group therapy, medication-assisted treatment
education and/or monitoring, family therapy, peer professional services, educational/occupational groups,
recreational therapy, intake, discharge, service planning, and other therapies.
“S ocial Determinants of Health” refers to the conditions in which individuals are born, grow, live, work and
age. They include factors such as socioeconomic status, education, neighborhood and physical
environment, employment, and social support networks, as well as access to health care.
“Stock Medication” means medication that is not labeled for, or intended for, use by a specific individual
when it leaves the pharmacy but is intended to be stored and ultimately administered by a licensed health
care professional in accordance with applicable laws and regulations.
“Sub-Endorsement” means a secondary endorsement for a specific type of service within the broader
category of an endorsement.
"Substance Use Disorder" has the same meaning as provided in Section 27-50-101(20), C.R.S.
“Supervising Entity” means the official employed by probation, parole, or other representative of the
criminal justice system who is responsible for oversight and supervision of the individual. Other
representatives may include, but are not limited to, direct employees or contractors of the Department of
Corrections, the Division of Criminal Justice, The Judicial Department, or the Department of Human
Services. The supervising entity is often responsible for referring individuals into specific education and/or
treatment services and reporting compliance with terms of supervision to the courts.
“S upervision” for the purposes of Chapter 6 only means weekly clinical guidance from a licensee or
authorized practitioner.
“Telehealth” means delivery of services through telecommunications systems that are compliant with all
federal and state protections of individual privacy, to facilitate individual assessment, diagnosis,
consultation, treatment, and/or service planning/case management when the individual and the person
providing services are not in the same physical location. Telecommunications systems used to provide
telehealth include information, electronic, and communication technologies. Telehealth may include
audio-only methods in accordance with state and federal regulation unless noted otherwise.
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“Tiered Inspection” means an on-site re-licensure survey that has a reduced scope and reviews fewer
items for compliance with applicable state regulations than a full re-licensure survey.
“Transfer” means being able to move from one body position to another. This includes, but is not limited
to, moving from a bed to a chair or standing up from a chair to grasp adaptive equipment.
“Trauma-Informed” means an approach to care that realizes the widespread impact of trauma,
understands potential paths for recovery, recognizes the signs and symptoms of trauma in individuals,
families, personnel, and others involved in the system, and responds by fully integrating knowledge about
trauma into policies, procedures, and practices, seeking to actively resist re-traumatization. The six key
principles of a trauma-informed approach include:
A. Safety, trustworthiness and transparency;
B. Peer support, collaboration and mutuality;
C. Empowerment, voice and choice;
D. Cultural issues;
E. Historical issues; and
F. Gender issues.
“Treatment Management System,” or “TMS” means the database utilized by endorsed DUI/DWAI
programs to electronically track and report an individual’s enrollment and status in required DUI/DWAI
services through the completion of the “DUI/DWAI reporting system,” or “DRS” record.
“T reatment Type” means the focus of behavioral health services that the agency provides. It may include
services focused on mental health disorders, substance use disorders, or both, also referred to as “co-
occurring” disorders.
“Triage” means a dynamic process of evaluating and prioritizing urgent needs and intervention options
based on the nature and severity of the individuals’ presenting situation.
“Two (2) Generational Approach'' means focusing on both children and parents’ and/or legal guardians’
needs at the same time. This approach focuses on breaking down barriers by strengthening education,
economic supports, social capital, and health and well-being. The core principles of the Two Generational
Approach are:
A. Measure and account for outcomes for both children and their parents and/or legal guardians;
B. Engage and listen to the voices of families;
C. Foster innovation and evidence together;
D. Align and link systems and funding streams; and
E. Ensure access.
“Underinsured” means an individual’s insurance plan does not cover the cost of necessary care, either
medical or behavioral, leaving the individual with out-of-pocket costs they are unable to pay.
“Understanding the ADDS Evaluation Training” means the mutually developed, webinar-based training
offered by the BHA and State Court Administrator’s Office.
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“Undue Hardship” means a situation where compliance with a rule creates a substantial, unnecessary
burden on the applicant or agency’s business operation or the families or community it serves, and which
reasonable means cannot remedy. An undue hardship does not include the normal cost of operating the
business.
"Walk-In Crisis Services" means immediate and confidential, in-person crisis support, information, and
referrals to any individual in need including to anyone experiencing a self-defined crisis.
“Warm Handoff” means an approach to care transitions in which a behavioral health care provider uses
face-to-face or telehealth contact to directly link individuals being treated to other providers or services.
“Warm Line/Support Line” means a telephonic service where individuals can “opt in” from the statewide
crisis line to receive individualized screening and resources by peer support professionals.
“Whole Person Health” means physical, mental, and social wellness which is achieved through integrated
care and adequately addressing social determinants of health.
“Withdrawal Management” or “WM” means the services required to assist an individual experiencing
withdrawal from the use of one (1) or more substances, as identified by the individual’s acute intoxication
and/or withdrawal potential, also known as the dimension 1 rating, from the ASAM Criteria. Withdrawal
management is divided into the following levels:
A. “ Lev el 1-WM” means ambulatory withdrawal management without extended on-site monitoring
services. This is an outpatient service that involves medically supervised evaluation, withdrawal
management, and referral services that are delivered on a regular schedule.
B. “ Level 2-WM'' means ambulatory withdrawal management with extended on-site monitoring. This
is an outpatient service that involves regularly scheduled sessions of physician approved
monitoring of withdrawal management protocols.
C. “ Level 3.2-WM” means clinically managed residential withdrawal management. This is an
organized service delivered in a setting that provides twenty-four (24) hour supervision,
observation, and support to individuals who are intoxicated and/or experiencing withdrawal. This
service is characterized by its emphasis on peer and social support rather than medical and/or
nursing care.
D. “ Level 3.7-WM” means medically monitored inpatient withdrawal management. This is an
organized service delivered by medical and nursing professionals, which provides for twenty-four
(24) hour evaluation and withdrawal management in a permanent facility with inpatient beds.
Services are delivered under a defined set of physician-approved policies and physician-
monitored procedures or clinical protocols.
“Women’s and Maternal Behavioral Health Treatment” means creating an environment and service
continuum that reflects an understanding of and is grounded in the unique biological, developmental,
historical, relational, economic and social experiences that shape women's lives, and thus responds
through factors which include, but are not limited to, site selection; personnel selection and training;
program development; content; and wrap-around supports that address gender-specific issues in the
course of prevention, intervention, treatment and recovery services. This was previously known as
gender-responsive treatment.
“Y outh” means an individual who is under twenty-one (21) years of age.
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1.3 Personnel Definitions
“Administrator” means a person implementing policies and procedures on an agency-wide, endorsement,
service, or physical location-specific basis, who is responsible for the day-to-day operation of such
endorsement, service, or location.
“Advanced Practice Registered Nurse” or “APRN” has the same meaning as provided in Section 12-255-
104, C.R.S.
“Approved Restoration Provider” means a comprehensive community behavioral health provider who
appears on the approved provider list as passing all contract application requirements with the outpatient
competency restoration services program department within the Office of Civil and Forensic Mental
Health (OCFMH).
“Authorized Practitioner” means the person (a) authorized by law to prescribe treatment, medication, or
medical devices, (b) who holds a current unrestricted license to practice, and (c) is acting within the scope
of such authority. This includes persons registered with the Drug Enforcement Administration (DEA) to
prescribe controlled substances. This includes, but is not limited to:
A. A physician, psychiatrist, medical doctor, or doctor of osteopathy licensed pursuant to Article 240
of Title 12, C.R.S.,
B. A physician assistant licensed pursuant to part 113 of Article 240 of Title 12, C.R.S., and
C. An a dvanced practice registered nurse (APRN), licensed pursuant to part 255 of Title 12, C.R.S.
“Candidate” means a person receiving clinical supervision, acting within their scope of practice, and
seeking licensure through DORA. It includes the following:
A. Psychologist candidates, pursuant to Section 12-245-3, C.R.S.;
B. Clinical social work candidates, pursuant to Section 12-245-4, C.R.S.;
C. Marriage and family therapist candidates, pursuant to Section 12-245-5, C.R.S.;
D. Licensed professional counselor candidates, pursuant to Section 12-245-6, C.R.S.; and
E. Licensed addiction counselor candidates, pursuant to Section 12-245-8, C.R.S.
“Certified Addiction Specialist” or “CAS,” means a person who possesses a valid, unsuspended, and
unrevoked addiction counseling certificate issued by DORA, authorizing them to practice addiction
counseling commensurate with their certification level and scope of practice, per Section 12-245-8,
C.R.S.
“Certified Addiction Technician” or “CAT” means a person who possesses a valid, unsuspended, and
unrevoked addiction counseling certificate issued by DORA, authorizing them to practice addiction
counseling commensurate with their certification level and scope of practice, per Section 12-245-8,
C.R.S.
“Clinical Director” means a person responsible for overseeing individual treatment services, including, but
not limited to ensuring appropriate training and supervision for clinical personnel.
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“Clinical Supervision” means the following:
A. Supervision that is received to meet the standard qualifications for clinical supervision as defined
by a professional practice board and standards in the Colorado Mental Health Practice Act,
pursuant to Article 245 of Title 12, C.R.S. the delivery, frequency, and specific requirements may
vary depending upon the credential and the respective skills of the two (2) professionals involved,
and the population and/or the specific individual being served.
B. Supervision provided to personnel who are not seeking or not eligible for professional licensure
but are otherwise qualified to provide services to individuals based on education, training, or other
credentials implies that the supervisor accepts oversight and responsibility for the services
provided by this personnel. The supervisor must follow standards in the Colorado Mental Health
Practice Act, pursuant to Article 245 of Title 12, C.R.S. The nature of the supervisory relationship
depends on the respective skills of the two professionals involved, the individual population
and/or the specific individual being served. It is usually ongoing, required, and hierarchical in
nature.
"Counselor-In-T raining" means a person currently in the process of obtaining a professional credential
pursuant to Article 245 of Title 12, C.R.S. "Counselor-In-Training" does not include candidates as defined
in this part 1.3.
“Colorado Department of Regulatory Agencies,” or “DORA” means the division of professions and
occupations within this state department as created in Section 24-1-122, C.R.S.
“Crisis Professional” means any person who is receiving or has received crisis professional curriculum
training approved by the BHA specific to crisis assessment, management, de-escalation, safety planning
and all relevant laws and provisions such that training is complete, and the person can lead a crisis
response.
“Group Living Worker” means a person without a behavioral health credential or license that is adequately
trained and supervised to recognize and respond to behavioral health concerns. This person may assist
in twenty-four (24) hour management and oversight of the milieu and, in certain facilities, may also serve
a correctional or supervision-focused role. This does not include peer support professionals.
“Intern'' means personnel completing a clinical degree program of study performing duties under the
direct clinical supervision of degree-corresponding licensed personnel.
“Li censed Addiction Counselor” or “LAC” means a person who possesses a valid, unsuspended, and
unrevoked addiction counseling license issued by DORA, authorizing them to practice addiction
counseling commensurate with their licensure level and scope of practice, per Section 12-245-801
through -806, C.R.S.
“Licensed Social Worker” means a person who:
A. Is a licensed social worker or licensed clinical social worker; and
B. Possesses a valid, unsuspended, and unrevoked license issued pursuant to Section 12-245-404,
C.R.S.
“Licensed Professional Counselor” or “LPC” means a person who is a professional counselor licensed
pursuant to Section 12-245-601 through -607, C.R.S.
“Licensee” means a psychologist, social worker, clinical social worker, marriage and family therapist,
licensed professional counselor, or addiction counselor licensed as defined in 12-245-202(8), C.R.S.
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“Manager” means a person involved in and/or responsible for decisions made on behalf of an agency
regarding clinical and/or operational policies, procedures, and actions for a physical location,
endorsement, service type, and/or the agency. This may include administrators or clinical directors,
depending on the structure and operation of the agency. An agency may have a single manager, or
multiple managers, as appropriate for the combination of endorsements, services, and locations included
in the agency license.
“Marriage and Family Therapist” or “LMFT” means a person who possesses a valid, unsuspended, and
unrevoked license as a marriage and family therapist pursuant to Section 12-245-504, C.R.S.
“Nurse” means a person who holds a current unrestricted license to practice pursuant to 12-255-110,
C.R.S., and is acting within the scope of such authority.
“Peer Support Professional” means the following persons who meet the qualifications as described in
Section 27-60-108(3)(a)(III), C.R.S.:
A. A peer support specialist;
B. A recovery coach;
C. A peer and family recovery support specialist;
D. A peer mentor;
E. A family advocate; or
F. A family systems navigator.
“Personnel” means persons employed by and/or providing services under the direction of an agency,
including, but not limited to managers, administrators, clinical directors, employees, contractors, students,
interns, volunteers, or treatment-involved mentors.
"Professional P erson" has the same meaning as described in Section 27-65-102(27), C.R.S.
“Psychologist” means a person who possesses a valid, unsuspended, and unrevoked license as a
psychologist licensed pursuant to Section 12-245-304, C.R.S.
“Qualified Medication Administration Person” or “QMAP” means a person who passed a competency
evaluation administered by the Department of Public Health and Environment before July 1, 2017, or
passed a competency evaluation administered by an approved training entity on or after July 1, 2017, and
whose name appears on the Department of Public Health and Environment’s list of persons who have
passed the requisite competency evaluation.
“Qualified Practitioner” means a physician or other person licensed, registered, or otherwise permitted to
distribute, dispense, or to administer a controlled substance in the course of professional practice.
“Supervision” for the purposes of Chapter 6 only means weekly clinical guidance from a licensee or
authorized practitioner.
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Chapter 2: General Behavioral Health Entity Licensing Standards
2.1 Authority and Applicability
A. Chapter 2 establishes the conditions that an agency must meet in order to be licensed as a
Behavioral Health Entity (BHE), and the minimum standards for the operation of a BHE. The
statutory authority for the promulgation of these regulations is set forth in Sections 27-50-
107(3)(b), C.R.S. and 27-50-502(1), C.R.S.
B. As of January 1, 2024, it is unlawful for any person, partnership, association, or corporation, not
already possessing a valid license to operate a BHE or substance use disorder facility, to conduct
or maintain a BHE, without having obtained a license from the Behavioral Health Administration
(BHA) per Section 27-50-501, C.R.S.
C. Pursuant to Section 27-50-502(1)(g), C.R.S., these rules shall include a timeline for compliance
with BHE standards that exceed the standards under which a BHE was previously licensed or
approved. BHEs shall be subject to the following rule compliance timeline:
1. Upon these rules going into effect, the BHA shall take immediate action on rule violations
that impact the health, safety, and welfare of individuals receiving services provided by a
BHE.
2. Al l BHEs, licensed by the BHA, shall be in full compliance of these rules, and any rules
that apply to any endorsements an entity has elected to obtain, by July 1, 2024.
2.2 License Requirement
A. Any entity seeking initial licensure as a BHE shall apply for a license from the (BHA) if the entity
would previously have been licensed or subject to any of the following:
1. BHE licensure by the Colorado Department of Public Health and Environment;
2. Approval or designation by the Office of Behavioral Health, as it existed before the
effective date of this part, or the BHA pursuant to Article 50 of Title 27, C.R.S. or Article
66 of Title 27 C.R.S.; or
3. Approval by the Office of Behavioral Health, as it existed before the effective date of this
part, or the BHA pursuant to Section 27-81-106, C.R.S. as an approved treatment
program for substance use disorders. This includes agencies that:
a. Are required by statute to be licensed by the BHA;
b. Receive public funds to provide substance use disorder treatment or substance
use disorder education;
c. Provide such treatment to individual populations whose referral sources require
them to be treated in agencies licensed by the BHA; or
d. Ar e acquiring existing agencies or sites licensed by the BHA.
B. Entities previously licensed as described in part 2.2.A of this Chapter shall seek an initial BHE
license at least sixty (60) calendar days prior to the expiration of their existing license.
C. Any entity that meets the definition of a BHE, as defined in these rules, shall be licensed pursuant
to this Chapter 2.
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D. Hospitals are exempt from BHE licensure as they do not meet the definition of providing
community-based services.
2.3 General Licensing Requirements
A. The BHE shall ensure compliance with the following:
1. The BHE may only provide services for which it holds an endorsement as part of its
license.
2. If a BHE has not provided behavioral health services specific to its endorsement for one
(1) year, the BHA will review the endorsement and may remove the endorsement from
the BHE’s license.
3. The following endorsements are considered outpatient service endorsements:
a. Behavioral Health Outpatient services as described in Chapter 4 of these rules;
b. Behavioral Health High-Intensity Outpatient services as described in Chapter 4 of
these rules;
c. Walk-In Crisis services as described in Chapter 6 of these rules;
d. Mobile Crisis services as described in Chapter 6 of these rules;
e. Ambulatory Withdrawal Management without Extended On-Site Monitoring (Level
1-WM) as described in Chapter 4 of these rules; and
f. Ambulatory Withdrawal Management with Extended On-Site Monitoring (Level 2-
WM) as described in Chapter 4 of these rules.
4. T he following endorsements are considered residential/overnight endorsements:
a. Residential services as described in Chapter 5 of these rules;
b. Crisis Stabilization Unit services as described in Chapter 6 of these rules;
c. Acute Treatment Unit services as described in Chapter 6 of these rules;
d. Residential Respite services as described in Chapter 6 of these rules;
e. Clinically Managed Residential Withdrawal Management (Level 3.2-WM) as
described in Chapter 5 of these rules; and
f. Medically Monitored Inpatient Withdrawal Management (Level 3.7-WM) as
described in Chapter 5 of these rules.
5. The BHE shall ensure all of its operations, locations, and services, including contracted
services or personnel, comply with laws, regulations, and standards as applicable and
required by Chapter 2 of these rules, in addition to Chapters specific to any
endorsements held by the BHE.
6. The BHE shall meet the requirements in Chapter 2 of these rules, regardless of
endorsements included as part of its BHE license.
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7. The BHE shall meet endorsement-specific requirements, as applicable to the
endorsements included as part of the BHE’s license.
8. The BHE shall have at least one endorsement and shall provide at least one type of
service for each endorsement held. Endorsement standards are detailed in Chapters 3
through 10 of these rules.
B. A BHE may only provide services for which it holds an endorsement, and at locations authorized
by its license.
C. A BHE will 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 by location. The BHE
shall display the license, or a copy thereof, in a manner readily visible to individuals at each
physical location included in the license.
D. Each physical location of the BHE must meet the standards adopted by the director of the
Division of Fire Prevention and Control (DFPC), as applicable to the services provided in that
location.
E. BHEs are prohibited from engaging in the following actions:
1. Making a false statement of material fact about individuals served by the BHE, its
personnel, capacity, or other operational components verbally to a BHA representative or
agent or in any public document or in relation to a matter under investigation by the BHA
or another governmental entity;
2. P reventing, interfering with, or attempting to impede in any way the work of a
representative or agent of the BHA in investigating or enforcing the applicable statutes or
regulations;
3. Falsely advertising or in any way misrepresenting the BHE’s ability to provide services for
the individuals served based on its license type or status;
4. Failing to provide reports and documents required by regulation or statute in a timely and
complete fashion;
5. Failing to comply with or complete a plan of action in the time or manner specified;
6 Falsifying records or documents;
7. Knowingly using or disseminating misleading, deceptive, or false information;
8. Accepting commissions, rebates, or other forms of remuneration for referrals or other
treatment decisions; or
9. Exercising undue influence or coercion over an individual to obtain certain 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 an individual, shall be
considered exercise of undue influence or coercion.
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2.4 Governance
A. The BHE shall have a governing body consisting of members who singularly or collectively have
professional or lived experience sufficient to oversee the types of endorsements, services, and
number of physical locations included in the BHE’s license.
B The governing body shall meet at regularly stated intervals at least four (4) times per calendar
year and maintain records of the meetings.
C. The governing body shall be responsible for high-level strategy, oversight, and accountability. If
the BHE has a board of directors as its governing body, the board of directors may delegate
operations and management responsibilities to an executive hired by the board who shall at the
executive’s discretion delegate specific operations and management responsibilities including
those in this part 2.4.C to an executive leadership team. These responsibilities include:
1. Ensuring the planning and organization of day-to-day operations.
2. Defining, in writing, the scope of services provided by the BHE, including services
provided through arrangements with, or referrals to, other health care service providers.
3. Ensuring the provision of facilities, personnel, and services in compliance with applicable
endorsement-specific standards found in Chapters 3 through 10 of these rules.
4. E stablishing organizational structures that clearly delineate personnel positions, lines of
authority, and supervision.
5. Ensuring all services and locations operate in compliance with applicable federal, state,
and local laws and regulations, including but not limited to the rehabilitation act of 1973,
29 U.S.C. § 794, and the Americans with Disabilities Act, 42 U.S.C. § 12101, et seq.
6. Ensuring professionally ethical conduct on the part of all personnel providing services,
whether paid, contracted, or volunteer, and ensuring a system is in place to implement
corrective measures when needed and monitor such system.
7. Developing and implementing a quality management program in compliance with the
requirements of part 2.17 of this Chapter, taking into account each endorsement's
services and any significant differences in individual populations served.
8. Ensuring emergency preparedness for the BHE, in accordance with part 2.4.F of this
Chapter.
9. Establishing and maintaining a system of financial management and accountability for the
BHE.
10. Developing, implementing, and reviewing policies at a minimum once every three years
or as needed in accordance with part 2.4.D of this Chapter.
11. Maintaining relationships and agreements with treatment facilities, organizations, and
services to provide individual transfers, referrals, and transitions of care.
12. E nsuring all marketing, advertising, or promotional information published or otherwise
distributed by the BHE is accurate, including, the services the BHE provides.
13. Considering and documenting the use of individual input in decision-making processes in
accordance with part 2.4.D.3.i of this Chapter.
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D. The governing body or executive leadership team if so, delegated as described in part 2.4.C shall
be responsible for ensuring the development and implementation of these policies and
procedures and must review any changes to policies and procedures for the BHE. The governing
body or executive leadership must ensure compliance with the policy requirements in this subpart
and as found elsewhere in this Chapter. Every three (3) years, the governing body or executive
leadership shall review all policies and procedures.
1. The BHE must have policies regarding administrative and/or clinical oversight of the
BHE’s endorsements, services, and/or physical locations that meet oversight
requirements. Requirements included in part 2.5.A of this Chapter, and shall include, but
not be limited to:
a. Oversight positions within the BHE, such as an administrator or clinical director,
and whether each position is for the endorsement, specific services, specific
locations, or a combination thereof.
b. The authority and responsibilities for each oversight position.
c. The model or framework for clinical supervision. Such model or framework may
differ by endorsement, service, or setting.
d. The procedure for accessing oversight personnel or their delegate when the
oversight personnel are not on-site, including, but not limited to, methods of
contact, on-call or other procedures, and required response times.
2. At a mi nimum, the BHE shall have policies and procedures that address the following
items:
a. Critical incident and occurrence reporting in accordance with part 2.16 of this
Chapter.
b. Individual rights in accordance with part 2.7 of this Chapter.
c. Individual grievances, including dispute resolution procedures, in accordance
with part 2.8 of this Chapter.
d. Infection prevention and control in accordance with part 2.4.E of this Chapter.
e. Personnel, including a code of ethics for all personnel. This also includes those
policies and procedures required by part 2.5 of this Chapter, and as required by
the endorsements of the BHE license. This code of ethics must be made
available to individuals upon request.
f. As applicable, screening, admission, assessment/discharge, service plan, and
care policies as required by parts 2.10, 2.12, and 2.13 of this Chapter.
g. As applicable, medication administration in accordance with part 2.15 of this
Chapter.
h. Defining and preventing conflicts of interest and dual relationships, and where
such conflicts exist, developing and implementing controls to minimize such
conflict and ensure decisions are made for the best interest of the individual.
i. The use of individual input and feedback in governing body decisions, including,
but not limited to:
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(1) The formal or informal processes, appropriate for the individuals served
and the size and complexity of services offered, to be used for collection
of individual input and feedback.
(2) How the governing body will document individual input and how that
feedback has been considered.
j. Individual records, including but not limited to confidentiality, access, and
disposal/destruction of records as required by part 2.11 of this Chapter.
k. Building safety and security
(1) Such policies may be for the agency, an endorsement, or physical
location.
(2) Policies must address the needs of the individual population being
served and/or the services being provided.
(3) policies may include, but are not limited to, electronic surveillance,
delayed egress, and/or locked settings as appropriate.
E. The BHE shall have infection prevention and control policies and procedures that reflect the
scope and complexity of the services provided across the BHE, including but not limited to:
1. Maintenance of a sanitary environment.
2. Mitigation of risks associated with infections and the prevention of the spread of
communicable disease, including, but not limited to, hand hygiene, bloodborne and
airborne pathogens, and respiratory hygiene and cough etiquette for individuals and BHE
personnel.
3. C oordination with other federal, state, and local agencies, including but not limited to a
process for when and how to seek assistance from a medical professional and/or the
local health department.
4. For BHEs that administer medications or injections on-site, as well as all agencies
providing overnight or residential services, a requirement that at least one person trained
in infection control be employed by or regularly available to the BHE.
F. The BHE shall be responsible for emergency preparedness policies and procedures, including
the following:
1. Completing a risk assessment of potential hazards and preparedness measures to
address natural and human-caused crises including, but not limited to, fire, gas
leaks/explosions, power outages, tornados, flooding, threatened or actual acts of
violence, and bioterror, pandemic, or disease outbreak events. The governing body shall
review such risk assessments annually and whenever BHE operations are modified
through the addition or discontinuation of a physical location, service, or endorsement.
2. Developing and implementing a written emergency management plan addressing the
hazards identified in part 2.4.F.1, above, and meeting, at a minimum, the following
requirements:
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a. The plan must differentiate between endorsements, physical locations, and
individual populations served and meet the requirements applicable to any
endorsements held by the BHE.
b. The plan must be updated based on changes in the risk assessment conducted
in accordance with part 2.4.F.1 of these rules, above.
c. The plan must address interruptions in the normal supply of essentials, including,
but not limited to water, food, pharmaceuticals, and personal protective
equipment (PPE), if these are regularly provided or used by BHE personnel or
individuals.
d. The plan must ensure continuation of necessary care to all individuals
immediately following any emergency.
e. The plan must address the protection and transfer of individual information, as
needed.
f. The plan must address the methods and frequency of holding routine drills to
ensure BHE personnel’s familiarity with emergency procedures, in compliance
with requirements established by the Department of Public Safety, Division of
Fire Prevention and Control in 8 CCR 1507-31 (December 15, 2021), which is
hereby incorporated by reference. No later editions or amendments are
incorporated. These regulations are available at no cost at
https://www.coloradosos.gov/CCR/DisplayRule.do?action=ruleinfo&ruleId=3177&
deptID=17&agencyID=43&deptName=Department%20of%20Public%20Safety&a
gencyName=Division%20of%20Fire%20Prevention%20and%20Control&seriesN
um=8%20CCR%20150. These regulations are also available for public
inspection and copying at the BHA, 710 S. Ash Street, Unit C140, Denver, CO
80246, during regular business hours.
3. If the BHE has an automated external defibrillator (AED), personnel must be trained in its
use, and it must be maintained in accordance with the manufacturer’s specifications.
2.5 Personnel and Contracted Services
A. The BHE shall ensure administrative and/or clinical oversight of endorsement(s), service(s), and
physical location(s), in accordance with policies and procedures adopted by the governing body
under part 2.4.D of these rules, including, as required by those policies:
1. An administrator responsible for implementing endorsement and service policies and
procedures adopted by the governing body, as well as the day-to-day operation of the
endorsement, services, or location, including, but not limited to:
a. Management of business and financial operations.
b. Ensuring standards in part 2 of this Chapter are met in the endorsement,
services, and location, including, but not limited to the standards in part 2.15 of
these rules, medication administration.
c. Ensuring buildings are properly maintained and building safety/security needs
are met.
d. Implementing infection control and emergency preparedness policies and
procedures, in accordance with governing body policies.
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e. Establishing and maintaining relationships with agencies, services, and
behavioral health resources within the community.
f. Identifying personnel to whom administrator responsibilities are delegated during
periods when the administrator is neither on-site nor available through interactive
means within thirty (30) minutes.
g. A BHE may have a single administrator, or multiple administrators for the
combination of endorsements, services, and locations included in the BHE
license.
2. For BHEs providing clinical services, a clinical director, responsible for the overall clinical
services provided to individuals, including, but not limited to:
a. Ensuring training and continuing education for all BHE personnel, relevant to the
services provided by the personnel.
b. Ensuring supervision and clinical oversight of BHE personnel in accordance with
part 2.5.1 of these rules.
c. Including a method to provide clinical supervision and oversight during periods
when the clinical director is unable to fulfill their duties within thirty (30) minutes.
d. Ensuring services provided are appropriate as indicated in screenings and
assessments.
3. A BHE may have a single clinical director, or multiple clinical directors, as appropriate for
the combination of endorsements, services, and locations included in the BHE license.
4. The minimum qualifications for the administrator and clinical director are set by the BHE’s
policies and procedures.
5. An a dministrator or clinical director may be specific to a physical location or may be
shared among locations, as appropriate for the services, size, and geographic dispersion
of the services.
6. A single person may serve as both the administrator and the clinical director, if that
person meets qualifications for both, and it is consistent with policies adopted by the
governing body.
B. The BHE shall maintain a sufficient number of qualified personnel for each endorsement and at
each physical location to provide the endorsed services, meet the clinical needs of the
individuals, and comply with state and federal requirements. The BHE shall ensure personnel are
only assigned duties they are competent to perform adequately and safely.
C. All personnel assigned to direct individual care must be qualified through either professional
credentials, education, training, and/or experience in the principles, policies, procedures, and
appropriate techniques for providing individual services.
1. Personnel providing individual services must be legally authorized to provide the service
in accordance with applicable federal, state, and local laws.
2. Licensed, certified, and/or registered personnel must have an active license, certification,
or registration in the state of Colorado and may only provide services within their scope of
practice.
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3. The BHE shall verify the license, certification, or registration, and check for any
disciplinary action against personnel providing individual services, through the Colorado
department of regulatory agencies or other state or federal agency not more than thirty
(30) days before official hire date prior to hire.
4. The BHE shall create policies and procedures regarding supervision of all personnel
pursuant to part 2.5.1 of this Chapter.
D. The BHE shall obtain, prior to hire or contract of new personnel or acceptance of persons for
volunteer service if that volunteer service involves unsupervised direct contact with individuals
receiving services, a name-based criminal history record check for each prospective personnel or
volunteer.
1. If the prospective personnel has lived in Colorado for more than three (3) years at the
time of application, the BHE shall obtain a name-based criminal history report conducted
by the Colorado Bureau of Investigation (CBI).
2. If the prospective personnel has lived in Colorado for three (3) years or less at the time of
application, the BHE shall obtain a name-based criminal history report for each state in
which the prospective personnel has lived during the past three (3) years, conducted by
the respective states’ bureaus of investigation or equivalent state-level law enforcement
agency, or a national criminal history report conducted by the federal bureau of
investigation.
3. T he BHE shall bear the cost of obtaining such information.
4. If a BHE contracts with a staffing agency for the provision of services, it shall require that
the staffing agency meet the requirements of this part 2.5.D.
5. When determining whether a prospective personnel is eligible for hire or contract, if the
criminal history record check reveals the person has a conviction or plea of guilty, active
deferred judgment, or nolo contendere, the BHE shall follow its policy developed in
accordance with part 2.5.E.3.a of this Chapter.
E. The BHE shall have written personnel policies developed in accordance with part 2.5.C of this
Chapter, including, but not limited to:
1. Line of authority/management hierarchy of personnel.
2. Job descriptions/responsibilities.
3. Written criteria and procedures for evaluating which convictions or complaints make
prospective personnel unacceptable for hire, or for existing personnel unacceptable for
retention, including:
a. Factors to be considered when determining whether prospective personnel are
eligible for hire when their criminal history record check reveals a conviction or
plea of guilty, active deferred judgment, or nolo contendere, including, but not
limited to:
(1) The nature and seriousness of the offense;
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(2) The nature of the position and how the offense relates to or may impact
the duties of the position. Experience in the criminal justice system is not
necessarily a disqualifier and, in certain circumstances, a BHE may
determine that some lived experiences would benefit a particular
position;
(3) The length of time since the conviction or plea;
(4) Whether such conviction is isolated or part of a pattern; and
(5) Whether there are mitigating or aggravating circumstances involved.
4. Conditions of employment, including but not limited to:
a. That personnel refrain from sexual or romantic relationships between supervisors
and supervisees and sexual or romantic relationships with individuals served.
5. Position qualifications and required credentials.
6. Orientation, training, and continuing education requirements, for the populations served
and services provided.
7. Routine monitoring of personnel credentials and disciplinary actions.
8. Requirements for self-reporting of new or current investigations, criminal charges,
indictments, or convictions that may affect the personnel’s ability to carry out their duties
or functions of the job.
9. Policies requiring all personnel to be free of communicable disease that can be readily
transmitted in the BHE.
a. All personnel that have direct contact with individuals must be required to have a
tuberculin skin test prior to direct contact with individuals. In the event of a
positive reaction to the skin test, evidence of a chest x-ray and other appropriate
follow-up may be required in accordance with community standards of practice.
F. T he BHE shall ensure that all personnel have access to and know about the BHE’s policies,
procedures, and state and federal laws and regulations relevant to their respective duties.
G. The BHE must maintain records on all personnel, including, but not limited to:
1. Date of hire;
2. Job description;
3. Results of criminal history record checks;
4. Documentation of professional credentials, education, and training;
5. Documentation of any disciplinary action taken against the person by a credentialing
body;
6. Documentation of orientation and training;
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7. Evidence of review of the BHE’s policies, procedures, and state and federal laws and
regulations relevant to their respective duties; and
8. Documentation of tuberculosis testing and results, for personnel who have direct contact
with individuals.
H. The BHE must ensure that all personnel complete an initial orientation on basic infection
prevention and control, safety, and emergency preparedness procedures.
I. The BHE must ensure that all personnel receive the following training prior to working
independently with individuals, and on a periodic basis consistent with policies developed in
accordance with part 2.5.E of this Chapter, above
1. Training specific to the particular needs of the populations served, including the provision
of person-centered, trauma-informed, harm reduction-focused, physically and
programmatically accessible, and culturally and linguistically responsive services;
2. Infection control;
3. Emergency preparedness, including de-escalation of potentially dangerous situations,
including but not limited to threats of violence, acts of violence, and abuse/mistreatment
of an individual;
4. Critical incident reporting;
5. Suicide prevention;
6. Individual rights of the population served;
7. Confidentiality, including individual privacy and records privacy and security;
8. BHE policies and procedures;
9. Mandatory reporting requirements for suspected abuse or neglect in accordance with part
2.8.A.9.a of this Chapter; and
10. Understanding of b asic pharmacology and medications that are relevant to the treatment
type and population served by the agency, including but not limited to medication-
assisted treatment (MAT) services and medications for opioid use disorders (MOUD).
a. This training requirement may not be used as reason to hold unqualified
personnel out as experts in pharmacology. BHEs must not encourage personnel
to hold themselves out as able to make recommendations that are outside of
their scope of practice to individuals receiving services. Rather, this training
requirement is meant to ensure that personnel receive a base knowledge for the
behavioral health community they service and allow for meaningful, timely, and
supportive recovery-focused interactions with individuals receiving services.
2.5.1 Clinical Supervision
A. The BHE must ensure that all personnel providing behavioral health services, with the exception
of peer support professionals, receive clinical supervision, as defined in part 1.3 of these rules.
B. The BHE will develop policies and procedures for supervision that address the following:
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1. Supervisee’s mandatory disclosure statement that clearly states they are under
supervision and by whom;
2. Requirements for regular evaluation of the supervisee’s progress with a rubric that is tied
to the responsibilities assigned;
3. Documentation and frequency of supervisor reviews and feedback provided;
4. Maximum number of supervisees a supervisor oversees; and
5. How supervision/consultation is covered by personnel with comparable credentials when
the usual supervisor is not available.
C. Clinical supervisors must at minimum:
1. Meet the standard qualifications for clinical supervision as defined by the supervisor’s
professional practice board.
2. Deliver clinical supervision within the supervisor’s professional practice license and
ethical standards for:
a. Those that are licensed or seeking professional licensure; or
b. When supervising personnel that are not seeking or not eligible for professional
licensure, such as group living workers, the supervisor must follow standards in
the Colorado Mental Health Practice Act, as defined in Article 245 of Title 12,
C.R.S.
3. Dedicate time between the supervisor and supervisee to instruct, model, and encourage
self-reflection regarding acquisition of clinical and administrative skills by the supervisees.
Clinical supervisor will determine skills through observation, evaluation, feedback, and
mutual problem-solving.
4. Address ethics and ethical dilemmas as aligned with the appropriate professional practice
board.
5. Provide professional direction based on experience, expertise, and/or for ethical or safety
concerns.
6. Ensure that safety and crisis management plans are followed and that clinical supervisors
are available to personnel for assistance in crisis situations and processing of the crisis
event afterwards.
7. Document the date, duration, and the content of supervision session for their
supervisee(s), which may include a professional development plan. All documents
pertaining to clinical supervision must be provided to the supervisee and the BHA upon
request.
D. P ersonnel -specific clinical supervision requirements
1. Licensees and authorized practitioners will be provided with clinical supervision and/or
consultation at minimum upon request by the licensee or authorized practitioner or during
times of individual emergency.
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2. Candidates will be provided with clinical supervision at a rate that will meet their licensing
requirements for the license they are pursuing or at a minimum of one (1) hour every two
(2) weeks, whichever provides a higher level of clinical supervision.
3. All clinical documentation completed by a counselor-in-training and/or intern still in pursuit
of their clinical degree must be reviewed and co-signed by a clinical supervisor able to
supervise pursuant to their scope of practice.
4. Personnel not seeking or not eligible for licensure, but that are providing clinical services,
will be provided clinical supervision at a frequency that ensures treatment to individuals is
appropriate, safe, and in line with assessment treatment needs and the individual’s
treatment goals.
2.6 General Building and Fire Safety Provisions
A. Each BHE shall be in compliance with all applicable local zoning, housing, fire, and sanitary
codes and ordinances of the city, city and county, or county where it is situated.
B. All physical locations of a BHE must be constructed in conformity with the standards adopted by
the director of the DFPC at the Colorado Department of Public Safety, as applicable.
C. A BHE that is subject to fire prevention and life safety code requirements, may not provide
services in areas subject to plan review, except as approved by DFPC.
D. The BHE shall provide an interior environment that is clean and sanitary, maintained and in good
repair, and free of hazards to health and safety.
E. The BHE shall ensure the prominent posting of evacuation routes and exits in each physical
location.
F. The BHE shall prominently post the hours of operation at the entrance of each physical location,
and on the BHE’s website.
2.7 Individual Rights
A. The BHE shall develop and implement a policy regarding individual rights. The policy must
ensure that each individual or, when applicable, the individual’s designated representative, has
the right to:
1. P articipate in all decisions involving the individual’s care or treatment.
2. Be informed about whether the BHE is participating in teaching programs, and to provide
informed consent prior to being included in any clinical trials relating to the individual’s
care.
3. Refuse any drug, test, procedure, service, or treatment and to be informed of risks and
benefits of this action.
4. Receive care and treatment, in compliance with state statute, that is free from
discrimination on the basis of physical or mental disability, race, ethnicity, socio-economic
status, religion, gender expression, gender identity, sex, sexuality, culture, and/or
languages spoken; and that recognizes an individual's dignity, cultural values and
religious beliefs; as well as provides for personal privacy to the extent possible during the
course of treatment.
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5. Be informed of, at a minimum, the first names and credentials of the personnel that are
providing services to the individual. Full names and qualifications of the service providers
must be provided upon request to the individual or the individual’s designated
representative or when required by the department of regulatory agencies.
6. Receive, upon request:
a. Prior to initiation of non-emergent care or treatment, the estimated average
charge to the individual. This information must be presented to the individual in a
manner that is consistent with all state and federal laws and regulations.
b. The BHE’s general billing procedures.
c. An itemized bill that identifies treatment and services by date. The itemized bill
must enable individuals or their legal representatives to validate the charges for
items and services provided and must include contact information, including a
telephone number, for billing inquiries. The itemized bill must be made available
either within ten (10) business days of the request, thirty (30) days after
discharge, or thirty (30) days after the service is rendered – whichever is later.
7. Give informed consent for all treatment and services. The personnel must obtain
informed consent for treatment they provide to the individual. Informed consent includes:
a. A w ritten agreement executed between the BHE and the individual or the
individual’s legal representative at the time of admission. The parties may amend
the agreement if there is written consent of both parties. No agreement will be
construed to relieve the BHE of any requirement or obligation imposed by law or
regulation.
b. Individual consents must include consent to treatment. If the individual is refusing
treatment or an aspect of treatment, the BHE must have the individual sign a
form to confirm their refusal.
c. If the governor or local government declares an emergency or disaster, a BHE
may obtain documented oral agreements or consents in place of written
agreements or consents. Documented oral agreements and consents may only
be used as necessary because of circumstances related to the emergency or
disaster. The BHE shall send a hard copy or electronic copy of the documented
agreement or consent to the individual within two (2) business days of the oral
agreement or consent.
8. Register disputes with the BHE and grievances with the BHA and to be informed of the
procedures for registering complaints and grievances including contact information.
9. Be free of abuse and neglect.
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a. The BHE must develop and implement policies and procedures that prevent,
detect, investigate, and respond to incidents of abuse or neglect. This includes
suspected physical, sexual, or psychological abuse; exploitation and/or caretaker
neglect; as well as child abuse, neglect and/or child safety issues, which must
include definitions of abuse and neglect under the Colorado Children’s Code
(Section 19-1-103, C.R.S.), and that are consistent with the reporting of child
abuse allowed under federal law. Policies and procedures must also be
consistent with definitions and mandated reporting requirements for
mistreatment, abuse, neglect, and exploitation of at-risk adults under the
Colorado Human Services and Criminal Codes (Sections 26-3.1-101, 26-3.1-102,
18-6.5-108, C.R.S.).
(1) Prevention includes, but is not limited to, adequate staffing to meet the
needs of the individuals, screening personnel for records of abuse and
neglect, and protecting individuals from abuse during investigation of
allegations.
(2) Detection includes, but is not limited to, establishing a reporting system
and training personnel regarding identifying, reporting, and intervening in
incidences of abuse and neglect.
b. The BHE shall investigate all allegations of abuse or neglect against BHE
personnel, or made against an individual, when the allegation occurs during
service provision or on BHE premises. The BHE shall implement corrective
actions in accordance with such investigations.
10. Be fr ee from the improper application of restraints or seclusion. Restraints or seclusion
may only be used in a manner consistent with part 2.14 of this Chapter.
11. Expect that the BHE in which the individual is admitted can meet the identified and
reasonably anticipated care, treatment, and service needs of the individual.
12. Receive care from the BHE in accordance with the individual’s needs.
13. Have the confidentiality of their individual records maintained.
a. A BHE must comply with all applicable state and federal laws and regulations for
release of information including but not limited to 42 C.F.R. Part 2, Section 27-
65-123, C.R.S. and HIPAA.
b. When obtaining informed consent or an authorization for release of information,
the signed release must state, at a minimum:
(1) Persons who may receive the information in the records;
(2) The purpose for obtaining this information;
(3) The information to be released;
(4) That the release may be revoked by the individual, or legal
representative at any time; and
(5) That the release of information is only valid for a time period specified
but such time cannot exceed two (2) years from the date of signature.
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14. Receive care in a safe setting.
15. Be notified if referrals to other providers are to entities in which the BHE has a direct or
indirect financial benefit, including a benefit that has financial value, but is not a direct
monetary payment.
16. Formulate medical and psychiatric advance directives and have the BHE comply with
such directives, as applicable, and in compliance with applicable state statute.
a. When the BHE is aware that an individual has developed advance directives, the
BHE shall make good faith efforts to obtain the directives and the directives must
become part of the individual’s record.
b. The BHE shall disclose the policy regarding individual rights to the individual or
the individual’s designated representative prior to treatment or upon admission,
where possible. For any services requiring multiple individual encounters,
disclosure provided at the beginning of such care or treatment course must meet
the intent of the regulations.
2.8 Dispute and Grievance Resolution
A. Each BHE shall post a clear and unambiguous notice of dispute and grievance procedures in
each physical location in an area that is open to the public and on the BHE’s website. The notice
must also be provided in writing and/or electronically upon admission to services.
1. T he BHE shall establish a uniform procedure for prompt management of disputes brought
by individuals accessing, receiving, or being evaluated for services and their family
members. The BHE shall develop policies and procedures for handling disputes.
2. The BHE shall provide a fair dispute resolution process that allows options for submitting
both verbal and/or written disputes. The process must provide the individual with a
response no later than thirty (30) business days from submission of the dispute. If the
dispute is received verbally, the representative shall create a written documentation of
the dispute.
B. As part of the BHE’s resolution process, the BHE must inform persons who have submitted a
dispute verbally or in writing that they may also submit a grievance to the BHA. The BHE must
provide information about how to submit a grievance to the BHA.
1. The BHE shall designate a representative, who must be available to assist individuals in
resolving disputes.
2. The BHE shall educate individuals and their representatives about the mechanisms in
place for filing disputes. This education must include an explanation of the individual's
rights; the dispute process and procedures; and the name, contact information, and
responsibilities of the designated representative within the BHE. Appropriate contacts for
external appeal must also be provided, which may include, but are not limited to, the
following: the Colorado Department of Regulatory Agencies; the Colorado Department of
Public Health and Environment; the Colorado Department of Health care policy and
financing; or the governor’s designated protection and advocacy system for individuals
with mental illness. Documentation in the records must include the dated signature of the
individual receiving the information.
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3. The BHE must post a notice of rights, dispute procedure, and the designated
representative’s name, office location, responsibilities, and telephone number in
prominent locations where persons access, receive or are evaluated for services. The
notice shall be translated into languages commonly used by the populations in the
service area.
4. The BHE must maintain a record of submitted disputes, separate from the individual
records that include the date, the type of dispute, and the outcome of investigation.
These dispute records must be provided annually to the BHA.
5. Upon request, the BHE must provide an individual and any interested person with contact
information for registering complaints with any other state departments.
2.9 Individual Services
A. The BHE must ensure individuals are provided services in the least restrictive setting that meets
the individual's needs.
B. The BHE may use telehealth methods for the provision of services under these regulations
except for services that specifically require in-person contact. If a service is allowable via
telehealth according to state and federal regulations, appropriate methods will be noted within the
applicable endorsement Chapter. If an individual prefers to receive services in-person and the
BHE does not offer the appropriate service in-person, the BHE shall refer the individual to another
entity that offers the service in-person.
1. If the BHE uses telehealth methods, it must develop and implement policies and
procedures regarding telehealth services, including:
a. Collection of required signatures;
b. Training for personnel specific to the modality or manner for determining
competence with the modality;
c. Procedure for personnel response if an individual experiences an emergency
while receiving services via telehealth, including collection of information about
the individual’s remote location for each session;
d. Confidentiality protocols designed to protect the individual’s privacy in
accordance with state and federal law; and
e. Specification as to whether policies apply to the BHE as a whole, a physical
location, or a specific endorsement, as appropriate.
2. Services provided via telehealth methods must be documented in the individual’s record,
consistent with documentation requirements for in-person services.
3. Services may be provided through synchronous audio-visual methods but must not
include text-only methods such as text message or email. Some services may be
provided through audio-only methods according to state and federal regulations. If audio-
only methods are used, the following must be noted in the individual record:
a. The reason that audio-visual methods were not utilized.
b. T he clinical determination of appropriateness for service delivery method.
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C. If the BHE uses public community settings for the provision of services, it shall develop and
implement policies and procedures regarding the delivery of such services, including:
1. Collection of required signatures when necessary;
2. Selection and utilization of public spaces that are safe and accessible to the individuals
being served;
3. Procedures for how the BHE will ensure individual privacy and confidentiality in the public
setting according to state and federal regulations;
4. Procedure for personnel response if an individual experiences an emergency while
receiving services in the public setting;
5. Procedure to promote and monitor personnel safety while providing services in this
setting; and
6. Such policies may apply to the BHE as a whole, a physical location, or a specific
endorsement, as applicable.
D. The BHE shall develop and implement policies and procedures regarding behavioral health
emergency services and methods for addressing individuals or individuals with unexpected high
acuity and/or urgent behavioral health needs. Such policies and procedures may apply to the
BHE as a whole, a specific endorsement, or a physical location, as appropriate, and must include,
but not be limited to:
1. The behavioral health emergency services provided by the BHE, if any, and the hours
during which such behavioral health emergency services are available.
2. H ow the BHE ensures access to behavioral health emergency services when not
provided directly by the BHE, including, but not limited to:
a. Criteria used in determining when behavioral health emergency services are
needed;
b. Internal protocols for personnel and supervisors in response to behavioral health
emergency;
c. Protocols for facilitating transfers to other agencies; and
d. Methods of providing information to individuals to ensure understanding of how to
access behavioral health emergency services.
3. The methods for identifying and responding to and/or mitigating sudden or unpredictable
high-acuity or increased needs in existing individuals within twenty-four (24) hours of
notification of increased need
E. The BHE must develop and implement policies and procedures regarding access to emergency
medical services. Such policies and procedures may be for the BHE as a whole, a specific
endorsement, or a physical location, as appropriate, and must include, but are not limited to:
1. The medical emergency services provided by the BHE, if any, and the hours during which
such medical emergency services are available.
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2. How the BHE ensures access to medical emergency services when not provided directly
by the BHE, including, but not limited to:
a. Criteria used in determining when medical emergency services are needed;
b. Internal protocols for personnel in response to a medical emergency; and
c. Protocols for facilitating transfers of individuals to emergency medical providers
or facilities.
3. Methods of providing information to individuals to ensure the individual’s understanding of
how to access medical emergency services.
F. The BHE shall inform individuals how to access medical and behavioral health crisis or
emergency services twenty-four (24) hours per day, seven (7) days per week.
G. The BHE shall provide care coordination to individuals consistent with the following requirements:
1. Care coordination must be carried out in keeping with the individual's needs for care and,
to the extent possible, in accordance with the individual's expressed preferences. Care
coordination may involve the individual's family, parent, legal guardian, caregiver, and
other supports identified by the individual.
2. Care coordination services may include the following, as appropriate for the needs of the
individual:
a. Screenings to identify the individual’s priorities, goals, strengths, and the barriers
faced, including those related to health-related social needs.
b. S upporting the individual in accessing care and services within the health care
and social service systems and equipping the individual with information to
navigate and manage their care.
(1) This shall include providing accessible and culturally and linguistically
meaningful resources and information, including resource directories
such as OWNPATH.
c. Conducting application assistance, referrals, and warm hand-offs to access
appropriate resources and care.
3. Information sharing
a. The BHE shall prioritize information sharing with other providers delivering
services to the individual for the purpose of care coordination.
b. Information sharing must occur as clinically indicated, and as approved by the
individual, throughout an individual’s episode of care.
c. Information sharing must include obtaining or demonstrated efforts to obtain
records from previous or existing behavioral health, physical health, and other
social needs service providers, during the assessment period, and on an ongoing
basis.
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d. The BHE shall ensure individuals’ preferences for shared information are
adequately documented in individual records, consistent with the principles of
person and family-centered care.
e. The BHE shall obtain authorization for release of information from individuals or
their legal representative for all care coordination relationships. If the BHE is
unable, after reasonable attempts, to obtain authorization for any care
coordination activity as required by this Chapter, the attempts must be
documented in the individual’s record and revisited periodically, such as during
transitions of care or when the individual receives a new diagnoses or has a
change in condition.
(1) Information sharing that is permissible under HIPAA without
authorization from the individual or legal representative is not subject to
this requirement.
f. The BHE must maintain the necessary documentation to satisfy the requirements
of all applicable federal and state privacy laws, including individual privacy
requirements specific to the care of children.
g. A referral must include, in accordance with individual consent and as clinically
necessary and applicable, information regarding:
(1) Health status;
(2) Active diagnoses;
(3) Known allergies;
(4) Test results;
(5) Lab results;
(6) Medications list;
(7) Treatment course, time and detail of modalities used, and response to
treatment or other recovery supports (status of changes);
(8) E xisting scheduled appointments to include physical health, behavioral
health and other recovery and supportive services that may be part of
the care plan;
(9) Recent history or risks for urgent/acute care (e.g., recent emergency
department visit, hospitalization, etc.); and
(10) Reasonable accommodations.
h. All information sharing must occur in compliance with applicable federal and
state laws, including but not limited to HIPAA and 42 C.F.R. Part 2.
H. Medication consistency
1. The BHE shall ensure all clinical staff are aware of and have access to the medication
formulary.
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2. The BHE shall ensure personnel have access to the medications on the medication
formulary when prescribing medications to treat behavioral health disorders for an
individual who is or was involved with the criminal or juvenile justice system.
2.10 Admission and Discharge Criteria
A. For applicable services, the BHE shall develop and implement admission and discharge policies.
Such policies may be for the BHE as a whole, a particular endorsement, and/or a specific
physical location, as appropriate, and must include, at a minimum:
1. Criteria to ensure the BHE, endorsement, and/or location only treats individuals for whom
it can provide immediate assessment and treatment based on the individual’s needs.
2. Admission criteria to ensure treatment in the least restrictive setting based on the
individual’s level of care needs. The following must not be the sole reason for treatment
ineligibility:
a. Relapse;
b. Leaving previous treatment against advice or lack of engagement in previous
treatment;
c. Pregnancy;
d. Drug use;
e. Involuntary commitment;
f. Current utilization of any medication-assisted treatment (MAT) or interest in
beginning MAT services;
g. Previous or pending disputes, grievances, or appeals; or
h. Place of residence.
3. P rocedures for transferring an individual from a level of care to a different level of care
within the BHE.
4. Procedures for referring an individual to other service providers when the individual
cannot be admitted to the BHE.
5. Criteria and procedures for an individual's discharge from treatment, including, but not
limited to:
a. When an individual is being transferred from the BHE to another provider.
b. Timely discharge of an individual receiving voluntary services upon the
individual’s request, once appropriate screening and assessment is complete.
c. Discharge and transfer procedures for an individual receiving services on an
involuntary basis, if applicable.
d. Subparts 2.10.A.5.a, 2.10.A.5.b and 2.10.A.5.c of this Chapter must comply with
the following requirements:
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(1) At the time of discharge, the BHE must, unless the individual refuses,
provide support to facilitate a smooth transition to alternate services to
address any existing service needs.
(2) If an individual declines support in connecting with additional services at
the time of discharge, the reason given by the individual shall be
documented within the record.
(3) When the individual agrees to BHE support in transitioning providers, the
BHE must obtain a release of information to communicate with and share
records with the new provider. The BHE shall ensure that the discharge
summary meets the requirements set forth in part 2.10.A.6 of this
Chapter and is provided to the receiving provider no later than fifteen
(15) days from the date of discharge. The BHE shall make every effort to
complete and send the discharge summary prior to the individual’s initial
appointment with the receiving provider.
(4) When the BHE facilitates the transition of care to a new behavioral health
provider or alternative resource at the time of discharge, the BHE shall
inform the individual of the date, time, and location of the scheduled visit
and/or any other information necessary to access the service or resource
to which the individual is referred. The BHE shall consider barriers to
care for the individual and support the individual in connecting with
necessary resources to promote access to care. If this cannot be
completed, the BHE shall document the reason within the record as well
as any attempts made.
e. I nformation and documentation to be provided to the individual upon discharge,
unless clinically contraindicated, including, but not limited to:
(1) Medication information, including medication name, dosage, instructions
for follow-up, and whether the individual was provided with medication
upon discharge.
(a) The BHE may provide individuals with unused, prescribed
medications as part of the discharge process, unless it has been
determined that doing so would pose a risk to the health and
safety of the individual.
(2) Detailed information on transitioning care to other providers, including
referral information, when providing referrals.
(3) Documentation that the discharge is being made against the advice of
the provider, as applicable.
(4) Documentation required when the above information in this subpart
2.10.A.5.e is not provided to the individual at discharge.
(5) Written notification of discharge with reason for discharge.
(6) Written notification of BHE and BHA dispute resolution and grievance
procedures.
6. Requirements for a discharge summary to facilitate continuity of individual care,
including, but not limited to:
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a. The timeframe for discharge summary completion, which may not be more than
fifteen (15) calendar days after discharge.
b. Information to be included in the discharge summary to inform future providers of
treatment history, including, but not limited to:
(1) Demographic information, including, but not limited to, name, date of
birth, gender identity, emergency contact information, insurance
information, preferred language, and any cultural factors to consider in
treatment;
(2) A brief summary of the episode of care, including, but not limited to, the
presenting issue, services received, diagnosis assigned or modified, and
any outstanding needs identified;
(3) Information on the individual’s status within the judicial system, including
any type of behavioral health certification or hold;
(4) A summary of medications prescribed during treatment, including the
individual's responses to medications;
(5) Medications recommended and prescribed at discharge; and
(6) Documentation of referrals and recommendations for follow-up care.
c. This discharge information may be in narrative or abbreviated format and must
be written in a manner that can be readily understood by a receiving provider to
allow for prompt resumption of services.
2.11 Individual Records
A. A confidential individual record must be maintained for each individual receiving services from the
BHE. This record must not contain protected health information pertaining to other individuals
receiving services.
B. Ea ch individual record must include at a minimum:
1. Demographic and medical information, including, but not limited to, individual name,
address, telephone number, emergency contact information, physician or health provider
information, and current diagnosis;
2. Screenings, assessments and reassessments, service plans, documentation of informed
consent including consent to treatment, releases of information, physician or practitioner
orders, documentation of services, treatment progress notes and medication, admission
summary, discharge summary, and any endorsement or service-specific requirements,
as set by this Chapter;
3. Medical and psychiatric advance directives when such directives are furnished by the
individual;
4. The individual’s medication administration record;
5. The out-of-state offender questionnaire, if providing substance use disorder (SUD)
services;
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6. Personal belonging inventories;
7. Court documents, when such documents are relevant to the individual’s treatment;
8. Records of required communication with referral sources such as court, probation, child
welfare, and parole; and
9. Drug and alcohol testing and monitoring results.
C. Individual records must be available to an individual or their designated representative through
the BHE or their designated representative at reasonable times and upon reasonable notice in
accordance with all applicable state and federal laws, including but not limited to HIPAA and 42
C.F.R. Part 2.
1. If the service provider is deceased or unavailable, the current custodian of the record
shall designate a substitute service provider for purposes of compliance with these
regulations.
D. A statement of the BHE’s procedures for obtaining records, and the right to appeal grievances
regarding access to records to the BHA must be posted in conspicuous public places on the
premises and made available to each individual upon admission to the BHE.
E. An individual, whether currently receiving services or discharged from a BHE, may inspect, or
obtain a copy of their own record. The BHE must act on the request to review the individual’s
record within a reasonable time, which must not exceed thirty (30) days except when an
extension is allowable in accordance with 45 C.F.R. 164.524(b)(2).
F. BH Es must not charge the individual or designated representative for inspection of the individual
record.
G. Records must be kept in accordance with all applicable state and federal laws and regulations.
H. Access to medical records contained within the individual’s records must be accessed in a
manner that is consistent with all applicable state and federal laws, including but not limited to the
Health Insurance Portability and Accountability Act of 1996 (HIPAA).
I. If there are changes/corrections, deletions, or other modifications to any portion of an individual
record, the person who is making the changes must note in the record the date, time, nature,
reason, correction, deletion, or other modification, and their name, to the change, correction,
deletion, or other modification.
J. Records must be retained as follows:
1. Adult outpatient endorsements as defined in 2.3.A.3 of this Chapter must be retained for
seven (7) years from the date of discharge from the BHE.
a. Records for individuals who are less than eighteen (18) years old when admitted
to the BHE must be retained until the individual is twenty-five (25) years old.
2. Adult residential/overnight endorsements as defined in part 2.3.A.4 of this Chapter must
be retained for ten (10) years from the date of discharge from the BHE.
a. R ecords for individuals who are less than eighteen (18) years old when admitted
to the BHE must be retained until the individual is twenty-eight (28) years old.
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3. The confidentiality of the individual record, including all medical, behavioral health,
psychological, and demographic information must be protected in accordance with all
applicable federal and state laws and regulations, including during record use, storage,
transportation, transmission, and disposal.
4. When a BHE closes a physical location and/or discontinues any endorsement, it must
maintain records of individuals served in accordance with the requirements of this part
2.11.J.
5. A BHE that ceases operation must comply with the provisions of part 2.24 of this Chapter
regarding individual records.
K. Effect of this part 2.11 on similar rights of an individual
1. Nothing in this part 2.11 may be construed to limit the right of an individual or the
individual’s designated representative to inspect individual records, including the
individual’s medical or psychological data pursuant to Section 27-65-123, C.R.S.
2. Nothing in this part 2.11 may be construed to require a person responsible for the
diagnosis or treatment of a child for substance use disorder or use of drugs, pursuant to
Sections 25-4-409 and 13-22-102, C.R.S. to release records of such diagnosis or
treatment to a parent, guardian, or person other than the minor or their designated
representative.
3. N othing in this part 2.11 may be construed to waive the responsibility of a custodian of
medical records in the BHE to maintain confidentiality of those records in its possession.
4. Nothing in this part 2.11 may limit the right of an individual, the individual’s personal
representative, or a person who requests the medical records upon submission of a
federal law compliant authorization, a valid subpoena, or a court order to inspect the
individual’s records.
2.12 Screening, Initial Assessment, and Comprehensive Assessment
2.12.1 Screening
A. Personnel meeting qualifications under part 2.5.C of this Chapter shall complete a screening and
triage process to determine urgency of the individual’s needs, including the need for emergency
or urgent medical or psychiatric services, and whether the BHE can provide the appropriate care
in light of the individual’s needs.
B. Screening tools/approaches must be culturally and linguistically appropriate and trauma-informed
and should accommodate an individual's disability/disabilities (hearing disability, cognitive
limitations, visual impairment, etc.) as required.
C. Screenings must collect at least the following information from an individual seeking services:
1. Identifying information;
2. Primary complaint/reason for seeking services;
3. Current behavioral health symptoms, including severity, duration, mental status, and
changes or impairments in functioning due to symptoms;
4. Med ical concerns/chronic health issues, including pregnancy and postpartum status; and
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5. Evaluation of imminent risk, including:
a. Suicide risk;
b. Danger to self or others;
c. Urgent or critical medical conditions, including withdrawal or overdose risk; or
d. Other immediate risks, including threats from another person;
(1) If, at any point in the course of treatment, a screening of imminent risk is
completed to assess the need for a mental health hold (M1 hold), all
personnel conducting the screening shall use the BHA-designated M1
screening form notwithstanding any 27-65 designation.
6. Preliminary determination of level of care needed.
D. Screenings that identify an imminent risk must be reviewed by a licensee, licensed addiction
counselor (LAC), a certified addiction specialist (CAS), authorized practitioner, or a licensure
candidate performing within the scope of their practice.
E. Screenings should be conducted in-person unless contraindicated. If contraindicated, screenings
may be conducted via audio-visual or audio only telehealth. Clinical rationale must be
documented in the case of a telehealth screening.
F. To avoid redundant screening, supporting documentation that a screening tool was administered
within the past six (6) months may be incorporated into an individual’s record in place of similar
screening requirements, with the exception of screenings for imminent risk as described in part
2.12.1.C.5 of this Chapter. Screenings for imminent risk as described in 2.12.1.C.5 of this
Chapter must be completed any time an individual is screened for treatment by a BHE
notwithstanding any other recent screenings.
G. Any BHE providing substance use disorder (SUD) services for any level of care shall:
1. Screen and register adults with out-of-state offenses in accordance with Section 17-27.1-
101, C.R.S.
a. This does not apply to crisis services found in Chapter 6 of these rules or
withdrawal management services found in Chapters 4 and 5 of these rules.
2.12.2 In
itial Assessment
A. An initial assessment must be completed and signed and/or approved by a licensee, licensed
addiction counselor (LAC), a certified addiction specialist (CAS), authorized practitioner, or a
licensure candidate performing within the scope of their practice. BHEs must meet timeline
requirements set forth in applicable endorsement Chapters. See endorsement Chapters 4
through 10 of these rules for additional initial assessment requirements.
B. The initial assessment, including information gathered as part of the preliminary screening and
risk assessment, includes, at a minimum:
1. Provisional diagnoses;
2. The source of referral;
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3. The reason for seeking care, as stated by the individual or other referral source(s);
4. Identification of the individual’s immediate clinical care needs related to the diagnosis for
mental and substance use disorders;
5. A list of current prescriptions and prescribing physicians, over-the-counter medications,
and any other substances the individual may be taking, including doses and frequency;
6. An assessment of whether the individual is a risk to self or to others, including suicide risk
factors;
7. An assessment of whether the individual has other concerns for their safety;
8. Assessment of need for medical care (with referral and follow-up as required);
9. A determination of whether the individual presently is or ever has been a member of the
U.S. Armed Services;
10. Current health care providers; and
11. Screening all individuals for current pregnancy status and desire to become pregnant
within the next year. If not pregnant or desirous of pregnancy in the next twelve (12)
months, individuals must be asked if they want access to contraceptive/family planning
care, and the individual must be appropriately referred.
a. Individuals shall be screened and appropriately referred, for past and present risk
factors associated with behavioral health disorders and that are associated with:
(1) P regnancy complications, including risks to the health of the pregnant
individual and fetus;
(2) Acquiring and transmitting Human Immunodeficiency Virus/Acquired
Immune Deficiency Syndrome (HIV/AIDS), Tuberculosis (TB), Hepatitis
A, B, or C, and other infectious diseases; and,
(3) If clinically indicated by the presence of continuing risk factors, screening
must be conducted at a minimum on a quarterly basis.
C. As needed, releases of information must be obtained.
2.12.3 Comprehensive Assessment
A. The BHE must complete a comprehensive best practices assessment that focuses on person-
centered care, which is signed and/or approved by a licensee, licensed addiction counselor
(LAC), a certified addiction specialist (CAS), an authorized practitioner, or a licensure candidate
performing within the scope of their practice. BHEs must meet timeline requirements set forth in
applicable endorsement Chapters. See endorsement Chapters 4 through 10 of these rules for
additional requirements.
B. Information gathered as part of screening and/or the initial assessment may be incorporated into
the comprehensive assessment.
C. For BHEs that have or are seeking a SUD sub-endorsement for any level of care, assessments
must:
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1. Use the ASAM Criteria as a guide for assessing and placing individuals in the appropriate
level of care;
2. Document information gathered on the six (6) dimensions outlined in the ASAM Criteria
for assessments; and
3. Utilize the decisional flow process as outlined in the ASAM Criteria to determine and
document the assessed level of care.
D. The BHE must conduct assessments throughout the course of treatment, review previous
assessments and update those assessments whenever there is a change in the person's level of
care or functioning. The assessments must occur, at minimum, every six (6) months, unless
otherwise indicated in an endorsement Chapter.
E. All methods and procedures used to assess and evaluate an individual must be developmentally
and age appropriate, culturally and linguistically appropriate and trauma informed. All methods
and procedures used to assess and evaluate an individual must be able to be provided in the
preferred language and/or communication method of frequently encountered Limited English
Proficiency (LEP) groups of the BHE.
F. The assessment must be documented in the individual’s record and, at minimum, include the
following information, if available and applicable:
1. Identification and demographic data;
2. Primary complaint/reason for seeking services, including onset of symptoms and severity
of symptoms;
3. Ment al health history, including but not limited to:
a. Suicidal risk and ideation, and
b. Homicidal ideation.
4. Substance use and substance use withdrawal history;
5. Physical and dental health status, including but not limited to human immunodeficiency
virus/acquired immune deficiency syndrome (HIV/AIDS), tuberculosis (TB), hepatitis A, B,
or C, and other infectious diseases status and risk evaluation;
6. A diagnosis with sufficient supporting criteria, as well as any subsequent changes in
diagnosis;
7. A mental status examination(s) for individuals who receive a diagnosis. When completing
a mental status exam, personnel must consider other diagnoses or disabilities that may
impact motor and speech activity;
8. History of involuntary treatment;
9. Advance directives, including medical and psychiatric;
10. Capacity for self-sufficiency and daily functioning;
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11. Cultural factors that may impact treatment, including age, ethnicity,
linguistic/communication needs, gender, gender identity, sexual orientation, relational
roles, spiritual beliefs, socio-economic status, personal values, level of acculturation
and/or assimilation, and coping skills;
12. Education, vocational training, and military service;
13. Family and/or social relationships;
14. Trauma and trauma history;
15. Physical and/or sexual abuse or perpetration and current risk;
16. Legal issues that may impact behavioral health outcomes;
17. Issues specific to older adults such as hearing loss, vision loss, strength; mobility and
other aging issues;
18. Issues specific to children such as growth and development, daily activities, legal
guardians and need for family involvement and engagement in the child's treatment;
19. Strengths, abilities, skills, and interests; and
20. Barriers to treatment.
G. Assessments must apprise individuals, as applicable, of risk factors associated with acquiring and
transmitting HIV/AIDS, Tuberculosis (TB), Hepatitis A, B, or C, and other infectious diseases.
Appropriate testing and pre and post-test counseling must be offered on-site or through referral.
H. Additional assessment requirements may be required for specific endorsements. See
endorsement Chapters 4 through 10 of these rules for additional requirements.
2.13 S ervice Planning
2.13.1 Service plan
A. If providing clinical services, the BHE shall ensure the development and review of a written
service plan for each individual as follows:
1. The service plan must be developed as soon as practicable after admission, but no later
than the timeframes identified in the endorsement-specific Chapters of these rules (i.e.,
Chapters 4 through 10).
2. The service plan must be reviewed and revised in writing when there is a change in the
individual’s level of functioning or service needs, and no later than applicable
endorsement-specific timeframes. Such revision must include documentation of progress
made in relation to planned treatment outcomes, changes in treatment focus, and length
of stay adjustments, as applicable.
3. The service plan must:
a. Meet the developmental and cultural needs of the individual;
b. Specify goals based on the initial and/or comprehensive assessment in a manner
understandable to the individual;
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c. Identify the type, frequency, and duration of services;
d. Be individually directed, including the individual’s strengths and identities; and
e. Include involvement of other identified family and/or supportive individuals, when
appropriate.
4. The service plan may include tasks or activities to be performed by the individual, such
as an individual doing their own laundry or preparing their own meals/snacks, only when
such tasks are therapeutic. Tasks must not be included in the service plan solely for the
convenience of the BHE.
5. The service plan must be signed by all parties involved in the development of the plan,
including the individual, or the individual’s parent or legal guardian in cases where the
individual is a child, or the individual has a court-appointed legal guardian and has not
consented to services without the involvement of the legal guardian. Signatures must
include at least one of the following: a licensee, licensed addiction counselor (LAC), a
certified addiction specialist (CAS), authorized practitioner, or a licensure candidate
performing within the scope of their practice.
a. A copy of the service plan must be offered to the individual, or to the individual’s
parent or legal guardian, as appropriate.
b. The BHE must include documentation in the individual record in cases where the
plan is not signed by the individual or the individual's parent or legal guardian if
involved in the development of the plan, and in cases where offering the service
plan to a parent or legal guardian is contraindicated.
2.13.2 Treatment Progress Documentation Requirements
A. The individual record must include progress notes, documenting a chronological record of
treatment, date and type of service, session activity, and progress toward individual-specific
treatment goals.
B. The minimum frequency of progress note completion may vary by endorsement. See specific
endorsement requirements in Chapters 4 through 10 of these rules for details.
C. P
rogress notes must include any noted change in physical, behavioral, cognitive, and functional
condition and action taken by personnel to address the individual’s changing needs.
D. Progress notes must be signed and dated or electronically approved by personnel, practicing
within the scope of their practice, at the time they are written, with at least first initial, last name,
and degree and/or professional credentials.
E. Verbal orders must be recorded at the time they are given and authenticated as soon as practical.
2.14 Protection of Individuals from Involuntary Restraint or Seclusion
2.14.1 General Provisions
A. The following rules covering seclusion, restraint, and physical management apply to all agencies
that use seclusion, restraint, and/or physical management. If a BHE has decided to use
seclusion, restraint, and/or physical management, the BHE shall use seclusion, restraint, and/or
physical management only in accordance with the rules in this part 2.14.
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B. These rules do not supersede any requirements under Sections 26-20-101 through -111, C.R.S.
C. If any provision of this part 2.14 conflicts with any provision concerning the use of seclusion,
restraint, and/or physical management on an individual with an intellectual or developmental
disability as stated in Article 10.5 of Title 27, C.R.S., Article 10 of Title 25.5, C.R.S. or any rule
adopted pursuant to those Articles, the provisions of those Articles or rules prevail.
D. Individuals being detained under Sections 27-65-106 through -110, C.R.S., may be secluded or
restrained involuntarily under the conditions in this part; otherwise, there must be a signed
informed consent for such an intervention as subject to part 2.11 of this Chapter.
E. A BHE may only use seclusion, restraint, and/or physical management:
1. In cases of emergency, as defined at Section 26-20-102(3), C.R.S., to be a serious,
probable, imminent threat of bodily harm to self or others where there is the present
ability to affect such bodily harm; and
2. After the failure of less restrictive alternatives, including but not limited to after all
attempts to verbally direct or de-escalate the individual have failed; or
3. A fter a determination that such alternatives would be inappropriate or ineffective under
the circumstances.
F. A BHE that uses seclusion, restraint, and/or physical management pursuant to the provisions of
part 2.14.1.E, may only use such seclusion, restraint, and/or physical management:
1. For the purpose of preventing the continuation or renewal of an emergency;
2. For the period of time necessary to accomplish its purpose; and
3. In the case of physical restraint, with no more force than is necessary to limit the
individual’s freedom of movement.
G. Seclusion, restraint, and/or physical management must never be used:
1. As a punishment or disciplinary sanction;
2. As a means of coercion;
3. As part of an involuntary service plan or behavior modification plan;
4. For convenience;
5. For the purpose of retaliation; or
6. For the purpose of protection, unless:
a. The restraint or seclusion is ordered by a court; or
b. In an emergency, as provided for in this part 2.14.1.F.1 above.
H. Physical management for individuals under the age of eighteen (18) must always be considered
as restraint and follow the restraint order rules pursuant to part 2.14.13 of this Chapter.
2.14.2 P olicies and Procedures Regarding Seclusion, Restraint, and Physical Management
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A. The BHE shall have and shall implement written policies and procedures that describe the
situations in which the use of seclusion, restraint, and/or physical management are considered
appropriate and the personnel who can order their use. The policies and procedures must include
the requirements in this part 2.14 and Section 26-20-101 through -111, C.R.S. these policies and
procedures must also include:
1. For a BHE that does not authorize the use of seclusion, restraint, and/or physical
management of any type, a policy statement noting the prohibition against the use of
seclusion, restraint, and/or physical management and the procedures that personnel will
utilize in lieu of seclusion, restraint, and/or physical management.
2. For a BHE that utilizes seclusion, restraint, and/or physical management, a policy
statement regarding the review process for the use of seclusion, restraint, and/or physical
management. The review process must include a provision for terminating the seclusion,
restraint, and/or physical management episode when the reviewer does not concur with
the order for continuation.
a. If the reviewer is not an authorized practitioner, then the order must be
discontinued by an authorized practitioner.
3. Personnel shall ensure that no individual endures harm or harassment when secluded
and/or restrained.
4. A p olicy statement that a BHE shall ensure that the care and treatment are skillfully and
humanely administered with full respect for the individual’s dignity, pursuant to Section
27-65-101(1)(a), C.R.S.
5. Protocols for when the use of restraint, seclusion, and/or physical management is
appropriate, which include restrictions on the use of these techniques. A BHE may
impose more, but not fewer, restrictions on the use of these techniques than is required
by this Chapter.
6. Details on the type of physical management interventions that personnel are approved to
use.
7. Details on how seclusion, restraint, and/or physical management will be altered to include
any necessary accommodations the individual may need, including but not limited to
changing emergency interventions to not restrain hands and ability to communicate for
those individuals that speak sign language.
8. If a BHE does not have a 27-65 designation with the BHA and is using seclusion and/or
restraint interventions, that BHE’s policies and procedures must include details on
transferring an individual to a 27-65 designated facility if after one (1) hour of seclusion
and/or restraint interventions have been used and the individual is assessed as continued
risk, meeting criteria for an emergency hold under 27-65-106, C.R.S., and needing further
intervention(s).
2.14.3 P ersonnel Training
A. The BHE shall ensure that all personnel involved in utilizing seclusion, restraint, and/or physical
management are trained in the use of seclusion, restraint, and/or physical management as
described in this part 2.14.
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B. The BHE shall ensure that personnel are trained to explain, where possible, the use of seclusion,
restraint, and/or physical management to the individual who is to be secluded, restrained, or
physically managed and to the individual’s designated representative, if appropriate.
C. Training must be standardized and evaluated every three (3) years to ensure incorporation of
evidence-based best practices for seclusion, restraint, and/or physical management.
D. Training must be provided to personnel within the first month of their orientation period and
annually thereafter unless training is needed sooner.
E. Personnel shall obtain certification in cardiopulmonary resuscitation (CPR), including periodic
recertification as needed to maintain certification.
F. Training must include at minimum, but is not limited to:
1. The safe use of seclusion, restraint, and/or physical management including content
related to the risks of positional asphyxia, aspiration, traumatization, and recognize and
respond to signs of physical distress of an individual who is secluded, restrained, and/or
physically managed;
2. Address concepts related to prevention and non-physical interventions such as de-
escalation and mediation;
3. Educate personnel of how their culture, language, biases, values, and perceptions
influence their response and escalation of person involved; and
4. U nderstanding and recognizing underlying behavioral health and physical health
conditions, medications, and their potential effects as well as how age, developmental
level, cultural background, language, history of physical or sexual abuse, and prior
experience with seclusion, restraint, and/or physical management will influence an
individual’s responses to seclusion, restraint, and physical management.
G. Personnel must demonstrate knowledge and application of seclusion, restraint, and physical
management training on an annual basis when working with persons over the age of twenty-one
(21), and on a semi-annual basis when working with youth twenty (20) years old and younger.
2.14.4 Standards of Care Upon Admission
A. At admission, the BHE shall inform both the individual and the individual’s legal representative, as
applicable, of the BHE’s policy regarding the use of seclusion, restraint, and physical
management during an emergency behavioral health episode for individuals in a treatment
program. This must, as is reasonable under the circumstances, be communicated in a language
and modality accessible to the individual.
B. Upon an individual’s admission, personnel shall collaborate with the individual and the individual’s
legal representative, when applicable, to formulate strategies that may minimize the potential for
a behavioral health emergency event that requires interventions of seclusion, restraint, and/or
physical management.
C. A B HE electing to utilize seclusion, restraint, and/or physical management shall assess each
individual upon admission regarding:
1. Assault and trauma history;
2. Seclusion, restraint, and/or physical management history;
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3. Individual’s risk factors for a behavioral emergency, and individually identified strategies
to avoid seclusion, restraint, and/or physical management; and
4. The BHE shall ascertain any applicable behavioral health advance directives.
2.14.5 Use of Physical Management
A. Physical management for individuals under the age of eighteen (18) must always be considered
as restraint and follow the restraint order rules pursuant to this part 2.14.13.
B. Physical management shall only be used on an emergency basis for a maximum of one (1)
minute, when the situation places the individual or others at imminent risk of serious physical
harm after all attempts to verbally direct or de-escalate the person have failed.
1. If physical management is used for longer than one (1) minute, the intervention is
restraint, pursuant to Section 26-20-102(6), C.R.S., and personnel must follow the
restraint order rules pursuant to part 2.14.7 of this Chapter.
C. To ensure the safety of each individual and personnel, each BHE shall designate emergency
physical management techniques to be utilized during emergency situations.
D. The term “physical management” does not include briefly holding an individual in order to comfort
them.
E. The physical management continuum may include:
1. U tilizing transitional measures;
2. Placing one’s hands on an individual to physically guide and/or physically control the
individual;
3. Use of an approved restraint method specified in the BHE’s policies and procedures to
maintain safety of the individual;
4. Placing an individual into an approved prolonged restraint method specified in the BHE’s
policies and procedures;
5. Physical management may be used to move or escort an individual into seclusion.
a. Seclusion, in itself, is not a form of physical management.
F. Physical management must be documented in the clinical record to include the following:
1. Documentation of the behavioral necessity for physical management and any de-
escalation techniques attempted prior to utilizing physical management.
2. Documentation of the approved physical management method utilized.
2.14.6 Use of Seclusion
A. If an order for seclusion is verbal, the verbal order must be received by a registered nurse or
other trained licensed personnel, such as a licensed practical nurse, while the emergency safety
intervention is being initiated by personnel or immediately after the emergency safety situation
begins.
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1. The physician or other authorized practitioner permitted to order seclusion must verify the
verbal order in a signed written form in the individual’s record. Signatures must be
entered into the record no more than twenty-four (24) hours after the event.
2. The physician or other authorized practitioner to order seclusion must be available to
personnel for consultation, at least by telephone, throughout the period of the emergency
safety intervention.
B. Within one (1) hour of the initiation of the original order of seclusion an authorized practitioner,
such as a registered nurse or physician assistant, trained in the use of emergency safety
interventions and permitted to assess the physical and psychological well-being of the individual,
shall conduct a face-to-face assessment of the physical and psychological well-being of the
individual including but not limited to:
1. The individual’s physical and psychological status;
2. The individual’s behavior;
3. The appropriateness of the intervention measures; and
4. Any complications resulting from the intervention.
C. When the one (1) hour assessment described in this part 2.14.6.B is conducted by a registered
nurse or a physician assistant, that personnel must consult with the attending physician when the
assessment is completed.
D. R esults of the one (1) hour assessment must determine if continued emergency interventions
need to be re-ordered by the authorized practitioner.
1. Assessment results and continuation order, if applicable, must be contained in the clinical
record.
E. Seclusion occurs any time an individual is placed alone in a room and not allowed to leave.
F. Seclusion must be used only when other less restrictive methods have failed.
1. Documentation of less restrictive methods and the outcome must be contained in the
clinical record.
G. Seclusion must not be used for punishment, for the convenience of personnel, or as a substitute
for a program of care and treatment.
H. Seclusion rooms must be lighted, clean, safe, and have a window for personnel to observe.
I. Seclusion rooms must be a minimum of 100 square feet.
J. Relief periods from seclusion must be offered for reasonable access to toilet facilities.
2.14.7 Use of Restraint
A. If an order for restraint is verbal, the verbal order must be received by a registered nurse or other
trained licensed personnel, such as a licensed practical nurse, while the emergency safety
intervention is being initiated by personnel or immediately after the emergency safety situation
begins.
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1. The physician or other authorized practitioner permitted to order restraint must verify the
verbal order in a signed written form in the individual’s record. Signatures must be
entered into the record no more than twenty-four (24) hours after the event.
2. The physician or other authorized practitioner to order restraint must be available to
personnel for consultation throughout the period of the emergency safety intervention.
B. An individual in physical restraint must be released from such restraint within fifteen (15) minutes
after the initiation of physical restraint, except when precluded for safety reasons pursuant to part
2.14.1 of this section.
C. Within one (1) hour of the initiation of the original order for the emergency safety intervention, an
authorized practitioner, such as a registered nurse or physician assistant, trained in the use of
emergency safety interventions and permitted to assess the physical and psychological well-
being of the individual, shall conduct a face-to-face assessment of the physical and psychological
well-being of the individual including but not limited to:
1. The individual’s physical and psychological status;
2. The individual’s behavior;
3. The appropriateness of the intervention measures; and
4. Any complications resulting from the intervention.
D. Wh en the one (1) hour assessment described in this part 2.14.7.C is conducted by a registered
nurse or a physician assistant, that personnel must consult with the attending physician when the
assessment is completed.
E. Results of the one (1) hour assessment must determine if continued emergency interventions
need to be reordered by the authorized practitioner.
1. Assessment results and continuation order, if applicable, must be contained in the clinical
record.
F. The decision to restrain must be based on a current clinical assessment and may also be based
on other reliable information including information that was used to support the decision to take
the individual into custody for treatment and evaluation. The fact that an individual is being
evaluated or treated under Sections 27-65-106 through 27-65-111 [effective July 1, 2024], C.R.S.,
must not be the sole justification for the use of restraint.
G. Restraint includes chemical restraint, mechanical restraint, and physical restraint.
H. Mechanical restraints may be used only for the purpose of preventing such bodily movement that
is likely to result in imminent injury to self or others. Mechanical restraint must not be used solely
to prevent unauthorized departure.
I. R estraint of an individual by a chemical spray is not permissible.
J. The type of restraint must be appropriate to the type of behavior to be controlled, the physical
condition of the individual, the age of the individual and the type of effect restraint may have upon
the individual.
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K. Restraint must be applied only if alternative interventions have failed. Justification for immediate
use of restraint without first attempting alternative interventions must be documented in the
clinical record; however, alternative techniques are not required if the alternatives would be
ineffective or unsafe when the individual’s behavior could cause harm to self or others.
L. The term “restraint” as used in this section, does not include restraints used while the BHE is
engaged in transporting an individual from one location to another location when it is within the
scope of that BHE's powers and authority to conduct such transportation pursuant to Section 26-
20-101 through -111, C.R.S.
M. No physical or mechanical restraint of an individual may place excess pressure on the chest or
back of that individual, cover the individual’s face, or inhibit or impede the individual’s ability to
breathe.
2.14.8 Chemical Restraint
A. If an order for chemical restraint is verbal, the verbal order must be received by a registered
nurse or other trained licensed personnel, such as a licensed practical nurse, while the
emergency safety intervention is being initiated by personnel or immediately after the emergency
safety situation begins.
1. The physician or other authorized practitioner permitted to order chemical restraint must
verify the verbal order in a signed written form in the individual’s record. Signatures must
be entered into the record no more than twenty-four (24) hours after the event.
2. T he physician or other authorized practitioner to order chemical restraint must be
available to personnel for consultation, throughout the period of the emergency safety
intervention.
B. An order for a chemical restraint, along with the reasons for its issuance, must be recorded in
writing at the time of its issuance;
C. An order for a chemical restraint must be signed at the time of its issuance by such authorized
practitioner, who is present at the time of the emergency;
D. An order for a chemical restraint, if authorized by telephone, must be transcribed, and signed at
the time of its issuance by personnel with the authority to accept telephone medication orders
who is present at the time of the emergency.
E. Personnel trained in the administration of medication shall make notations in the record of the
individual as to the effect of the chemical restraint and the individual’s response to the chemical
restraint.
2.14.9 Explanation to Individual in Seclusion/Restraint
A. In any situation in which seclusion/restraint is utilized, information must be given to the
secluded/restrained individual, and the individual’s legal representative when applicable, as soon
as possible after they have been secluded or restrained. The individual must be given a clear
explanation of:
1. T he reasons for use of such intervention;
2. The observation procedure, the desired effect; and
3. The circumstances under which the procedure will be terminated.
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B. That the explanation has been given to the individual and the individual’s legal representative,
when applicable, must be documented in the clinical record.
C. As soon as possible, upon termination of seclusion and/or restraint, personnel shall debrief with
the individual and assess for any traumatic stress that may have been triggered as a result of
seclusion/restraint.
2.14.10 Observation & Care of Individuals in Seclusion and/or Restraint
A. An individual who is in seclusion/restraint must be observed in-person by trained BHE personnel
at no more than ten (10) feet physical distance from the individual.
1. Such observation, along with the behavior of the individual, must be documented every
fifteen (15) minutes.
B. Unless contraindicated by the individual's condition, such observation must include consistent
efforts to interact personally with the individual throughout the episode.
C. Ongoing provisions must be made for nursing care, hygiene, diet, and motion of any restrained
limbs throughout the episode.
D. BHE personnel must maintain a continuous line-of sight throughout the episode with the
individual held in mechanical restraints.
E. For individuals held in mechanical restraints, BHE personnel must observe the individual at least
every fifteen (15) minutes to ensure that:
1. T he individual is properly positioned;
2. The individual’s blood circulation is not restricted;
3. The individual’s airway is not obstructed; and
4. The individual’s other physical needs are met, pursuant to this part 2.14.10.
F. For individuals held in mechanical restraints, the BHE shall offer relief periods of at least ten (10)
minutes as often as every two (2) hours, so long as relief from the mechanical restraint is
determined by personnel to be safe pursuant to part 2.14.1 of this section.
G. Personnel must document relief periods both offered and granted.
H. The individual must have access to food at least every four (4) hours.
I. The individual must have access to fluids and toileting upon request or during offered relief
periods but must at minimum be offered every two (2) hours.
1. During such relief periods, personnel shall ensure proper positioning of the individual and
provide movement of limbs, as necessary.
J. Personnel must provide assistance for use of necessary toileting methods.
1. Appropriate toileting does not include the use of adult diapers if not typically used by the
individual when not restrained or secluded.
2. If the individual typically uses adult diapers, they are to be changed immediately if soiled.
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K. Personnel shall maintain the individual’s dignity and safety during relief periods.
L. Cameras and other electronic monitoring devices must not replace face-to-face observations.
M. To the extent that the duties specified in Section 26-20-101 through -111, C.R.S. are more
protective of individual rights or are in conflict with the provisions in this part 2.14, the provisions
of Section 26-20-101 through -111, C.R.S. shall apply.
2.14.11 Continued Use of Seclusion and/or Restraint
A. Personnel must document efforts to assure that the use of seclusion/restraint is as brief as
possible.
B. The original order of seclusion/restraint of an individual must not exceed one (1) hour without an
order for continued seclusion/restraint from an authorized practitioner. A verbal order, including
telephone or other electronic orders, may be used if followed by a written order from the
authorized practitioner.
C. Seclusion/restraint must not be ordered on an “as needed” basis.
D. A new written order is required every four (4) hours and shall include a documented examination
by an authorized practitioner.
E. Continued seclusion/restraint in excess of twenty-four (24) hours shall require an administrative
review.
1. T he administrative reviewer shall be a different authorized practitioner with the authority
and knowledge necessary to review clinical information and reach a determination that
the extension of a seclusion and/or restraint episode beyond twenty- four (24) hours is
clinically necessary.
2. If the administrative reviewer does not concur with the order for continuation of
seclusion/restraint, the order shall be discontinued and the authorized practitioner in
charge of treatment shall be notified of such discontinuation.
F. An administrative review must be initiated at the conclusion of each twenty-four (24) hour period
of continuous use of seclusion/restraint.
2.14.12 Documentation Requirements
A. Each BHE must ensure that an appropriate notation of the use of seclusion, restraint and/or
physical management is documented in the record of the individual who was secluded,
restrained, and/or physically managed and must be completed before the end of the shift of the
personnel involved in the seclusion, restraint and/or physical management episode(s). Each BHE
shall document the following in the individual’s record:
1. Specifics of the episode including identified triggers, precipitating events, the individual's
specific behavior(s) and the nature of the danger;
2. Type of restraint, if utilized;
3. Specific date and times of initiation and discontinuation of seclusion, restraint and/or
physical management and total length of time individual is secluded, restrained, and/or
physically managed;
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4. A description of specific non-physical and least restrictive interventions that were
attempted prior and the individual’s response;
5. Identification of personnel involved in the initiation and application of the seclusion,
restraint and/or physical management;
6. Notification to an authorized practitioner within one (1) hour of the seclusion/restraint
intervention;
7. Care provided while individual was secluded, restrained, and/or physically managed,
including:
a. Observations conducted;
b. Assessments of position, respiration, circulation, and range of motion;
c. Documentation of ongoing 15-minute observation and care checks, as subject to
applicable rules, along with relief periods both offered and granted for food, fluid,
and/or toileting;
d. Interventions provided to promote comfort and safety as well as expedite release;
e. The individual’s response to these interventions; and
f. The effect of the restraint or seclusion on the individual;
8. Documentation that the individual, and the individual’s legal representative if applicable,
was given a clear explanation of the reasons for use of such intervention, the observation
procedure, the desired effect, and the circumstances under which the intervention will be
terminated including criteria for release and individual understanding of that criteria; and,
9. Documentation that personnel debriefed the incident with the individual and assessed for
trauma, processed the traumatic event, and identified triggers.
B. An y administrative reviewer shall document the clinical justification for the continued use of
seclusion/restraint in the individual's chart. The justification must include:
1. Documentation that the authorized practitioner ordering the continuous use of
seclusion/restraint in excess of four (4) hours has conducted a face-to-face evaluation of
the individual within the previous four (4) hours;
2. Documentation of the ongoing behaviors or findings that warrant the continued use of
seclusion/restraint and other assessment information as appropriate;
3. Documentation of a plan for ongoing efforts to actively address the behaviors that
resulted in the use of seclusion/restraint;
4. A determination of the clinical appropriateness of the continuation of seclusion/restraint;
and
5. A summary of the information considered by the reviewer and the result of the
administrative review with the date, time and signature of the individual completing the
review.
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C. Information regarding use of seclusion/restraint must be readily accessible to authorized
individuals for review. The BHE shall have the ability to gather data as follows:
1. Each seclusion/restraint episode including date and time the episode started and ended,
specific to each individual over the period of one complete calendar year from January 1
through December 31.
2.14.13 Additional Procedures and Requirements for Seclusion/Restraint of a Youth
A. Procedures for youth must include the following in addition to the requirements found in part 2.14
of this Chapter, unless otherwise required in this part 2.14.13.
B. This part 2.14.13 does not apply to adult individuals over the age of 21.
C. An emergency safety intervention must be performed in a manner that is safe, proportionate, and
appropriate to the severity of the behavior, and the youth’s chronological and developmental age;
size; gender; physical, medical, and psychiatric condition; and personal history (including any
history of physical or sexual abuse).
1. Physical management is always considered restraint for an individual under age eighteen
(18) and must follow the restraint order rules pursuant to this part 2.14 of this Chapter.
D. Orders for seclusion/restraint must be by an authorized practitioner in the BHE to order
seclusion/restraint and trained in the use of emergency safety interventions. Federal regulations
at 42 C.F.R. Part 441, specifically 441.151 require that inpatient psychiatric services for
individuals under age twenty-one (21) be provided under the direction of a physician.
1. If the individual’s treatment team assigned physician is available, only they can order
seclusion/restraint. If they are not available, then another team physician may make the
order.
E. A physician or other authorized practitioner must order the least restrictive emergency safety
intervention that is most likely to be effective in resolving the emergency safety situation based on
consultation with personnel.
F. If the order for seclusion/restraint is verbal, the order must be received by a registered nurse or
other trained licensed personnel, such as a licensed practical nurse, while the emergency safety
intervention is being initiated by personnel or immediately after the emergency safety situation
begins.
1. The physician or other authorized practitioner permitted to order restraint or seclusion
must verify the verbal order in a signed written form in the minor’s record. Signatures
must be entered into the record no more than twenty-four (24) hours after the event.
2. The physician or other authorized practitioner to order restraint or seclusion must be
available to personnel for consultation, at least by telephone, throughout the period of the
emergency safety intervention.
G. Each order for seclusion/restraint must be limited to no longer than the duration of the emergency
safety situation.
H. U nder no circumstances may the total order time exceed:
1. Four (4) hours for persons ages eighteen (18) to twenty-one (21);
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2. Two (2) hours for persons ages nine (9) to seventeen (17); or
3. One (1) hour for persons under the age of nine (9).
I. Within one (1) hour of the initiation of the order of the emergency safety intervention, a physician,
or other authorized practitioner trained in the use of emergency safety interventions and permitted
to assess the physical and psychological well-being of the youth, must conduct a face - to - face
assessment of the physical and psychological well-being of the individual including but not limited
to:
1. The youth’s physical and psychological status;
2. The youth’s behavior;
3. The appropriateness of the intervention measures; and
4. Any complications resulting from the intervention.
J. Results of the one (1) hour assessment must be documented in the individual’s record.
K. Notification of parent(s) and/or legal guardian(s), when applicable:
1. The BHE must notify the parent(s) and/or legal guardian(s) of the individual who has
been in seclusion or restraint as soon as possible after the initiation of each emergency
safety intervention.
2. The BHE shall document in the individual’s record that the parent(s) or legal guardian(s)
have been notified of the emergency safety intervention, including date and time of the
notification and the name of personnel providing the notification.
2.15 Med ication Administration
A. The BHE shall ensure that medications are administered only by licensed or certified personnel
allowed to administer medications under their own scopes of practice, or unlicensed personnel
who are qualified medication administration persons (QMAPs) acting within their own scope of
practice.
B. When using QMAPs to administer medication, the BHE shall ensure compliance with 6 CCR
1011-1, Chapter 24 (March 17, 2025), which is hereby incorporated by reference. No later
editions or amendments are incorporated. This Colorado Department of Public Health and
Environment rule is available at no cost at
https://www.coloradosos.gov/CCR/GenerateRulePdf.do?ruleVersionId=11868&fileName=6%20C
CR%201011-1%20Chapter%2024. Individuals may inspect or obtain a copy of the rule at the
BHA, 710 S. Ash Street, Unit C140, Denver, CO 80246, during regular business hours.
2.16 Critical Incident Reporting
A. A critical incident includes but is not limited to the following:
1. Breach of confidentiality: any unauthorized disclosure of protected health information as
described in HIPAA, 42 C.F.R. Part 2, and/or Section 27-65-101 through -131, C.R.S.
2. Death: including the death of an individual inside of or outside of the BHE’s physical
location while an individual is receiving services or where an individual has attempted to
receive services from the BHE within the past thirty (30) calendar days.
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3. Elopement: absconding from a mental health hold, certification, emergency/involuntary
commitment, or a secure facility where an individual is being held as a result of a court
order. This includes any unauthorized absence of a child, when a child cannot be
accounted for or when there is reasonable suspicion to believe the child has absconded.
4. Any instance when an individual cannot be located following a search of the BHE, the
BHE grounds, and the area surrounding the BHE, and:
a. There are circumstances that place the individual’s health, safety, or welfare at
risk; or
b. The individual has been missing for eight (8) hours.
5. Medication diversion: any medication diversion as defined in part 1.2 of these rules if the
diverted drugs are injectable, the BHE shall also report the full name and date of birth of
any individual who diverted the injectable drugs, if known.
6. Medication error: medication error that resulted or could have resulted in harm to the
individual.
7. Medical emergency: any suicide attempt/self-injury, other form of serious injury, health
emergency, overdose or serious illness which occurred on BHE premises or in the
presence of BHE personnel.
8. An y instance involving physical, sexual, or verbal abuse of an individual, as described in
Sections 18-3-202, 18-3-203, 18-3-204, 18-3-206, 18-3-402, 18-3-404, 18-3-405, 18-3-
405.3, 18-3-405.5, and 18-9-111 (exempting however, the phrase “intended to harass”),
C.R.S. by another individual, personnel, or a visitor to the BHE.
9. Any instance that results in any of the following serious injuries to an individual:
a. Brain or spinal cord injuries;
b. Life-threatening complications of anesthesia or life-threatening transfusion errors
or reactions; or,
c. Second- or third-degree burns involving twenty percent (20%) or more of the
body surface area of an adult or more than fifteen percent (15%) of the body
surface area of a child.
10. Any instance involving caretaker neglect of an individual, as defined in 26-3.1-101(2.3),
C.R.S. or child abuse or neglect as defined in 19-1-103(1), C.R.S.
11. Any instance involving misappropriation of an individual’s property, meaning patterns of
loss or single incidences of deliberately misplacing, exploiting, or wrongfully using, either
temporarily or permanently, an individual’s belongings or money without the individual’s
consent.
12. An y occurrence involving the malfunction or intentional or accidental misuse of care
equipment that occurs during treatment or diagnosis of an individual and that significantly
or adversely affects or, if not averted, would have significantly adversely affected an
individual.
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B. Critical incidents must be reported to the BHA within one (1) business day after the incident.
Critical incidents must also be reported to the BHA within one (1) business day of when the BHE
determines that a reportable incident has occurred and the BHA requests such reporting.
C. The BHA may conduct scheduled or unscheduled site reviews for specific monitoring purposes
and investigation of critical incidents reports in accordance with:
1. BHA policies and procedures,
2. Regulations that protect the confidentiality and individual rights in accordance with
Sections 27-65-101 through -131, C.R.S.; HIPAA; and 42 C.F.R. Part 2,
3. Controlled Substance Licensing; Section 27-81-113, C.R.S.; Section 27-80-212, C.R.S.,
and Section 18-18-503, C.R.S.
D. The BHA shall have access to relevant documentation required to determine compliance with
these rules.
E. The BHE must:
1. Establish written policies and procedures for reporting and reviewing all critical incidents
occurring at the BHE;
2. Submit critical incidents reports to the BHA using state prescribed forms that can be
obtained from the BHA’s website at https://bha.colorado.gov/for-providers. This is not in
lieu of other reporting mandated by state statute or federal guidelines;
3. Mak e available a report with the investigation findings for review by the BHA, upon
request; and,
4. Maintain critical incidents reports for a minimum of three (3) years following the incident
unless it would violate any other federal or state law.
F. Nothing in this part shall be construed to limit or modify any statutory or common law right,
privilege, confidentiality, or immunity.
2.17 Quality Management Program
A. Every BHE must have a quality management program (QMP) designed to improve individual
safety and well-being. The individual safety component of the program must implement
improvements in response to patterns and trends associated with service delivery errors and
potential for error. The individual well-being component of the QMP must implement
improvements that are not necessarily tied to errors or potential for error but instead to the
continuous quality improvement principle that opportunities always exist to enhance service
delivery.
B. The BHE must implement the QMP in accordance with a quality management plan that is
reviewed and approved annually by the governing body. The plan must have the following
elements:
1. Identification of quality management programs
a. For the individual safety component of the QMP, the plan must identify:
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(1) The types of service delivery errors and potential for error that will be
monitored, which must be based, at minimum, on a review of negative
individual outcomes that are unanticipated, individual disputes, critical
incidents, deficiencies cited by regulatory agencies, occurrences and/or
errors, and potential for errors reported by personnel.
(2) A process for personnel to report service delivery error and potential for
error within a prescribed period of time and a plan for how personnel will
be trained regarding such reporting.
(3) The methods used to collect and analyze data to find patterns and
trends. The plan must also include how the governing body, if applicable,
and the administrator will be informed of such patterns and trends.
(4) The method(s) used to select quality management projects.
(5) The method(s) for selecting the service delivery practice(s) that will be
reviewed.
2. Implementation of the individual well-being component
a. The plan must include development of improvement strategies. This may include
identifying the personnel that will be involved in designing the intervention,
opportunities for individual input, and the administrative approvals needed to
finalize the intervention design.
b. The plan must document each improvement strategy including:
(1) A d escription of the intervention design. For individual safety
improvements, this must include how information about patterns and
trends will be shared with personnel and how the underlying systemic
problem(s) that led to the pattern or trend will be addressed.
(2) How personnel will be allocated and/or trained to implement the strategy.
(3) How the strategy will be evaluated for effectiveness.
(4) Timelines for implementation and evaluation of the strategy and how the
BHE is tracking the meeting of these milestones.
C. The BHA may audit a BHE’s QMP to determine compliance with part 2.17 of this Chapter.
1. If the BHA determines that an investigation of any incident or outcome is necessary, it
may, unless otherwise prohibited by law, investigate and review documents related to the
incident or outcome to determine actions taken by the BHE.
2.18 Initial Application Procedure
A. Any person or business entity seeking a license to operate a BHE shall initially notify the BHA by
submitting a letter of intent. Upon receipt of a letter of intent, the BHA will open a license
application file.
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B. The applicant must provide the BHA with a complete application including all information and
attachments specified in the application form, which is available to access on the BHA’s website,
and any additional information requested by the BHA. The appropriate non-refundable fee(s) for
the license category requested must be submitted with the application. Applications must be
submitted at least ninety (90) calendar days before the anticipated start-up date.
1. A license application may be considered abandoned if the applicant fails to complete the
application within twelve (12) months. The BHA may administratively close the
application process.
2. After an administrative closure, the applicant may file a new license application along with
the corresponding initial license fee.
C. With the submission of an application for a license to operate a BHE, or within ten (10) days after
a change in ownership or management of a BHE, each owner and manager shall submit a
complete set of the owner's and manager's fingerprints to the Colorado Bureau of Investigation
(CBI) for the purpose of conducting a fingerprint-based criminal history record check. The CBI
shall forward the fingerprints to the Federal Bureau of Investigation (FBI) for the purpose of
conducting fingerprint-based criminal history record checks. Each owner and each manager shall
pay the CBI the costs associated with the fingerprint-based criminal history record check. Upon
completion of the criminal history record check, the CBI shall forward the results to the BHA. The
BHA 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.
D. Ea ch applicant must provide the following information:
1. The legal name of the applicant and all other names used by it to provide services. The
BHE has a continuing duty to submit notification to the BHA for all name changes at least
thirty (30) calendar days prior to the effective date of the change.
a. Applicants for initial licensure must submit a distinctive license name that does
not need to include the services to be provided, but it may not mislead or confuse
the public regarding the license or type of services to be provided.
b. Duplication of an existing name is prohibited except between agencies that are
affiliated through ownership or controlling interest.
c. Each BHE shall be identified by this distinctive name on stationery, billing
materials, and exterior signage that clearly identifies the licensed entity. Exterior
signage must conform to the applicable local zoning requirements.
d. If the BHE has a “doing business as” name, it must hold itself out to the public
using such name, as it appears on the license.
2. Contact information for the BHE must include a mailing address, telephone number, and
e-mail addresses. If applicable, the BHE’s website and facsimile number must be
provided.
3. T he identity, address, and telephone number of all persons and business entities with a
controlling interest in the BHE, including but not limited to:
a. A non-profit corporation shall list the governing body and officers.
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b. 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.
c. A sole proprietor shall include proof of lawful presence in the United States.
d. A partnership shall list the names of all partners.
e. The chief executive officer of the BHE.
f. If the addresses and telephone numbers provided above are the same as the
contact information for the BHE itself, the BHE shall also provide an alternate
address and telephone number for at least one person for use in the event of an
emergency or closure of the BHE.
4. Proof of professional liability insurance. BHEs must maintain such coverage for the
duration of the license term and must notify the BHA of any change in the amount, type,
or provider of professional liability insurance coverage during the license term.
5. 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.
6. T he address(es) of the physical location(s) where services are delivered, as well as, if
different, where records are stored for BHA review.
7. A map for each floor of the BHE’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 BHE regardless if services are being
delivered under the terms of the license.
a. If services are delivered in multiple buildings located on a campus, a street map
of the campus must be submitted that indicates which buildings and floors are
occupied as part of the license.
b. Maps must be submitted to the BHA.
8. A copy of any management agreement pertaining to operation of the entity that sets forth
the financial and administrative responsibilities of each party.
9. If an applicant leases one or more building(s) to operate under the license, a copy of the
lease or leases must 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.
10. A statement, on the applicant’s letterhead, if available, signed and dated, submitted with
the application stating whether any of the actions listed in this part 2.17.D.10.a.(2) of
these rules 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 BHA may, based upon information received in the statement, request additional
information from the applicant beyond the ten-year time frame.
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a. For initial licensure of the BHE, whether one or more individuals or entities
identified in the response to part 2.18.D.3 of this Chapter has a controlling or
ownership interest in the BHE and has been the subject or party to any of the
following:
(1) A civil judgment or criminal conviction resulting from conduct or an
offense in the operation, management or ownership of a BHE 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.
(2) A disciplinary action imposed upon the BHE by a governmental entity in
another state that registers or licenses agencies including but not limited
to, a sanction, probation, civil penalty, or a denial, suspension,
revocation, or modification of a license or registration.
(3) Limitation, denial, revocation, or suspension by any federal, state, or
local authorities of any health care related license.
(4) The refusal to grant or renew a license for operation of a BHE, or
contract for participation or certification for Medicaid, Medicare, or other
public health or social services payment program.
b. For a change of ownership of a BHE, whether any of the new owners have been
the subject of, or a party to, one of more of the following events:
(1) A ci vil 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 BHE or other entity related to substandard care or
health care fraud.
(2) Limitation, denial, revocation, or suspension of a state license or federal
certification by another jurisdiction.
11. Any statement regarding the information requested in 2.18.D.10 of this Chapter must
include the following, as applicable:
a. If the event is an action by a governmental agency, as described in part
2.18.D.10.b: 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.
b. 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. For the purposes of this rule, “crimes of moral turpitude” include the
following felony, misdemeanors, or municipal offenses:
(1) Any of the offenses against the person set forth in Title 18, Article 3 of
the Colorado Revised Statutes. Examples of such offenses include, but
are not limited to, any assault, menacing, or unlawful sexual behavior;
(2) An y of the offenses against property set forth in Title 18, Article 4 of the
Colorado Revised Statutes. Examples of such offenses include, but are
not limited to, any arson, theft, trespass, or criminal mischief;
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(3) Any of the offenses involving fraud set forth in Title 18, Article 5 of the
Colorado Revised Statutes;
(4) Computer crime as set forth in Title 18, Article 5.5 of the Colorado
Revised Statutes;
(5) Any of the offenses involving the family relations set forth in Title 18,
Article 6, Part 4 (wrongs to children), when committed intentionally and
knowingly or recklessly; Part 6 (harboring a minor); or Part 8 (domestic
violence), of the Colorado Revised Statutes;
(6) Any of the offenses constituting wrongs to at-risk adults set forth in Title
18, Article 6.5 of the Colorado Revised Statutes;
(7) Any of the offenses relating to morals set forth in Title 18, Article 7 of the
Colorado Revised Statutes. Examples of such offenses include, but are
not limited to, prostitution, indecent exposure, and criminal invasion of
privacy;
(8) Any other offense in any jurisdiction whatsoever that is committed
intentionally, knowingly, or recklessly, and involves violence, coercion,
threats, cruelty, fraud, deception, or deprivation of legally recognized
rights; and,
(9) Any conspiracy, solicitation, or criminal attempt to commit any of the
above offenses, or participation as an accessory to any of the above
offenses.
c. If the event is 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.
E. The BHA will not issue or renew a BHE license unless it has received a certificate of compliance
as defined in Chapter 1 of these rules for each physical location where services are provided
F. Each application must be signed under penalty of perjury by an authorized corporate officer,
general partner, member, or sole proprietor of the BHE as appropriate.
G. The BHA shall conduct a preliminary assessment of the application and notify the applicant of any
application defects.
1. The applicant shall respond within fourteen (14) calendar days to written notice of any
application defect.
H. License fees must be submitted to the BHA as specified below:
1. An applicant for an initial license as a BHE shall submit the following nonrefundable
fee(s) with the application for licensure, as applicable:
a. A base fee of $500, regardless of endorsements or physical locations included as
part of the application for initial licensure. The base fee includes one physical
location in which services are to be provided under an outpatient endorsement as
defined in part 2.3.A.3 of this Chapter.
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b. A fee of $300 for each additional physical location in which services are to be
provided under an outpatient endorsement as defined in part 2.3.A.3 of this
Chapter included as part of the application for initial licensure, to be paid only by
applicants that are seeking licensure that includes endorsement for outpatient
services.
c. A fee of $600 for each physical location in which services are to be provided
under a residential/overnight endorsement as defined in part 2.3.A.4 of this
Chapter, to be paid only by applicants seeking such endorsement.
d. Endorsements for services not listed in parts 2.3.A.3 or 2.3.A.4 shall not require a
fee.
2. A BHE may apply to add an endorsement to its license at any time with the submission of
fees outlined in part 2.20.H.1.b and part 2.20.H.1.c.
I. The duration of the initial license will be one (1) year from the date of issuance.
J. The BHA will provide written notice to the applicant within thirty (30) calendar days of receipt of a
complete application.
K. The BHA will act on an application within thirty (30) calendar days of receipt of the completed
application.
2.19 Provisional Licenses
A. W here an applicant for an initial license fails to fully conform to the applicable statutes and
regulations but the BHA determines the applicant is in substantial compliance with these rules
and regulations and is temporarily unable to conform to all the minimum standards, a provisional
license may be granted. No provisional license may be issued to an applicant if the operations
may adversely affect the health, safety, or welfare of individuals, personnel, or other persons. A
provisional license will only be issued upon payment of the non-refundable provisional license
fee.
1. A provisional license will be valid for ninety (90) days.
2. A second provisional license may be issued if the BHA determines that it is likely
compliance can be achieved by the date of expiration of the second provisional license.
3. The second provisional license may be issued for the same duration as the first upon
payment of a second non-refundable provisional license fee. The BHA will not issue a
third or subsequent provisional license to the applicant.
4. During the term of the provisional license, the BHA shall conduct any review it deems
necessary to determine if the applicant meets the requirements for a regular license.
5. If the BHA determines, prior to expiration of the provisional license, that the applicant is in
compliance with all applicable rules, it may issue a regular license upon payment of the
applicable initial license fee. The regular license will be valid for one (1) year from the
date of issuance of the regular license, unless otherwise acted upon pursuant to part 2.24
of this Chapter.
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2.20 License Renewal
A. A BHE seeking renewal must provide the BHA with a license application, signed under penalty of
perjury by an authorized corporate officer, general partner, member, or sole proprietor of the BHE
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 2.18.D of
this Chapter unless the information has been previously submitted and no changes have been
made to the information currently held by the BHA.
B. Failure to submit a completed renewal application to the BHA thirty (30) calendar days prior to
expiration of the existing license will result in assessment of a late fee in an amount equal to the
renewal fee.
C. Failure of the BHE to accurately answer or report any of the information requested by the BHA
will be considered good cause to deny the license renewal application.
D. The BHA shall conduct a preliminary assessment of the renewal application and notify the BHE of
any application defects.
1. The BHE shall respond within fourteen (14) calendar days to written notice of any
application defect.
E. A BHE submitting a renewal application shall submit the following nonrefundable fees, as
applicable:
1. A bas e fee of $500, regardless of endorsements or physical locations included as part of
the application for licensure renewal. The base fee includes one physical location in
which services are to be provided under an outpatient endorsement as defined in part
2.3.A.3 of this Chapter.
2. A fee of $300 for each additional physical location in which services are to be provided
under an outpatient endorsement as defined in part 2.3.A.3 of this Chapter included as
part of the application for licensure renewal, to be paid only by applicants that are
seeking licensure that includes endorsement for outpatient services.
3. A fee of $600 for each physical location in which services are to be provided under a
residential/overnight endorsement as defined in part 2.3.A.4 of this Chapter, to be paid
only by applicants seeking such endorsement.
4. Endorsements for services not listed in parts 2.3.A.3 or 2.3.A.4 shall not require a fee.
F. The duration of the renewal license will be one (1) year from issuance.
2.21 Change of Ownership/Management
A. If a BHE undergoes a change in ownership without following the procedures outlined in this part
2.21, their existing license may be terminated. Termination of the license may not occur until after
a hearing and in compliance with the provisions and procedures specified in 24-4-101 through -
109, C.R.S.
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B. When a BHE initiates a change of ownership, the BHE must submit notification to the BHA within
the specified time frame, and the prospective new BHE shall submit an application and
supporting documentation for change of ownership along with the requisite fees in part 2.21.G of
this Chapter within the same time frame. The time frame for submission of the notification and the
application and supporting documentation shall be at least thirty (30) calendar days before a
change of ownership involving any BHE.
C. The BHA will consider the following criteria in determining whether there is a change of ownership
of a BHE that requires a new license. The transfer of fifty percent (50%) of the ownership interest
referred to in this part 2.21 may occur during the course of one transaction or during a series of
transactions occurring over a five-year period.
1. Sole proprietors:
a. The transfer of at least fifty percent (50%) of the ownership interest in a BHE
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.
b. Change of ownership does not include forming a corporation from the sole
proprietorship with the proprietor as the sole shareholder or forming a limited
liability company from sole proprietorship with the proprietor as the sole member.
2. P artnerships:
a. 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 ownership to one or more new owners.
b. Change of ownership does not include dissolution of the partnership to form a
corporation with the same persons retaining ownership in the new corporation.
3. Corporations:
a. Merger of two or more corporations resulting in the creation of a new corporate
entity will be considered a change of ownership if the consolidation includes a
transfer of at least fifty percent (50%) of the ownership to one or more new
owners.
b. Formation of a corporation from a partnership, a sole proprietorship, or a limited
liability company will be considered a change of ownership if the change includes
a transfer of at least fifty percent (50%) of the ownership to one or more new
owners.
c. The transfer, purchase, or sale of shares in the corporation such that at least fifty
percent (50%) of the ownership of the corporation is shifted to one or more new
owners will be considered a change of ownership.
4. L imited liability companies:
a. The transfer of at least fifty percent (50%) of the ownership interest in the
company will be considered a change of ownership.
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b. The termination or dissolution of the company and the conversion thereof into
any other entity will be considered a change of ownership if the conversion also
includes a transfer of at least fifty percent (50%) of the ownership to one or more
new owners.
c. 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.
5. Non-profits:
a. The transfer of at least fifty percent (50%) of the controlling interest in the
nonprofit is considered a change of ownership.
6. Management contracts, leases, or other operational arrangements:
a. If the BHE enters into a lease arrangement or management agreement whereby
the owner retains no authority or responsibility for the operation and
management of the BHE, the action will be considered a change of ownership
that requires a new license.
7. Legal structures:
a. The conversion of a BHE’s legal structure, or the legal structure of a business
entity that has an ownership interest in the BHE is a change of ownership if the
conversion also includes a transfer of at least fifty percent (50%) of the BHE’s
ownership interest to one or more new owners.
D. Ea ch BHE undergoing a change of ownership shall submit an application as prescribed in 2.18.B
through 2.18.F of this Chapter.
E. The existing BHE is responsible for correcting all rule violations and deficiencies in any current
plan of action before the change of ownership becomes effective. In the event that such
corrective actions cannot be accomplished in the time frame specified, the prospective BHE shall
be responsible for all uncorrected rule violations and deficiencies including any current plan of
action submitted by the previous BHE unless the prospective BHE submits a revised plan of
action, approved by the BHA, before the change of ownership becomes effective.
F. When the BHA issues a license to the new owner, the previous owner must return its license to
the BHA within five (5) calendar days of the new owner’s receipt of its license.
G. For a change of ownership, a BHE must submit the following nonrefundable fee(s) with the
application for licensure, as applicable:
1. A base fee of $500, regardless of endorsements or physical locations included as part of
the application for licensure. The base fee includes one physical location in which
services are to be provided under an outpatient endorsement as defined in part 2.3.A.3 of
this Chapter.
2. A fe e of $300 for each additional physical location in which services are to be provided
under an outpatient endorsement as defined in part 2.3.A.3 of this Chapter included as
part of the application for licensure, to be paid only by applicants that are seeking
licensure that includes endorsement for outpatient services.
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3. A fee of $600 for each physical location in which services are to be provided under a
residential/overnight endorsement as defined in part 2.3.A.4 of this Chapter, to be paid
only by applicants seeking such endorsement.
4. Endorsements for services not listed in parts 2.3.A.3 or 2.3.A.4 shall not require a fee.
2.22 Rule Waivers
A. This part establishes procedures with respect to waiver of regulations relating to BHE licensing.
B. Any BHE or applicant that has applied for or been issued a license to operate a BHE has the right
to apply for a waiver of any rule or standard set forth in these rules which, in their opinion, poses
an undue hardship on the applicant, BHE, or community.
C. Nothing contained in these provisions abrogates the BHE's obligation to meet minimum
requirements under local safety, fire, electrical, building, zoning, and similar codes.
D. Nothing herein authorizes a waiver of any statutory requirement under state or federal law, except
to the extent permitted therein.
E. Upon application to the BHA, a waiver may be granted in accordance with this part 2.22. Absent
the existence of a current waiver issued pursuant to this part, BHEs are expected to comply at all
times with all applicable regulations except in instances where they are granted a provisional
license in accordance with part 2.19 of this Chapter. BHEs must comply with all regulations in this
part as well as all regulations in the endorsement parts of these rules (i.e., Chapters 3 through
10) that apply to a BHE unless and until a waiver is granted.
F. W aiver applications must be submitted to the BHA in writing.
1. The BHA will only consider one regulation per waiver.
2. The waiver application must provide the BHA information related to:
a. The regulation the BHE or applicant is requesting to waive;
b. The reason why the waiver is being requested;
c. A proposed alternate compliance plan;
d. Any other information relevant to the waiver request that would inform the BHA’s
decision in either granting or denying the waiver.
3. The waiver application must be signed by an authorized representative of the BHE or
applicant, who is the primary contact person and the person responsible for ensuring that
accurate and complete information is provided to the BHA.
G. In making its determination, the BHA may consider any information it deems relevant, including
but not limited to:
1. Critical incident and complaint investigation reports, licensure or certification survey
reports, anticipated impact of the waiver on individual safety and quality of care if any,
and findings of these reports related to the BHE and/or the operator or owner thereof.
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2. When determining whether a waiver should be granted, the BHA shall prioritize
consideration of the impact of the waiver on the health, safety, and welfare of individuals
over any alleged undue hardship.
H. The BHA shall act on a waiver application within ninety (90) calendar days of receipt of the
completed application. An application will not be deemed complete until the BHE has provided all
information and documentation requested by the BHA.
I. The BHA may specify terms and conditions under which any waiver is granted, including which
terms and conditions must be met in order for the waiver to remain effective. The term for which
each waiver granted will remain effective must be specified at the time of issuance but may not
exceed the term of the current license.
1. At any time, upon reasonable cause, the BHA may inspect a BHE with an active waiver
to ensure that the terms and conditions of the waiver are being observed, and/or that the
continued existence of the waiver is otherwise appropriate.
2. Within thirty (30) calendar days of the termination, expiration, or revocation of a waiver,
the BHE shall submit to the BHA an attestation of compliance with the regulation to which
the waiver pertained.
J. A w aiver will automatically terminate upon a change of ownership of the BHE, as defined in part
2.21 of this Chapter. However, to prevent such automatic termination, the prospective new owner
may submit a waiver application to the BHA prior to the effective date of the change of ownership.
Provided the BHA receives the new application by this date, the waiver will be deemed to remain
effective until such time as the BHA acts on the application.
1. Except as otherwise provided in this part 2.22, a waiver may not be granted for a term
that exceeds the current license term.
2. If a BHE wishes to maintain a waiver beyond the stated term, it must submit a new waiver
application to the BHA not less than ninety (90) calendar days prior to the expiration of
the current term of the waiver or with a license renewal.
K. Notwithstanding anything in this part 2.22 to the contrary, the BHA may revoke a waiver if it
determines that:
1. The waiver's continuation jeopardizes the health, safety, or welfare of individuals served
by the BHE;
2. The waiver application contained false or misleading information;
3. The terms and conditions of the waiver have not been complied with;
4. T he conditions under which a waiver was granted no longer exist or have changed
materially; or,
5. A change in a federal or state statute or regulation prohibits, or is inconsistent with, the
continuation of the waiver.
L. Notice of the revocation of a waiver must be provided to the BHE in accordance with the
Colorado administrative procedures act, Section 24-4-101 through -109, C.R.S.
M. A BHE may appeal the decision of the BHA regarding a waiver application or revocation, as
provided in the Colorado administrative procedures act, Section 24-4-101 through -109, C.R.S.
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2.23 Continuing Obligations and BHA Oversight
A. Each BHE must have and maintain electronic business communication tools, including but not
limited to, internet access and a valid e-mail address. The BHE must use these tools to receive
and submit information.
B. The license is only valid while in the possession of the BHE to whom it is issued and may not be
subject to sale, assignment, or other transfer, voluntary or involuntary, nor is a license valid for
any premises other than those for which it was originally issued.
C. The BHE must provide accurate and truthful information to the BHA during inspections,
investigations, and licensing activities.
D. When a BHE is subject to inspection, certification, or review by other agencies, accrediting
organizations, or inspecting companies, the BHE shall provide and/or release to the BHA, upon
request, any correspondence, reports, or recommendations concerning the BHE that were
prepared by such organizations.
E. Each BHE must submit notification to the BHA of any change in the information required by part
2.18.D of this Chapter from what was contained in the last submitted license application.
1. Changes to the operation of the BHE may not be implemented without prior approval
from the BHA. A BHE shall, at least thirty (30) calendar days in advance, submit
notification to the BHA regarding any of the following proposed changes.
a. C hange in license category or classification.
b. Change in the scope of services, including the addition or removal of an
endorsement, a service, or a physical location.
c. Change in legal name of the BHE and all other names used by it to provide
services.
F. The BHA and any duly authorized representatives thereof have the right to enter upon and into
the premises of any licensed BHE or applicant for a BHE license in order to determine the state of
compliance with the statutes and regulations and must initially identify themselves to the person
in charge of the BHE at the time.
G. Licensure surveys and tiered inspections
1. For each BHE that is eligible, the BHA will either extend the standard licensure survey
cycle up to three (3) years or utilize a tiered licensure inspection system.
2. To be eligible, the BHE must meet all the following criteria:
a. Licensed for at least three (3) years;
b. No conditions imposed on the license within three (3) years prior to the date of
the survey;
c. No patterns of rule violations, which occurs when a BHE commits the same class
of rule violation three or more times in consecutive inspections, as documented
in the inspection and survey reports issued by the BHA within the three (3) years
prior to the date of the inspection; and,
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d. No substantiated complaint resulting in the discovery of significant deficiencies
that may negatively affect the life, health, or safety of individuals served by the
BHE within the three (3) years prior to the date of the survey.
3. The BHA may expand the scope of a tiered inspection to an extended or full survey if the
BHA finds rule violations during the tiered inspection process.
H. The BHA may use the following measures to ensure a BHE’s full compliance with the applicable
statutory and regulatory criteria.
1. The BHA may conduct an unscheduled or unannounced review of a current BHE based
upon, but not limited to, the following criteria:
a. Routine compliance inspection;
b. Reason exists to question the BHE’s continued fitness to conduct or maintain
licensed operations;
c. A complaint alleging non-compliance with license requirements;
d. Discovery of previously undisclosed information regarding a BHE or any of its
owners, officers, managers, or other personnel if such information affects or has
the potential to affect the BHE’s provision of services; or
e. The omission of relevant information from documents requested by the BHA or
indication of false information submitted to the BHA.
2. P lan of action
a. If after review or pursuant to a complaint, it is determined that a BHE is not in
compliance with these rules, the BHE shall be notified in writing, within thirty (30)
business days of the specific deficiency/deficiencies.
b. After any review, the BHA may request a plan of action from a BHE or require a
BHE’s compliance with a BHA directed plan of action.
c. If the BHE does not agree with any or all the findings regarding non-compliance,
the BHE has fourteen (14) business days from the receipt of non-compliance
notice to dispute the findings by submitting evidence to the BHA.
d. The BHE shall receive a written response within thirty (30) business days of the
review of submitted evidence.
e. If the submitted information is sufficient, the BHE shall be determined in
compliance with these rules.
f. If the BHE continues to be found out of compliance with these rules, the BHE
shall have thirty (30) business days from the date of receipt of the review findings
to submit a plan of action.
g. The plan of action must be in the format prescribed by the BHA and included, but
not be limited to, the following:
(1) A d escription of how the BHE will correct each identified deficiency.
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(a) If deficient practice was cited for specific personnel, 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 individuals(s) and/or other individuals
having the potential to be affected.
(2) A description of how the BHE will monitor the corrective action to ensure
each deficiency is remedied and will not reoccur, and
(3) A completion date that is no later than ninety (90) calendar days from the
issuance of the deficiency list, unless otherwise required or approved by
the BHA. The completion date is the date that the entity deems it can
achieve compliance.
h. A completed plan of action must be:
(1) Signed by the BHE’s director, administrator, or manager, and
(2) Submitted to the BHA within thirty (30) calendar days after the date of
the BHA’s written notice of deficiencies.
(a) If an extension of time is needed to complete the plan of action,
the BHE shall request an extension in writing from the BHA prior
to the plan of action due date. The BHA may grant an extension
of time.
i. The BHA has discretion to approve, impose, modify, or reject a plan of action.
(1) If the plan of action is accepted, the BHA shall notify the BHE by issuing
a written notice of acceptance.
(2) If the plan of action is unacceptable, the BHA shall notify the BHE in
writing, and the BHE shall re-submit the changes within the time frame
prescribed by the BHA.
(3) If the BHE fails to comply with the requirements or deadlines for
submission of a plan or fails to submit requested changes to the plan, the
BHA may reject the plan of action and impose disciplinary sanctions as
set forth in part 2.24 of this Chapter.
(4) If the BHE fails to implement the actions agreed to by the action date in
the approved plan of action, the BHA may impose enforcement sanctions
as set forth below.
I. The BHE must provide, upon request, access to or copies of the following to the BHA for the
performance of its regulatory oversight responsibilities:
1. Individual records.
2. Reports and information including but not limited to, staffing reports, census data,
statistical information, and other records, as determined by the BHA.
J. Oversight and enforcement activities may include review of endorsements and/or separate
physical locations as necessary for the BHA to ensure the health, safety, and welfare of
individuals.
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2.24 Enforcement and Adverse Actions
2.24.1 License, Designation, or Endorsement Denials
A. The BHA may deny an application for an initial or renewal license, or an application for
endorsement(s) for reasons including but not limited to, the following:
1. The BHE has not fully complied with all local, state, and federal laws and regulations
applicable to that license category, endorsement, or classification;
2. The application or accompanying documents contain a false statement of material fact;
3. The BHE fails to respond to BHA requests for additional information in the time frame
indicated in the request;
4. The BHE refuses any part of an inspection;
5. The BHE fails to comply with or successfully complete an acceptable plan of action;
6. The results of the background check reveal a felony or misdemeanor conviction of a
crime of moral turpitude as described in part 2.18.D.11.b of this Chapter;
7. The BHE has failed to cooperate with the investigation of any local, state, or federal
regulatory body or law enforcement agency; or
8. The BHE 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 individual(s) served.
B. I f BHA denies an application for an initial or renewal license, it shall provide the BHE with a
written notice by mail to the applicant at the address shown on the application. The notice must
explain the basis for the denial and afford the BHE the opportunity to respond.
C. Appeals of licensure denials must be conducted in accordance with the State Administrative
Procedure Act, Section 24-4-101 through -109, C.R.S. and 26-1-106, C.R.S.
2.24.2 Revocation or Suspension of a License, Designation, or Endorsement
A. The BHA may limit, revoke, or suspend an existing license or endorsement if a BHE fails or
refuses to comply with the statutory and/or regulatory requirements applicable to its license and
endorsements associated with its license. The BHA may limit the overall BHE license, any
endorsements or physical locations, or any combination thereof for failure or refusal to comply.
Failures to comply include, but are not limited to:
1. Making a false statement of material fact about individuals served by the BHE, its
personnel, capacity, or other operational components verbally or in any public document
or in a matter under investigation by the BHA or another governmental entity,
2. Preventing, interfering with, or attempting to impede in any way the work of a
representative or agent of the BHA in investigating or enforcing the applicable statutes or
regulations,
3. Falsely advertising or in any way misrepresenting the BHE’s ability to provide services for
the individuals served based on its license type or status,
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4. Failing to provide reports and documents required by regulation or statute in a timely and
complete fashion,
5. Failing to comply with or complete a plan of action in the time or manner specified,
6. Falsifying records or documents,
7. Knowingly using or disseminating misleading, deceptive, or false information,
8. Accepting commissions, rebates, or other forms of remuneration for referrals or other
treatment decisions, or
9. Exercising undue influence or coercion over an individual to obtain certain 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 an individual.
10. Noncompliance with the requirements of Sections 27-50-501 through 27-50-509, C.R.S.
and any applicable regulations promulgated pursuant to those statutes.
B. The BHA may revoke or suspend an existing license if one or more individuals or entities
identified in the response to part 2.18.D.3 of this Chapter has a controlling or ownership interest
in the BHE and:
1. Has been the subject or party to any of the actions described in part 2.18.D.10.a:
2. H as a felony or misdemeanor conviction of a crime of moral turpitude as described in part
2.18.D.11.b of this Chapter.
C. Except in the case of a summary suspension in accordance with 24-4-104(4)(a), C.R.S.,
suspension or revocation must not occur until after a hearing and in compliance with the
provisions and procedures specified in Section 24-4-101 through Section -109, C.R.S. and
Section 27-50-505, C.R.S.
2.24.3 Conditional Licenses
A. If a BHE is found to be out of compliance with applicable BHA, state, or federal law or regulations,
the BHA may impose conditions upon a license prior to issuing an initial or renewal license or
during an existing license term. If the BHA imposes conditions on a license, the BHE shall
immediately comply with all conditions until and unless said conditions are overturned or stayed
on appeal.
1. Imposition of conditions on a license does not constitute a modification to the license if
the BHE agrees to the conditions. If an agreement is not reached, the BHE may appeal in
accordance with part 2.24.5 of this Chapter, Section 24-4-101 through -109, and Section
27-50-505, C.R.S.
B. If conditions are imposed at the same time as an initial or renewal license, the BHE shall pay the
applicable initial or renewal license fee plus the conditional fee equal to the amount of their initial
or renewal license fee.
C. If conditions are imposed during the license term, the BHE shall pay the conditional fee and the
conditions must run concurrently with the existing license term.
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D. If the conditions are renewed in whole or in part for the next license term, the BHE shall pay the
applicable renewal fee along with the conditional fee in effect at the time of renewal.
E. If the BHA imposes conditions of continuing duration that require only minimal administrative
oversight, it may waive the conditional fee after the BHE has complied with the conditions for a
full license term.
F. If a BHE holds a conditional license, it shall post a clearly legible copy of the license conditions in
a conspicuous public place in the BHE.
2.24.4 Intermediate Restrictions
A. The BHA may impose the following intermediate restrictions or conditions on a BHE in
accordance with Section 27-50-505 (3), C.R.S.:
1. Retaining a consultant to address corrective measures including deficient practice
resulting from systemic failure;
2. Monitoring by the BHA for a specific period;
3. Providing additional training to employees, 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. The
assessment of these fines shall follow the procedures set forth in Section 26.5.-5-323,
C.R.S.
B. T he BHE may appeal any intermediate restriction or condition to the BHA in accordance with the
Colorado Administrative Procedures Act Section 24-4-101 through -109, C.R.S.
2.24.5 Right to Appeal
A. Any BHE adversely affected or aggrieved by the BHA’s decisions in regard to implementation of
these rules, has the right to appeal to the Colorado Department of Personnel and Administration,
Office of Administrative Courts, and may subsequently seek judicial review of the BHA’s action in
accordance with Section 24-4-101 through -109, C.R.S.
B. The following actions may be submitted to an administrative law judge for an evidentiary hearing:
denial of a license, designation, or endorsement; denial of a renewal; provisional license;
conditional license; revocation; denial of a waiver; limitation of a license, denial of a modification;
and imposition of an intermediate restriction or condition.
C. After written notification from the BHA of intended action, the BHE has twenty-one (21) calendar
days to submit a written appeal. The appeal must be received by the BHA within twenty-one (21)
days from the date the written notification of action letter was sent by the BHA.
D. In all cases except waiver denials, the BHA will file a notice of charges with the office of
administrative courts to begin the administrative process. In waiver denials, if the applicant for the
waiver requests an appeal, the request for appeal must be forwarded to the office of
administrative courts. Once the appellant’s request is forwarded to the office of administrative
courts, the BHA may file a notice of charges.
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E. Subsequent to an evidentiary hearing at the office of the administrative courts and the issuance of
a final agency decision, a party may seek to appeal the final agency decision through judicial
review in accordance with Section 24-4-106, C.R.S.
2.25 BHE Closure
A. Each license issued by the BHA will become invalid if the BHE fails to timely renew the license,
ceases operation, or there is final BHA action suspending or revoking the license. The license
must be returned to the BHA within ten (10) calendar days of the event that invalidated it.
2.25.1 Emergency Closures
A. In the event of an emergency affecting the physical space of the BHE that necessitates the
removal of individuals and personnel from the BHE, a BHE shall provide the BHA 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 BHE to provide
services that meet the health and safety needs of the individuals. Based on the extenuating
circumstances, the BHA may approve the continuation of the license during the time period that it
takes to make the physical space appropriate for individuals and personnel to return.
2.25.2 P ermanent Closures
A. Each BHE that surrenders its license shall accomplish the following with regard to any individual
records that the entity is legally obligated to maintain:
1. Within ten (10) calendar days prior to closure, inform the BHA in writing of the specific
plan for storage and retrieval of individual records;
2. Unless noted otherwise within an endorsement Chapter, within ten (10) calendar days of
closure, inform all individuals or designated representatives thereof, in writing, how and
where to obtain their individual records; and
3. Provide secure storage for any remaining individual records.
B. In the event of a BHE closure, the BHE shall be responsible for appropriate continuity of care for
each individual served by the BHE.
2.26 Residential and Overnight Standards
A. A BHE providing residential and/or overnight services as defined in part 2.3.A.4 of this Chapter
shall meet the standards in this part 2.26.
B. Each physical location in which residential and/or overnight services are provided must meet the
following personnel requirements:
1. Each physical location must have appropriate oversight personnel, such as an
administrator and/or clinical director, or personnel delegated those same responsibilities,
available twenty-four (24) hours per day, seven (7) days per week.
a. O versight personnel when the administrator and/or clinical director are not
physically on-site must be in accordance with policies as required at part
2.2.4.A.6 of this Chapter.
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2. Each physical location must have at least one person trained in cardio-pulmonary
resuscitation (CPR) and first aid on-site and on-duty at all times when individuals are
present.
C. Personnel providing services under the residential/overnight endorsement shall be trained in the
following:
1. The recognition and response to common side effects of medications used for behavioral
health disorders, and response to emergency drug reactions;
2. Behavior management and de-escalation techniques, including incidents involving harm
to self or others, and elopement; and,
3. Behavioral health and medical emergency response training, consistent with emergency
services policies required in parts 2.9.D and 2.9.E of this Chapter.
4. Personnel preparing or serving food shall complete food safety training. At a minimum,
this must include that personnel overseeing dietary services shall have knowledge of
foodborne disease prevention, including, but not limited to, hygienic practices and food
safety techniques pertaining to preparation, food storage, and dishwashing.
D. The BHE shall have policies and procedures specific to the residential/overnight endorsement,
services, or physical location, as applicable, including, but not limited to:
1. Policies and procedures to be followed in the event of serious illness, injury, or death of
an individual during their stay, including, but not limited to:
a. C riteria for when an individual's injury or illness warrants medical treatment or an
in-person medical evaluation.
b. Requirements for notifying the individual’s emergency contact, including
immediate notification in the case of an emergency room visit or unscheduled
hospitalization.
c. Reporting procedures within the BHE.
2. BHEs that provide overnight/residential services shall maintain enough food and water on
hand to provide all individuals with three (3) nutritionally balanced meals for four (4) days.
3. Written policies and procedures for the management of individuals’ personal funds and
property, including, but not limited to:
a. An inventory of all the individual’s personal belongings must be conducted upon
admission, and documented by at least two (2) individuals, one of which must be
the individual when the individual is capable and willing to document the
inventory. Such inventory must be maintained in the individual record.
b. All inventoried property must be returned to the individual upon discharge, and
such return must be documented by at least two (2) individuals, one of which
must be the individual when the individual is capable and willing to document the
inventory. Such documentation must be included in the individual record.
4. I nfection control policies to address risks associated with housekeeping, dietary services,
and linen and laundry services, in addition to the requirements at part 2.4.E of this
Chapter.
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a. Policies for linen and laundry services must include:
(1) Procedures for preventing contamination between soiled linen and clean
linen through either the use of gloves or hand washing.
(2) Procedures for soiled linen to be stored separately from clean linen, in
separate enclosed areas.
b. Dietary services must be provided using methods that conform to state or local
food safety standards, including, at a minimum:
(1) Food must be prepared, handled, and stored in a sanitary manner, so
that it is free from spoilage and/or contamination, and must be safe for
human consumption.
(2) Reusable equipment, dishes, cutlery, and other wares used for the
preparation, serving, or storage of food must be washed in a safe and
sanitary manner, and, in the case of dishwashing machines, in
accordance with manufacturer’s instructions.
5. The provision of linen and laundry services, including, but not limited to:
a. Individuals must have access to laundry services for personal clothing, which
may be provided through the use of personal laundry facilities, a centralized
laundry service, or may be contracted for with an outside provider.
b. A requirement to maintain a sufficient supply of clean linen, including sheets and
towels.
6. T he provision of dietary services, including but not limited to:
a. The BHE must ensure enough food and water on hand to provide all individuals
with three (3) nutritionally balanced meals for four (4) days.
b. A BHE responsible for providing meals to individuals must:
(1) Provide at least three meals daily, at regular times comparable to normal
mealtimes in the community, or in accordance with individual needs,
preferences, and plans of care.
(a) Nourishing meal substitutes and between-meal snacks must be
provided, in accordance with plans of care, to individuals who
want to eat at non-traditional times or outside of scheduled meal
service times.
(b) Meals must include a variety of foods, be nutritionally balanced,
and sufficient in amount to satisfy appetites of individuals.
(c) Appealing substitutes of similar nutritive value must be available
for individuals who choose not to eat food that is initially served
or who request an alternative meal.
(2) Offer drinks, including water and other liquids, to individuals with every
meal and between meals throughout the day.
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(3) Ensure that individuals have independent access to water at all times.
7. If the population served includes individuals assessed to be at risk of imminent harm to
self or others, the BHE shall require safety checks be conducted at least every fifteen
(15) minutes and at every shift change to identify and remedy hazards and shall maintain
documentation of such checks.
8. The type of first aid equipment maintained by the BHE, including a requirement that such
equipment be maintained in a readily accessible location, at each physical location
providing services under the residential and/or overnight endorsement. First aid
equipment must include, but not be limited to, an automated external defibrillator (AED).
a. First aid supplies and equipment must be kept unexpired and in a reliable
condition.
9. Smoking policies applicable to individuals, including, but not limited to any prohibitions on
smoking, designated areas for smoking, and methods/substances allowed under any
smoking policy, such as tobacco, electronic cigarettes, vaporizers, etc.
E. The BHE must ensure there is a minimum of one (1) full bathroom for every six (6) individuals,
including a toilet, sink, toilet paper dispenser, mirror, tub and/or shower, and towel rack.
F. B athrooms must be equipped with soap dispensers, or the BHE shall have a procedure in place
that prevents individuals from sharing soap.
G. The BHE shall ensure that individuals have access to basic hygiene supplies.
H. In addition to the requirements of part 2.4 of this Chapter, each BHE’s emergency policies must
address:
1. When to evacuate the premises, when to shelter in place, and the procedures for doing
so;
2. A predetermined means of communicating with individuals, families, staff and other
providers;
3. A plan that ensures the availability of, or access to, emergency power for essential
functions and all individual required medical devices or auxiliary aids or services;
4. Storage and preservation of medications; and
5. In the event relocation of individuals becomes necessary, written agreements with other
health facilities and/or community agencies.
I. The BHE shall have readily available a roster of current individuals, their room assignments and
emergency contact information, along with a facility diagram showing room locations.
J. Hot water must not measure more than 120 degrees Fahrenheit at taps which are accessible by
individuals.
K. A BHE serving both adults and children must ensure management of the living space
assignments includes physical barriers and personnel oversight of activities to ensure safety. This
management must include, but is not limited to:
1. P hysical barriers, such as doors or walls;
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2. Personnel stations that separate living space assignments;
3. Other practical arrangements that support the safe management of the individuals
receiving services.
2.27 Fentanyl and Other Opioid Use Disorder Education and Treatment
2.27.1 Statutory Authority and Applicability
A. Authority to approve BHEs to provide treatment of substance use disorders, including fentanyl
and other opioid use disorders, is provided by Section 18-1.3-401 and 18-1.3-501, C.R.S.
B. BHEs providing services for the treatment of substance use disorders including fentanyl and other
opioid use disorders must exist across all endorsed service types. For this reason, all BHEs shall
comply with this part 2.27. In addition to this part 2.27, BHEs shall comply with provisions of the
applicable endorsed services, as noted below:
1. BHEs providing outpatient and high-intensity outpatient services shall comply with parts
4.3, 4.6, and/or 4.7 of these rules.
2. BHEs providing residential services shall comply with parts 5.1 through 5.4 of these rules
and the applicable sub-endorsement(s) of residential services (parts 5.6, 5.8, 5.10, and
5.11 of these rules).
3. BHEs providing withdrawal management services shall comply with parts 4.5, 4.8, 5.1,
5.2, 5.3, 5.7, and 5.12 of these rules.
2.27.2 P lacement in Services
A. Individuals receiving fentanyl and other opioid use disorder treatment must be assessed and
referred into education and/or treatment by a supervising entity as a condition of probation or
parole. The BHE is expected to evaluate whether the supervising entity’s recommendation
matches the individual’s assessed clinical need(s). The BHE is expected to address any
differences identified with the supervising entity directly and document results in the individual’s
record.
B. BHEs shall include a copy of the referral paperwork, demonstrating placement in the fentanyl or
other opioid-specific treatment services as required by the supervising entity, in the individual’s
record.
C. If a BHE is unable to obtain a copy of the court order and/or written documentation of supervising
entity’s recommendation for education and/or treatment, there must be documentation of
attempt(s) to obtain the paperwork from the referral source.
D. Individuals receiving fentanyl and other opioid use disorder treatment are expected to complete
the required fentanyl education program as part of that process. The BHE must verify that the
individual completes this requirement when it is clinically appropriate for the individual, prior to
discharging from services. Documentation of this must be kept in the individual’s record.
2.27.3 S upport Systems
A. The BHE shall be capable of delivering all necessary medication for opioid use disorder (MOUD)
services that are clinically indicated for the individual under applicable law. These services may
be provided through direct service provision or active collaboration with other agencies that are
able to provide MOUD services.
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B. Opioid antagonists
1. Opioid antagonists must:
a. Be discussed and provided upon individual request at the initial assessment.
b. Documentation shall be reflected in the individual record response from individual
and if dosages were provided for the individual to keep on their person.
2. BHEs shall:
a. Ensure that opioid antagonists are available on-site at all times,
b. Ensure that opioid antagonists are made available to all individuals being served
to keep on their person. This may be achieved through providing access to the
opioid antagonist directly, or through coordination with another resource;
c. Make reasonable documented attempts and to ensure that all individuals
receiving treatment know how to administer the opioid antagonist in case of
emergency, and,
d. Promote or directly provide information to the individual’s referred support system
to allow for the administration of opioid antagonists.
2.27.4 Personnel Training and Competencies
A. All personnel interacting with individuals receiving fentanyl and other opioid-specific services shall
be trained in the following:
1. Proper use of opioid antagonists, and
2. Recognition and response to signs and symptoms of drug overdose.
B. Additionally, all personnel providing treatment and peer support professionals interacting with
individuals receiving fentanyl and other opioid-specific services shall be trained and demonstrate
competency in the following topics:
1. S ubstances of misuse and dependence including, but not
limited to alcohol, tobacco, and other drugs, and
polysubstance abuse;
2. Pharmacology of the medications for opioid use disorder (MOUD), including but not
limited to loss of tolerance to opioids, dangerous drug or alcohol interactions with the
MOUD, and purpose of the medication’s use;
3. Culturally and linguistically appropriate services, awareness, and responsiveness to
current misuse trends for opioid-involved individuals; and
4. Harm-reduction and trauma-informed practices in the treatment of opioid use disorder.
2.27.5 Collaboration and Termination of Court-Ordered Services
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A. With written permission from individuals who are required to attend services as a condition of
probation, agencies shall communicate regular updates to the referring supervising entity for the
portion of the treatment episode in which fentanyl and other opioid-specific services are
determined to be clinically necessary. This determination of clinical necessity must be made by:
1. A licensee;
2. A candidate;
3. An authorized practitioner; or
4. A certified addiction specialist (CAS).
B. Individuals that no longer meet clinical necessity for fentanyl or other opioid-specific treatment as
a condition of probation, pursuant to Section 18-1.3-510(3)(a), C.R.S., but may benefit from
aftercare or continued services to address other relevant behavioral health needs may remain in
treatment. The BHE is not required to communicate further progress updates to the referring
supervising entity unless the individual requests and consents to this communication.
Chapter 3: Behavioral Health Recovery Supports
3.1 Authority and Applicability
A. Chapter 3 establishes the standards that BHEs must follow when electing to provide mental
health and substance use recovery supports as part of a recovery supports endorsement. The
authority to promulgate these service-specific requirements that apply to BHEs electing to provide
this service comes from Sections 27-50-107(3) and 27-50-502(1), C.R.S.
B. All agencies providing recovery support services rendered by peer support professionals shall
meet the standards in this Chapter. If the agency requires a BHE license, the agency must
comply with Chapter 2.
C. This Chapter does not apply to licensed recovery support services organizations. Regulations for
licensed recovery support services organizations are found in Section 21.600.
3.2 S ervice Provision
A. Recovery support services include a variety of recovery-focused services and supports for
individuals with a behavioral health disorder and/or who are in recovery from a behavioral health
disorder. These services are rendered by peer support professionals. These services must
include engaging individuals in peer-to-peer relationships that support healing, personal growth,
life skills development, self-care, and crisis strategy development to help achieve recovery,
wellness, and life goals. These services include:
1. Peer support professional-run drop in centers;
2. Recovery and wellness centers;
3. Employment services;
4. Prevention and early intervention activities;
5. Peer support professional mentoring for children and youth;
6. Warm lines, as defined in Chapter 1 of these rules;
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7. Advocacy services;
8. Recovery coaching;
9. Peer support professional-led support groups;
10. Navigating services (resources);
11. Recovery planning services; and
12. Other activities supporting the recovery experience of an individual.
B. A peer support professional may provide services in a variety of settings, if permitted access, that
may include but are not limited to:
1. Court-affiliated settings, such as the Department of Corrections, county jails, or
community correctional placements;
2. Physical health settings, such as primary care physician offices;
3. Emergency departments;
4. Audio-visual or audio-only telehealth;
5. Agencies serving homeless communities;
6. Peer respite homes;
7. School-based health centers;
8. Home and community-based settings, including salons and other gathering places; and
9. Brick and mortar recovery community organizations, including faith based organizations.
C. Agencies endorsed pursuant to this Chapter 3 must ensure peer support professionals are not
required to provide services that compromise the dynamic of a peer-to-peer relationship or that
are outside the scope of providing recovery-focused services. Activities that are outside of the
scope of a peer support professional include, but are not limited to:
1. P erforming clinical/diagnostic assessments, service planning, or treatment; and
2. Drug and/or alcohol testing, monitoring, and/or collection of toxicology samples.
D. Agencies endorsed pursuant to this Chapter 3 must submit job descriptions of all peer support
professional positions in accordance with part 2.6.E of these rules.
E. Peer support professionals must provide individuals with a written disclosure at the time of first
contact that includes
1. Their full name;
2. Their contact information;
3. Their qualifications;
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4. Their role in work with the individual;
5. Their supervisor's name;
6. Their supervisor's contact information; and
7. The name of the agency that employs the peer support professional.
3.3 Personnel Qualifications and Training
A. Peer support professionals providing peer recovery support services must hold a professional
peer support certification credential or have successfully completed formal training that covers all
content areas outlined in “core competencies for peer workers in behavioral health services -
2018” (December 13, 2018), established by United States Department of Health and Human
Services, Substance Abuse and Mental Health Services Administration (SAMHSA), which is
incorporated herein by reference and does not include any later amendments or editions. These
standards are available at no cost at https://www.samhsa.gov/ and are also available for public
inspection and copying at the Behavioral Health Administration, 710 S. Ash Street, Unit C140,
Denver, CO 80246, during regular business hours.
B. Training or proof of certification must be documented in personnel files.
C. For peer support professionals with a certification credential, the certification credential must
include the following requirements:
1. At least sixty (60) hours of training, including training covering all content areas in “core
competencies for peer workers in behavioral health services – 2018” established by
United States Department of Health and Human Services, Substance Abuse and Mental
Health Services Administration (SAMHSA), incorporated by reference in subsection A,
above;
2. At l east 200 hours of experience as a peer support professional; and
3. Passing a certification exam.
D. Peer support professionals with a certification credential must be in good standing with their
certifying body, including compliance with the certifying body’s code of ethics.
3.4 Supervision
A. Peer support professionals must be supervised on at least a monthly basis for at least an hour by
a licensee or authorized practitioner in good standing with their credentialing body and/or an
experienced peer support professional who meets the criteria set forth in Section 3.3 of this
Chapter. Supervisors shall document supervision date, time, duration, and topics discussed.
B. Supervisors of peer support professionals must demonstrate to the BHA that they have received
training in
1. The provision of peer support services;
2. The supervision of peer support professionals; and
3. The role of peer support professionals.
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C. Supervision of a peer support professional may include co-reflective supervision strategies in
which supervisors and supervisees engage in a relationship of mutual learning.
3.5 Documentation Requirements
A. Agencies endorsed to provide recovery supports must maintain records of the services provided
to individuals by peer support professionals. These records shall include at a minimum the date,
time, and duration of the service.
Chapter 4: Behavioral Health Outpatient and High Intensity Outpatient Services
4.1 Authority and Applicability
A. Chapter 4 establishes the standards for and applies to agencies electing to provide mental health
and substance use outpatient services and high-intensity outpatient services. The authority to
promulgate these service-specific requirements that apply to BHEs electing to provide this service
comes from Sections 27-50-502(1), 27-50-106, 27-50-301(5), and 27-50-107(3)(b), C.R.S.
B. These rules apply to and are established to create standards for agencies seeking sub-
endorsements to provide behavioral health outpatient services, which includes early intervention,
outpatient, intensive outpatient, partial hospitalization, and ambulatory withdrawal management
services. Agencies may also choose to provide optional sub-endorsements of minor in
possession services, in conjunction with the correlated sub-endorsements in this Chapter.
4.2 Ea rly Intervention Services Standards
A. These rules are established to create standards for agencies seeking sub-endorsements to
provide early intervention, which includes ASAM Criteria Level 0.5 type services.
B. Agencies providing early intervention services must meet the standards in part 4.2 of these rules.
4.2.1 Service Delivery and Setting
A. Early intervention services are generally intended for individuals who are not appropriate for more
intensive levels of care, are sufficiently stabilized to complete early intervention services prior to
moving to a different level of care, are attending education-only services, or are being screened in
a stabilization setting and are provided referrals for appropriate level of care once stabilized.
B. Early intervention services are appropriate for individuals with mental health, substance use, and
co-occurring disorders that are of low severity, or are of moderate to high severity, as defined by
the DSM-5-TR, but have been stabilized and are awaiting entry into a higher level of care.
C. All services provided must be adapted to the individual’s developmental stage, physical, cultural,
and comprehensive needs.
D. Early intervention services may be delivered via telehealth in accordance with the standards set
in part 2.9 of these rules.
E. If early intervention services are related to court-ordered DUI/DWAI requirements, services must
comply with parts 10.1 through 10.9 of these rules, including telehealth provisions.
F. Treatment groups must not exceed twelve (12) individuals receiving services.
4.2.2 Personnel
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A. The agency must ensure early intervention services are provided by personnel meeting the
qualifications in parts 1.3 and 2.5 of these rules.
B. Agencies providing early intervention services must ensure treatment personnel have supervisor
consultation within twenty-four (24) hours via in-person or telephone to discuss, at minimum,
psychiatric or medical concerns of individuals receiving services as necessary.
1. Personnel must have supervisor consultation available within one (1) hour via in-person
or by telehealth to discuss, when warranted crisis and/or emergency situations.
4.2.3 Service Provisions
A. Duration of early intervention services may vary dependent upon individual needs.
B. Early intervention services must be provided in accordance with individual screening information
as defined in part 2.12.1 of these rules, or the court ordered education requirements for
education-only individuals.
1. Continued screening will be conducted when symptomology and risk factors for a
diagnosis of mental health, substance use, and/or co-occurring disorder(s), as defined by
the DSM-5-TR, are identified by personnel. Referral(s) to match screened treatment
needs will be provided to the individual and documented pursuant to part 4.2.4 of these
rules.
2. Referral(s) will be provided in collaboration with the individual.
C. E arly intervention services may include brief therapeutic interventions of individual, group, or
family counseling, peer support services, medication/psychiatric-only services, follow-up services,
and/or regulated education groups mandated to the individual by a supervising entity.
1. An individual is classified as receiving medication/psychiatric - only services when the
agency provides a maximum of three (3) services, in addition to services related to
medications, within a six (6) month period of time.
4.2.4 Documentation and Timeliness
A. Early intervention agencies must complete appropriate screening in accordance with screening
guidelines in part 2.12.1 of these rules upon intake of individual into services.
1. Other screening may be used in addition for program and/or individual specific needs.
B. Agencies must complete the screening requirements within two (2) calendar days.
C. Early intervention level services are exempt from assessment and service plan expectations of
parts 2.12.2, 2.12.3 and 2.13.1 of these rules, unless the individual attending services is moved to
a higher level of care within the same agency.
D. Progress notes must be completed for each early intervention session. Progress notes must be
completed to standards identified in part 2.13.2 of these rules, and at a minimum frequency of
one (1) note per session.
E. R eferrals to other services must be documented in the individual’s file including:
1. Recommendations of care;
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2. Reason for discharge;
3. Recommended programs for individual to enroll in; and
4. Follow-up plan including care coordination and documentation needs.
F. If providing medication/psychiatric-only services, a licensee or authorized practitioner shall
complete and document in the individual record at least annually:
1. Clinical rationale supporting a medication/psychiatric-only service status;
2. An updated assessment; and
3. An updated service plan.
4.3 Outpatient Services Standards
A. These rules are established to create standards for agencies seeking a sub-endorsement to
provide outpatient services, which includes ASAM Criteria Level 1.0 type services.
B. All agencies providing behavioral health outpatient treatment services must meet the standards in
this part 4.3.
4.3.1 Service delivery and setting
A. Outpatient services are generally intended for individuals who are assessed as not appropriate
for more intensive levels of care. Outpatient services may also be a step-down from a higher level
of care or offered when an individual is in early stages of change and declines participation in the
higher level of care indicated by the assessment.
B. Outpatient services are appropriate for individuals diagnosed with mental health, substance-
related, and co-occurring disorders if the mental health disorders are of moderate severity, or are
of high severity, as defined by the DSM-5-TR, but have been stabilized.
C. Al l services provided must be adapted to the individual’s developmental stage, physical, cultural,
and comprehensive needs.
D. Outpatient services may be delivered via in-person, audio-visual telehealth, or audio-only
telehealth format in accordance with part 2.9 of these rules.
E. Treatment groups must not exceed twelve (12) individuals receiving services.
4.3.2 Personnel
A. Treatment personnel, for the purpose of outpatient services, unless otherwise noted, means the
following behavioral health professionals trained in mental health and/or substance use disorder
identification and treatment and acting within their scope of practice:
1. Authorized practitioners;
2. Licensees;
3. Certified addiction specialists (CAS);
4. Candidates;
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5. Certified addiction technicians (CAT); and
a. If utilizing certified addiction technicians (CAT), the agency must ensure that
CATs do not comprise more than twenty-five (25%) of the agency’s personnel.
6. Counselors-in-training and/or interns.
a. If utilizing counselors-in-training and/or interns, the agency must ensure that all
clinical documentation is reviewed and co-signed by a clinical agency supervisor
able to supervise pursuant to their scope of practice. Counselor-in-training and/or
intern personnel must not comprise more than twenty-five percent (25%) of the
agency’s personnel.
B. Outpatient services may include recovery support services rendered by peer support
professionals in accordance with Chapter 3 of these rules.
C. Agencies providing outpatient services must ensure treatment personnel have supervisor
consultation available within twenty-four (24) hours via in-person or by telehealth to discuss,
when warranted, psychiatric or medical concerns of individuals receiving services.
1. Personnel must have supervisor consultation available within one (1) hour via in-person
or telehealth to discuss, when warranted crisis and/or emergency situations.
4.3.3 Service Provisions
A. Outpatient services must be conducted in regularly scheduled sessions of no more than eight (8)
treatment contact hours per week for adults, and no more than five (5) treatment contact hours
per week for children.
1. T reatment contact hours does not include pro-social activities.
2. Treatment contact hours may include medication/psychiatric-only services pursuant to
this part 4.3.3.
B. Outpatient treatment services must be provided in accordance with the individual’s service plan.
C. When referral(s) are needed to best meet the individual assessed needs, referral(s) must be
provided in collaboration with the individual and their choice(s) for referred services.
D. Medication/psychiatric-only services may be provided when:
1. An individual is classified as receiving medication/psychiatric - only services when the
agency provides a maximum of three (3) services, in addition to services related to
medications, within a six (6) month period of time.
4.3.4 Documentation and Timeliness
A. Outpatient service documentation must follow the provisions set forth in parts 2.10, 2.11, 2.12,
and 2.13 of these rules.
B. Upon intake into services, preliminary screening and risk assessment must be completed in
compliance with part 2.12.1 of these rules.
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C. As soon as is practicable upon admission, but no later than ten (10) calendar days from the date
of preliminary screening and risk assessment, the agency must complete an initial assessment in
accordance with part 2.12.2 of these rules.
1. If the screening and risk assessment identifies an urgent clinical need, clinical services
must be provided, and the initial assessment must be completed within one (1) calendar
day of preliminary screening.
D. As soon as is practicable upon admission, but no later than sixty (60) calendar days from the first
date of services, the agency must complete a comprehensive assessment in accordance with
part 2.12.3 of these rules. Completion of the comprehensive assessment does not preclude the
initiation of services.
E. The individual service plan must be created, in accordance with part 2.13.1 of these rules, within
fourteen (14) calendar days after the initial assessment. The service plan must be updated to
reflect information from the comprehensive assessment. The agency must update the service
plan throughout the course of treatment, review previous goals, and update those goals
whenever there is a change in the individual's level of care or functioning, and must occur, at
minimum, every six (6) months.
F. O utpatient treatment services must be documented in the individual’s record in accordance with
part 2.13.2 of these rules, and at a minimum frequency of one (1) note per session.
G. If providing medication/psychiatric-only services, a licensee or authorized practitioner shall
complete and document in the individual record at least every six (6) months:
1. Clinical rationale supporting a medication/psychiatric-only service status;
2. An updated assessment; and
3. An updated service plan.
4.4 Minor in Possession (MIP): Education and Treatment Services Standards
4.4.1 MIP General Provisions
A. Agencies providing Minor in Possession education and treatment must comply with this part 4.4.
B. If providing MIP treatment to individuals under eighteen (18) years of age, agencies must receive
the Children and Family endorsement and follow the standards of care in Chapter 8 of these
rules.
C. Agencies must not place an individual with a MIP citation in DUI/DWAI education or therapy
groups unless the youth also has a DUI/DWAI offense.
D. All agency education and treatment personnel must have documented training, supervision and
experience in youth development and prevention, intervention, and treatment approaches.
E. Individuals that are sixteen (16) years of age and under must be treated in separate groups than
those treating individuals seventeen (17) to twenty (20) years old.
F. A gencies must conduct ongoing assessment of progress in education and/or treatment level of
care to determine if individuals are in the appropriate service level.
4.4.2 MIP: First Offense Education and Early Intervention
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A. MIP education is for individuals who have received their first MIP citation and must be conducted
in an outpatient setting and comply with early intervention procedures in part 4.2 of these rules.
B. MIP education must be at least eight (8) hours, completed over no less than a two (2) day period
with no more than four (4) hours of education per day.
C. Education topics must include:
1. Current legal consequences for additional MIP citations;
2. Resources or referrals for treatment level services, when indicated;
3. Developmental impact of early onset substance use and subsequent impact on the
developing brain;
4. Physiological effect of alcohol and other drug use;
5. Refusal skills; and
6. Avoidance of high-risk situations.
D. For children, agencies must include and document a minimum of two (2) hours of parental or
legal guardian involvement, unless contraindicated, and document the determination to not
include parental or guardian involvement and reasoning for this determination.
4.4.3 MIP: Second and Subsequent Offense Outpatient Treatment
A. In addition to the provisions outlined in this part 4.4.3, agencies providing MIP outpatient
treatment must also comply with part 4.3.
B. S econd offense MIP therapy must be conducted in an outpatient setting, must be a minimum of
twelve (12) hours in duration over eight (8) weeks, and must not exceed ninety (90) minute
sessions, excluding breaks and administrative procedures.
C. Agencies must complete an individualized service plan, with each individual in accordance with
parts 2.13.1 and 8.5 of these rules.
D. For children, agencies must include and document a minimum of four (4) hours of parental or
legal guardian involvement, unless contraindicated, and document the determination to not
include parental or guardian involvement and reasoning for this determination.
E. For third and subsequent minor in possession offenses, agencies shall conduct a comprehensive
assessment to determine substance use disorder treatment needs of the individual.
F. Third and subsequent MIP outpatient treatment must be conducted at a minimum of twenty (20)
hours of substance use disorder treatment over a minimum thirteen (13) week period, as
determined by the assessment. Groups must not exceed ninety (90) minutes in duration.
G. Additional assessed service offerings and referral(s) must be offered to meet the needs of the
individual and family members, when determined by the assessment.
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4.5 Level 1-Withdrawal Management (Level 1-WM): Ambulatory Withdrawal Management
Without Extended On-Site Monitoring Standards
A. This part 4.5 is established to create standards for agencies seeking a sub-endorsement to
provide outpatient Level 1-Withdrawal Management (Level 1-WM) services in accordance with
Chapter 6 of the ASAM Criteria.
B. Agencies providing Level 1-WM services must meet the standards in this part 4.5. Agencies
providing Level 1-WM services may:
1. Also engage in outpatient behavioral health treatment services by meeting the standards
for the outpatient sub-endorsement(s) selected by the agency, or
2. Provide only Level 1-WM services and coordinate with other providers for ongoing and
concurrent outpatient behavioral health treatment services.
4.5.1 Service delivery and setting
A. Level 1-WM is an outpatient withdrawal management service that complements individualized
behavioral health treatment services.
B. Individuals may participate in Level 1-WM for a period of time in which it is determined to be
medically appropriate. Admission to Level 1-WM services must not hinder the individual’s ability
to participate in concurrent behavioral health services. This includes the potential process of
admitting to, and discharging from, such withdrawal management services one (1) or more times
by the individual.
C. Lev el 1-WM services are generally provided in a clinical or addiction-focused treatment office,
medical health care facility, or home health care-type agency.
D. Level 1-WM services offered by agencies that do not provide behavioral health services within
their agency structure must be affiliated with agencies or other behavioral health providers as
needed to ensure the treatment needs of all individuals served can be met. Documentation of this
affiliation must be presented to the BHA, upon request. Referral(s) will be provided in
collaboration with the individual and their choice(s) for referred services.
E. Support systems
1. Agencies must:
a. Have the ability to obtain a comprehensive medical history and physical
examination at the time of admission to Level 1-WM services;
b. Have twenty-four (24)-hour access to emergency medical consultation services,
should services become indicated;
c. Have the ability to provide or assist in accessing transportation services for
individuals who lack safe transportation; and
d. Have the ability to coordinate services with behavioral health personnel, within
the agency or through referral.
F. Diagnostic criteria
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1. Individuals participating in Level 1-WM services typically exhibit a mild to moderate
withdrawal severity rating on standardized withdrawal severity scales as well as
mild/stable psychiatric symptoms for emotional, behavioral, and cognitive conditions.
2. Individuals may also present with a higher withdrawal severity rating on standardized
withdrawal severity scales, with protective factors and other support system(s) in place to
safely participate in this level of outpatient care.
3. Due to the safety concerns inherent with withdrawal, the following may not be appropriate
for Level 1-WM services:
a. Individuals who are experiencing withdrawal from more than one class of
substance.
b. Individuals with recent complicated withdrawal symptoms as identified by ASAM
Criteria.
c. If the medical personnel determines that an individual meeting one or both of the
above criteria can be safely and effectively served in a Level 1-WM setting, the
rationale and plan for safe management and services must be documented in the
individual’s record.
G. Individuals may be more advanced in their readiness to change and need minimal assistance
with transportation and other engagement barriers.
H. Individuals may participate in Level 1-WM services without a formal substance use disorder
diagnosis if collateral information indicates a high probability of such diagnosis. The agency must
ensure further evaluation of this probable diagnosis, either completed within the agency or
through referral to a behavioral health provider.
I. A gencies must:
1. Provide safe management and documentation of signs and symptoms of intoxication and
withdrawal; and
2. Ensure that discharge planning begins at the time of admission to Level 1-WM services,
to allow for necessary care coordination and transition into ongoing or concurrent
treatment services to occur successfully based on screening or assessment of needs.
4.5.2 Personnel
A. Level 1-WM services are primarily provided by medical professionals who are acting within the
scope of their practice and are trained in assessing and managing intoxication and states of
withdrawal. This may include, but is not limited to, authorized practitioners.
4.5.3 Service Provisions
A. Agencies must develop policies and procedures to address service delivery expectations. These
policies and procedures must address, but are not limited to the following:
1. Consultation with specialized clinical and medical professionals for individualized Level 1-
WM care;
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2. Coordinating an individual’s transition into other levels of care, determined to be
appropriate through triage, screening, evaluation, and/or assessment processes
completed during their Level 1-WM services. This may include collaboration with
emergency behavioral health services, such as Colorado Crisis Services, as appropriate;
3. Conducting or arranging for laboratory and/or toxicology tests to be completed;
4. Responding to individuals who are assessed as being a current threat to themselves or
others, including the appropriate use of law enforcement;
5. Communication with intoxicated individuals leaving Level 1-WM services against
personnel recommendations, including the use of emergency commitments; and
6. Circumstances under which individuals may be discharged from Level 1-WM services,
other than completing withdrawal management or leaving against personnel
recommendations.
B. Admission procedures for Level 1-WM services must include at a minimum:
1. Collecting of information regarding the degree of alcohol and/or other drug intoxication as
evidenced by breathalyzer, urinalysis, self-report, observation or other evidence-based or
best practices;
2. A pregnancy screening for pregnancy-capable individuals;
3. Taking of vital signs; and
4. Administration of a validated clinical withdrawal assessment tool.
C. Therapies offered by the agency must include a range of treatment approaches and support
services based on the screening or assessment of the individual’s treatment needs. Treatment
services may include but are not limited to:
1. S creening;
2. Assessment;
3. Group and individual counseling;
4. Motivational enhancement;
5. Family therapy;
6. Educational groups;
7. Occupational and recreational therapy;
8. Addiction pharmacology;
9. Mental health and physical health pharmacology, as needed;
10. Medication management;
11. Peer, social and recovery support;
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12. Care coordination; and
13. Support for the development of life skills.
D. If the agency does not provide a treatment approach or support service necessary to meet the
individual’s treatment needs, the agency must ensure that care coordination occurs.
E. Agencies must provide additional service planning for managing individuals with medical
conditions, suicidal ideation, pregnancy, psychiatric conditions, and other conditions which place
individuals at additional risk during withdrawal management.
F. Agencies must provide assessments of individual readiness for treatment and services based on
the service plan and the assessments and interventions shall be documented in the individual’s
record.
G. Medication-assisted treatment (MAT) for withdrawal management
1. Agencies must continue individuals on their medication-assisted treatment regimen and
will only remove individuals from medications treating opioid use disorders at the
individual’s request or if it is deemed medically appropriate by an authorized practitioner.
2. Agencies must inform individuals receiving services about access to medication-assisted
treatment. Upon the individual’s consent, the agency must provide medication-assisted
treatment directly.
3. Agencies must obtain a controlled substance license pursuant to section 21.300 of 2
CCR 502-1 from the BHA if they plan to dispense, compound, or administer a controlled
substance from stock medication in order to treat a substance use disorder or to treat the
withdrawal symptoms of a substance use disorder.
a. A c ontrolled substance license is not required if the agency intends to provide
medication-assisted treatment (MAT) services through prescription writing only,
under an independent prescriber’s license.
4.5.4 Documentation and Timeliness
A. Upon admission to Level 1-WM services, the agency must complete the following requirements,
keeping documentation of timely completion in the individual’s record:
1. Conduct a physical examination of the individual. This may be conducted by an
authorized practitioner;
2. Conduct an addiction-focused history of the individual. This may be conducted by an
authorized practitioner; and
3. Utilize screening tools in the process of gathering sufficient biopsychosocial and ASAM
dimensional criteria as outlined in Chapter 6 of the ASAM Criteria, to inform an
individualized, withdrawal management-focused service plan.
B. Implementation of the service plan, including any amendments to the service plan and the
individual’s clinical response to the services provided, must be maintained in the individual’s
record during the time they remain engaged in Level 1-WM services. This may include withdrawal
rating scales or flow sheets that are used, as needed.
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C. The service plan and progression tracking may be indicated in progress notes that align with the
existing medical model for documentation.
D. Individuals may engage in a pattern of admitting to, and discharging from, Level 1-WM services in
a repeated and fluid manner throughout a concurrent behavioral health episode of care.
Documentation specific to these engagement milestones for Level 1-WM services may be
reflected in the existing medical model documentation and does not require a formal discharge
summary as detailed in part 2.10.A.5 of these rules.
E. Considerations for discharge from Level 1-WM services include, but are not limited to:
1. Resolution of withdrawal symptoms;
2. Symptoms that have not improved or have intensified after engaging in Level 1-WM
services and the individual requires a higher service, such as Level 2-withdrawal
management (Level 2-WM); or
3. The individual is unable to participate in Level 1-WM and may require a different support
system or delivery mechanism.
F. If a higher level of care is required, the Level 1-WM agency must initiate a referral to the
appropriate level of care.
4.6 Intensive Outpatient Program (IOP) Services Standards
A. T hese rules are established to create standards for agencies seeking a sub-endorsement to
provide intensive outpatient program (IOP) services, which includes ASAM Criteria Level 2.1 type
services.
B. Agencies providing intensive outpatient program services must meet the standards in this part
4.6.
4.6.1 Service Delivery and Setting
A. Individuals receiving this level of service meet diagnostic criteria of acute state moderate severity
mental illness, substance use, or co-occurring disorder criteria, as defined in the DSM-5-TR.
Individuals may also meet high severity, as defined in the DSM-5-TR, but are stabilized and/or
receiving medication-assisted treatment, as defined in part 1.2 of these rules, or
pharmacotherapy, as defined in part 1.2 of these rules.
B. IOP services are intended for individuals who require a higher level of intervention than can be
provided in standard outpatient services.
C. All services must be adapted to the individual’s developmental stage and physical and
comprehensive needs.
D. Services may be delivered via in-person, audio-visual telehealth, or audio-only telehealth format
in accordance with telehealth regulations found in part 2.9 of these rules.
E. Treatment groups must not exceed twelve (12) individuals receiving services.
F. IO P support systems
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1. Agencies providing IOP services must have direct affiliation or close coordination through
referral to more and less intensive levels of care. Agencies must also have a documented
consultation and/or referral process through internal staff or other affiliation in place for
medical, psychiatric, and medication-assisted treatment needs.
a. Referral(s) will be provided in collaboration with the individual and their choice(s)
for referred services.
4.6.2 Personnel
A. Treatment personnel, for the purpose of this Chapter, unless otherwise noted, means the
following behavioral health professionals trained in mental health, substance use, and/or co-
occurring disorder identification and treatment and acting within their scope of practice:
1. Authorized practitioners;
2. Licensees;
3. Certified addiction specialists (CAS);
4. Candidates;
5. Certified addiction technicians (CAT);
a. If utilizing certified addiction technicians (CAT), the agency must ensure that
CATs do not comprise more than twenty-five (25%) of the agency’s personnel.
6. Counselors-in-training and/or interns.
a. If utilizing counselors-in-training and/or interns, the agency must ensure that all
clinical documentation is reviewed and co-signed by a clinical agency supervisor
able to supervise pursuant to their scope of practice. Counselor-in-training and/or
intern personnel must not comprise more than twenty-five percent (25%) of the
agency’s personnel.
B. A gencies providing IOP must ensure treatment personnel have supervisor consultation available
within eight (8) hours via in-person or by telehealth to discuss, when warranted, at minimum,
psychiatric or medical concerns of individuals receiving services.
C. Personnel must have supervisor consultation available within one (1) hour via in-person or
telehealth to discuss, when warranted crisis/emergency situations.
D. Services may include recovery support services rendered by peer support professionals in
accordance with Chapter 3 of these rules.
E. Agencies providing IOP services must provide training appropriate to the treatment-type focus
and best practice standards.
1. Training must include that treatment personnel understand the signs and symptoms of
mental health, substance use, and co-occurring disorders and the basics of
psychopharmacology.
4.6.3 Service Provisions
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A. Services must be conducted in regularly scheduled sessions that follow a planned format of
treatment services of nine (9) to nineteen (19) contact hours per week for adults and six (6) to
nineteen (19) contact hours per week for children under the age of eighteen (18).
B. Services may include individual therapy, group therapy, medication-assisted treatment (MAT)
monitoring and/or education, psychiatric medication education and/or monitoring, family therapy,
peer professional services, educational/occupational groups, recreational therapy, and other
therapies as deemed appropriate by assessment of the individual receiving services.
4.6.4 Documentation and Timeliness
A. Agencies providing IOP services must document services pursuant to the standards set in parts
2.10, 2.11, 2.12, and 2.13 of these rules.
B. Upon initiation of services to an individual, preliminary screening and risk assessment must be
completed in compliance with part 2.12.1 of these rules.
C. As soon as is practicable upon admission, but no later than ten (10) calendar days from the date
of preliminary screening and risk assessment, the agency must complete an initial assessment in
accordance with part 2.12.2 of these rules.
1. If the screening and risk assessment identifies an urgent clinical need for treatment of the
individual, clinical services must be provided immediately, and the initial assessment
must be completed within one (1) calendar day of preliminary screening.
D. As s oon as is practicable upon admission, but no later than sixty (60) calendar days from the first
date of services, the agency must complete a comprehensive assessment in accordance with
part 2.12.3 of these rules. The requirement that the comprehensive assessment be completed
within sixty (60) days does not preclude the initiation or completion of the comprehensive
assessment or the provision of treatment during the intervening sixty (60) day period.
E. Individual service plans must be created, in accordance with part 2.13.1 of these rules, within
fourteen (14) calendar days after initial assessment. The service plan must be updated to reflect
information from the completed comprehensive assessment. The agency must update the service
plan throughout the course of treatment, review previous goals, and update those goals
whenever there is a change in the person's level of care or functioning, and must occur, at
minimum, every six (6) months.
F. IOP services must be documented in the individual’s record in accordance with part 2.11 and
2.13.2 of these rules and at a minimum frequency of one (1) progress note per session.
4.7 Partial Hospitalization Program (PHP) Services Standards
A. These rules are established to create standards for agencies seeking a sub-endorsement to
provide partial hospitalization program (PHP) services, which includes ASAM Criteria Level 2.5
type services.
B. A gencies providing partial hospitalization program services must meet the standards in this part
4.7.
4.7.1 Service Delivery and Setting
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A. PHP services must generally be intended for individuals who require daily monitoring or
management to treat mental health, substance use, and co-occurring disorders, as defined by the
DSM-5-TR, that can be provided in a structured outpatient setting. Services include direct access
to medical, psychiatric, and laboratory services.
B. PHP service sites for children must include access to educational services and coordination with
a school system, as appropriate.
C. PHP services are appropriate for individuals with co-occurring mental health and substance use
disorders if the disorders are diagnosed as moderate severity or are of higher severity, as defined
by the DSM-5-TR, but have been stabilized.
D. All services provided must be adapted to individual’s developmental stage and physical and
comprehensive needs.
E. Services may be delivered via in-person, audio-visual telehealth, or audio-only telehealth format
in accordance with telehealth regulations found in part 2.9 of these rules.
F. PHP agencies must meet the facility requirements set forth in part 2.6 of these rules or
requirements in accordance with facility mandates under other regulatory state and federal
entities for licensure in cases such as a medical facility, school, or other.
G. T reatment groups must not exceed twelve (12) individuals receiving services.
H. PHP support systems
1. Agencies providing PHP services must inform individuals receiving treatment how to
access emergency services by telephone twenty-four (24) hours per day, seven (7) days
per week when the program is not in session. At minimum, agencies must provide
emergency services information that includes contact information for services provided by
the behavioral health crisis response system created pursuant to Section 27-60-103,
C.R.S.
2. Agencies providing PHP services must have direct affiliation or close coordination
through referral to more and less intensive levels of care. Agencies providing PHP
services must also have a documented consultation and/or referral process through
internal staff or other affiliation for medical, psychiatric, and medication-assisted
treatment needs.
a. Referral(s) will be provided in collaboration with the individual and their choice(s)
for referred services.
4.7.2 Personnel
A. Treatment personnel, for the purpose of PHP services, unless otherwise noted, means the
following behavioral health professionals trained in mental health and/or substance use disorder
identification and treatment and acting within their scope of practice:
1. Authorized practitioners;
2. Licensees;
3. Certified addiction specialists (CAS);
4. C andidates;
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5. Certified addiction technicians (CAT);
a. If utilizing certified addiction technicians (CAT), the agency must ensure that
CATs do not comprise more than twenty-five (25%) of the agency’s personnel.
6. Counselors-in-training and/or interns.
a. If utilizing counselors-in-training and/or interns, the agency must ensure that all
clinical documentation is reviewed and co-signed by a clinical agency supervisor
able to supervise pursuant to their scope of practice. Counselor-in-training and/or
intern personnel must not comprise more than twenty-five percent (25%) of the
agency’s personnel.
B. Services may include recovery support services rendered by peer support professionals in
accordance with Chapter 3 of these rules.
C. Agencies providing PHP services must ensure treatment personnel have supervisor consultation
available within eight (8) hours via in-person or by telehealth and within two (2) calendar days in-
person or by telehealth, when warranted, at minimum, to discuss at minimum psychiatric or
medical concerns of individuals receiving services.
D. Personnel must have supervisor consultation available within one (1) hour via in-person or
telehealth to discuss, when warranted crisis and/or emergency situations.
E. In addition to trainings required as a BHE in part 2.5 of these rules, PHP endorsed agencies must
provide training appropriate to their treatment-type focus, as well as best practice standards.
1. T raining for PHP endorsed agencies must include training that treatment personnel
understand the signs and symptoms of mental health, substance use, and co-occurring
disorders and the basics of psychopharmacology.
2. PHP endorsed agencies must ensure that all personnel providing medical services at the
PHP have completed and maintained any training required by the personnel’s applicable
government licensing entity in order to work within behavioral health focused services.
4.7.3 Service Provisions
A. Mental health - only service provisions
1. Individuals for this level of treatment meet diagnosed acute state severe and persistent
mental illness criteria, as defined in the DSM-5-TR, and are not at current risk of harming
themselves or others.
2. Services must be provided at a minimum of twenty (20) or more hours a week including a
minimum of three (3) hours per day and a minimum of four (4) calendar days per week.
Service frequency and intensity must be modified to meet assessment and service plan
objectives.
3. Services may include medical services, individual therapy, group therapy, medication
management, educational/occupational groups, peer professional services, recreational
therapy, and other therapies as deemed appropriate by assessment of the individual
receiving services.
B. S ubstance use disorder and co-occurring service provisions (including ASAM Criteria Level 2.5)
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1. Individuals for this level of treatment meet diagnostic criteria for a substance use related
disorder as defined in the DSM-5-TR and are at low risk of withdrawal or have minimal
remaining withdrawal symptoms.
2. Services must be conducted with a minimum frequency of twenty (20) regularly
scheduled treatment contact hours per week.
3. Services may include medical services, individual therapy, group therapy, medication
management, medication-assisted treatment monitoring/education,
educational/occupational groups, recreational therapy, peer professional services, and
other therapies as deemed appropriate by assessment of individual receiving services.
4.7.4 Documentation and Timeliness
A. All PHP service documentation requirements must follow the requirements set forth in parts 2.10,
2.11, 2.12, and 2.13 of these rules.
B. Upon entrance into service, preliminary screening and risk assessment must be completed in
compliance with part 2.12.1 of these rules.
C. As soon as practicable upon admission, but no later than ten (10) calendar days from the date of
preliminary screening and risk assessment, the agency must complete an initial assessment in
accordance with part 2.12.2 of these rules
1. If the screening identifies an urgent need, clinical services are provided, and the initial
assessment must be completed within one (1) calendar day of preliminary screening.
D. As s oon as practicable upon admission, but no later than sixty (60) calendar days from the first
date of services, the agency must complete a comprehensive assessment in accordance with
part 2.12.3 of these rules. The requirement that the comprehensive assessment be completed
within sixty (60) days does not preclude the initiation or completion of the comprehensive
assessment or the provision of treatment during the intervening sixty (60) day period.
E. The individual service plan must be created, in accordance with part 2.13.1 of these rules, within
fourteen (14) calendar days after initial assessment. The service plan must be updated to reflect
information from the completed comprehensive assessment. The agency must update the service
plan throughout the course of treatment, review previous goals and update those goals whenever
there is a change in the person's level of care or functioning, and must occur, at minimum, every
fourteen (14) calendar days.
F. PHP services must be documented in the individual’s record in accordance with part 2.11 and
2.13.2 of these rules and at a minimum frequency of one (1) progress note per session and one
(1) progress note per week.
4.8 Level 2-Withdrawal Management (Level 2-WM): Ambulatory Withdrawal Management with
Extended On-Site Monitoring Services Standards
A. T his part 4.8 is established to create standards for agencies seeking a sub-endorsement to
provide outpatient Level 2-Withdrawal Management (Level 2-WM) services in accordance with
Chapter 6 of the ASAM Criteria.
B. Agencies providing Level 2-WM services must meet the standards in this part 4.8. Agencies
providing Level 2-WM services may:
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1. Also engage in outpatient behavioral health services by meeting the standards for the
outpatient sub-endorsement(s) selected by the agency; or
2. Provide only Level 2-WM services and coordinate with other providers for ongoing and
concurrent outpatient behavioral health treatment services.
4.8.1 Service Delivery and Setting
A. Level 2-WM is an outpatient withdrawal management service that complements individualized
behavioral health treatment services.
B. Individuals may participate in Level 2-WM for a period of time in which it is determined to be
medically appropriate. Admission to Level 2-WM services must not hinder the individual’s ability
to participate in concurrent behavioral health services. This includes the potential process of
admitting to, and discharging from, such withdrawal management services one (1) or more times
by the individual.
C. Level 2-WM services are generally provided in a day hospital-type setting, general health care
facility, or an agency providing substance use disorder or mental health treatment.
D. Level 2-WM services offered by agencies that do not provide behavioral health services within
their agency structure must be affiliated with BHEs or other necessary providers to ensure the
treatment needs of all individuals served can be met. Documentation of this affiliation must be
presented to the BHA, upon request. Referral(s) will be provided in collaboration with the
individual and their choice(s) for referred services.
E. S upport systems
1. Agencies must:
a. Have the ability to obtain a comprehensive medical history and physical
examination at the time of admission to Level 2-WM services;
b. Have twenty-four (24)-hour access to emergency medical consultation services,
should emergency services become indicated;
c. Have the ability to provide or assist in accessing transportation services for
individuals who lack safe transportation; and
d. Have the ability to coordinate services with behavioral health personnel, within
the agency or through referral.
F. Diagnostic criteria
1. Individuals participating in Level 2-WM services typically exhibit a moderate withdrawal
severity rating on standardized withdrawal severity scales as well as mild/stable
psychiatric symptoms for emotional, behavioral, and cognitive conditions.
2. Individuals may also present with a higher withdrawal severity rating on standardized
withdrawal severity scales or with higher psychiatric symptom requirements, with
sufficient protective factors and other support system(s) in place to safely participate in
Level 2-WM services.
3. Due to the safety concerns inherent with withdrawal, individuals with complicated
withdrawal severity ratings may not be appropriate for Level 2-WM services.
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a. If the medical personnel determines that an individual meeting the above criteria
can be safely and effectively served in a Level 2-WM setting, the rationale and
plan for safe management and services must be documented in the individual’s
record.
4. Individuals may be more advanced in their readiness to change and may require
assistance with transportation or other engagement barriers.
5. Individuals may participate in Level 2-WM services without a formal substance use
disorder diagnosis if collateral information indicates a high probability of such diagnosis.
The agency must ensure further evaluation of this probable diagnosis, either completed
within the agency or through referral to a behavioral health provider.
G. Agencies must:
1. Provide safe management and documentation of signs and symptoms of intoxication and
withdrawal; and
2. Ensure that discharge planning begins at the time of admission to Level 2-WM services,
to allow for necessary care coordination and transition into ongoing or concurrent
treatment services to occur successfully based on screening or assessment of needs.
4.8.2 Personnel
A. Level 2-WM services are primarily provided by medical professionals who are acting within the
scope of their practice and are trained in assessing and managing intoxication and states of
withdrawal. This may include, but is not limited to:
1. A uthorized practitioners; and
2. Nurses.
B. Level 2-WM is an outpatient service that requires daily monitoring of withdrawal symptoms and
assessments of progress. This requires medical personnel to be readily accessible and able to
evaluate an individual’s needs and safe placement in Level 2-WM.
4.8.3 Service Provisions
A. Agencies must develop policies and procedures to address service delivery expectations. These
policies and procedures must address, but are not limited to the following:
1. Consultation with specialized clinical and medical professionals for individualized Level 2-
WM care;
2. Coordinating an individual’s transition into other Levels of care determined to be
appropriate through triage, screening, evaluation, and/or assessment processes
completed during their Level 2-WM services. This may include collaboration with
emergency behavioral health services, such as Colorado Crisis Services, as appropriate;
3. Conducting or arranging for laboratory and/or toxicology tests to be completed;
4. Responding to individuals who are assessed as being a current threat to themselves or
others, including the appropriate use of law enforcement;
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5. Communication with intoxicated individuals leaving Level 2-WM services against
personnel recommendations, including the use of emergency commitments; and
6. Circumstances under which individuals may be discharged from Level 2-WM services,
other than completing withdrawal management or leaving against personnel
recommendations.
B. Admission procedures for Level 2-WM services must include at a minimum:
1. Collection of information regarding the degree of alcohol and/or other drug intoxication as
evidenced by breathalyzer, urinalysis, self-report, observation, or other evidence-based
or best practices;
2. A pregnancy screening for pregnancy-capable individuals;
3. Taking of vital signs; and
4. Administration of a validated clinical withdrawal assessment tool.
C. Therapies offered by the agency must include a range of treatment approaches and support
services based on the screening or assessment of the individual’s treatment needs. Treatment
services may include but are not limited to:
1. Screening;
2. Assessment;
3. Group and individual counseling;
4. Motivational enhancement;
5. Family therapy;
6. Educational groups;
7. Occupational and recreational therapy;
8. Addiction pharmacology;
9. Mental health and physical health pharmacology, as needed;
10. Medication management;
11. Peer, social and recovery support;
12. C are coordination; and
13. Support for the development of life skills.
D. If the agency does not provide a treatment approach or support service necessary to meet the
individual’s treatment needs, the agency must ensure that care coordination occurs.
E. Agencies must provide additional service planning for managing individuals with medical
conditions, suicidal ideation, pregnancy, psychiatric conditions, and other conditions which place
individuals at additional risk during withdrawal management.
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F. Agencies must provide assessments of individual readiness for treatment and services based on
the service plan and the assessments and interventions shall be documented in the individual’s
record.
G. Medication-assisted treatment (MAT) for withdrawal management
1. Agencies must continue individuals on their medication-assisted treatment regimen and
will only remove individuals from medications treating opioid use disorders at the
individual’s request or if it is deemed medically appropriate by an authorized practitioner.
2. Agencies must inform individuals receiving services about access to medication-assisted
treatment. Upon the individual’s consent, the agency must provide medication-assisted
treatment directly.
3. Agencies must obtain a controlled substance license pursuant to section 21.300 of 2
CCR 502-1 from the BHA if they plan to dispense, compound, or administer a controlled
substance from stock medication in order to treat a substance use disorder or to treat the
withdrawal symptoms of a substance use disorder.
a. A controlled substance license is not required if the agency intends to provide
medication-assisted treatment (MAT) services through prescription writing only,
under an independent prescriber’s license.
4.8.4 Documentation and Timeliness
A. Upon admission to Level 2-WM services, the agency must complete the following requirements,
keeping documentation of timely completion in the individual’s record:
1. C onduct a physical examination of the individual. This may be conducted by an
authorized practitioner;
2. Conduct an addiction-focused history of the individual. This may be conducted by an
authorized practitioner; and
3. Utilize screening tools in the process of gathering sufficient biopsychosocial and ASAM
dimensional criteria as outlined in Chapter 6 of the ASAM Criteria, to inform an
individualized, withdrawal management-focused service plan.
B. Implementation of the service plan, including any amendments to the service plan and the
individual’s clinical response to the services provided, must be maintained in the individual’s
record during the time they remain engaged in Level 2-WM services. This may include serial
medical assessments, withdrawal rating scales and/or flow sheets that are conducted, as needed.
C. The service plan and progression tracking may be indicated in progress notes that align with the
existing medical model for documentation.
D. Individuals may engage in a pattern of admitting to, and discharging from, Level 2-WM services in
a repeated and fluid manner throughout a concurrent behavioral health episode of care.
Documentation specific to these engagement milestones for Level 2-WM services may be
reflected in the existing medical model documentation and does not require a formal discharge
summary as detailed in part 2.10.A.5 and 2.10.A.6 of these rules.
E. C onsiderations for discharge from Level 2-WM services include, but are not limited to:
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1. Resolution or diminishing of withdrawal symptoms, that allow the individual to be safely
served at a lower service level, such as Level 1-WM;
2. Symptoms that have not improved or have intensified after engaging in Level 2-WM
services and the individual requires a higher service, such as Level 3-withdrawal
management (Level 3-WM); or
3. The individual is unable to participate in Level 2-WM and may require a different support
system or delivery mechanism.
F. If a different level of care is required, the agency providing Level 2-WM services must initiate a
referral to the appropriate level of care.
Chapter 5: Behavioral Health Residential and Level 3-Withdrawal Management Services
5.1 Authority and Applicability
A. Chapter 5 establishes the standards for agencies electing to provide behavioral health residential
and/or Level 3-Withdrawal Management (Level 3-WM) services. The authority to promulgate
these service-specific requirements that apply to BHEs electing to provide this service comes
from Sections 27-50-502(1), 27-50-106, 27-50-301(5), 27-71-105(1), and 27-50-107(3)(b), C.R.S.
B. These rules are established to create standards for agencies seeking an endorsement to provide
behavioral health residential and/or Level 3-WM.
C. In a ddition to the overall endorsement associated with this Chapter 5, agencies must hold the
relevant sub-endorsement(s) to provide these services, as detailed below. The sub-
endorsements build in alignment with the natural progression of the continuum of care, with parts
that detail applicability standards as noted in parts 5.4 through 5.11 of this Chapter.
D. Agencies must elect a treatment type sub-endorsement to provide services to individuals, which
may include mental health treatment services, substance use disorder treatment services, or
both.
E. Agencies are not required to serve all treatment types within their selected sub-endorsement(s). If
the agency does not provide a service needed by an individual, the agency must ensure that care
coordination for the needed service occurs.
F. Agencies providing behavioral health residential services must meet the standards in:
1. This part 5.1 through part 5.3 of this Chapter; and
2. The standards required for the sub-endorsement(s) of the agency that are set forth in
these rules, including treatment type(s) provided.
G. Agencies providing Level 3-WM services must meet the standards in:
1. This part 5.1 through part 5.2 of this Chapter; and
2. T he standards required for the sub-endorsement(s) of Level 3-WM services provided by
the agency as set forth in part 5.6 and/or part 5.11 of this Chapter.
H. The continuum of behavioral health residential and Level 3-WM services are set forth in the
following section of this Chapter:
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1. Clinically monitored services, part 5.4 of this Chapter, including:
a. Level one mental health transitional living homes: part 5.4 of this Chapter.
2. Clinically managed services, part 5.5 through part 5.9 of this Chapter, including:
a. ASAM 3.1-type services: part 5.5 of this Chapter.
b. Level 3.2-WM services: part 5.6 of this Chapter.
c. ASAM Level 3.3 services: part 5.7 of this Chapter.
d. Level two mental health transitional living homes: part 5.8 of this Chapter.
e. ASAM 3.5-type services: part 5.9 of this Chapter.
3. Medically monitored services, part 5.10 through 5.11 of this Chapter, including:
a. ASAM 3.7-type services, part 5.10 of this Chapter.
b. Level 3.7-WM services, part 5.11 of this Chapter.
I. If the agency provides services to both mental health and substance use disorder treatment
types, they must meet the standards of all relevant sub-endorsement(s) set forth in this Chapter
as noted above.
5.2 Behavioral Health Residential and Level 3-Withdrawal Management (Level 3-WM) Services
Standards
A. This part 5.2 applies to all agencies providing behavioral health residential and/or Level 3-
Withdrawal Management (Level 3-WM) services.
5.2.1 S ervice Delivery and Setting
A. The agency must promote safety and avoid abuse, including psychological abuse, for all
individuals served by the agency. The agency must prioritize the living space assignment process
to ensure person-centered and trauma-informed services are received by the individual and
overall milieu. Factors to be considered in the determination of a safe living space assignment
may include, but are not limited to:
1. Age (child, youth or adult);
2. Gender identity;
3. Cultural needs identified during the assessment process;
4. The individual’s sex (male, female, intersex);
5. Individual’s ability to interact safely with others; and
6. The individual’s requests.
B. The agency must have physical barriers such as doors and walls, and personnel oversight of
activities to ensure safety for all personnel and individuals served. This management may also
include, but is not limited to:
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1. Personnel oversight, such as workstations that separate living space assignments;
2. Video or other monitored oversight that promptly notifies personnel of unexpected
movement in the milieu; and
3. Other practical arrangements that support the safe management of the individuals
receiving services.
5.2.2 Personnel
A. Agencies providing behavioral health residential and/or Level 3-WM services must have on-site
personnel twenty-four (24) hours per day, seven (7) days per week.
1. This coverage may include a combination of personnel qualified to provide treatment to
individuals receiving services as well as personnel who are trained to provide milieu
management services.
2. Personnel qualified to provide treatment may also provide milieu management, as noted
below.
3. On-site personnel must be sufficient to address the needs of the individuals served as
well as the safety of personnel providing oversight. See the relevant sub-endorsement(s)
in this Chapter for specific ratios of individuals served to personnel, if applicable.
B. Minimum agency personnel ratios, percentages and requirements are specific to each physical
location where services are being provided. This includes on-call personnel that may assist the
site, as needed.
C. The qualifications and credentialing of personnel providing treatment must be reflective of the
population(s) receiving services and meet the minimum standards and ratios present in the
relevant sub-endorsement(s), as applicable.
D. T reatment personnel
1. For agencies providing clinically managed or medically monitored residential and/or Level
3-WM services, personnel qualified to provide treatment means the following behavioral
health professionals acting within their scope of practice and trained in mental health
and/or substance use disorder identification and treatment:
a. Authorized practitioners;
b. Licensees;
c. Candidates;
d. Counselors-in-training; and
e. Interns.
2. Agencies providing residential substance use disorder, residential co-occurring, and/or
Level 3-WM services may also utilize the following as treatment personnel, when
applicable:
a. Certified addiction specialists (CAS); and
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b. Certified addiction technicians (CAT).
E. Milieu management personnel
1. In addition to the treatment personnel noted in part 5.2.2.D of this Chapter, agencies
providing behavioral health residential and/or Level 3-WM services may utilize the
following personnel for milieu management:
a. Peer support professionals, and
b. Group living workers.
(1) If utilizing group living workers for milieu management, these personnel
must:
(a) Be assigned duties and responsibilities that are within their
training and scope of practice. They must not perform tasks that
are required to be performed by treatment personnel as outlined
in part 5.2.2.D; and
(b) Be assigned to the clinical director, a licensee, or authorized
practitioner for training and oversight of milieu management
services provided.
(c) If correctional personnel, such as security or correctional officers,
are utilized as group living workers within an agency that
provides services in a correctional setting, they must be
responsive and accountable to the clinical director or other
assigned clinical supervisor to ensure the culture of the program
is supported.
2. If utilizing peer support professionals for milieu management, the agency must follow
standards for recovery support services rendered by peer support professionals in
accordance with Chapter 3 of these rules.
3. Agencies that have shifts without credentialed personnel on-site as a result of utilizing
CATs, counselors-in-training, interns, peer support professionals, and/or group living
workers for milieu management must ensure that consultation with a credentialed person
is immediately available. This consultation must be provided by the clinical director, a
licensee, or an authorized practitioner.
a. Excluding clinically monitored services, this consultation must include an on-site
response by the credentialed personnel within thirty (30) minutes if needed.
5.2.3 Service Provisions
A. Agencies providing behavioral health residential and/or Level 3-WM services must offer a range
of treatment approaches and support services to meet the individual’s treatment needs, as
determined by the screening and/or assessment process. Services offered may include, but are
not limited to:
1. Screening;
2. Comprehensive assessment;
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3. Group and individual counseling;
4. Motivational enhancement;
5. Family therapy;
6. Educational groups;
7. Occupational and recreational therapy;
8. Behavioral health pharmacology;
9. Physical health pharmacology;
10. Medication management;
11. Peer, social and recovery support;
12. Care coordination; and
13. Support for the development of life skills.
B. If the agency does not provide a treatment approach or support service necessary to meet the
individual’s treatment needs, the agency must ensure that care coordination for the needed
service occurs.
5.2.4 Documentation and Timeliness
A. See the behavioral health residential and/or Level 3-WM services sub-endorsement(s) as set
forth in this Chapter for relevant documentation and timeliness standards.
5.3 Behavioral Health Residential Services
A. This part 5.3 applies to all agencies providing behavioral health residential services.
B. This part 5.3 does not apply to agencies providing only Level 3-WM services.
5.3.1 Service Delivery and Setting
A. Agencies providing behavioral health residential services must ensure that they can sufficiently
provide for the behavioral health needs of all individuals served. These services may occur
through direct service provision by agency personnel or through the coordination of services with
other agencies endorsed to provide the services an individual requires.
B. A gencies must prioritize the development of necessary living skills to support the individual’s
successful integration, or reintegration, into independent or other living situations within their
community. This may include services developed for participation by all individuals as well as
services tailored to an individual's assessed needs.
C. Services offered by the agency must be regularly scheduled and relevant to the treatment type
and population receiving services.
D. Agencies providing behavioral health residential services must:
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1. Have direct affiliation or close coordination through referral to more and less intensive
levels of behavioral health care;
2. Have the ability to conduct or arrange for laboratory and/or toxicology tests to be
completed; and
3. Develop and maintain house rules as noted in part 5.3.3.C of this Chapter.
5.3.2 Personnel
A. All personnel must receive training and demonstrate competency in areas relevant to their
specific duties and responsibilities prior to working independently in the residential setting.
Training may be provided through formal instruction, self-study courses, or on-the-job training.
Personnel training must include, but is not limited to the following topics:
1. House rules development, implementation, and updating; and
2. How to access and utilize an individual’s psychiatric advanced directive (PAD), when
applicable.
a. If the individual does not have a PAD completed, personnel must offer to assist in
PAD completion if the individual is interested and it is clinically appropriate.
5.3.3 General Provisions
A. Between 10 pm and 6 am, personnel must conduct, and document safety checks of all individuals
served. The intervals in which safety checks are completed must be sufficient to provide for the
health and safety of the individuals being served.
B. T he agency must ensure that telephone services available on-site include videophones for
hearing or speech-impaired individuals served.
C. House rules
1. The agency must establish written house rules and place them in a location where they
are always available to individuals and visitors.
2. The agency must develop policies and procedures regarding house rules which includes
a list of all possible actions which may be taken by the agency if any rule is knowingly
violated by an individual served, and how the agency will document violations and actions
taken.
3. House rules must address, at a minimum, the following items:
a. Smoking and tobacco utilization, including the use of electronic cigarettes,
vaporizers, and chewing tobacco;
b. Cooking;
c. Visitors;
d. Telephone usage, including frequency and duration of calls;
e. Use of common areas and devices, such as television, radio, and computer;
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f. Consumption of alcohol and marijuana; and
g. Pets.
(1) Service animals, as determined by the Americans with Disabilities Act
(ADA), are not classified as pets. House rules must not limit an
individual’s right to have a service animal while served by the agency.
4. House rules must not:
a. Take the place of, or conflict with, any requirements of these rules; or
b. Delay, discourage, or prevent an individual’s exercise of their rights.
5. The agency must revisit and update house rules at least annually and allow for
collaboration and feedback from individuals.
D. Court ordered referrals for residential services may require a length of stay that is based on a
legal requirement and may not be clinically necessary for the duration of that period of time. The
agency is expected to evaluate if the supervising entity’s recommendation matches the
individual’s assessed clinical needs. The agency must address any differences identified with the
supervising entity directly and document the results in the individual’s record.
E. See the behavioral health residential services sub-endorsement(s) as set forth in this Chapter for
relevant service provision standards.
5.4 Level One Mental Health Transitional Living Home Services
A. T his part 5.4 applies to agencies operating level one mental health transitional living homes. This
level of care is defined in Chapter 1 of these rules.
5.4.1 Service Delivery and Setting
A. Level one mental health transitional living homes shall comply with the requirements of parts 5.1
through this part 5.4, unless otherwise noted.
5.4.2 Personnel
A. To determine level of oversight needed to ensure safety, the agency shall consider, at a
minimum, the following items:
1. The acuity and needs of the individuals, and
2. The services outlined in the service plan of an individual.
B. Personnel shall be sufficient in number to help individuals needing or potentially needing
assistance, and to account for the risk of accident, hazards, or other challenging events based on
the number of individuals in residence.
C. When determining personnel requirements, the agency must consider the needs of the
individuals receiving services. Oversight of individuals must include on-site and on-call availability
of personnel with appropriate training and expertise based on the needs of the individuals.
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D. Personnel must be assigned to complete tasks commensurate with their skills and training.
Personnel that are not licensed or credentialed shall not complete specialized screenings,
assessments, therapies, or techniques for which they are not qualified.
E. Only personnel with the appropriate training and expertise may train personnel on specialized
techniques beyond general personal care and assistance with activities of daily living as defined
in these rules. This includes, but is not limited to, transfers requiring specialized equipment, and
assistance with therapeutic diets. Personnel must be evaluated for proficiency in demonstrating
the specialized technique before the delivery of a personal service requiring a specialized
technique.
1. Documentation regarding training and proficiency in specialized techniques must be
included in the personnel files.
F. A nurse who is employed or contracted by the agency may delegate to other personnel in
accordance with the Nurse and Nurse Aide Practice Act pursuant to Article 255 of Title 12,
C.R.S., if the nurse is the supervising nurse for the personnel.
G. The agency shall ensure that personnel comply with all agency policies and procedures and shall
not allow personnel to perform any functions which are outside of their job description, scope of
practice, or an individual's service plan.
H. P ersonnel providing non-medical transportation to individuals must meet the following
requirements:
1. Must be eighteen (18) years of age or older to render services;
2. Has at least one year of driving experience;
3. Possesses a valid driver’s license;
4. Has provided a copy of their current Colorado motor driving vehicle record, with up to the
previous seven years of driving history as applicable; and
5. Has completed a Colorado or national-based criminal history record check.
I. Vehicles used during the provision of non-medical transportation must be safe and in good
working order. To ensure the safety and proper functioning of the vehicles, vehicles must pass a
vehicle safety inspection prior to it being used to render services. Inspection requirements must
be outlined in the agency’s policies and procedures, and records of such inspections must be
maintained by the agency.
J. The agency shall have policies and procedures for determining when personnel are not permitted
to provide non-medical transportation based on violations presented on the driver’s motor vehicle
record.
K. An agency that uses a separate agency, organization, or personnel to provide services for the
mental health transitional living home or a specific individual shall have a written agreement that
sets forth the terms of the arrangement. The agreement must specify, at a minimum, the following
items:
1. T he specific services to be provided;
2. The time frame for the provision of such services;
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3. The contractor’s obligation to comply with all applicable agency policies and procedures,
including personnel qualifications;
4. How such services will be coordinated and overseen by the agency; and
5. The procedure for payment of services provided under the contract.
L. If contract personnel and/or services are used, the agency shall ensure the contractor meets all
applicable requirements of these regulations.
M. Notwithstanding the above criteria, the agency shall retain responsibility to ensure the health,
safety and welfare of the individuals, and the provision of necessary services, including but not
limited to, the minimum necessary services set forth in part 5.5.1.B.
5.4.3 Service Provisions
A. The agency shall ensure the provision of accommodations, personnel, and services necessary for
the welfare and safety of individuals.
B. The agency shall make available, either directly or indirectly through contracted services, the
following services, sufficient to meet the needs of the individuals. These services must include but
are not limited to:
1. A physically safe and sanitary environment that includes, but is not limited to, measures
to reduce the risk of potential hazards in the physical environment and that accounts for
the unique characteristics of the resident population;
a. Wh en a transitional living home utilizes a delayed egress door at an exit point,
the exit door must allow full egress in emergencies, and must only be used to
assist personnel in maintaining supervision and redirecting individuals back into
the care setting.
b. Egress alert devices must only be used to assist personnel in redirecting
individuals back into the mental health transitional living home when personnel
are alerted to an individual's departure, as opposed to restricting the free
movement of individuals.
2. Room and board;
3. Personnel to assist with personal services;
4. Assistance with medication;
5 Life skills training;
a. The agency shall support individuals to maintain and develop skills for
independent living through regular, structured individual and group engagement
opportunities.
b. Training opportunities must include therapeutic and habilitative activities to
facilitate the development of life skills and promote independent living and must
support the pursuit of individual’s interests and goals.
c. The agency shall document in the record the individual’s engagement and
progress in life skills training and other training opportunities.
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d. If requested, the agency shall assist an individual with identifying and accessing
outside services and community events.
6. Intensive case management;
a. As appropriate for the needs of the individual, the agency shall:
(1) Convene the individual, their legal representative and/or the persons
involved in the individual’s treatment and care, including medical and
behavioral health providers, and persons identified by the individual, for
the purpose of care planning and coordination, in order to facilitate
wellness, self-management, and recovery of the whole person.
(2) Provide proactive and intentional outreach and engagement with the
individual and their identified support persons to build necessary trust
and support.
(3) Assess for support needs, risk factors and health related social needs
and support the individual in accessing care, resources, and services to
address health related social needs including but not limited to:
(a) Food security
(b) Housing stability and security
(c) Personal safety
(d) Access to health services including preventative health care
(e) Physical health concerns for which the individual is not receiving
adequate treatment
(f) Ongoing behavioral health care needs
b. Intensive case management must involve discharge planning in accordance with
the requirements of part 2.10.A.6 of these rules.
7. N on- medical transportation and access to the community
a. The agency shall provide for community access through non-medical
transportation services. This includes providing accessible transportation when
an individual requires adaptive supports.
C. Agencies will arrange for the individual to receive community-based behavioral health services.
D. The agency shall assume responsibility for all services it provides, including those provided by
contract.
E. Services provided by or coordinated by the agency may be provided via telehealth at the
discretion of the administrator, to the extent that such services meet the needs of the individual,
fulfill the requirements set forth in this Chapter, and account for individuals’ preferences for
service delivery
F. Admission and discharge
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1. The agency shall ensure, prior to admission and move-in, that an individual’s needs can
be fully met either directly or through coordination with additional providers. The agency's
ability to meet individual needs must be based upon a comprehensive pre-admission
assessment of an individual's physical, mental, and social needs, which must be
documented in, and become part of, the individual’s record. The pre-admission
assessment must also include all screening and initial assessment requirements set forth
in part 2.12 of these rules.
2. An agency shall not admit any individual who:
a. Needs regular 24-hour medical or nursing care,
b. Has an acute physical illness which cannot be safely managed through
medication or prescribed therapy
3. The agency shall arrange for the transfer or transition of care for any individual who has
an acute physical illness which cannot be safely managed through medication or
prescribed therapy, or for an individual who develops a need for 24-hour medical or
nursing care
4. Prior to discharging an individual because of increased care needs, which may include,
but are not limited to, changes in health status or where an individual becomes an
imminent danger to self or others, the agency shall make documented efforts to meet the
individual’s needs through other means. The documented efforts must include:
a. T aking all measures necessary to protect the individual and others, including
following agency policies and procedures for behavioral and physical health
emergencies, as required per parts 2.10.D and 2.10.E of these rules;
b. Reassessing the individual and revising their service plan to identify the
individual's current needs and what services the agency will provide or
coordinate to meet those needs or address newly assessed risks; and
c. Ensuring all personnel are aware of any revisions to the service plan and are
properly trained to provide supervision and support consistent with the service
plan.
5. The agency shall coordinate a voluntary or involuntary discharge with the individual, the
individual's legal representative and/or the persons, including medical and behavioral
health providers, who will be responsible for services provided to the individual per the
discharge plan.
6. In the event an individual is transferred to another health care provider for additional care,
the agency shall arrange to evaluate the individual prior to readmission or shall discharge
the individual in accordance with the discharge procedures set forth in this Chapter.
7. When an individual is discharged, it is the responsibility of the agency to develop a
discharge plan, and provide care coordination to facilitate, to the extent possible, the
individual's transition to an appropriate level of care. Care coordination efforts must be
documented and maintained within the individual’s record.
G. P ractitioner assessment
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1. The agency shall have policies and procedures that are consistent with state and federal
law for promptly contacting the individual’s authorized practitioner for assessment when:
a. The individual experiences a significant change in their baseline status;
b. The individual has known exposure to a communicable disease;
c. The individual develops any condition which would have initially precluded
admission to the agency;
d. The individual has any observed or reported unfavorable reactions to
medications;
e. The individual is affected by a medication error; and/or
f. The individual engages in a pattern of refusing medications or medical
recommendations.
2. The agency shall ensure that any of the events in this part 5.4.3.G of this Chapter are
documented in the individual’s record.
3. As applicable, the individual’s legal representative must be promptly notified any time
assessment is indicated per this part.
5.4.4 Documentation and Timeliness
A. Comprehensive individual assessment
1. Within ten (10) calendar days of admission, the agency shall complete a comprehensive
assessment that meets the requirements set forth in part 2.12 of these rules as well as
the requirements of this part 5.4.4.A. The assessment must reflect information requested
and received from the individual, the individual's representative if requested by the
individual, and an authorized practitioner. Information from the comprehensive
assessment must be used to establish an individualized service plan.
2. T he comprehensive assessment must include all the following items:
a. Information from the comprehensive pre-admission assessment described in part
5.4.3.F.1;
b. Information regarding the individual's overall health and physical functioning
ability, including supports needed with activities of daily living;
c. Communication ability and any specific needs to facilitate effective
communication;
d. Food and dining preferences, unique dietary needs, allergies, and restrictions;
e. Reactions to the environment and others, including changes that may occur at
certain times or in certain circumstances;
f. Routines and interests;
g. Safety awareness;
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h. Types of physical, mental, and social support required;
i. History of or potential risk of harm to self or others, including aggressive
behaviors, and any known approaches to prevent future occurrences including
previously developed safety plans.
3. The comprehensive assessment must be documented in writing and kept in the
individual's health information record.
4. The comprehensive assessment must be updated for each individual at least every six
(6) months and whenever the individual's condition changes from baseline status.
B. Individual service plan
1. An initial service plan, based upon information from the pre-admission assessment
described in part 5.4.3.G.1 of this Chapter, must be developed within twenty-four (24)
hours of admission and must address, at a minimum, an individual's daily support needs,
including assistance with activities of daily living, medication management, behavioral
and physical health diagnoses, and support needs.
2. Within fourteen (14) calendar days of completion of the comprehensive assessment, the
agency shall develop a comprehensive service plan. In addition to the requirements of
part 2.13.1 of these rules, the service plan must:
a. Be developed with input from the individual and the individual's representative, if
applicable;
b. Reflect the most current assessment information;
c. P romote individual choice, mobility, independence and safety;
d. Detail specific personal service needs and preferences along with the supports
necessary to meet those needs; personal service needs must consider:
(1) individual prioritized needs for life skills training, and
(2) medical and therapeutic care needs;
e. Identify all external service providers along with care coordination arrangements;
f. Identify engagement opportunities that match the individual's personal choices
and needs; and
g. Outline a plan for ensuring the individual’s behavioral health care needs are met,
which may include access to community-based services.
3. The agency shall be responsible for the coordination of individual care services with
external service providers identified in the individual service plan.
4. The agency shall be responsible for implementing recommendations made by the
external service providers identified in the individual service plan.
5. As applicable, the agency shall ensure that an individual receives nursing and therapeutic
supports prescribed by the individual’s authorized practitioner.
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6. Only personnel employed or contracted by the agency may provide or assist with nursing
or therapeutic services on behalf of the agency.
7. If the agency utilizes delayed egress or egress alert devices, it must be noted within the
individual’s service plan.
8. The service plan must be updated for each individual at least every six (6) months and
whenever the individual's condition changes from baseline status.
C. Records
1. In addition to the requirements set forth in part 2.11 of these rules, individual records
must contain, but not be limited to, the following minimum items:
a. Current practitioner orders;
b. Individualized service plan;
c. Daily progress notes, in accordance with part 2.13.2 of these rules, which must
include information on individual status, well-being, and engagement, as well as
documentation regarding any out of the ordinary event or issue that affects an
individual's physical, behavioral, cognitive and/or functional condition, along with
the action taken by personnel to address that individual's changing needs; and
d. Documentation of physical and mental health care services received including
any on-going services provided by external service providers.
5.5 Clinically Managed Residential Services, Including ASAM 3.1-Type Services
A. T his part 5.5 applies to agencies providing ASAM 3.1-type clinically managed behavioral health
residential services.
B. This part 5.5 does not apply to agencies providing only Level 3-WM services.
C. This part 5.5 does not apply to recovery residences, as defined in BHA rule section 21.500 of 2
CCR 502-1.
5.5.1 Service Delivery and Setting
A. These services are intended for individuals who may benefit from twenty-four (24) hour structure
and supportive services to develop, practice, and integrate coping skills in preparation for
reintegration into their community of choice. Group homes, community corrections agencies, or
other supportive living environments that provide twenty-four (24) hour on-site personnel, a focus
on community re-integration, and treatment services on-site are examples of this level of care.
B. Agencies must ensure individuals receiving services have at least one (1) of the following
concerns to address during their residential episode of care:
1. A history of mental health, substance use, or co-occurring disorders;
2. A lack of stable or supportive housing options;
3. Unemployment or education concerns; and/or
4. Social or psychological dysfunction that necessitates this twenty-four (24) hour structure.
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C. Agencies must provide services that include (1) motivational enhancement to increase the
individual’s level of readiness to change and (2) individual monitoring and support to facilitate the
discovery of the individual’s needs. Services must also prioritize continued engagement in
treatment services beyond the residential episode of care.
D. The length of stay allows individuals to remain in residential services for a sufficient period of time
to familiarize themselves with and integrate the skills obtained into regular use.
E. Support systems
1. Agencies must:
a. Ensure the availability of telehealth or on-site consultation with an authorized
practitioner or nurse twenty-four (24) hours per day, seven (7) days per week;
b. Ensure the availability of consultation with emergency services twenty-four (24)
hours per day, seven (7) days per week; and
c. Have the capacity to arrange for medication-assisted treatment (MAT) and/or
psychiatric medications in a timely manner for individuals served.
(1) This may include services provided through coordination and referral but
must not exceed twenty-four (24) hours from the time the need is
identified to when arrangements are made.
5.5.2 Personnel
A. Agencies must maintain an individual-to-personnel ratio not exceeding twenty to one (20:1) at all
times, per physical location. This includes nighttime and weekend hours.
5.5.3 S ervice Provisions
A. Services must be regularly scheduled and include a minimum of five (5) hours of planned
treatment services per week for each individual in care.
5.5.4 Documentation and Timeliness
A. Agencies must complete and document the following items in the individual’s record within
twenty-four (24) hours of admission:
1. All required demographic, intake and consent paperwork, as specified in part 2.11 of
these rules;
2. Screenings, as required in part 2.12.1 of these rules;
3. The initial assessment as required in part 2.12.2 of these rules; and
4. The initial service plan, addressing immediate needs and other relevant concerns
identified in the initial assessment, as required in part 2.13.1 of these rules.
B. Screenings and assessments conducted in accordance with this part 5.5.4.A must be used to
determine appropriateness for this level of care.
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C. As soon as possible, but no later than ten (10) calendar days after an individual’s admission, the
agency must complete and document the comprehensive assessment for the individual, as
required in part 2.12.3 of these rules.
D. As soon as possible, but no later than three (3) calendar days after an individual’s comprehensive
assessment is completed, the agency must complete and document an individualized and
comprehensive service plan, informed by the comprehensive assessment, as required in part
2.13.1 of these rules.
E. If the individual’s comprehensive assessment indicates they may benefit from further evaluation,
medication, and/or specialty behavioral health care to address mental health, substance use-
specific, or co-occurring needs, the agency must ensure their individualized treatment needs are
addressed during the episode of care. The individual record must contain documentation
reflecting how these assessed needs were met.
F. Service plan reviews and revisions must be completed and documented in the individual’s record
when there is a change in the individual’s level of functioning or service needs, but in no case
may service plan reviews and revisions occur later than:
1. Monthly for the first six (6) months after admission, and
2. At least quarterly for the remainder of time that the individual remains in residential
services.
G. P rogress notes must be present in the individual’s record, in accordance with part 2.13.2 of these
rules and must be completed at least weekly for this level of care.
5.5.5 Treatment Type Standards for Residential Services, Including ASAM 3.1-Type Services
A. Agencies that provide mental health-only or co-occurring residential services must ensure that
individuals served meet at least one (1) of the following criteria:
1. Are diagnosed with a serious mental illness (SMI) or comorbid diagnoses at a mild to
moderate level defined in the DSM-5-TR, or
2. Have sufficient collateral information present that indicates a high probability of a serious
mental illness or comorbid diagnoses at a mild to moderate level as defined in the DSM-
5-TR.
B. Agencies that provide co-occurring or substance use disorder-only residential services at an
ASAM 3.1-type must ensure the following personnel requirements are met:
1. If utilizing certified addiction technicians (CAT), these personnel do not comprise more
than twenty-five percent (25%) of the agency’s total personnel, and
2. If utilizing counselors-in-training and/or interns, these personnel do not comprise more
than twenty-five percent (25%) of the agency’s total personnel.
5.6 C linically Managed Residential Withdrawal Management (ASAM Level 3.2-WM) Services
A. This part 5.6 applies to agencies providing withdrawal management services at an ASAM 3.2-WM
level of care.
B. This part 5.6 does not apply to agencies providing behavioral health residential services only.
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5.6.1 Service Delivery and Setting
A. Level 3.2-WM services provide a twenty-four (24) hour setting in which individuals may withdraw
from substances while supervised by personnel, responsible for the implementation of medical
provider-approved protocols.
B. Agencies must develop policies and procedures to address service delivery expectations. These
policies and procedures must address, but are not limited to the following:
1. Consultation with specialized clinical and medical professionals for individualized
withdrawal management care;
2. Coordinating an individual’s transition into other levels of care, determined to be
appropriate through triage, screening, evaluation, and/or assessment processes
completed during the course of Level 3.2-WM services. This may include collaboration
with emergency behavioral health services, such as Colorado Crisis Services, as
appropriate;
3. Conducting or arranging for laboratory and/or toxicology tests to be completed;
4. Responding to individuals who are assessed as being a current threat to themselves or
others. This must include appropriate use of law enforcement and monitoring any use of
individual restraint and/or seclusion in accordance with part 2.14 of these rules;
5. Communication with intoxicated individuals leaving treatment against personnel
recommendations, including the use of emergency commitments; and
6. Circumstances under which individuals must end Level 3.2-WM services, other than
completing services or leaving against personnel recommendations.
C. S upport systems
1. Agencies must:
a. Implement protocols that are developed and supported by a physician
knowledgeable in addiction medicine;
b. Have protocols in place to address an individual’s evolving treatment and
withdrawal needs, including protocols for if the individual’s condition deteriorates
and requires medical or nursing care services;
c. Have protocols that clearly determine the nature of medical or nursing care
required. These protocols must include how to determine when nursing and/or
physician care is warranted, and/or when transfer to a medically monitored
facility or acute care hospital is necessary;
d. Ensure that medical evaluation and consultation is available twenty-four (24)
hours per/day; and
e. Ensure that medications that are self-administered, monitored, or dispensed at
the agency are supervised and documented in accordance with agency policy
and procedures, state, and federal law.
D. Diagnostic criteria
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1. Individuals participating in Level 3.2-WM services are generally intoxicated, under the
influence, or in any stage of withdrawal from alcohol and/or other drugs.
2. In addition to the ASAM Criteria guidelines detailed in part 2.12.3.C of these rules,
individuals participating in Level 3.2-WM services must meet the diagnostic criteria for
substance withdrawal disorder, as indicated in the DSM-5-TR.
3. Upon admission to Level 3.2-WM services, the agency must complete the following
minimum requirements:
a. Collect information regarding the degree of alcohol and/or other drug intoxication
as evidenced by breathalyzer, urinalysis, self-report, observation or other
evidence-based or best practices;
b. A pregnancy screening for pregnancy-capable individuals;
c. Taking of vital signs; and
d. Administration of a validated clinical withdrawal assessment tool.
E. The agency must conspicuously post procedures for responding to circumstances and events
that warrant entering a divert status.
5.6.2 Personnel
A. Personnel must be trained in, and evaluated in knowledge of the following areas before providing
services independently, if within their scope of practice and job description:
1. Withdrawal management process;
2. Monitoring vital signs;
3. Conducting assessment and triage, including identifying and properly responding to
suicidal ideation;
4. C ollecting urine and breath samples; and
5. Basic counseling and motivational interviewing skills.
B. Agencies providing Level 3.2-WM must ensure all personnel working with children under the age
of eighteen (18) are trained and knowledgeable in child development and engaging children in
states of intoxication and withdrawal management care.
C. Each work shift at an agency must have a minimum of two (2) personnel, whenever one (1) or
more individuals are present. At least one (1) of those persons must be treatment personnel as
listed in part 5.2.2.D of this Chapter.
D. The individual-to-personnel ratio must not exceed ten to one (10:1).
E. The agency personnel requirements below are specific to each physical location where Level 3.2-
WM services are provided. This includes on-call personnel that may assist as needed.
1. At least fifty percent (50%) of the agency’s personnel providing Level 3.2-WM services
must consist of treatment personnel identified in part 5.2.2.D of this Chapter.
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a. If utilizing counselors-in-training and/or interns, the agency must ensure that all
clinical documentation is reviewed and co-signed by a clinical agency supervisor
able to supervise pursuant to their scope of practice. Plans for addiction
counselor certification must be available for review.
b. Full-time personnel must obtain at least an addiction technician certification
within eighteen (18) months of employment.
2. Uncertified personnel or personnel without a plan for addiction counselor certification
must not comprise more than fifty percent (50%) of an agency’s total personnel. This
includes group living workers that may be utilized for milieu management.
F. The person overseeing day-to-day operations for agencies providing Level 3.2-WM services must
be one of the following:
1. An authorized practitioner,
2. A licensee; or
3. A certified addiction specialist (CAS).
5.6.3 Service Provisions
A. Agencies must:
1. Provide safe management and documentation of signs and symptoms of intoxication and
withdrawal;
2. Ensure that transition planning begins at the time of admission to Level 3.2-WM services,
to allow for necessary care coordination and transition into ongoing or concurrent
treatment services to occur successfully;
3. Provide additional service planning for managing individuals with medical conditions,
suicidal ideation, pregnancy, psychiatric conditions, and other conditions which place
individuals at additional risk during withdrawal management; and
4. P rovide assessments of individual readiness for treatment and services based on the
service plan and the assessments and interventions shall be documented in the
individual’s record.
B. Medication-assisted treatment (MAT) for withdrawal management
1. Agencies must continue individuals on their medication-assisted treatment regimen and
will only remove individuals from medications treating opioid use disorders at the
individual’s request or if it is deemed medically appropriate by an authorized practitioner.
2. Agencies must inform individuals receiving services about access to medication-assisted
treatment. Upon the individual’s consent, the agency must provide medication-assisted
treatment directly.
3. Agencies must obtain a controlled substance license pursuant to section 21.300 of 2
CCR 502-1 from the BHA if they plan to dispense, compound, or administer a controlled
substance from stock medication in order to treat a substance use disorder or to treat the
withdrawal symptoms of a substance use disorder.
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a. A controlled substance license is not required if the agency intends to provide
medication-assisted treatment (MAT) services through prescription writing only,
under an independent prescriber’s license.
C. Discharge from Level 3.2-WM services
1. Agencies must ensure referral and care coordination for continued behavioral health
treatment that occurs at the time of discharge from Level 3.2-WM services. This may be
made available within the agency’s structure or through referral.
2. Agencies must provide discharge information as required in part 2.10.A.6 of these rules
to the individual and document that it was provided.
3. Agencies must provide the following information to individuals at the time of discharge
from Level 3.2-WM services:
a. Effects of alcohol and other drugs;
b. Risk factors associated with alcohol and other drug abuse for acquiring and
transmitting HIV/AIDS (Human Immunodeficiency Virus/Acquired Immune
Deficiency Syndrome), Tuberculosis (TB), and other infectious diseases, and for
pregnancy;
c. Availability of testing and pre/post-test counseling for HIV/AIDS, TB, Hepatitis C
and other infectious diseases, and pregnancy; and
d. Availability of harm-reduction and alcohol and other substance use disorder
treatment resources.
5.6.4 Documentation and Timeliness
A. The following must be addressed within three (3) hours of an individual’s arrival at the agency:
1. Personnel must complete the screening and triage process as indicated in part 2.12.1 of
these rules to determine the urgency and appropriateness of care within the agency
including the need for emergency or urgent medical or psychiatric services;
2. In c ollaboration with the individual, personnel must develop withdrawal management-
focused initial service plan, tailored to the safe withdrawal of the individual from the
substance(s) of concern;
3. In addition to required intake documentation and consents as noted in part 2.11 of these
rules, the agency must inventory and secure the individual’s personal belongings. This
must be observed and confirmed through documentation by at least two (2) personnel;
and
4. Personnel must monitor and document vitals in real-time.
B. As soon as clinically feasible, but no later than seventy-two (72) hours following admission of an
individual to Level 3.2-WM services, the agency must:
1. Update or amend any intake paperwork or consents that the individual was not able to
complete or comprehend due to their state of intoxication upon admission;
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2. Complete at least the initial assessment as indicated in part 2.12.2 of these rules,
including substance use disorder history and the degree to which the use of substances
affects personal and social functioning;
3. Update the individual’s service plan to reflect ongoing treatment needs as identified
through the assessment; and
4. Document referral and care coordination activities to support the individual’s transition
into beginning or resuming behavioral health treatment services.
C. Observation and monitoring requirements
1. Agencies must conduct routine monitoring of physical and mental status of the individual
throughout their time in Level 3.2-WM services. This must include:
a. Vital signs taken and documented in real-time at the following minimum
frequency:
(1) Every two (2) hours until vitals remain at the individual’s baseline for at
least four (4) consecutive hours,
(2) Then every eight (8) hours thereafter until discharge.
(a) Documentation per shift to include all individual monitoring
activities.
5.7 Clinically Managed Residential Services, Including ASAM Level 3.3 Services
A. This part 5.7 applies to agencies providing behavioral health residential services at an ASAM 3.3
level of care.
B. This part 5.7 does not apply to agencies providing Level 3-WM services only.
C. T his part 5.7 does not apply to services to children under the age of eighteen (18) seeking
residential services.
5.7.1 Service Delivery and Setting
A. These services are intended for individuals who are unlikely to benefit from outpatient services or
other residential levels of care due to a temporary or permanent cognitive impairment resulting
from an addictive or co-occurring disorder. Therapeutic rehabilitation facilities or traumatic brain
injury programs are examples of this level of care.
B. Agencies shall confirm that individuals served have a history of substance use or co-occurring
disorders or difficulty with interpersonal relationships, coping skills, or comprehension that
necessitates this twenty-four (24) hour structured recovery environment, in combination with high-
intensity clinical services.
C. If agency personnel determine that an individual served may benefit from deliberately repetitive
and/or concrete services, those services shall be delivered on a timeline appropriate to the
individual’s assessed cognitive needs.
D. The agency must ensure that treatment is focused on preventing relapse, continued problems
and/or continued use, enhancing readiness to change, and promoting the eventual reintegration
of the individual into the community.
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E. Individuals with a temporary cognitive impairment may be transferred to another level of care
after the impairment has resolved. Individuals with chronic cognitive impairment may remain in
this level of care for a longer duration, if assessed as continuing to meet their individual needs.
F. Support systems
1. Agencies must:
a. Ensure the availability of telehealth or on-site consultation with an authorized
practitioner or nurse twenty-four (24) hours per day, seven (7) days per week;
b. Ensure the availability of consultation with emergency services twenty-four (24)
hours per day, seven (7) days per week; and
c. Have the capacity to arrange for medication-assisted treatment (MAT) and/or
psychiatric medications in a timely manner for individuals served.
(1) This may include services provided through coordination and referral but
must not exceed twenty-four (24) hours from identifying the need to
complete.
5.7.2 Personnel
A. If utilizing certified addiction technicians (CAT), these personnel must not comprise more than
twenty-five percent (25%) of the agency’s total personnel; and
B. If utilizing counselors-in-training and/or interns, these personnel must not comprise more than
twenty-five percent (25%) of the agency’s total personnel.
5.7.3 S ervice Provisions
A. Services must be regularly scheduled services and include a minimum of nine (9) hours of
planned treatment services per week.
B. Services must be delivered in a manner that is matched to the individual’s functioning. These
services may be provided in a deliberately repetitive manner or with a timeline appropriate to
address the cognitive needs of individuals for whom this level of care is considered a medical
necessity.
5.7.4 Documentation
A. Agencies must complete and document the following items in the individual’s record within
twenty-four (24) hours of admission:
1. All required demographic, intake and consent paperwork, as specified in part 2.11 of
these rules;
2. Screenings, as required in part 2.12.1 of these rules;
3. The initial assessment as required in part 2.12.2 of these rules; and
4. The initial service plan, addressing immediate needs and other relevant concerns
identified in the initial assessment, as required in part 2.13.1 of these rules.
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B. As soon as possible, but no later than ten (10) calendar days after an individual’s admission, the
agency must complete and document the comprehensive assessment for the individual, as
required in part 2.12.3 of these rules.
C. As soon as possible, but no later than three (3) calendar days after an individual’s comprehensive
assessment is completed, the agency must complete and document an individualized and
comprehensive service plan, informed by the comprehensive assessment, as required in part
2.13.1 of these rules.
D. If the individual’s comprehensive assessment indicates they may benefit from further evaluation,
medication, and/or specialty behavioral health care to address mental health, substance use-
specific, or co-occurring needs, the agency must ensure their individualized treatment needs are
addressed during the episode of care. The individual record must contain documentation
reflecting how these assessed needs were met.
E. Service plan reviews and revisions must be completed and documented in the individual’s record
when there is a change in the individual’s level of functioning or service needs, but in no case
may service plan reviews and revisions occur later than:
1. Monthly for the first six (6) months after admission, and
2. At least quarterly for the remainder of time that the individual remains in residential
services.
F. P rogress notes must be present in the individual’s record, in accordance with part 2.13.2 of these
rules. Progress notes must be completed at least daily for this level of care.
5.8 Level Two Mental Health Transitional Living Home Services
A. Level two mental health transitional living homes shall comply with the rules in parts 5.1 through
5.4 of this Chapter.
B. Level two mental health transitional living homes shall ensure that 600 minutes (ten hours) of
planned treatment services are provided to each individual on a weekly basis.
C. Level two mental health transitional living homes must either:
1. Be designated pursuant to part 11.18 of these rules to provide care and treatment to
individuals on short-term and long-term certifications on an outpatient basis; or
2. Establish facility agreements with designated facilities in order to treat individuals on
short-term or long-term certifications on an outpatient basis.
5.9 Clinically Managed Residential Services, Including ASAM 3.5-Type Services
A. This part 5.9 applies to agencies providing ASAM 3.5-type clinically managed behavioral health
residential services.
B. This part 5.9 does not apply to agencies providing only Level 3-WM services.
5.9.1 S ervice Delivery and Setting
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A. These services are intended for individuals who have multifaceted treatment needs requiring a
twenty-four (24) hour treatment environment, and who are unable to be properly treated at a
lower level of residential care. A variable-length therapeutic community or residential treatment
center are examples of this level of care.
B. Agencies must confirm that any individuals served have multiple treatment considerations to be
addressed during the residential episode of care, which may include, but are not limited to the
following:
1. A history of mental health, substance use or co-occurring disorders.
2. Engagement in behaviors and/or thought processes that contribute to impaired social,
interpersonal, and/or vocational functioning, necessitating this highly structured twenty-
four (24) hour treatment environment.
C. Services provided by the agency must be directed toward developing and enhancing prosocial
behaviors, sustaining recovery, reducing relapse risk when applicable, and the promotion of
successful reintegration into the community.
D. Support systems
1. Agencies providing this clinically managed residential service shall:
a. Ensure the availability of telehealth or on-site consultation with an authorized
practitioner twenty-four (24) hours per day, seven (7) days per week;
b. Ensure the availability of consultation with emergency services twenty-four (24)
hours per day, seven (7) days per week; and
c. H ave the capacity to arrange for medication-assisted treatment (MAT) and/or
psychiatric medications in a timely manner that must not exceed twelve (12)
hours to complete.
5.9.2 Personnel
A. Agencies must:
1. Ensure that each work shift has a minimum of two (2) personnel on-site, whenever one
(1) or more individuals are present in the milieu; and
2. Maintain individual-to-personnel ratios not exceeding twenty to one (20:1) at all times, per
physical location, unless otherwise noted. This includes nighttime and weekend hours.
5.9.3 Service Provisions
A. Services for individuals must be regularly scheduled and include a minimum of ten (10) hours of
planned treatment services per week.
5.9.4 Documentation and Timeliness
A. Agencies must complete and document the following items in the individual’s record within
twenty-four (24) hours of admission:
1. All required demographic, intake and consent paperwork, as specified in part 2.11 of
these rules;
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2. Screenings, as required in part 2.12.1 of these rules;
3. The initial assessment as required in part 2.12.2 of these rules; and
4. The initial service plan, addressing immediate needs and other relevant concerns
identified in the initial assessment, as required in part 2.13.1 of these rules.
B. Screenings and assessments conducted in accordance with 5.9.4.A must be used to determine
appropriateness for this level of care.
C. As soon as possible, but no later than ten (10) calendar days after an individual’s admission, the
agency must complete and document the comprehensive assessment for the individual, as
required in part 2.12.3 of these rules.
D. As soon as possible, but no later than three (3) calendar days after an individual’s comprehensive
assessment is completed, the agency must complete and document an individualized and
comprehensive service plan, informed by the comprehensive assessment, as required in part
2.13.1 of these rules.
E. If the individual’s comprehensive assessment indicates they may benefit from further evaluation,
medication, and/or specialty behavioral health care to address mental health, substance use-
specific, or co-occurring needs, the agency must ensure their individualized treatment needs are
addressed during the episode of care. The individual record must contain documentation
reflecting how these assessed needs were met.
F. S ervice plan reviews and revisions must be completed and documented in the individual’s record
when there is a change in the individual’s level of functioning or service needs, but in no case
may service plan reviews and revisions occur later than:
1. Monthly for the first six (6) months after admission, and
2. At least quarterly for the remainder of time that the individual remains in residential
services.
G. Progress notes must be present in the individual’s record, in accordance with part 2.13.2 of these
rules. The minimum frequency of progress note completion for this level of care may vary,
depending upon the individual’s time in the level of care and/or anticipated length of stay.
1. For the first thirty (30) days of the stay, daily progress notes are required.
2. After the first thirty (30) days where there is an anticipated length of stay of three (3)
months or less, providers shall continue required daily progress notes.
3. After the first thirty (30) days when there is an anticipated length of stay of more than
three (3) months, providers shall complete progress notes at a minimum of weekly.
5.9.5 Treatment Type Standards for Clinically Managed Behavioral Health Residential Services
and ASAM 3.5-Type Services
A. A gencies that provide mental health-only or co-occurring residential services must confirm the
following:
1. Individuals served meet at least one (1) of the following criteria:
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a. Are diagnosed with a serious mental illness (SMI) or comorbid diagnoses at a
moderate level, per the DSM-5-TR, or
b. Have sufficient collateral information to indicate there is a high probability that the
individual has a serious mental illness or comorbid diagnoses at a moderate
level, as defined in the DSM-5-TR.
B. Agencies that provide co-occurring or substance use disorder-only residential services at an
ASAM 3.5-type must ensure the following:
1. If utilizing certified addiction technicians (CAT), these personnel do not comprise more
than twenty-five percent (25%) of the agency’s total personnel, and
2. If utilizing counselors-in-training and/or interns, these personnel do not comprise more
than twenty-five percent (25%) of the agency’s total personnel.
5.10 Medically Monitored Residential Services, Including ASAM 3.7-Type Services
A. This part 5.10 applies to agencies providing ASAM 3.7-Type medically monitored behavioral
health residential services.
B. This part 5.10 does not apply to agencies providing only ASAM Level 3.7-WM services.
5.10.1 Service Delivery and Setting
A. Medically monitored residential services are intended for individuals whose medical, emotional,
behavioral and/or cognitive problems are severe enough to require twenty-four (24) hour medical
monitoring, but do not require the full resources of an acute care general hospital or medically
managed inpatient treatment program. These services may be offered in free-standing buildings
providing residential services or incorporated into specialty units within general health care or
psychiatric hospitals.
B. A gencies must ensure that individuals receiving services receive multiple treatment
considerations including but not limited to: a history of mental health, substance use or co-
occurring disorders, along with medical, cognitive, or complicated withdrawal management needs
that require the structured regimen of twenty-four (24) hour evaluation, observation, and medical
monitoring in order to safely provide the necessary behavioral health services.
C. Agencies must ensure treatment is designed for individuals who have functional limitations in the
areas of intoxication/withdrawal potential, biomedical conditions, and/or emotional, behavioral, or
cognitive conditions. This level of care focuses on the monitoring of the individual’s biomedical
needs to promote physical and psychiatric stabilization and allow for continued engagement in a
lower level of care once the individual is stabilized.
D. Support systems
1. Agencies must:
a. Ensure the availability of telehealth or on-site consultation with an authorized
practitioner or nurse twenty-four (24) hours per day, seven (7) days per week;
b. Ensure the availability of consultation with emergency services twenty-four (24)
hours per day, seven (7) days per week;
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c. Have the capacity to arrange for medication-assisted treatment (MAT) and/or
psychiatric medications in a timely manner for individuals served. This must not
exceed eight (8) hours from identifying the need to complete;
d. Ensure the availability of additional medical specialty consultation, psychological,
laboratory and toxicology services; and
(1) These services may be provided through consultation or referral; and
e. Ensure that psychiatric services, if not provided, are available on-site through
consultation or referral within eight (8) hours by telehealth or twenty-four (24)
hours in-person.
5.10.2 Personnel
A. Agencies must:
1. Ensure that each work shift has a minimum of two (2) personnel on-site whenever one (1)
or more individuals are present in the milieu;
2. Maintain an individual-to-personnel ratio not exceeding twenty to one (20:1) at all times,
per physical location. This includes nighttime and weekend hours;
3. Utilize an interdisciplinary team that includes physicians, nurses and mental health
professionals licensed or certified pursuant to Article 245 of Title 12, C.R.S. that provide
twenty-four (24) hour professionally directed evaluation, care and treatment services
including administration of prescribed medications, withdrawal management and
integrated treatment of co-occurring medical, emotional, behavioral or cognitive
conditions;
4. Be ov erseen by a physician licensed pursuant to Article 240 of Title 12, in order to assure
the quality of care; and
5. Have a nurse as defined in part 1.3 of these rules, responsible for monitoring the
individual’s progress and/or medication administration twenty-four (24) hours per day,
seven (7) days per week.
5.10.3 Service Provisions
A. Medically monitored residential services must be regularly scheduled and include a minimum of
twenty (20) hours of planned treatment services per week.
B. At the time of admission to the agency, a registered nurse must conduct an alcohol or other drug-
focused assessment, if applicable.
C. As soon as clinically feasible, but no later than twenty-four (24) hours after admission to the
agency, an authorized practitioner must perform a physical examination of the individual.
1. Physical examinations performed by authorized practitioners must be completed as
necessary for the individual throughout the episode of care.
5.10.4 Documentation and Timeliness
A. Agencies must complete and document the following items in the individual’s record within
twenty-four (24) hours of admission:
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1. All required demographic, intake and consent paperwork, as specified in part 2.11 of
these rules;
2. Screenings, as required in part 2.12.1 of these rules;
3. The initial assessment as required in part 2.12.2 of these rules; and
4. The initial service plan, addressing immediate needs and other relevant concerns
identified in the initial assessment, as required in part 2.13.1 of these rules.
B. Screenings and assessments conducted in accordance with 5.10.4.A of this Chapter must be
used to determine appropriateness for this level of care.
C. As soon as possible, but no later than ten (10) calendar days after an individual’s admission, the
agency must complete and document the comprehensive assessment for the individual, as
required in part 2.12.3 of these rules.
D. As soon as possible, but no later than three (3) calendar days after an individual’s comprehensive
assessment is completed, the agency must complete and document an individualized and
comprehensive service plan, informed by the comprehensive assessment, as required in part
2.13.1 of these rules.
E. If the individual’s comprehensive assessment indicates they may benefit from further evaluation,
medication, and/or specialty behavioral health care to address mental health, substance use-
specific, or co-occurring needs, the agency must ensure their individualized treatment needs are
addressed during the episode of care. The individual record must contain documentation
reflecting how these assessed needs were met.
F. S ervice plan reviews and revisions must be completed and documented in the individual’s record
when there is a change in the individual’s level of functioning or service needs, but in no case
may service plan reviews and revisions occur later than:
1. Monthly for the first six (6) months after admission, and
2. At least quarterly for the remainder of time that the individual remains in residential
services.
G. Progress notes must be present in the individual’s record, in accordance with part 2.13.2 of these
rules. Progress notes must be completed at least daily for this level of care.
5.10.5 Treatment Type Standards for Medically Monitored Behavioral Health Residential Services
and ASAM 3.7-Type Services
A. Agencies that provide mental health-only or co-occurring residential services must ensure the
following:
1. Individuals served meet at least one (1) of the following criteria:
a. Are diagnosed with a serious mental illness (SMI) or comorbid diagnoses at a
severe level, as defined in the DSM-5-TR;
b. Have sufficient collateral information that indicates a high probability that the
individual has a serious mental illness or comorbid diagnoses at a severe level,
as defined in the DSM-5-TR; or
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c. Are diagnosed with a serious mental illness (SMI) or comorbid diagnoses at a
mild to moderate level, as defined in the DSM-5-TR, with additional biomedical
needs that require a higher level of medical oversight.
B. Agencies that provide co-occurring or substance use disorder-only residential services at an
ASAM 3.7-type must ensure the following:
1. If utilizing certified addiction technicians (CAT), these personnel do not comprise more
than twenty-five percent (25%) of the agency’s total personnel, and
2. If utilizing counselors-in-training and/or interns, these personnel do not comprise more
than twenty-five percent (25%) of the agency’s total personnel.
5.11 Medically Monitored Inpatient Withdrawal Management (ASAM Level 3.7-WM) Services
A. This part 5.11 applies to agencies providing withdrawal management services at an ASAM 3.7-
WM level of care.
B. This part 5.11 does not apply to agencies providing behavioral health residential services only.
5.11.1 Service Delivery and Setting
A. Level 3.7-WM services are available for individuals who require the oversight of medical and
nursing professionals in order to complete a safe period of withdrawal. This level of care provides
a twenty-four (24)-hour service in which individuals have prompt access to medical evaluations as
needed, as well as an interdisciplinary team available to meet the individual’s needs. Services are
developed and delivered under the monitoring of a physician. This may be observed as a
freestanding withdrawal management center or as a step-down service from an acute care
hospital.
1. S ervices must be provided by licensed medical personnel qualified to supervise
withdrawal from alcohol and other drugs through the use of medication and/or medical
procedures in residential settings which possess a controlled substances license in
compliance with Part 2 of Article 80 of Title 27, C.R.S.
B. Agencies must develop policies and procedures to address service delivery expectations. These
policies and procedures must address, but are not limited to the following:
1. Consultation with specialized clinical and medical professionals for individualized
withdrawal management care;
2. Coordinating an individual’s transition into other levels of care, determined to be
appropriate through triage, screening, evaluation, and/or assessment processes
completed during the course of Level 3.7-WM services. This may include collaboration
with emergency behavioral health services, such as Colorado Crisis Services, as
appropriate;
3. Conducting or arranging for laboratory and/or toxicology tests to be completed;
4. Responding to individuals who are assessed as being a current threat to themselves or
others. This must include appropriate use of law enforcement and monitoring any use of
individual restraint and/or seclusion in accordance with part 2.14 of these rules;
5. Communication with intoxicated individuals leaving treatment against personnel
recommendations, including the use of emergency commitments; and
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6. Circumstances under which individuals must end Level 3.7-WM services, other than
completing services or leaving against personnel recommendations.
C. Support systems
1. Agencies must:
a. Implement protocols that are developed and approved by a physician
knowledgeable in addiction medicine.
b. Develop and implement specific admission protocol detail for which substances,
including both drugs and alcohol, medical withdrawal management services are
provided. This protocol must include processes for customary and atypical
withdrawal management from each drug delineated in the admission protocol,
and must include at minimum, the following elements:
(1) Types of intoxication;
(2) Tolerance levels for the individual's drug of choice;
(3) Degrees of withdrawal;
(4) Possible withdrawal and/or intoxication complications;
(5) Other conditions affecting medical withdrawal management procedures;
(6) Types of medications used;
(7) Recommended dosage levels;
(8) Procedures to follow in the event of withdrawal management
complications;
(9) Daily assessments including expected improvements as well as potential
problems; and
(10) Expected duration of withdrawal management.
c. Ensure that prompt medical evaluation and consultation is available twenty-four
(24) hours/day.
d. Ensure that hourly nurse monitoring of the individual’s progress is available, if
medically indicated.
e. E nsure that medications that are self-administered, monitored, or dispensed at
the facility are supervised and documented in accordance with agency policy and
procedures, state, and federal law.
f. Ensure referral and care coordination for continued behavioral health treatment
occurs. This may be made available within the agency’s structure or through
referral.
D. Diagnostic criteria
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1. Individuals participating in Level 3.7-WM services are generally intoxicated, under the
influence, or in a severe stage of withdrawal from alcohol and/or other drugs. These
individuals may have comorbid medical issues that require additional medical oversight.
2. In addition to the ASAM Criteria guidelines detailed in part 2.12.3.C of these rules,
individuals receiving Level 3.7-WM services must meet the diagnostic criteria for
substance withdrawal disorder, as indicated in the DSM-5-TR.
3. Upon admission to Level 3.7-WM services, the agency must complete the following
minimum requirements:
a. Collect information regarding the degree of alcohol and/or other drug intoxication
as evidenced by breathalyzer, urinalysis, self-report, observation or other
evidence-based or best practices;
b. A pregnancy screening for pregnancy-capable individuals;
c. Taking of vital signs; and
d. Administration of a validated clinical withdrawal assessment tool.
E. The agency must conspicuously post procedures for responding to circumstances and events
that warrant entering a divert status.
5.11.2 Personnel
A. Personnel must be trained in, and evaluated in knowledge of the following areas before providing
services independently:
1. Withdrawal management;
2. Monitoring vital signs;
3. Conducting assessment and triage, including identifying and properly responding to,
suicidal ideation;
4. C ollecting urine and breath samples; and
5. Basic counseling and motivational interviewing skills.
B. Agencies providing Level 3.7-WM must ensure all personnel working with children under the age
of eighteen (18) are trained and knowledgeable in child development and engaging children in
states of intoxication and withdrawal management care.
C. Each work shift must have a minimum of two (2) personnel, whenever one (1) or more individuals
are present.
D. Treatment personnel as defined in part 5.3.2.D must be present at a rate that meets the needs of
the individuals receiving Level 3.7-WM services.
E. Agencies must employ, at minimum, the following personnel:
1. A medical director who is licensed as a physician or medical doctor pursuant to Article
240 of Title 12, C.R.S.,
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2. A registered nurse or licensed practical nurse with at least one (1) year of withdrawal
management experience; and
3. Treatment personnel as defined in part 5.3.2.D of this Chapter.
F. Personnel oversight
1. The person overseeing day-to-day operations for an agency providing Level 3.7-WM
services must be the medical director.
2. The medical director’s responsibilities must include, at minimum:
a. Quarterly reviews and revisions of drug withdrawal management categories and
protocols;
b. Reviews of individual withdrawal management plans;
c. Reviews of individual prescriptions;
d. Direct supervision of individual withdrawal management cases that deviate from
standard protocols and/or the individual experiences complications;
e. Five (5) hours of monthly supervision of and consultation with personnel
providing withdrawal management services;
f. Development and implementation of back-up systems for physician coverage
when medical director(s) are unavailable and/or for emergencies;
g. Review of critical incidents reported in accordance with part 2.16 of these rules;
and
h. Review of admission, medical exclusion, and medical care policies at least
annually.
G. Agencies must ensure twenty-four (24) hour access to clinical personnel by telehealth and
accommodations for unscheduled visits in the event of crises or problem situations.
5.11.3 S ervice Provisions
A. Agencies must:
1. Provide safe management and documentation of signs and symptoms of intoxication and
withdrawal;
2. Ensure that transition planning begins at the time of admission to Level 3.7-WM services,
to allow for necessary care coordination and transition into ongoing or concurrent
treatment services to occur successfully;
3. Provide additional service planning for managing individuals with medical conditions,
suicidal ideation, pregnancy, psychiatric conditions, and other conditions which place
individuals at additional risk during withdrawal management; and
4. Provide assessments of individual readiness for treatment and services based on the
service plan and the assessments and interventions shall be documented in the
individual’s record.
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B. Medication-assisted treatment (MAT) for withdrawal management
1. Agencies must continue individuals on their medication-assisted treatment regimen and
will only remove individuals from medications treating opioid use disorders at the
individual’s request or if it is deemed medically appropriate by an authorized practitioner.
2. Agencies must inform individuals receiving services about access to medication-assisted
treatment. Upon the individual’s consent, the agency must provide medication-assisted
treatment directly.
3. Agencies must obtain a controlled substance license pursuant to section 21.300 of 2
CCR 502-1 from the BHA if they plan to dispense, compound, or administer a controlled
substance from stock medication in order to treat a substance use disorder or to treat the
withdrawal symptoms of a substance use disorder.
a. A controlled substance license is not required if the agency intends to provide
medication-assisted treatment (MAT) services through prescription writing only,
under an independent prescriber’s license.
C. Discharge from Level 3.7-WM services
1. Agencies must ensure referral and care coordination for continued behavioral health
treatment occurs at the time the individual is discharged from Level 3.7-WM services.
This may be made available within the agency’s structure or through referral.
2. A gencies must provide discharge information as required in part 2.11 of these rules to the
individual and document that it was provided.
3. In addition to these requirements, agencies must provide the following information to
individuals at the time of discharge from Level 3.7-WM services:
a. Effects of alcohol and other drugs;
b. Risk factors associated with alcohol and other drug abuse for acquiring and
transmitting HIV/AIDS (Human Immunodeficiency Virus/Acquired Immune
Deficiency Syndrome), Tuberculosis (TB), and other infectious diseases, and for
pregnancy;
c. Availability of testing and pre/post-test counseling for HIV/AIDS, TB, Hepatitis C
and other infectious diseases, and pregnancy; and
d. Availability of harm-reduction and alcohol and other substance use disorder
treatment resources.
D. Agencies must provide medical evaluations completed by authorized practitioners. The medical
evaluations must consist of, at minimum:
1. Medical histories including detailed chronologies of substance use disorders;
2. Identification of current physical addiction including drug types;
3. Physical examinations to determine appropriateness for outpatient or inpatient medical
withdrawal management; and
4. Appropriate laboratory tests and other evaluations, as indicated.
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E. Medication dispensation and administration procedures
1. Agencies using stock-controlled substances in order to treat a substance use disorder or
to treat the withdrawal symptoms of a substance use disorder are required to have a
controlled substance services license issued by the BHA and comply with the applicable
portion(s) of section 21.300 of 2 CCR 502-1 that deal with a controlled substance license.
2. Agencies may utilize buprenorphine for medications for opioid use disorder (MOUD)
services without requiring an opioid treatment program endorsement. If an agency
intends to utilize controlled substances other than/in addition to buprenorphine for MOUD
services, the agency must be endorsed as an opioid treatment program, verified through
the Drug Enforcement Administration (DEA), and coordinated with the SAMHSA.
3. Qualified practitioners may prescribe buprenorphine under their own Drug Enforcement
Administration (DEA) registration number for individuals admitted to this level of care for
withdrawal management or addiction treatment.
4. Agencies must develop and implement policies and procedures for dispensing
medications per standard withdrawal management protocols that are in accordance with
applicable state and federal statutes and for the following:
a. Individual prescriptions filled and dispensed by a registered pharmacist at a
designated pharmacy location;
b. I ndividual prescriptions from medical directors that are filled from stock
quantities; and
c. Storage and accounting of all medications, including controlled substances.
5.11.4 Documentation and Timeliness
A. The following must be addressed within three (3) hours of an individual’s arrival at the agency:
1. Personnel must complete the screening and triage process as indicated in part 2.12.1 of
these rules to determine the urgency and appropriateness of care within the agency
including the need for emergency or urgent medical or psychiatric services;
2. In collaboration with the individual, personnel must develop a withdrawal management-
focused initial service plan, tailored to the safe withdrawal of the individual from the
substance(s) of concern;
3. In addition to required intake documentation and consents as noted in part 2.11 of these
rules, the agency must inventory and secure the individual’s personal belongings. This
must be observed and confirmed through documentation by at least two (2) personnel;
and
4. Personnel must monitor and document vitals in real-time.
B. As soon as clinically feasible, but no later than seventy-two (72) hours following admission of an
individual into Level 3.7-WM services, the agency must:
1. U pdate or amend any intake paperwork or consents that the individual was not able to
complete or comprehend due to their state of intoxication upon admission;
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2. Complete at least the initial assessment as indicated in part 2.12.2 of these rules,
including substance use disorder history and the degree to which the use of substances
affects personal and social functioning;
3. Update the individual’s service plan to reflect ongoing treatment needs as identified
through the assessment; and
4. Document referral and care coordination activities to support the individual’s transition
into beginning or resuming behavioral health treatment services.
C. The individual record must contain informed consent to receive medical withdrawal management
services that includes at minimum:
1. Medications to be used; and
2. Need to consult with primary care physicians.
D. Observation and monitoring requirements
1. Agencies must conduct routine monitoring of physical and mental status of the individual
throughout their time in Level 3.7-WM services. This must include:
a. Vital signs taken and documented in real-time at the following minimum
frequency:
(1) Every two (2) hours until vitals remain at the individual’s baseline for at
least four (4) consecutive hours,
(2) Then every eight (8) hours thereafter until discharge.
(a) Documentation per shift to include all individual monitoring
activities.
2. If medical personnel determine that an individual requires vital signs to be monitored and
documented in real-time at a frequency that is less than the minimum requirement above,
the rationale and plan for this variance must be documented in the individual’s record.
Non-medical personnel must not make or document such a determination.
Chapter 6: E mergency and Crisis Behavioral Health Services
6.1 Authority and Applicability
A. Chapter 6 establishes the standards for and is applicable to BHEs electing to provide behavioral
health crisis and emergency services. The authority to promulgate these service-specific
requirements that apply to BHEs electing to provide these services comes from Sections 27-50-
502(1), 27-50-106, and 27-50-107(3)(b), C.R.S.
6.2 General Provisions
A. All agencies providing residential services to individuals shall comply with the residential and
overnight requirements set forth in part 2.26 of these rules.
B. Each component within the behavioral health crisis response system must provide services in a
trauma-informed, culturally responsive manner.
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C. Agencies must incorporate peer support professionals in accordance with Chapter 3 of these
rules into the services they provide, when clinically appropriate.
6.3 Walk-In Crisis Services
6.3.1 Applicability
A. These rules set forth in this section 6.3 are established to create standards for and apply to
agencies with an endorsement to provide walk-in crisis services.
6.3.2 General Provisions
A. Each walk-in crisis agency must obtain a 27-65 designation and be in compliance with Section
27-60-104, C.R.S.
B. All walk-in crisis agencies are required to obtain a Children and Families endorsement pursuant
to Chapter 8 of these rules.
C. Walk-in crisis services must be accessible to all individuals throughout the state of Colorado
twenty-four (24) hours per day, seven (7) days per week, and 365 days per year. Every walk-in
crisis services agency must have the ability to provide information and referrals to anyone in
need, and crisis assessment when indicated, including, if appropriate, access and clinically
appropriate transportation to crisis stabilization in a crisis stabilization unit. Walk-in crisis service
agencies must collaborate with other agencies endorsed pursuant to this Chapter 6, and
community-based organizations.
D. A w alk-in crisis agency must have the capacity to:
1. Screen and triage every individual who presents at the agency, with any presenting
problem including acute and chronic substance use and/or intellectual and developmental
disability;
2. Coordinate multiple simultaneous requests for services;
3. Work closely with community partners, family members or caregivers; and
4. Work with local hospitals to develop accepted clearance practices to divert the individual
in crisis from emergency departments for purpose of verifying medical stability prior to
residential or inpatient admission.
E. Walk-in crisis agencies must employ an integrated care model based on evidence-based
practices that consider an individual's physical and emotional health.
F. Walk-in crisis agencies shall manage and prevent elopement of individuals on an emergency
mental health hold using strategies in conformity with state and federal laws.
G. Walk-in crisis agencies must develop crisis safety plans in collaboration with the individual in
crisis and/or their family member(s) or other social supports. Safety plans should include
psychiatric advanced directives and referrals/warm hand offs to health and social services and
supports, as needed.
H. Follow-up services must be provided to every individual and must include:
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1. Follow-up to each individual and authorized caregiver and/or family member(s) by phone
or in-person, based on clinical need and individual preferences. The first follow-up must
be within twenty-four (24) hours after services were provided. Follow-up attempts must
be documented in the individual’s record. Follow-up communications must be compliance
with state and federal data protection laws.
2. Follow-up communication may be conducted face-to-face, via telehealth, or via telephone
only, based on an individual’s clinical need and preferences.
6.3.3 Service Provisions
A. Walk-in crisis services must include screening as defined in part 2.12.1 of these rules, triage,
crisis assessment, and referrals to appropriate resources. Individuals in crisis must be screened
and triaged within fifteen (15) minutes of arrival.
1. Walk-in crisis agencies are exempt from assessment requirements in Part 2.12.2 and
2.12.3 of these rules. Walk-in crisis agencies shall complete a crisis assessment, in full,
on a BHA-created form that is available on BHA’s website, if clinically indicated by the
initial screening in part 2.12.1 of these rules.
B. Prior to an individual leaving a walk-in crisis agency, screenings must be reviewed by a crisis
professional who is licensed or a candidate receiving supervision from a licensee or authorized
practitioner.
1. Walk-in crisis agencies shall refer all individuals seeking crisis services to appropriate
resources based on the level of care indicated by the screening or crisis assessment.
C. Walk-in crisis services must include:
1. Brief intervention, stabilization and de-escalation intended to maintain stability in the
community, whenever possible to include such activities as:
a. On-site interventions, including solution-focused crisis counseling, for immediate
de-escalation of presenting behavioral health issues.
b. Coordination with other providers involved in the individual’s or individual’s
family’s care.
c. Skill development, psychosocial education and initial identification of resources
needed to stabilize the presenting situation.
d. Crisis prevention strategies, including resources to cope with presenting
emotional symptoms, behaviors, and existing circumstances to avoid future
crises.
e. I
mmediate coordination with other crisis providers when needed (e.g., crisis
stabilization units and respite, psychiatric emergency services).
f. Prioritization of remaining in the community, especially for children. Prioritize
crisis response in home and community-based settings, including schools,
recreational centers, homeless shelters, and other community centers for
children.
g. Lethal means restriction.
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h. Peer support to reduce stigma and build connection.
i. Identifying and engaging natural supports.
2. Substance use services:
a. Walk-in crisis agencies shall provide harm reduction interventions, including the
administration of opioid receptor antagonists to reverse an overdose, if needed.
b. Evaluation of withdrawal management needs. Walk-in crisis agencies may offer
withdrawal management services if endorsed to provide such services.
c. Evaluation of appropriateness for medication-assisted treatment (MAT) and
referrals to providers that can initiate treatment as indicated.
3. Physical health screen, if indicated, to inform crisis planning and/or as part of the
clearance practice.
a. Physical health screens may be provided by qualified walk-in crisis agency
personnel or through coordination or referral to a medical provider.
4. Referrals:
a. Walk-in crisis agency personnel are responsible for referrals and warm hand-offs
to health and social services and supports, including withdrawal management
and medication-assisted treatment, as needed.
b. Walk-in crisis agency personnel must make documented efforts to schedule
follow-up appointments within seven (7) business days of referral.
6.3.4 Personnel Requirements
A. A walk-in crisis agency must be staffed twenty-four (24) hours per day, seven (7) days per week,
and 365 days per year.
B. A walk-in crisis agency must include a number of trained professionals on their team which may
include licensees, authorized practitioners, peer support professionals, case managers, nurses,
and other trained crisis personnel.
C. A walk -in crisis agency must employ sufficient personnel to ensure that the provision of services
meets the needs of individuals. At minimum, the agency must have two (2) personnel on- site at
all times.
D. A walk-in crisis agency must always be staffed by crisis professionals who can lead the crisis
assessment and intervention. This may include crisis professionals receiving supervision from a
licensee or authorized practitioner.
E. A walk-in crisis services agency must have access to a licensee or authorized practitioner within
fifteen (15) minutes via telehealth if one is not available onsite.
F. Every agency endorsed to provide walk-in crisis services must employ or contract with a peer
support professional who may lead initial engagement and assist with follow-up services. Any
recovery support services rendered by peer support professionals shall be provided in
accordance with part 3.1 through 3.5 of these rules.
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G. A walk-in crisis agency must include a personnel member trained in working with children,
families and their caregivers who experience crisis.
H. A walk-in crisis agency must develop a training plan for personnel to ensure expertise in
addressing and responding to individuals with physical or intellectual/developmental disabilities
(I/DD), traumatic brain injury, severe mental illness, serious emotional disturbance, substance
use disorders, co-occurring disorders, and other cognitive or neurodiverse needs who are in
crisis.
I. A walk-in crisis agency may develop contractual relationships with local providers with expertise
in working with the populations referenced in part 6.3.4.H of this Chapter above. These providers
must be engaged during or immediately after initial face-to-face intervention as needed to support
individuals in crisis who do not already have an existing relationship with a provider. Telehealth
may be used to secure expertise for individuals served by the mobile crisis response team with a
physical or I/DD.
J. Providers seeking crisis professional status must complete training required by the BHA found on
the BHA website. Status will be tracked on a yearly basis by the BHA.
6.4 Crisis Stabilization Units
6.4.1 Applicability
A. These rules set forth in this section 6.4 are established to create standards for and apply to
agencies with an endorsement to operate a crisis stabilization unit (CSU).
6.4.2 S tandards for crisis stabilization services
A. Crisis stabilization services must meet the requirements of part 2.12 of these rules, including, but
not limited to requirements for screening, initial assessment, and comprehensive assessment,
with the following additions:
1. Comprehensive assessments must be completed within twenty-four (24) hours of
admission of an individual;
2. Medical and medication treatment in accordance with parts 11.8 and 11.17.13 of these
rules and coordination with medical services;
3. Peer support, in accordance with Chapter 3 of these rules, when clinically appropriate;
4. Discharge and service planning in accordance with part 2.10 and 2.13 of these rules;
5. Safety planning:
a. Safety planning is required, and safety plans must be developed in collaboration
with the individual and the individual’s family members and/or other social
supports, if not clinically contraindicated.
b. Safety plans must include psychiatric advance directives.
6. Care coordination and referral services.
B. Crisis stabilization services must include, at a minimum:
1. Medication management; and
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2. Individual and/or group counseling.
C. The agency shall ensure individuals admitted for crisis stabilization services cannot be
appropriately treated in a less restrictive setting.
D. The individual must be assessed for continued appropriateness for treatment in the crisis setting
at least every three (3) days.
1. When an individual’s assessment indicates the individual should be transferred to a
different setting but placement in that setting is delayed due to lack of availability, the
agency shall document that in the service plan, and continue reassessing the individual in
accordance with part 6.5.2.A above.
2. Assessments for continued stays in the crisis stabilization setting past seven (7) days
must include consideration regarding whether the individual would be more appropriately
served, and should be transferred to, a different level of care.
6.4.3 Crisis Stabilization Unit Staffing Requirements
A. In addition to the walk-in crisis service staffing requirements listed in part 6.3.4 of these rules,
crisis stabilization units must have:
1. Access to an authorized practitioner upon admission; and
2. At minimum, one (1) on-site personnel member qualified to administer medications.
6.5 Mobile Crisis Services
6.5.1 Applicability
A. The rules set forth in this section 6.5 are established to create standards for and apply to
agencies with an endorsement to provide mobile crisis services pursuant to Section 27-60-104,
C.R.S.
6.5.2 G eneral Provisions
A. Mobile crisis service agencies are intended to provide a timely paired mobile response as
described in part 6.5.3.B to a behavioral health crisis in the community. Mobile crisis service
agencies must provide referrals and facilitate transitions to other crisis agencies, behavioral
health entities, and community-based services as clinically indicated.
B. All agencies providing mobile crisis services or responding to crisis calls shall meet critical
incident reporting procedures in accordance with part 2.16 of these rules.
6.5.3 Service Provisions
A. Mobile crisis service agencies must have the capacity to:
1. Intervene where the crisis occurs;
2. Coordinate multiple simultaneous requests for services;
3. Work closely with law enforcement, emergency medical services, crisis hotlines, schools,
and hospital emergency departments; and
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4. Serve priority populations.
B. An agency’s mobile crisis response teams must arrive at the community-based location where a
crisis occurs within two (2) hours of accepting a dispatch request for rural and frontier areas as
defined in Section 23-76.5-101(6), C.R.S. and within one (1) hour of accepting a dispatch request
for urban areas, including dispatch from the statewide hotline/988 either face-to-face or using
telehealth operations.
1. The mobile crisis service agency shall develop policies for dispatch criteria related to
serving:
a. Populations listed in part 6.5.4.E of this Chapter
b. Individuals of all ages
c. Individuals demonstrating aggressive behavior
d. Individuals who are uninsured or unable to pay for services
e. Individuals who may lack Colorado residency or legal immigration status
2. If the statewide hotline/988 requests a mobile crisis response, a mobile crisis service
agency shall immediately accept the request which means to affirm the request from the
hotline and immediately dispatch the mobile crisis response team. Rejected requests are
subject to review from the BHA or their designee.
C. Mobile crisis service agencies must operate twenty-four (24) hours per day, seven (7) days per
week, and 365 days per year in providing community-based crisis intervention, screening, crisis
assessment on a BHA created form that is available on the BHA’s website, and referrals to
appropriate resources.
D. T he mobile crisis service agency must complete screening requirements as defined in part 2.12.1
of these rules. In addition to these screening requirements, the mobile crisis service agency must
also attempt to collect the following information:
1. Strengths and resources of the individual experiencing the crisis, their family members,
and other social supports
2. Recent inpatient hospitalizations and/or any current relationship with a behavioral health
provider
3. Medications prescribed, medications taken recently, current prescriber and information
about the individual’s ongoing medication regimen
E. The screening process referenced in this section’s subpart D above must also include a rapid
determination as to whether the crisis warrants medical or law enforcement response.
F. The mobile crisis service agency must administer a crisis assessment, in full, on a BHA-created
crisis assessment form that is available on the BHA’s website if clinically indicated by the initial
screening in part 2.12.1 of these rules.
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G. Mobile crisis service agencies through mobile crisis response teams shall develop crisis safety
plans in collaboration with individuals in crisis and their authorized family members and/or other
social supports, unless clinically contraindicated. The safety plan shall be in writing and copies of
the plan must be offered to the individual, the individual’s caregiver when applicable, and to other
service providers or social supports when authorized by the individual.
1. Safety plans must include any psychiatric advance directives in effect.
2. Safety plans shall also include:
a. Short-term strategies for immediate stabilization
b. Long-term strategies to support a return to the pre-crisis level of functioning
c. Referrals to services, supports, and resources identified by the mobile crisis
team.
H. Mobile crisis teams of a mobile crisis service agency must follow-up with an individual and
authorized caregiver and/or family member(s) by phone or in-person, based on clinical need and
individual preferences, within twenty-four (24) hours from when services are provided. Follow-up
attempts must be documented in the individual’s record.
I. Mobile crisis response teams of a mobile crisis service agency must provide brief intervention,
stabilization and de-escalation services intended to maintain stability in the community, whenever
possible. This may include but is not limited to:
1. On-s ite interventions, including solution-focused crisis counseling, for immediate de-
escalation of presenting behavioral health issues.
2. Coordination with other providers involved in the individual’s or family’s care.
3. Skill development, psychosocial education and initial identification of resources needed to
stabilize the presenting situation.
4. Crisis prevention strategies and resources to cope with presenting emotional symptoms,
behaviors and existing circumstances and avoid future crises.
5. Immediate coordination with other crisis providers, including peer support professional
services, when needed. Other crisis providers may include walk-in centers, crisis
stabilization units and respite, psychiatric emergency services.
6. Prioritization of remaining in the community, especially for children and young people.
Prioritize crisis response in home and community-based settings, including schools,
recreational centers, homeless shelters, and other community centers for children.
7. Provide harm reduction interventions, including the administration of an opioid receptor
antagonist to reverse an overdose, when needed.
8. Evaluation of appropriateness for medication-assisted treatment (MAT) and referrals to
providers that can initiate treatment as indicated.
J. Mobile crisis response teams of a mobile crisis service agency must provide or coordinate
clinically appropriate and accessible transportation to an appropriate level of care as needed
following a response. An agency’s mobile crisis team may only provide transportation directly if
they are appropriately licensed by their county as a secure transportation provider.
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6.5.4 Personnel Requirements
A. All mobile crisis service agencies must include a mobile crisis response team.
1. Every mobile crisis response team must include a licensee or authorized practitioner, or
2. Must have a licensee or authorized practitioner immediately available via telehealth.
3. Mobile crisis response teams may also include a number of trained professionals on their
teams including emergency medical technicians, community paramedics, peer support
professionals, mobile crisis case managers, nurses, and other trained crisis personnel.
B. Every mobile crisis response team must include a crisis professional who can lead the crisis
assessment and intervention.
C. Every agency endorsed to provide mobile crisis services must employ or contract with a peer
support professional who can be included in the mobile crisis response team as appropriate and
available, and who may take the lead on initial engagement and assist with follow-up services.
1. A peer support professional must be available for follow-up services within one (1)
business day of the crisis response.
D. Every mobile crisis response team must include a personnel member with specific training and
expertise in serving children and their caregivers who experience crisis.
E. Personnel on a mobile crisis response team must be trained in responding to individuals with
physical or intellectual/developmental disabilities (I/DD), traumatic brain injury, severe mental
illness, serious emotional disturbance, substance use disorders, co-occurring disorders, and
other cognitive or neurodiverse needs who are in crisis.
F. Mobile crisis service agencies may develop contractual relationships with local providers with
expertise working with the populations referenced in 6.4.4.H of this Chapter. These providers
must be engaged during or immediately after initial face-to-face intervention as needed to support
individuals in crisis who do not already have an existing relationship with a provider. Telehealth
may be used to secure expertise for individuals served by the mobile crisis response team with a
physical disability or I/DD.
G. Mob
ile crisis service agencies must develop a training plan to ensure expertise in addressing
specific population needs as described in part 6.3.4.H of this section. If not utilizing contractual
relationships to meet requirements in part 6.5.4.F of this section, the plan must address training
for serving populations described in that part.
6.6 Respite Care Services
6.6.1 Applicability
A. These rules set forth in this section 6.6 are established to create standards for and apply to
agencies with an endorsement to provide residential or community-based respite care services.
6.6.2 General Provisions
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A. Residential or community-based respite care services provide temporary or short-term care by a
licensee, authorized practitioner, candidate or other personnel based on the level of care being
provided and is designed for an individual that has experienced a self-defined crisis. Crisis respite
is intended to be a flexible intervention or set of services based on the presenting concerns of the
individual in a self-defined crisis and must have the capacity to:
1. Provide supports necessary to alleviate the conditions leading to the initial crisis; and
2. Enhance an individuals’ sense of safety and agency in managing their crisis.
B. Residential or community-based respite care services include a range of short-term services
twenty-four (24) hours per day, seven (7) days per week, and 365 days per year. Respite care
services shall be flexible to ensure that the individual’s daily routine is maintained.
C. Length of stay determinations must be ongoing, transparent to the individual and family to the
extent allowable under state and federal privacy laws, and jointly determined by the individual,
family, respite provider, and treatment team.
D. In order to be eligible for residential or community-based respite services, an individual that has
experienced a behavioral health crisis must:
1. Be referred by personnel within other agencies endorsed pursuant to this Chapter 6;
2. Agree to residential or community-based respite services;
3. Not meet emergency procedure criteria outlined in Section 27-65-106, C.R.S., Care and
Treatment for Persons with Mental Illness;
4. Present a minimal risk of significant withdrawal complications;
5. Cooperate with program guidelines; and
6. Be able and willing to participate, with accommodations if needed, in forming a service
plan.
6.6.3 S ervice Provisions
A. Services must be intended to improve/maintain the condition and functional level of the individual
and prevent relapse or hospitalization while providing a safe environment to address precipitating
factors to the crisis. Services must include structure, support, and care coordination, and may
include but not be limited to the following:
1. Comprehensive assessment as described in part 2.12.3 of these rules;
2. Assistance with monitoring, completing, or prompting of activities of daily living (ADLs);
3. Assistance with medical and physical health needs, including medication administration
and monitoring;
4. Life skills and environmental maintenance;
5. Assistance/supervision needed by an individual to participate in social, recreational and
community activities;
6. Referral to and establishing a stronger connection to community resources;
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7. Relationship building;
8. Safety planning;
9. Stigma reduction; and
10. Monitoring of personal hygiene, nutritional support, safety, and environmental
maintenance.
6.6.4 Personnel Requirements
A. Respite agency personnel shall be multidisciplinary, with the intention of subclinical stabilization,
responsive to the unique needs of the individual. Respite agency personnel shall include
expertise in meeting the need of children if the agency holds a Children and Families
endorsement, which includes but is not limited to:
1. Child and family peer support providers; psychiatrists, psychiatric nurse practitioners, or
physicians; and social workers, counselors, and crisis specialists;
2. Have personnel who can assess physical health needs and deliver care for most minor
physical health challenges;
3. Have an identified pathway to transfer the child to more medically staffed services, if
needed; and
4. Ensure that personnel have child and family expertise and experience, training in trauma-
responsive care and cultural responsiveness.
B. Peer support professionals must be utilized in accordance with Chapter 3 of these rules if
providing residential or community-based respite services.
C. Every respite agency must include a licensee or authorized practitioner. This licensee or
authorized practitioner must be immediately available via telehealth.
6.6.5 Respite Care Settings
A. Respite care services may be provided in residential or community-based settings.
1. R esidential respite care services must comply with residential and overnight
requirements in accordance with part 2.26 of these rules.
2. Community-based respite care services may be provided in the individual's home or
community as a temporary relief from stressful situations or environments, or to provide
additional support in the individual’s home environment.
6.7 Acute Treatment Services
6.7.1 Applicability
A. These rules set forth in this section 6.7 are established to create standards for and apply to
agencies with an endorsement to operate an acute treatment unit (ATU).
6.7.2 Standards for Acute Treatment Services
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A. Agencies providing acute treatment unit services must be designated pursuant to Chapter 11 of
these rules.
B. The agency shall ensure the admission/discharge criteria and service planning requirements in
part 2.10 and 2.13.1 of these rules, as well as assessment requirements in parts 2.12.2 and
2.12.3 of these rules are met with the following additions:
1. The agency shall ensure individuals admitted for acute treatment services are age
eighteen (18) years or older, in need of psychiatric care, and cannot be appropriately
treated in a less restrictive setting.
2. The individual shall be assessed for continued appropriateness for treatment in the acute
treatment services setting at least every three (3) days. Individual stays may be extended
when such extension is determined to be the most appropriate course of treatment based
on an updated individual assessment and service plan, as follows:
a. When an individual’s assessment indicates the individual should be transferred to
a different setting but placement in that setting is delayed due to lack of
availability, the agency shall document that in the service plan, and continue to
reassess the individual in accordance with part 6.7.2.B.2.
b. Assessments for continued stays in the acute treatment services setting past ten
(10) days shall include consideration regarding whether the individual would be
more appropriately served, and should be transferred to, a different level of care.
3. An in dividual may only be admitted into a locked setting if there is no less restrictive
appropriate alternative and admitting to a locked facility is in compliance with Chapter 11
of these rules.
4. An individual may be admitted into a 27-65 designated facility on a voluntary basis, as
long as the following requirements are met and the individual signs a form that
documents the following:
a. The individual is aware the setting is locked.
b. The individual has the ability to exit the setting with personnel assistance.
5. An individual who is an imminent danger to self or others may only be admitted to acute
treatment services upon completion of the agency’s comprehensive assessment and
determination that the individual’s safety and the safety of others can be maintained.
6. If an individual is admitted and personnel subsequently determine the individual’s
behavior cannot be safely and successfully treated in the acute treatment services
location, the agency shall make arrangements to transfer the individual to the nearest
hospital or other appropriate level of care for further assessment and evaluation.
7. The agency shall have policies that identify when an individual requires a physical health
assessment by a qualified licensed practitioner, including, but not limited to:
a. W ithin twenty-four (24) hours of admission;
b. When there is a significant change in the individual’s condition;
c. When the individual has evidence of a possible infection, such as swelling or
open sores;
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d. When the individual experiences an injury or accident that might cause a change
in condition;
e. When the individual has known exposure to a communicable disease; or
f. When the individual develops any condition that would have initially precluded
admission to the acute treatment service setting.
8. The agency shall ensure the individual’s service plan is created within twenty-four (24)
hours after admission. Such service plan shall include any special dietary instructions,
physical or cognitive limitations, and a description of the services which the agency will
provide to meet the needs identified in the individual’s assessment(s).
a. The individual may request a modification of the services identified in the service
plan at any time.
b. The service plan shall include goals of the acute treatment services stay and
standards to be met for discharge.
C. The agency shall ensure acute treatment services meet personnel training requirements in
accordance with part 2.14.3 of these rules, with the following additions:
1. The agency’s administrator shall have training in assessment skills, nutrition, and
identifying and dealing with behavioral health crises and behavior management, and be
responsible for the overall direction and supervision of personnel;
2. T he agency’s clinical director shall have training in assessment and identifying and
treating individuals who display behaviors that are common to individuals with severe and
persistent mental health disorders; and
3. The agency shall ensure the staffing level in each physical location providing acute
treatment services is adequate to provide services to meet the needs of the individuals at
the location, in accordance with the individuals’ service plans.
D. The agency shall ensure compliance with parts 2.15 and part 11.17.15 of these rules, regarding
medication administration, storage, handling, and disposal.
E. The agency shall establish written house rules for the acute treatment services setting which do
not violate or contradict rules found in this Chapter 6, and which do not restrict an individual’s
rights. Such house rules shall be provided to the individual upon admission and be prominently
posted at the location services are provided.
F. Alternate building standards. The following building standards shall apply only to the physical
locations in which acute treatment services are provided.
1. The interior environment shall be clean and sanitary, free of hazards to health and safety,
including:
a. Layout, finishes, and furnishings must minimize the opportunity for residents to
injure themselves or others.
b. I nterior areas, finishes, and furnishings must be maintained in good repair and
promote sanitary conditions. All spaces shall have adequate heat, lighting, and
ventilation sufficient for its intended use and individual needs.
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c. Windows that can be accessed by individuals must have security glazing or other
appropriate security features to reduce the possibility of injury or elopement.
d. Items/substances that could be used for self-harm or harm to others, including,
but not limited to, sharp knives and cleaning solutions, must be appropriately
labeled and stored in a safe manner, inaccessible to individuals.
e. The physical location shall be maintained free of infestations of insects and
rodents and all openings to the outside must be screened.
f. An adequate supply of safe, potable water must be available.
g. Hot water shall not be more than 120 degrees Fahrenheit at taps which are
accessible by individuals, and there must be a sufficient supply of hot water to
meet the needs during peak usage.
G. The agency shall provide a clean, sanitary, and secure exterior environment for the year-round
use of individuals, free of hazards to health and safety.
1. Exterior areas must be maintained to prevent hazardous slopes, holes, or other hazards,
and must be kept free of high weeds and grass, garbage, and/or rubbish.
2. Secure outdoor areas shall be fenced or enclosed to prevent elopement and protect the
safety and security of individuals.
H. T he agency shall ensure the following standards are met regarding the physical operation of the
acute treatment services location:
1. The agency’s physical operation shall be in compliance with all applicable:
a. Local zoning, housing, fire, and sanitary codes and ordinances of the city, city
and county, or county where the location is situated.
b. State and local plumbing laws and regulations, including that plumbing must be
maintained in good repair, free of the possibility of backflow and back siphonage
through the use of vacuum breakers and fixed air gaps, in accordance with state
and local codes.
c. Sewage disposal requirements, including that sewage must be discharged into a
public sewer system or disposed of in a manner approved by the local health
department, or local laws if no local health department exists, and the Colorado
water quality control commission.
2. The agency shall have common areas adequate to accommodate all individuals,
including a designated dining area capable of seating all individuals, and meeting the
following accessibility requirements:
a. All common areas and dining areas must be accessible to individuals using an
auxiliary aid without requiring transfer from a wheelchair to walker or from a
wheelchair to a regular chair.
b. D oors to individual accessible rooms shall be at least thirty-two (32) inches wide.
c. A minimum of two entryways shall be provided for ingress and egress from the
building by individuals using a wheelchair.
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3. The following requirements must be met for bedrooms:
a. No individual may be assigned to any room other than a regularly designated
bedroom. Temporary occupancy of a room not designated as a bedroom is
permissible on a limited basis when the use of the assigned bedroom is
contraindicated due to circumstances related to individual safety or emergent
issues. Justification for such placement, and the length of placement, shall be
documented in the individual record.
b. No more than two (2) individuals shall reside in a bedroom.
c. Each bedroom for individuals must have at least 100 square feet for a single
individual, or 120 square feet for two residents. Bathroom areas and closets shall
not be included in the determination of square footage.
d. Each individual shall have separate storage facilities adequate for personal
Articles, such as a closet or locker, available inside their bedroom. Shelves may
be provided for folded garments in lieu of hanging garments.
e. Each bedroom must include a comfortable, standard-sized bed with a clean
mattress, mattress protector, pillow, rollaway-type beds, cots, folding beds, or
bunk beds are not permitted.
f. The bedroom shall have a safe and sanitary method to store the individual’s
towel, such as a breakaway towel rack.
g. E xtension cords and multiple-use electrical sockets shall be prohibited in
individual bedrooms.
h. The bedroom shall include a chair unless contraindicated, in which case alternate
seating shall be provided in close proximity to the bedroom.
4. The following standards must be met for bathrooms:
a. Each floor with bedrooms must have at least one bathroom which can be
accessed without entering a bedroom.
b. The physical location of the agency’s operations must have at least one full
bathroom accessible to any individual using an auxiliary aid, including properly
installed grab bars at each tub and/or shower, and adjacent to each toilet.
c. Bathtubs and shower floors must have non-skid surfaces.
d. Toilet seats shall be constructed of non-absorbent materials and free of cracks.
e. Individuals must have individualized personal care Articles and supplies, such as
soap and towels, and such Articles and supplies shall not be shared.
f. Toilet paper must be available at all times in each bathroom.
g. Liquid soap and paper towels must be available at all times in the common
bathrooms.
5. The following standards must be met for seclusion rooms:
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a. The seclusion room must be constructed to prevent an individual from hiding,
escaping, being injured, or dying by suicide, and must be free of all protrusions,
sharp corners, hardware, fixtures or other devices, and furnishings which may
cause injury to the individual.
b. The seclusion room must maintain a temperature appropriate for the season.
c. The seclusion room must be located in a manner affording direct observation of
the individual by personnel.
d. The seclusion room must have a window that allows someone outside the room
to see into all of the corners of the room. All windows in the seclusion room must
be constructed to prevent breakage and otherwise prevent self-harm.
e. Doors to the seclusion room shall be at least thirty-two (32) inches wide and must
open outward.
f. Light fixtures and other electrical outlets in the seclusion room must be limited to
those required and necessary, must be recessed, and must be constructed to
prevent self-harm. Such fixtures and outlets must be controlled by labeled on/off
switches located outside the seclusion room.
6. The agency shall meet the following requirements regarding linen and laundry:
a. The agency may have laundry room(s) with residential-style washer(s) and
dryer(s) in an area with adequate square footage and ventilation for the number
of washers and/or dryers included in the space.
b. T he laundry room(s) must not be used for storage of soiled or clean linen.
c. There must be a separate enclosed area for receiving and holding soiled linen
until ready for pickup or processing, in addition to a separate enclosed area for
clean linen storage.
d. There must be hand-washing, or other appropriate hand-sanitizing, facilities in
each area where unbagged, soiled linen is handled.
Chapter 7: Emergency and Involuntary Substance Use Disorder Commitment Services
7.1 Authority and Applicability
A. Chapter 7 establishes the standards for emergency and involuntary commitment of a person with
a substance use disorder. The authority to promulgate these rules necessary to carry out the
BHA’s programs for emergency and involuntary commitment of a person with a substance use
disorder comes from Section 27-50-107(3), C.R.S. and Section 27-50-502(1), C.R.S. authority for
BHA administration of these programs is found in Section 27-50-105(1)(pp), C.R.S. and Section
27-50-105(1)(qq), C.R.S.
B. These rules are established to create standards for agencies seeking an endorsement to provide
services to individuals on emergency substance use disorder commitments pursuant to Section
27-81-111, C.R.S. and Section 27-81-112, C.R.S.
C. Al l agencies providing services to individuals on emergency substance use disorder commitments
shall meet the standards in this Chapter 7. If the agency requires a BHE license, the agency shall
comply with Chapter 2 of these rules.
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7.2 Emergency Substance Use Disorder Commitment Services
A. Emergency commitment policies and procedures, based on compliance with Section 27-81-111,
C.R.S., shall be developed and implemented by the licensed and appropriately endorsed agency
providing withdrawal management services pursuant to Chapter 4 (Outpatient and High Intensity
Outpatient Services) or Chapter 5 (Residential Services) of these rules. Such policies and
procedures shall require agency personnel to:
1. Ascertain if grounds for commitment exist;
2. Assure that individuals and their legal representatives receive copies of the application
for emergency commitment forms and are advised verbally and in writing of the right to
challenge commitment through the courts; and,
3. Determine when grounds for emergency commitment no longer exist.
B. The treatment agency administrator shall designate, in writing, qualified personnel who meet the
criteria established in part 5.6.2.F of these rules, to assume responsibility for accepting,
evaluating, informing, and providing treatment to individuals on an emergency commitment.
C. Applications for emergency commitments must be prepared on BHA designated forms available
on the BHA website.
D. Daily evaluations shall be completed for the continuance of an emergency commitment. Daily
evaluations shall be documented in the individual record.
E. If individuals on an emergency commitment require treatment in other licensed and appropriately
endorsed withdrawal management programs, transfers shall be managed by the programs that
initially authorized the commitments.
F. When transferring individuals, withdrawal management programs shall use BHA designated
transfer forms available on the BHA website. Completed copies shall be given to:
1. Individuals and/or their legal representatives; and,
2. The withdrawal management programs to which individuals are being transferred.
G. When a child is transferred and/or the child's emergency commitment has been discontinued,
parents or legal guardians who have given permission for treatment must receive copies of
transfer form and emergency commitment form.
H. When it is determined that grounds for an emergency commitment no longer exist, the individual
must be transferred to voluntary status and the emergency commitment shall be discontinued and
documented. A copy of the emergency commitment form that specifies discontinuation of the
emergency commitment must be given to the individual and made part of the individual record as
described in part 2.11 of these rules.
I. Discharge summaries, as outlined in part 2.10.A.6 of these rules must be submitted to the BHA,
the referring source, and to the referral agency in accordance with state and federal
confidentiality laws and regulations.
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7.3 Involuntary Substance Use Disorder Commitment Services
A. These rules are established to create standards for agencies seeking an endorsement to provide
services for individuals on involuntary substance use disorder commitments pursuant to Section
27-81-112, C.R.S.
7.3.1 General Provisions
A. Involuntary commitment policies and procedures must be developed and implemented based on
and in compliance with Section 27-81-112, C.R.S.
B. The BHA may delegate physical custody of individuals involuntarily committed to an appropriate
approved treatment agency pursuant to Section 27-81-112(5), C.R.S.
C. Passes may be issued to individuals on involuntary commitments in residential settings only if
they are directly related to treatment. Passes shall not be issued during the initial thirty (30) days
of treatment, except in emergencies, as defined in part 1.2 of these rules, and with BHA approval.
D. The following information shall be reported to the BHA using the process outlined on the BHA
website:
1. Non-compliance with program requirements shall be reported within three (3) business
days;
2. Non-compliance with court orders shall be reported within 24 hours;
3. Failure to appear for admission to treatment shall be reported within 24 hours;
4. Leav ing treatment in violation of court orders shall be reported within 24 hours;
5. Failure to return from passes shall be reported within 24 hours; and,
6. Monthly treatment status reports shall be due by the 15th day of the month.
E. Discharge summaries, as outlined in part 2.10.A.6 of these rules shall be submitted to the BHA,
the referring source, and to the referral agency in accordance with state and federal
confidentiality laws and regulations.
F. An agency may not grant an individual’s requests for early discharge and/or transfer to other
treatment programs without first obtaining BHA approval.
7.3.2 Personnel Requirements
A. Primary counselors for individuals on an involuntary commitment, means the following behavioral
health professionals trained in substance use disorder identification and treatment and acting
within their scope of practice:
1. Authorized practitioner;
2. Licensee;
3. Certified addiction specialist (CAS); or,
4. Candidate personnel.
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B. All of the personnel noted in part 7.3.2.A above shall complete at least fourteen (14) hours of
training in interviewing techniques related to engaging individuals in treatment.
C. Copies of primary counselor credentials and other relevant documentation shall be maintained in
counselor personnel files as described in part 2.5.G of these rules.
Chapter 8: Services for Children and Families
8.1 Authority and Applicability
A. Chapter 8 establishes standards for agencies seeking an endorsement to provide services for
children and families. Rules include requirements for individual assessment, treatment and
patient rights. The authority for these standards comes from Section 27-50-502(1)(a)(I), C.R.S.
authority to promulgate these rules establishing additional competencies related to serving priority
populations, including children, comes from Section 27-50-502(6) C.R.S., and for children
Sections 27-50-301(3)(c), C.R.S., 27-50-301(5), C.R.S., and 27-50-107(3), C.R.S.
B. These rules are established to create standards for agencies seeking an endorsement to provide
psychotherapy services, as defined in part 1.2 of these rules, and services for children and
families. Services for children and families include Behavioral Health Early Intervention and
Outpatient Services as outlined in part 4.1 through 4.4.3 of these rules, Behavioral Health High-
Intensity Outpatient Services as outlined in part 4.6 through 4.7.4 of these rules, Behavioral
Health Residential Services as outlined in part 5.1 through 5.3.3 of these rules and part 5.5
through part 5.6 of these rules and part 5.9 through 5.9.5 of these rules and Emergency and
Crisis Behavioral Health Services as outlined in part 6.1 through 6.7.2 of these rules.
C. Al l agencies providing psychotherapy services and children and family services must meet the
standards in this Chapter 8. If the agency requires a BHE license, the agency shall comply with
Chapter 2 of these rules.
D. An agency with a Children and Families endorsement must also have at least one other
endorsement of these rules.
8.2 Behavioral Health Services for Children
8.2.1 Criminal History Record Check
A. In addition to criminal background checks required under part 2.6.D of these rules, agencies
must, prior to hiring or accepting new personnel, submit to the Federal Bureau of Investigation
(FBI) a complete set of fingerprints taken by a qualified law enforcement agency to obtain any
criminal record held by the FBI, for each prospective personnel. Payment of the fee for the
criminal record check is the responsibility of the agency. No direct contact with children may take
place until the background check is cleared by the FBI.
8.3 Rights of Children
A. Parents or legal guardians must be contacted without the child’s written or verbal consent, unless
notifying the parent or legal guardian would be inappropriate or detrimental to the minor’s care
and treatment, as authorized by Section 12-245-203.5(7), C.R.S., if:
1. T he child presents or communicates a danger to self or others, including a person who is
identifiable by the person’s association with a specific location or entity.
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B. Section 27-65-104(1), C.R.S. allows children who are fifteen (15) years of age or older, with or
without the consent of a parent or legal guardian, to knowingly consent to mental health services,
which includes the provision of psychotropic medications.
8.3.1 Rights of Children Receiving Outpatient Services
A. Agencies must obtain parental or legal guardian consent for children under fifteen (15) years of
age, with the following exception:
1. Section 12-245-203.5(2), C.R.S., allows psychotherapy services, as defined in Section
12-245-202(14)(a), C.R.S., to be provided to a child who is twelve (12) years of age or
older, with or without the consent of the child’s parent or legal guardian, if the child is
knowingly and voluntarily seeking such services and the provision of psychotherapy
services is clinically indicated and necessary to the child’s well-being. The following
mental health professionals are the only professionals within an agency allowed to
provide outpatient psychotherapy services in an outpatient setting to a child who is twelve
(12) years of age or older, without the consent of the child’s parent or legal guardian:
a. A professional person as defined in Section 27-65-102(27), C.R.S., which means
a person licensed to practice medicine in this state, a psychologist licensed to
practice in this state, or a person licensed and in good standing to practice
medicine in another state or a psychologist licensed to practice and in good
standing in another state who is providing medical or clinical services at a
treatment facility in this state that is operated by the Armed Forces of the United
States, the United States Public Health Service, or the United States Department
of Veterans Affairs;
b. A m ental health professional licensed pursuant to Article 245, of Title 12, C.R.S.,
which in accordance with Section 12-245-203.5, C.R.S., includes:
(1) A licensed psychologist or a psychologist candidate pursuant to Section
12-245-301 through -309, C.R.S.;
(2) A licensed clinical social worker or a licensed social worker candidate
pursuant to Section 12-245-401 through -410, C.R.S.;
(3) A marriage and family therapist licensed or a licensed marriage and
family therapist candidate pursuant Section 12-245-501 through -506,
C.R.S.;
(4) A licensed professional counselor or a licensed professional counselor
candidate pursuant to Section 12-245-601 through -607, C.R.S.; and,
(5) A licensed addiction counselor or an addiction counselor candidate
licensed pursuant to Section 12-245-801 through -806, C.R.S.
2. A child may not refuse psychotherapy services when a mental health professional and
the child’s parent or legal guardian agree psychotherapy services are in the best interest
of the child.
3. If the child voluntarily seeks psychotherapy services on their own behalf pursuant to
Section 12-245-203.5(2)(a), C.R.S.:
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a. The mental health professional may notify the child’s parent or legal guardian of
the psychotherapy services given or needed, with the child’s consent, unless
notifying the parent or legal guardian would be inappropriate or detrimental to the
child’s care and treatment.
b. The mental health professional shall engage the child in a discussion about the
importance of involving and notifying the child’s parent or legal guardian and
shall encourage such notification to help support the child’s care and treatment;
and,
c. Notwithstanding the provisions of Section 12-245-203.5(3)(a), C.R.S., a mental
health professional may notify the child’s parent or legal guardian of the
psychotherapy services given or needed, without the child’s consent, if, in the
professional opinion of the mental health professional, the child is unable to
manage the child’s care or treatment.
4. A mental health professional shall fully document in the child’s individual record, when
the mental health professional attempts to contact or notify the child’s parent or legal
guardian and whether the attempt was successful or unsuccessful, or the reason why, in
the mental health professional’s opinion, it would be inappropriate to contact or notify the
child’s parent or legal guardian.
a. If the child seeks psychotherapy services on their own behalf pursuant to Section
12-245-203.5(2)(a), C.R.S., documentation must be included in the child’s
individual record, along with a written statement signed by the child, indicating
the child is voluntarily seeking psychotherapy services.
5. In addition to the individual rights specified in part 2.7 of these rules, children who meet
the requirements of part 8.3.1.A.1, without the consent of a parent or legal guardian, have
the right to:
a. Consent to release of information
8.3.2 Rights of Children in Hospitalization
A. In addition to the individual rights specified in part 2.7 of these rules, and notwithstanding any
other provision of law, a child who is fifteen (15) years of age or older, with or without the consent
of a parent or legal guardian, has the right to consent to receive behavioral health services to be
rendered by an agency, a professional person, or a mental health professional pursuant to
Section 27-65-104(1), C.R.S., in any practice setting;
1. Consent to voluntary hospitalization for mental health services;
2. Object to hospitalization and to have that objection reviewed by the court under the
provision of Section 27-65-104(6), C.R.S.; and
3. C onsent to release of information.
B. Children who are under the age of fifteen (15), have the right to object to hospitalization and to
have a guardian ad litem appointed pursuant to Section 27-65-104(6)(b),(c), C.R.S.
8.4 Screening and Assessment of Children
A. Agencies shall follow screening as required in part 2.12.1 of these rules.
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B. Agencies shall follow the requirements of part 2.12.2 and part 2.12.3 of these rules in addition to
the following:
1. Comprehensive assessments must include an evaluation of the family's, or legal
guardian’s social determinants of health, as well as needs and strengths that may pertain
to the child’s treatment. If family or legal guardian basic needs are identified, including,
but not limited to, food, clothing, shelter and health, this must be addressed in the
individualized and family-oriented service plan and referral made to the identified services
and supports, if needed. Such comprehensive assessments will maintain the
confidentiality of participants records in accordance with applicable state and federal
laws.
2. The comprehensive assessment must explore how the identified family members, natural
supports or legal guardians will be involved in whole person and Two (2) -Generational
behavioral health services. In the event that any person’s involvement is contraindicated,
the clinical rationale must be documented.
3. The comprehensive assessment must also include a trauma assessment specific to
children, which can include but is not limited to: an ACEs screen, or a pediatric ACEs
screener. This shall be completed with the child utilizing any standardized screening tool.
a. Parent(s) or legal guardian(s) shall be included, unless involvement in the screen
is contraindicated, then the clinical rationale must be documented in the
individual record. If completing the aces screen, parent(s) and/or legal
guardian(s) shall complete this separately.
b. F or clarity and accuracy, a child under the age of twelve (12), must be given the
option to answer the questions verbally to the provider.
4. The comprehensive needs and strengths assessment must be incorporated into the
service plan, reassessment, and discharge plan, when or where appropriate, and assess
and triage for the needs of a child, who are at least seventeen (17) years of age who is
expected to require behavioral health services and supports beyond the age of eighteen
(18). This may include, but is not limited to:
a. Housing and/or housing stability;
b. Insurance or lack of insurance;
c. Transportation;
d. Employment and/or education;
e. Social supports;
f. Medical/dental needs; and
g. Food security and/or insecurity
8.5 Service Planning for Children and Families
A. Agencies shall follow part 2.13 of these rules, service planning and reviews, in addition to the
following:
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1. The service plan must be developed in collaboration with the child, and the child’s parent
or legal guardian and be signed by the child, if the child is over the age of twelve (12),
and by the parent or legal guardian. In the event that involvement of the parent or legal
guardian is contraindicated, the rationale shall be documented.
a. In all instances where prescription psychiatric medications are to be ordered as a
part of a mental health treatment program, the following information shall be
provided, in an accessible manner, to the child and parent(s) or legal guardian(s).
(1) The name(s) of the medication being prescribed.
(2) The usual uses of the medication(s).
(3) The reasons for ordering the medication(s) for the child.
(4) A description of the benefits expected.
(5) The common side effects and common discomforts, if any.
(6) The major risks, if any.
(7) The probable consequences of not taking the medication(s).
(8) Any significant harmful drug or alcohol interactions, or food interactions.
(9) Appropriate treatment alternatives, if any; and,
(10) That the child may withdraw agreement to take the medication at any
time.
2. A c opy of the service plan shall be provided, upon request, to the child, if they are over
the age of twelve (12), and parent or legal guardian. In the event that involvement of the
parent or legal guardian would be detrimental to the child’s health, safety, or welfare, the
rationale shall be documented.
3. The service plan shall be individualized and use a Two (2)- Generational approach to
include family driven goals and objectives that address the child and family services,
supports, needs and building on their strengths and natural supports as identified in the
assessment.
4. Service plans must be implemented in partnership with children and families. Service
plans must support planning and transition to another services and/or setting.
Chapter 9: Women’s and Maternal Behavioral Health Treatment
9.1 Authority and Applicability
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A. Chapter 9 establishes the standards for agencies electing to provide Women’s and Maternal
Behavioral Health Treatment. Authority to promulgate rules establishing requirements for
individual assessment, treatment, and patient rights, comes from Sections 27-50-107(3) and 27-
50-502(1)(a)(b), C.R.S. authority to promulgate these rules establishing additional competencies
related to serving priority populations comes from Section 27-50-502(6), C.R.S. additionally, the
BHA has authority to administer the treatment program for high-risk pregnant women created
pursuant to Sections 27-80-112 and 27-80-113, C.R.S. authority for BHA administration of this
program is found in Section 27-50-105, C.R.S. authority to promulgate rules required for the
administration of this program comes from Section 27-50-107(3)(a), C.R.S.
B. All agencies providing Women’s and Maternal Behavioral Health Treatment services shall meet
the standards in this Chapter 9. If the agency requires a BHE license, the agency shall comply
with Chapter 2 of these rules.
C. An agency with a Women’s and Maternal Behavioral Health Treatment endorsement shall also
have at least one level of care endorsement to provide substance use disorder treatment
pursuant to Chapters 4 through 7 of these rules.
9.1.1 General Provisions
A. P ersonnel shall have documented training, experience, and access to supervision in women-
specific issues and services. Training and experience may include topics such as:
1. Trauma-informed care;
2. Trauma;
3. Women’s and/or pregnancy-related health during the reproductive years;
4. Infertility;
5. Pregnancy loss;
6. Infant loss;
7. Perinatal mood and anxiety disorders;
8. Stigma and substance use disorder among pregnant and parenting women/ individuals
and perinatal substance exposure;
9. Body image/disordered eating;
10. Relationship violence/ healthy relationships;
11. Dyadic attachment/parenting;
12. American Society of Addiction Medicine (ASAM) Criteria for parents or prospective
parents receiving addiction treatment concurrently with their children; and,
13. Child welfare reporting requirements and alternatives.
B. Treatment for behavioral health shall be provided to and/or coordinated with family members,
unless clinically contraindicated. Clinical contraindications to this provision and referrals for
dyadic and/or family treatment must be documented in the individual record.
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C. Agencies shall make every attempt to offer any pregnant or postpartum women/individuals’
admission to treatment within forty-eight (48) hours and shall demonstrate compliance with part
9.1.5.D.
D. Agencies providing gender specific women’s and/or pregnancy-related behavioral health
treatment may include the following components:
1. Emotional and physical safety of individuals take precedence over all other
considerations in the delivery of services, as outlined within trauma-informed principles;
2. Services designed to increase women’s and/or pregnancy-related access to wraparound
services, and engagement and retention of individuals (such as peer services,
transportation, childcare);
3. Women-only therapeutic environments;
4. Women-specific service needs and topic areas;
5. Program services shall directly address trauma issues currently manifesting in the
individual’s life, either through direct service provision or by referral; and,
6. Multiple modalities that meet the specific needs of women (group and individual therapy,
case management and opportunities for women to be in treatment with their children
where possible).
E. Agency policy and procedures must include the criteria for interventions offered and expected
outcomes of services delivered.
9.1.2 Screening
A. In addition to the part 2.12.1 of these rules, screening shall include all the following unless
clinically contraindicated:
1. S creening and documentation of individual’s need for prenatal/postpartum care (where
applicable), primary medical care and family planning services; and
2. Screening and documentation of child safety issues and/or referrals for children in the
individual’s home that need behavioral health and/or medical care utilizing an evidence-
based instrument or best practice approach.
9.1.3 Treatment
A. Service plans shall be established in accordance with part 2.13 of these rules and shall address
each of the need areas identified in part 9.1.3.B and 9.1.3.C.
B. When not clinically contraindicated the following topic areas shall be addressed in treatment or
through comprehensive care coordination as outlined in part 2.9.G and the following, when
applicable:
1. Reductions or elimination of substance use;
2. Individual safety;
3. Child safety;
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4. Trauma;
5. Parenting, including attachment and co-regulation;
6. Ways in which behavioral health impacts family and relationships across the lifespan;
7. Primary care, medical care, lactation, pelvic health, dental health, reproductive health,
and family planning care;
8. Mental health, including parental mental health conditions; and
9. Nutrition assessment in relation to pregnancy, lactation, early childhood, and behavioral
health.
C. Any agency that qualifies to provide services pursuant to Sections 25.5-5-202(1)(r), 27-80-112,
C.R.S. and 27-80-113, C.R.S., in regard to the Treatment Program for High-Risk Pregnant
Women, shall make available, in addition to substance use and addiction counseling and
treatment:
1. Needs assessment services;
2. Preventive services;
3. Rehabilitative services;
4. Care coordination;
5. Psychosocial counseling;
6. Intensive health education;
7. Home visits;
8. Transportation;
9. Development of provider training;
10. Child care;
11. Child care navigation; and,
12. Other necessary components of residential or outpatient treatment or care.
9.1.4 Services for Pregnant and Postpartum Women/Individuals
A. Pregnant women/individuals shall be given priority admission and/or care coordination to
treatment for substance use disorders.
1. A gencies cannot deny services to pregnant and postpartum women/individuals due to
sobriety status.
B. Agencies shall develop policies and procedures for service delivery to pregnant and postpartum
women/ individuals, which shall include circumstances under which pregnant and postpartum
women/individuals may be discharged from treatment.
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1. Pregnant women/individuals may not be discharged from treatment solely for failure to
maintain abstinence from substance use.
2. Every effort shall be made to retain pregnant and postpartum women/individuals in
treatment for the duration of their pregnancies in order to maintain an optimal period of
abstinence from substance use.
C. Every attempt shall be made to admit pregnant women/individuals to treatment within forty-eight
(48) hours of first contact between the woman/individual and the admitting program.
D. If a pregnant woman/individual is not admitted to treatment within forty-eight (48) hours of first
contact, the reason shall be clearly documented in their individual record. If the individual is
working with a care coordinator through their managed care entity or managed service
organization, the care coordinator shall be informed. Interim services shall be provided consisting
of the following at minimum:
1. Referral for prenatal care;
2. Information on the effects of alcohol and drug use on the fetus and perinatal individual;
3. Daily phone contact with the individual for those seeking residential care; and,
4. Education regarding the transmission and prevention of communicable diseases such as
Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS),
Tuberculosis (TB), and Hepatitis A, B, or C.
E. P regnant and postpartum women/individuals shall be linked to prenatal and postpartum care
immediately and barriers to accessing prenatal and postpartum care including, but not limited to
transportation to care, must be addressed, and documented in their individual record.
F. If a pregnant or postpartum woman/individual declines prenatal or postpartum care, this shall be
documented in the individual record, and offers for care shall continue to be offered at a minimum
of one attempted contact monthly and documented. If no contact occurs within six (6) months, the
reason shall be documented, and the agency is no longer required to contact.
1. This does not include individuals who have completed their treatment goals or
disengaged from treatment.
Chapter 10: Services for Criminal Justice-Involved Individuals
10.1 Authority and Applicability
A. Chapter 10 establishes the standards for and applies to BHEs providing services to criminal
justice involved individuals, including specific criminal justice programs. The BHA has authority
for administration of DUI treatment programs pursuant to Article 2 of Title 42, C.R.S., and Alcohol
and Drug Driving Safety Education or Treatment pursuant to Section 42-4-1301.3, C.R.S. and
Section 27-50-105(1)(vv)(ww), C.R.S. authority to promulgate rules required for the administration
of this program comes from Section 27-50-107(3)(a), C.R.S. authority to promulgate rules
establishing requirements for individual assessment and treatment comes from Section 27-50-
502(1)(a)(I), C.R.S.
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B. Services for criminal justice-involved individuals must generally be intended for individuals who
are referred into education and/or treatment services as a result of, or in connection to,
involvement with the criminal justice system. This does not include juvenile justice system
services that are regulated by the responsible state agencies as indicated in Section 19-2.5-1401,
C.R.S.
C. Services for criminal justice-involved individuals must involve a continuum of education and/or
treatment options available to individuals as they proceed through the criminal justice system.
These services must be available across multiple settings, including community-based and
locked facility-based settings. Services offered must vary depending upon the needs of the
individual and the specific criminal justice program endorsement.
D. These rules are established to create standards for BHEs seeking endorsements to provide
education and/or treatment services, as defined in part 10.1.1 of this Chapter, for individuals
involved with the criminal justice system. This criminal justice endorsement and all corresponding
sub-endorsements may not be held alone, but in addition to appropriate corresponding
endorsement(s) and sub-endorsement(s) for the type of services being provided.
10.1.1 Definitions
“Contact Hours”, for the purposes of parts 10.5 through 10.9 of this Chapter means the time that an
individual participates in Level I Education, Level II Therapeutic Education, and/or Level II Treatment.
“C redit Hours”, for the purposes of parts 10.5 through 10.9 of this Chapter means the time that an
individual participates in non-DUI/DWAI specific education or treatment. These hours may be granted
towards education and/or treatment requirements for DUI/DWAI services within the parameters set forth
in this part 10.5.11.
“Education and/or Treatment” means the programs developed that are structured in such a manner to
provide a continuum of education and treatment for each individual as they proceed through the criminal
justice system and may include but shall not be limited to, attendance at self-help groups, group
counseling, individual counseling, outpatient treatment, inpatient treatment, day care, or treatment in a
therapeutic community. Education and treatment are to be accessible by all individuals involved in the
criminal justice system, pursuant to Section 16-11.5-102, C.R.S.
“Enhanced Outpatient Services,” or “EOP,” means services in which an individual receives an increased
number of therapeutic contacts and interactions with personnel, intended to expedite stabilization of
assessed behavioral health concerns. The goal is to stabilize the individual to allow for more effective
engagement in education and other treatment services.
“Program(s)” for the purpose of this Chapter, means the systems of education and treatment services
addressing abuse of substances which can be utilized by individuals who are placed on probation,
incarcerated with the Department of Corrections, placed on parole, or placed in community corrections,
pursuant to Sections 16-11.5-102(1)(b), C.R.S. and 42-4-1301.3, C.R.S.
“T elehealth, ” in addition to the requirements of part 1.2 and 2.9 of these rules, telehealth services for the
purpose of this Chapter 10, does not include consistent and regular in-session use of audio-only
telehealth services.
10.1.2 Assessment and Placement in Services
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A. Unless otherwise noted, BHEs endorsed to provide treatment programming to criminal justice-
involved individuals must receive placement recommendation(s) for each individual served,
completed by the referring supervising entity. The BHE is expected to evaluate if the supervising
entity’s recommendation matches the individual’s assessed clinical need(s). The BHE is expected
to address any differences identified with the supervising entity directly and document results in
the individual’s record.
B. The type of placement recommendation(s) from the supervising entity will vary depending upon
the type of supervising entity and the individual’s type of offense leading to the treatment referral.
BHEs must include a copy of the referral paperwork, demonstrating treatment in accordance with
the placement initial assessment and treatment recommendation(s) from the supervising entity, in
the individual’s record.
C. If a BHE is unable to obtain a copy of the placement recommendation(s) from the supervising
entity there must be documentation of attempt(s) to obtain the paperwork from the referral source,
if applicable.
D. BHEs must assess for and prioritize the delivery of services that support the individual’s
placement in the community, including reintegration into the community if incarcerated. This must
include engagement of the individual’s identified support system throughout the episode of care,
as permitted by the individual.
10.1.3 P ersonnel Training
A. All BHE personnel providing education and/or treatment services to individuals involved in the
criminal justice system must:
1. Be knowledgeable about the criminal justice system, including the sequential intercept
model and the processes and phases through which an individual moves in the criminal
justice system;
2. Be knowledgeable of the principles of risk, need, and responsivity;
3. Be knowledgeable about the criminal justice system in the state of Colorado, including
competency restoration services, as explained in Chapter 12 of these rules, and
situations involving individuals determined to be not guilty by reason of insanity (NGRI);
and
4. Attend at least one (1) training during their active licensing or approval term unique to
individuals involved in the criminal justice system.
5. Personnel providing curriculum-driven education and/or treatment services, including but
not limited to DUI/DWAI programming, to individuals involved in the criminal justice
system must be trained in the curriculum and be qualified to provide such services, as
indicated in parts 10.4 through 10.9 of this Chapter.
B. The above training requirements may be satisfied by completing the BHA-developed criminal
justice services curriculum on the statewide Learning Management System (LMS), once
developed and available in the LMS.
C. BH Es endorsed to provide programming to DUI/DWAI-involved individuals must maintain proof of
completion of the training in personnel files and provide verification to the BHA upon request.
10.1.4 Documentation
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A. In addition to documentation requirements applicable to the BHE’s license and selected
endorsement(s), individual records must include documentation of intentional collaboration and
communication with the supervising entity. Collaboration and communication efforts must include,
but are not limited to:
1. Ongoing communication and coordination of care with supervising entities;
2. Case consultation;
3. Development of referral processes; and
4. Incorporation of issues related to criminal justice involvement into ongoing service
planning processes.
B. Identified RNR principles must be incorporated in the individual’s record and addressed in
treatment services, as appropriate.
C. Documentation in the individual record must reflect and demonstrate personnel’s knowledge of
the criminal justice system including, for example, the proper use of criminal justice system
terminology. Documentation must also demonstrate an understanding of how involvement in the
criminal justice system relates to providing care for the individual.
D. Documentation in the individual’s record must reflect how, the individual’s identified support
system is engaged throughout the episode of care.
1. If the individual does not permit support system involvement, it is clinically
contraindicated, or the individual is unable to identify a support system, the record must
reflect efforts to help the individual build a recovery-focused support system. This may
include post-treatment referral(s) and peer recovery support services, as applicable.
E. I ndividual records must reflect efforts to deliver services necessary based on the individual’s
assessment and service planning process. This must involve documentation of care coordination
with other providers, resources, and support systems as necessary.
F. Documentation in the individual’s record must reflect service delivery that is person-centered,
trauma-informed, harm reduction focused, physically and programmatically accessible, and
culturally and linguistically appropriate for all individuals served.
1. This may include connecting to referrals, and/or providing translation and/or interpreter
services for those individuals that need this service to receive treatment.
G. BHEs endorsed to provide programming to criminal justice-involved individuals must provide
individuals with a complete copy of the participant materials and workbook associated with the
curriculum being used, when applicable.
1. BHEs must supply materials and workbooks associated with curriculum in ways that
reasonably accommodate the individual’s needs and facilitate access, utilization, and
understanding of the information.
2. BHEs must supply youth with age-appropriate materials/workbooks.
10.2 Enhanced Outpatient Services (EOP)
10.2.1 Applicability
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A. BHEs endorsed to provide an EOP level of programming to criminal justice-involved individuals
must meet all requirements set forth in part 4.3 of these rules in addition to parts 10.1 and 10.2 of
this Chapter.
B. BHEs providing EOP level of services must be intended for individuals who are assessed as
needing increased services for immediate stabilization, but not appropriate for more intensive
levels of care. EOP services are often utilized by individuals who require stabilization prior to
engaging in required education or treatment services and a recommendation or referral may be
received for this level of care from a supervising entity.
C. BHEs providing EOP level of services are appropriate for individuals with substance-related
disorders, mental health disorders, or co-occurring disorders if:
1. The behavioral health disorders are of moderate or high severity, as defined in the DSM-
5-TR;
2. Require additional stabilization; and
3. May be safely managed in this level of care.
D. BHEs providing EOP level of services must be endorsed by the BHA to provide this level of care.
If the BHE refers the individual to another provider to address stabilization needs that are
identified through the assessment and service planning process, the referring BHE must be
responsible for care coordination and communication of progress updates with the supervising
entity.
10.2.2 EO P Service Provisions
A. BHEs providing EOP level of services must provide between three (3) and eight (8) treatment
contact hours per week for individuals.
B. BHEs providing EOP level of services must be conducted over a minimum of two (2) calendar
days per week.
C. BHEs providing EOP level of services must be provided by personnel as defined in part 4.3.2 of
these rules.
D. The treatment duration in EOP services must be determined by one (1) or more of the following
treatment personnel, acting within their scope of practice:
1. Authorized practitioners;
2. Licensees;
3. Certified addiction specialists (CAS); and/or
4. Candidates.
E. Determination of treatment duration must be based on the individual’s assessment, continued
screened/assessed needs while attending services, and documented progress towards treatment
goals.
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1. When a supervising entity recommends a treatment duration or a specific number of
hours in EOP services that is not justified by the individual’s assessment, the BHE must
address the discrepancy with the supervising entity, provide alternative service
recommendations to the supervising entity, and document the result of the collaboration
in the individual’s record.
2. In the instance where this collaboration does not result in alignment with the assessed
treatment recommendations, the BHE must follow the supervising entity’s
recommendation.
F. Services attended while in EOP level of care must be variable and responsive to the individual’s
behavioral health needs as identified in the assessment and service plan, unless otherwise
decided per this part 10.2.2.D.
1. EOP services attended must not include education related to the originating offense.
10.3 Intensive Outpatient Services (IOP)
10.3.1 Applicability
A. BHEs endorsed to provide an IOP level of programming to criminal justice-involved individuals
(including ASAM Criteria Level 2.1) must meet all requirements set forth in part 4.6 of these rules
in addition to parts 10.1 and 10.3 of this Chapter.
10.3.2 IOP Service Provisions
A. The treatment duration in IOP services must be determined by one (1) or more of the following
treatment personnel, acting within their scope of practice:
1. A uthorized practitioners;
2. Licensees;
3. Certified addiction specialists (CAS); and/or
4. Candidates.
B. Determination of treatment duration must be based on the individual’s assessment and
documented progress towards treatment goals.
1. When a supervising entity recommends a treatment duration or a specific number of
hours in IOP services that is not justified by the individual’s assessment the BHE must
address the discrepancy with the supervising entity, provide alternative service
recommendations to the supervising entity, and document the results of the collaboration
in the individual’s record.
2. In the instance where this collaboration does not result in alignment with the assessment
treatment recommendations, the BHE must follow the supervising entity’s
recommendation.
10.4 Criminal Justice Services Programs
10.4.1 Authority and Applicability
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A. This part 10.4 details standards for and applies to BHEs with an endorsement to provide
substance use disorder education and treatment for individuals involved in the criminal justice
system programming, pursuant to Section 16-11.5-102, C.R.S., and
B. Parts 10.5 through 10.9 of this Chapter detail standards for and apply to BHEs endorsement to
provide DUI/DWAI Level I and Level II education and treatment programming, pursuant to
Sections 42-4-1301.3(3)(c), C.R.S. and 27-81-106, C.R.S.
10.4.2 General Provisions
A. Individuals convicted of misdemeanor or felony offenses who are assessed as needing substance
use disorder treatment, as indicated in Section 16-11.5-102, C.R.S. and in accordance with
current standardized assessment and placement protocol of the referring supervising entity, must
receive court-ordered education, treatment, and care coordination services.
B. All BHEs admitting out of state offenders must identify and notify the interstate compact unit for
adult offender supervision pursuant to Section 17-27.1-101, C.R.S.
C. Services must be based on the results of current screening and assessments.
D. BHEs must render treatment to individuals involved in the criminal justice system according to the
placement recommendation(s) provided by the referring supervising entity.
E. E ducation, treatment and care coordination services, as indicated by assessment and included in
the service plan, must be provided for by the BHE or through referrals.
F. BHEs must have a written memorandum of understanding with community supports or other
agencies to provide agreed upon services, as well as any specific data and/or information needed
for individualized services. Agreements as to disclosure of information must be in compliance with
state and federal law.
G. Education and treatment must be a minimum of nine (9) months or as required by the referring
supervising entity.
1. The BHE is expected to address any discrepancies regarding court-ordered length of
stay in services with the supervising entity and document in the individual’s record.
H. Frequency and intensity of education and treatment services must be based on assessments and
at minimum one (1), two (2) hour session per week.
I. The following content/topics must be presented during treatment:
1. Physiological and psychological effects of alcohol, controlled substances, and other
drugs;
2. Signs and symptoms of substance use disorders;
3. Stress management and substance use disorders;
4. Anger management and substance use disorders;
5. Behavioral triggers leading to substance use disorders;
6. D rugs in the workplace; and
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7. Legal issues and substance use disorders.
J. BHEs must implement treatment curricula that are written in manual format and are evidence-
based or best practices. These materials must be provided in the language and modality of
frequently encountered limited English proficiency groups.
K. Education and treatment sessions must not include administrative procedures or breaks in
accounting for their duration.
L. BHE personnel working directly with individuals must have documented qualifications and training
in forensic populations and criminal justice systems.
M. Drug and alcohol toxicology collection must be observed by trained personnel when requested by
the referral source.
N. Records must contain monthly documentation of communication with the criminal justice referral
source describing progress toward specific treatment goals. BHEs must be responsible for
monitoring and reporting to referring courts or their representatives the individual's progress with
ancillary services.
O. BHEs must have written documentation in an individual's record that the individual has received
services to assist in continued community placement, or community reintegration, whichever is
applicable.
10.5 Driving Under the Influence/Driving While Ability Impaired (DUI/DWAI) Services
10.5.1 Authority and Applicability
A. Authority to establish the endorsement of BHEs to provide DUI/DWAI Level I and Level II
Education and Treatment programming is provided by Sections 42-4-1301.3(3)(c), C.R.S. and 27-
81-106, C.R.S.
10.5.2 L evels of DUI/DWAI Program Endorsements
A. BHEs seeking an endorsement to provide DUI/DWAI education and/or treatment programming in
Colorado shall identify in their application the level of services they plan to provide. DUI/DWAI
education and treatment services include:
1. Level I Education, part 10.6 of this Chapter, and Level II Therapeutic Education, part 10.7
of this Chapter;
2. Level II Treatment (Tracks A - D), part 10.8 of this Chapter; or
3. Level II Treatment Track F (Level II Four (4) Plus), part 10.9 of this Chapter.
B. Locked correctional facilities may provide DUI/DWAI education services only.
C. BHEs shall not provide DUI/DWAI education or treatment services they are not endorsed to
provide.
10.5.3 General DUI/DWAI Services Provisions
A. The following provisions are applicable to all levels of DUI/DWAI services:
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1. BHEs must develop and implement policies and procedures related to the provision of
DUI/DWAI services. Personnel must have access to and be knowledgeable about the
BHEs policies, procedures, and state and federal laws and regulations relevant to their
respective duties.
B. All BHEs must have:
1. A formalized process for referring individuals to higher or lower levels of care;
2. A process to ensure individual data is accurate and submitted within seven (7) calendar
days of service or change in status and entered into the Treatment Management System
(TMS), unless prohibited by state or federal law;
3. A process for how the BHE must determine a method of service delivery that best meets
the needs of the individual. This process must include but not be limited to:
a. A plan for regular review, evaluation, and modification of service delivery to
continue meeting the individual’s needs; and
b. A referral process to BHEs and/or other agencies that provide alternate methods
of service delivery, if not available through the current BHE.
4. A process addressing how concurrent treatment provider(s) may be utilized or engaged
to ensure coordination of individualized services is available to the individual. This must
include a plan for data and exchange of information related to the individualized services
received;
5. A pr ocess for how granting of DUI/DWAI services credit hours, as noted in this part
10.5.11, must be achieved. This includes providing DUI/DWAI services credit for
individuals assessed as needing mental health services to address primary treatment
concerns, and/or referral into non-English-speaking treatment options;
6. A process for how individuals will be monitored for drug and alcohol use while
participating in education and/or treatment services must occur. This process must
include a plan for responding and incorporation of monitoring results into the individual’s
services.
7. Groups for ADDS education and treatment services must be restricted to those arrested,
convicted of or receiving deferred prosecutions, pending prosecution, sentences, or
judgments for DUI/DWAI.
8. Individuals with DUI/DWAI must not be treated in offender-specific groups with individuals
with other offenses unless they need these groups as determined by the assessment and
supported by the service plan.
C. Prior to admission of an individual for DUI/DWAI services, the BHE must obtain a current ADDS
program screening and referral for placement. This screening and referral may be completed by a
supervising entity as a condition of probation, parole, or pretrial services.
1. If a BHE is unable to obtain a copy of the ADDS or other court paperwork at the time the
individual is admitted, there must be documentation of attempt(s) to obtain the paperwork
from referral source, if applicable.
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2. If the court paperwork is unavailable, or the individual is pretrial, the BHE must conduct a
screening of the individual using an evidence-based or best practices screening process
and instrument, following track placement guidelines as indicated in the legal
supplement.
D. Prior to admission, BHEs must complete a screening for:
1. Congruence of level and track assignment with ADDS evaluation, if available. Any
deviation or discrepancy must be addressed with the referral source prior to engaging the
individual in DUI/DWAI services;
2. The individual’s number of DUI/DWAI-related offenses. If the individual is pre-sentenced
with three or more prior convictions of DUI/DWAI-related offenses, or newly sentenced
with four or more DUI/DWAI-related offenses, they must be immediately referred to a
BHE endorsed to provide Level II Four Plus programming, as defined in part 10.9 of this
Chapter, the referral source must be notified;
3. Youth status for the individual and clinical appropriateness for placement in DUI/DWAI
education and/or treatment groups. If the youth is not clinically appropriate for placement
in a DUI/DWAI education or treatment group with adults, the BHE must develop an age
and developmentally appropriate intervention for the youth. If the BHE is unable to
accommodate the youth’s treatment needs, the BHE must refer the youth to another BHE
endorsed to provide DUI/DWAI programming and the referral source must be notified;
and
4. A bility to provide necessary services as identified through the screening or the
individual’s court order. If the BHE does not provide the necessary services, the BHE
must:
a. Refer the individual back to an ADES with documentation of which service(s) will
not be provided within the BHE and identified referrals and suggestions for
alternative services; and
b. Be responsible for monitoring and reporting to referring courts or their
representatives the individual's progress with concurrent services.
E. BHEs must document collaboration with recent or concurrent treatment service providers in
accordance with all applicable federal and state confidentiality laws and regulations in the
individual’s record.
F. Level I Education, Level II Therapeutic Education, and Level II Treatment must not be combined,
nor must contact hours completed for one count as contact hours completed in another.
G. Individuals must not be reported as finishing Level I Education or Level II Therapeutic Education
until all required content/topics have been completed over the minimum required contact hours
and weeks.
H. BHEs must provide individuals with an orientation of the DUI/DWAI program requirements and
anticipated timelines for completion. Documentation of the orientation must be maintained in the
individual record.
10.5.4 DUI /DWAI Reporting and Data Requirements
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A. BHEs providing Level I Education, Level II Therapeutic Education, and Level II Treatment must
submit information into the Treatment Management System (TMS), including but not limited to
DUI/DWAI reporting system (DRS) submissions.
B. BHEs must maintain access to TMS by submitting approval form(s) annually. These form(s) are
available on the BHA’s website.
C. Prior to releasing any treatment information, BHEs shall obtain releases of information in
accordance with all applicable federal and state confidentiality laws and regulations.
1. Identifying information of the judicial district in which an individual committed a DUI/DWAI
offense shall not be put into TMS and/or the individual’s DRS record without a valid
release of information for the assigned judicial district. This includes pre-sentenced
DUI/DWAI individuals.
D. DRS requirements
1. At admission and throughout the duration of treatment:
a. A DRS record must be entered into TMS for all individuals enrolled in DUI/DWAI
education and/or treatment.
b. The admission date for the DRS must be the date of enrollment with the BHE
providing DUI/DWAI programming.
c. If the individual discharges from services and readmits, a new DRS with a current
date of admission must be input into TMS.
(1) I nformation in the individual’s DRS record must be updated in TMS in a
timely manner, not to exceed more than seven (7) calendar days after a
service is provided or a change in status.
E. Affidavit of enrollment requirements
1. BHEs must provide individuals assigned to a Level II Treatment Track, as defined in parts
10.8, and 10.9 of this Chapter, Track with a Division of Motor Vehicles affidavit of
enrollment upon request, or by the next scheduled session. This form may be found on
the BHA’s website.
2. BHEs must provide proof of enrollment and status in Level II Education and Treatment,
as defined in parts 10.7 through 10.9 of this Chapter including discharge, to the Colorado
Department of Revenue, Division of Motor Vehicles via the Treatment Management
System (TMS), within seven (7) calendar days of the service, in accordance with state
and federal confidentiality laws, and Sections 42-2-132 and 42-2-114, C.R.S.
F. At discharge of treatment
1. BHEs must provide a copy of the discharge DRS, validated with signature of authorized
personnel, to individuals and referral sources upon discharge from education and/or
treatment.
2. An initial copy of the discharge DRS must be provided to individuals at no charge.
3. T he discharge DRS shall not be withheld from the individual for any reason including, but
not limited to, collection of outstanding balances.
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4. The discharge DRS must reflect all DUI/DWAI services the individual completed in a
given episode of care. This includes any non-DUI/DWAI specific services, or services
provided by non-DUI/DWAI endorsed programs, reviewed and granted towards
DUI/DWAI credit hours.
5. BHEs must obtain a copy of all validated discharge DRS records for individuals who have
completed any prior DUI/DWAI services for DUI/DWAI treatment requirement.
6. If the individual successfully completed DUI/DWAI education services while incarcerated
for the current offense, the community-based BHE endorsed to provide DUI/DWAI
programming shall not require the individual to repeat the completed education.
7. If the discharge DRS from a previous treatment episode is not available, the BHE must
outreach the BHA for a record search.
10.5.5 Training
A. Personnel providing DUI/DWAI services must:
1. Receive the “Understanding the ADDS Evaluation” training; and,
2. Be trained in or otherwise knowledgeable of, interlock enhancement counseling (IEC).
B. All personnel accessing the TMS must receive training by authorized BHA representatives.
C. BHEs must maintain proof of completion of training in personnel files and provide verification to
the BHA upon request.
10.5.6 Provision of DUI/DWAI Services
A. BH Es must use and adhere to a curriculum written in a manual form that is evidence-based or
best practices specific to DUI/DWAI, unless otherwise noted.
B. BHEs must assign individuals to a specific group or individual session, unless clinical reason is
documented for change in service delivery.
C. Personnel conducting DUI/DWAI education and treatment must meet the minimum qualifications
as noted in the specific sub-endorsements for education and treatment in parts 10.6 through 10.9
of this Chapter.
D. Hours of attendance must only be granted for education or treatment contacts and must not
include administrative procedures or breaks.
E. If telehealth services do not best meet the needs of the individual and the BHE endorsed to
provide DUI/DWAI programming cannot accommodate in-person services, the BHE must refer
the individual to a provider that can meet the individual’s needs.
10.5.7 Testing and Monitoring
A. BHEs must ensure that testing and/or monitoring of individuals served for alcohol and drug use
occurs during the course of services. This testing and monitoring may be completed on-site or
through a third-party testing entity.
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1. If the BHE elects to collect toxicology samples on-site, the BHE must ensure that
samples will be safely collected, packaged, stored, and transferred to the lab for testing,
as well as address all points of this part 10.5.8.
2. Drug and alcohol toxicology collection that occurs on-site must be observed by trained
personnel.
3. If testing is completed by a third-party testing entity, there must be documentation of the
BHE’s effort(s) to obtain test results.
B. The testing and/or monitoring schedule and method of collection must be determined by the BHE
endorsed to provide DUI/DWAI programming or in collaboration with the supervising entity.
C. Method of testing and/or monitoring may include but is not limited to the following:
1. Urinalysis;
2. Breath analysis;
3. Continuous alcohol monitoring;
4. Mobile/remote breath testing;
5. Direct and indirect biomarker testing; and
6. Drug and other testing as appropriate.
D. With appropriate written consent or assent, the BHE shall coordinate and share testing and/or
monitoring results with the supervising entity.
10.5.8 Youth DUI/DWAI Education and Treatment
A. BHEs endorsed to provide DUI/DWAI education and treatment programming must have the ability
to provide youth DUI/DWAI education and treatment or assist in direct referral and care
coordination for the individual to another BHE that is endorsed to provide these DUI/DWAI
programs for youth.
B. BH Es providing DUI/DWAI services to youth under the age of eighteen (18) shall obtain a
Children and Families services endorsement in accordance with Chapter 8 of these rules.
C. BHEs must hold youth that receive a DUI/DWAI to the same requirements under ADDS education
and treatment services.
D. BHEs must use clinical judgment when determining age-appropriate placement of youth in a
DUI/DWAI group, including but not limited to:
1. Providing a separate group for youth, when possible; and
2. Providing individual sessions to meet the developmental needs of the youth if group
placement is not clinically indicated or available.
10.5.9 Content of Records for DUI/DWAI Services
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A. Individual records must be maintained for all levels of DUI/DWAI education and treatment, and in
addition to the requirements set forth under part 2.11 of these rules, must contain at least the
following:
1. Court documents regarding classification, referral and placement;
2. Attendance, individualized progress notes, and course completion data;
3. Descriptions of content and topics covered during each session;
4. Relevant reports and records of communication with the supervising entity regarding
participation and termination of the episode of care; and
5. Copies of discharge DRS.
B. Additional content of record requirements must be noted within the specific DUI/DWAI
endorsements in parts 10.6 through 10.9 of this Chapter.
10.5.10 DUI/DWAI Education and Treatment Credit for Specialized Services Attended
A. BHEs endorsed to provide DUI/DWAI programming must consider and be authorized to grant
Level I and Level II Education and Treatment credit for services an individual received at non-
DUI/DWAI or out-of-state treatment providers. Services considered may include DUI/DWAI-
specific education and treatment, substance use disorder education and treatment, mental health
or co-occurring disorder services, or other clinically necessary services.
B. The granting of credit hours must be based on the assessed clinical need for services that
support reduced engagement in impaired driving behaviors and activities.
C. C redit toward Level I and Level II Education and Treatment requirements are allowed on an hour-
for-hour and week-for-week basis. No more than two (2) clinical contact hours per week must be
documented for credit. Extra credit hours must not be permitted for individual counseling.
D. If the DUI/DWAI services credit hours being considered occurred previously, the BHE must:
1. Complete a new assessment;
2. If valid written consents or assents in place, obtain and review sufficient documentation of
prior education and/or treatment, which includes at a minimum:
a. Admission and discharge date;
b. Description of services completed;
c. Progress on goals;
d. Discharge status; and
e. Copy of discharge summary.
E. If the DUI/DWAI services credit hours being considered are concurrent, the BHE must:
1. If valid written consents or assents in place, refer the individual to an additional treatment
provider, as indicated by the clinical assessment.
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2. Coordinate between the individual and the concurrent treatment provider.
3. Document collaboration and care coordination in the individual’s record and service plan.
F. Credit hours must be assigned only if progress in treatment can be demonstrated in the clinical
record review.
G. The granting of any education or treatment credit is subject to the following criteria:
1. Education or treatment must have occurred after the date of the last DUI/DWAI offense.
2. Any hours considered must have been completed in-person or through telehealth.
3. All levels of care are subject to the maximum of two (2) credit hours/week, including
higher intensity services such as EOP, IOP, partial hospitalization, and residential.
4. Only partial track credit must be considered for treatment completed exclusively in a non-
community-based facility, such as while incarcerated.
H. DUI/DWAI services credit hours must not be granted if:
1. The hours were completed in a virtual class and/or webinar format and/or in-person or
telehealth support group setting that does not include active facilitation and engagement
with one (1) or more of the following treatment personnel, acting within their scope of
practice for the behavioral health service being considered for credit hours;
a. A uthorized practitioners;
b. Licensees;
c. Certified addiction specialists (CAS);
d. Candidates;
e. Certified addiction technicians (CAT); and
f. Counselors-in-training and/or interns.
2. The hours were completed prior to the last date of DUI/DWAI offense;
3. The individual has a diagnosed substance use disorder and exhibits continued risky
substance use related to their DUI/DWAI offense. The determination of risky substance
use may include but is not limited to the following considerations: drug/alcohol
screening/monitoring, individual self-report, observation by the professional, or another
manner documented by the professional.
4. The documented evidence of completed hours or services shows insufficient progress
towards goals.
I. Documentation requirements
1. Documentation of rationale for granting or denying of credit hours must be included in the
individual’s record.
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2. All supporting documentation used for consideration in granting or denying of education
and treatment credit must be maintained in the individual’s record.
3. The BHE endorsed to provide DUI/DWAI programming shall enter all hours of education
or treatment credit granted in the individual’s DRS.
a. For DUI/DWAI services credit hours achieved prior to current episode of care
where a DRS record of that care is not provided, the BHE endorsed to provide
DUI/DWAI programming must enter hours in a separate DRS record using the
actual admission and discharge dates from the prior provider.
J. If treatment credits are not granted pursuant to part 10.5.11.H of this section, the individual must
complete all the court mandated hours of treatment assigned by the referring supervising entity.
10.5.11 Ignition Interlock Enhancement Counseling (IEC)
A. IEC must be made available to all individuals who currently or will have an ignition interlock
device installed in their vehicle during the episode of care.
1. If the BHE endorsed to provide DUI/DWAI programming does not provide IEC services,
documentation of referral and collaboration with another BHE endorsed to provide
DUI/DWAI programming that offers IEC services must be maintained in the individual’s
record.
B. BH Es must ask DUI/DWAI-involved individuals about their ignition interlock requirements upon
admission and thereafter as needed.
1. Documentation of this inquiry must be maintained in the individual’s record.
C. BHEs must inform all individuals that participation in IEC is voluntary for DUI/DWAI-involved
individuals assigned to Level II Treatment Tracks B, C, or D, as defined in part 10.8 of this
Chapter.
1. Participation in IEC is mandatory for DUI/DWAI-involved individuals assigned to Level II
Four Plus who have an interlock device installed at any time while participating in Level II
Four Plus services and BHEs endorsed to provide Level II Four Plus programming must
encourage completion prior to the end of phase 3, as defined in part 10.9.4 of this
Chapter.
D. IEC may be completed:
1. In-person; or
2. Utilizing telehealth.
E. IEC must be provided using a BHA-approved curriculum.
1. All BHE personnel providing IEC services must be trained in the curriculum.
F. Progress notes and service plans must reflect an individual’s participation in IEC, whether offered
by the BHE or through referral.
G. BHEs must enter ten (10) hours into the individual’s DRS towards Level II Treatment
requirements upon successful completion of all IEC requirements.
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1. If referred out for IEC services, DRS record entry is completed by the BHE endorsed to
provide DUI/DWAI programming that initiated the referral.
2. BHEs may enroll individuals in IEC concurrent to Level II Therapeutic Education or Level
II Treatment.
10.6 Level I Education (which includes ASAM Level 0.5)
A. BHEs endorsed to provide Level I Education programming shall meet the requirements in parts
10.1 and 10.5, and 4.2 of these rules in addition to this part 10.6.
B. Level I education may be completed:
1. In-person; or
2. Utilizing telehealth.
C. Level I Education may be provided by a certified addiction technician (CAT), certified addiction
specialist (CAS), licensee, authorized practitioner, or a candidate for a mental health professional
license.
D. BHEs endorsed to provide Level I Education programming must use and adhere to a curriculum
written in a manual form that is evidence-based or are best practices specific to DUI/DWAI.
1. Education about the interlock device and Colorado’s current interlock laws and
requirements must be a required topic in the legal session of Level I Education groups.
E. Level I Education must be twelve (12) contact hours of instruction.
1. No more than four (4) contact hours must be conducted in one (1) calendar day.
2. Groups must not exceed twenty (20) individuals receiving services.
3. Missed groups may be made up by attending another education session that covers the
missed content.
F. There are no additional content of record or assessment requirements for this level of care.
10.7 L
evel II Therapeutic Education (which includes ASAM Level 0.5)
A. BHEs endorsed to provide Level II Therapeutic Education programming shall meet the
requirements in parts 10.1 and 10.5 and 4.2 of these rules in addition to this part 10.7.
B. Level II Therapeutic Education may be completed:
1. In-person; or
2. Utilizing telehealth.
C. Level II Therapeutic Education must be provided by a certified addiction technician (CAT),
certified addiction specialist (CAS), licensee, authorized practitioner, or a candidate for a mental
health professional license.
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1. If a counselor-in-training and/or intern is involved in the facilitation of Level II Therapeutic
Education, the group may be co-facilitated and documentation signed by a CAS or
mental health professional licensed pursuant to Article 245 of Title 12, C.R.S.
D. BHEs endorsed to provide Level II Therapeutic Education programming must use and adhere to
a curriculum written in a manual form that is evidence-based or best practices specific to
DUI/DWAI.
1. Education about the interlock device and Colorado’s current interlock laws and
requirements must be a required topic in the legal session of Level II Therapeutic
Education groups.
2. Missed content of the curriculum must be made up in compliance with the requirements
of curriculum authors.
E. Level II Therapeutic Education must consist of twenty-four (24) contact hours.
1. No more than two (2) contact hours must be granted per week.
2. Individuals must attend for a minimum of twelve (12) weeks for completion.
3. Groups must not exceed twelve (12) individuals receiving services.
4. Must not be combined with Level II Treatment unless clinical rationale is documented.
The combined time in Level II Therapeutic Education and Level II Treatment must not be
less than the minimum number of weeks required for the assigned Level II Treatment
Track.
F. The BHE must provide the screening(s) required in part 2.12.1 of these rules to DUI/DWAI-
involved individuals assigned to education-only services upon admission. The BHE must arrange
for care coordination needs of the individual, if clinically indicated in the screening results.
G. BH Es endorsed to provide Level II Therapeutic Education and Treatment programming are
subject to the full requirements of Chapter 2 of these rules.
H. If the individual transitions between BHEs endorsed to provide DUI/DWAI programming during
the course of services, the discharging BHE must provide the individual with a discharge DRS
reflecting partial completion of treatment requirements and the supervising entity must be notified.
10.8 Level II DUI/DWAI Outpatient Treatment (which includes ASAM Level 1.0, Treatment Tracks
A through D)
A. BHEs endorsed to provide Level II Outpatient Treatment programming shall meet the
requirements in parts 10.1 and 10.5, and 4.3 of these rules in addition to this part 10.8.
B. Treatment must be completed:
1. In-person; or
2. Utilizing telehealth.
C. Treatment may be provided by a CAS, licensee, authorized practitioner, or a candidate for a
mental health professional license.
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1. If a CAT, counselor-in-training, and/or intern is involved in facilitation of treatment, the
group must be co-facilitated and documentation co-signed by a CAS, licensee, or
authorized practitioner pursuant to Article 245 of Title 12, C.R.S.
D. Treatment must consist of services that:
1. Are evidence-based or best practice curriculum specific to DUI/DWAI;
2. Are necessary behavioral health services, as determined by the individual’s assessment
and service plan; or
3. Are a combination of (1) and (2) noted above.
E. The BHE endorsed to provide DUI/DWAI programming is responsible for recording clinical
contact hours in the TMS database.
1. A maximum of two (2) clinical contact hours of DUI/DWAI treatment credit may be
granted per week of participation.
2. Services provided in any level of care may count towards the individual’s assigned track
requirement.
3. Clinical contact hours or weekly requirements must only be assigned in the DRS if
progress in treatment can be demonstrated in a clinical record review.
4. Clinical contact hours attended must be conducted over the minimum number of weeks
associated with the treatment Track assigned.
5. Make-up sessions for missed treatment sessions are not permitted.
F. If a Track has not been assigned by an ADES or the BHE is unable to obtain documentation of
Track placement, the BHE must assign a Track based on the BHA Track placement guidelines
located within the legal supplement.
G. T rack requirements
1. Track A individuals whose breath or blood alcohol content was below the statutorily
defined PDD level, did not refuse breath or blood testing and who have one (1) offense
for DUI/DWAI. Track A is a minimum forty-two (42) telehealth or in-person hours of group
and/or individual treatment conducted over twenty-one (21) or more weeks.
2. Track B individuals whose breath or blood alcohol content was at or above the statutorily
defined PDD level or refused breath or blood testing and who have one (1) offense for
DUI/DWAI. Track B is a minimum of fifty-two (52) telehealth or in-person hours of group
and/or individual treatment conducted over twenty-six (26) or more weeks.
3. Track C individuals whose breath or blood alcohol content was below the statutorily
defined PDD level, did not refuse breath or blood testing, and who have two (2) or more
offenses for DUI/DWAI. Track C is a minimum of sixty-eight (68) telehealth or in-person
hours of group and/or individual treatment conducted over thirty-four (34) or more weeks.
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4. Track D individuals whose breath or blood alcohol content was at or above the statutorily
defined PDD level or refused breath or blood testing, and who have two (2) or more
offenses for DUI/DWAI. Track D is a minimum of eighty-six (86) telehealth or in-person
hours of group and/or individual treatment conducted over forty-three (43) or more
weeks.
5. Track F; refer to this part 10.9, Level II Four Plus Treatment.
H. Level II treatment must be conducted only after Level II Therapeutic Education has been
completed unless there is documented assessment and clinical rationale to do otherwise.
I. The assessment must be updated at the onset of treatment, and as required in Chapter 2 of
these rules thereafter.
J. Using the initial service plan as a basis, a revised service plan and subsequent reviews must be
developed for individuals in treatment in accordance with part 2.13.1 of these rules.
K. Treatment group sessions must not be less than two (2) hours of therapeutic contact, and the two
hours must not include administrative procedures and breaks.
L. Treatment groups must not exceed twelve (12) individuals receiving treatment.
M. Individual treatment sessions must not be less than one (1) hour of therapeutic contact, and
administrative procedures and breaks must not count towards the duration.
N. I ndividuals are expected to attend group one (1) time per week. Clinical rationale for any changes
in frequency of group attendance (fewer or more) must be documented. At minimum, a BHE shall
require individuals to attend at least one (1) group or individual session per month.
O. Credit toward clinical contact hours for treatment provided by an agency outside of a BHE
endorsed to provide DUI/DWAI programming may be granted in accordance with this part
10.5.11.
10.9 Level II Four Plus Treatment (Track F)
10.9.1 General provisions
A. BHEs endorsed to provide Level II Four Plus services shall meet the requirements in part 4.3 of
these rules and parts 10.1, 10.5 of this Chapter, and this part 10.9.
B. BHEs endorsed to provide DUI/DWAI Level II Four Plus programming shall:
1. Have an active BHE license issued by the BHA, pursuant to Chapter 2 of these rules.
2. Have provided Level II DUI/DWAI treatment services for at least twelve (12) months.
C. BHEs endorsed to provide DUI/DWAI Level II Four Plus programming must:
1. Document active collaboration with referral sources and concurrent treatment entities to
meet individualized cross-system needs; and
2. Be a ble to provide or refer to clinically relevant in-person services.
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10.9.2 Training
A. In addition to meeting training requirements in part 2.5 of these rules and this part 10.5.6, the
BHE endorsed to provide Level II Four Plus programming must ensure that personnel involved in
the provision of Level II Four Plus services attend no less than two (2) BHA-provided sessions
during their active approval or licensing term that address the provision of Level II Four Plus
services.
B. BHEs must maintain documentation of all training sessions attended in personnel records and
provide verification to the BHA, upon request.
10.9.3 Service Provisions
A. Level II Four Plus must be completed as in-person services.
1. Telehealth may only be utilized if clinically indicated for the individual, or if the individual
is unable to attend in-person. Documentation must be present in the individual record
stating why telehealth was utilized.
B. There must not be a designated “Level II Four Plus Treatment Group,” as all services must be
individualized and based on the individual’s assessment.
C. Length of stay in Level II Four Plus must be determined by competency and phase progression
with a minimum of one-hundred eighty (180) clinical contact hours received in no less than
eighteen (18) months.
1. T he number of clinical contact hours attended will vary throughout an individual’s
treatment episode, depending upon the current phase and individual’s treatment needs
and progress.
2. Contact hours must not include DUI/DWAI education unless clinically indicated for the
individual.
10.9.4 Level II Four Plus Competencies and Phases
A. Level II Four Plus must be structured and provided as follows:
1. The individual must demonstrate proficiency in all of the competencies contained within
each phase prior to progressing into the next (higher) phase.
2. The BHE endorsed to provide Level II Four Plus programming must document that each
individual was provided a copy of the phases and competencies as part of the orientation
phase of treatment.
3. Individual progress towards Level II Four Plus completion must be a combination of
treatment and phase competency progress.
4. The BHE endorsed to provide Level II Four Plus programming must review each
individual’s phase and competency achievements at a minimum every sixty (60) days in
collaboration with available members of the individual’s multidisciplinary team.
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a. For the purposes of Level II Four (4) Plus Treatment, multidisciplinary team
means a team consisting of at least the endorsed DUI/DWAI program and the
supervising entity. The MDT may include other professionals relevant to the
individual’s assessed treatment needs. Available members of the MDT must be
consulted by the agency in Level II Four Plus phase progression, service
planning, changes in levels of treatment, and discharge process.
B. All individuals in Level II Four Plus who have an interlock device installed in their vehicle must
complete IEC.
1. The BHE endorsed to provide Level II Four Plus programming must make every effort to
ensure the individual completes IEC prior to the end of phase 3.
10.9.5 Level II Four Plus Care Coordination
A. The BHE endorsed to provide Level II Four Plus programming must establish and regularly
maintain collaborative relationships with other agencies, treatment providers, referral sources, or
any other entities involved in the individual’s multidisciplinary team.
B. BHEs endorsed to provide Level II Four Plus treatment must provide care coordination, where
applicable, to ensure individual service needs are addressed.
10.9.6 Level II Four Plus Assessments
A. All Level II Four Plus services must be driven by an evidence-based or best practices
assessment process and resulting individualized service plan.
B. Lev el II Four Plus assessments must include incorporation of standardized screening tools
specifically designed to evaluate individuals in each of the following areas:
1. Cognitive functioning;
2. Traumatic brain injury;
3. Adverse childhood experiences (ACEs);
4. Grief and loss;
5. Co-occurring mental health issues; and
6. Polysubstance use concerns.
C. Level II Four Plus assessment must inform the determination of what combination of services the
individual must complete that are non-DUI/DWAI Therapeutic Education and Treatment
strategies. These services include, but are not limited to:
1. Individual counseling;
2. Group therapy, unless clinically contraindicated;
3. Family/other supportive therapy, if applicable;
4. Medication-assisted treatment, if applicable;
5. Residential treatment, if applicable;
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6. DUI/DWAI Level II Therapeutic Education or Level II Treatment, if applicable;
7. Other education or treatment as indicated by the initial and ongoing clinical assessment.
D. BHEs endorsed to provide Level II Four Plus programming must ensure that personnel
completing the assessment are properly credentialed and hold a valid certification to use the
specific assessment instrument. Certification must be attained from entities or professionals
authorized to provide such training regarding the instrument.
E. Clinically indicated services may be offered within the BHE or via external referral.
1. If at any time during the treatment episode a need is identified that the BHE endorsed to
provide Level II Four Plus programming does not provide, the program must refer the
individual to an appropriately licensed and/or credentialed facility or professional.
2. The BHE endorsed to provide Level II Four Plus programming must document evidence
of communication with the other agency regarding assessment results, service plans, the
individual’s participation, and progress.
10.9.7 Level II Four Plus Service Planning and Reviews
A. Level II Four Plus service planning and reviews must be administered in accordance with part
2.13.1 of these rules and this Chapter 10.
B. BH Es endorsed to provide Level II Four Plus Treatment must conduct service plan, phase, and
competency reviews at a minimum of every sixty (60) days. Reviews must be conducted in
collaboration with available members of the individual’s multidisciplinary team, in accordance with
state and federal confidentiality laws.
C. All services determined to be necessary for the individual must be incorporated into the service
plan, whether offered by the BHE endorsed to provide Level II Four Plus programming or another
provider.
10.9.8 Level II Four Plus Discharge Planning and Process
A. Level II Four Plus discharge planning must be administered in accordance with part 2.10 of these
rules and must include a warm handoff when possible. A validated copy of the discharge DRS
must be provided to the individual and receiving BHE endorsed to provide Level II Four Plus
programming, when applicable, and as appropriate under state and federal confidentiality laws.
B. Consideration must be given to an individual’s needs for post-discharge clinical needs and peer
recovery support services.
Chapter 11: Designation of Facilities for the Care and Treatment of Persons with Mental Health
Disorders (Title 27, Article 65, C.R.S.)
11.1 Authority
A. C hapter 11 establishes standards for and is applicable to facilities that are designated pursuant to
Article 65 of Title 27, C.R.S. the authority to promulgate these rules establishing minimum
standards for the Care and Treatment of Persons with Mental Health Disorders comes from
Sections 27-50-107(3) and 27-65-128, C.R.S.
B. Facilities designated pursuant to this Chapter 11 shall be subject to the following rule compliance
timeline:
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1. Upon these rules going into effect, the BHA shall take immediate action on rule violations
that impact the health, safety, and welfare of persons receiving services provided by a
designated facility.
2. All designated facilities shall be in full compliance of these rules by July 1, 2024.
C. On an annual basis, the BHA will review the effectiveness of these rules and produce a written
report of the results of this review to the state board of human services. This review will include
engagement with stakeholders and may include, but is not limited to, analysis of grievance data
and trends in enforcement actions taken by the BHA. The BHA will provide this report annually to
SBHS by September 1 starting September 1, 2024. The BHA will present information in the report
to SBHS at the board's next session following submission of the written report unless the board
and the BHA agree that presentation of the report occur at a different session of the board. If it is
determined based on this review that changes to these rules are advised, the BHA shall propose
these changes to the state board of human services for promulgation in accordance with Section
26-1-107, C.R.S.
11.2 D efinitions
“Bedridden” means a form of immobility that can present as the inability to ambulate or move about
independently or with the assistance of an auxiliary aid, and also requires assistance in turning and
repositioning in bed. Such immobility may be due to medical orders or due to incapacitation.
“Behavioral Health Crisis Response Team”, as defined in Section 27-65-102(4), C.R.S., means a mobile
team that responds to people in the community who are in a behavioral health crisis and includes at least
one licensed or bachelor-degree-level behavioral health worker. A "Behavioral Health Crisis Response
Team" includes, but is not limited to, a co-responder model, mobile crisis response unit, or a community
response team.
“Certified Peace Officer”, as defined in Section 27-65-102(6), C.R.S., means any certified peace officer as
described in Section 16-2.5-102, C.R.S.
“Child”, for the purposes of this Chapter 11, means the same as “Minor”.
“Colorado Crisis Services” means the statewide behavioral health crisis response system offering
individuals mental health, substance use or emotional crisis help, information and referrals.
"Court-Ordered Evaluation" means an evaluation ordered by a court pursuant to Section 27-65-106,
C.R.S.
“D iscrimination ” for the purposes of this Chapter 11, has the same meaning as 27-65-117, C.R.S.
"Emergency Medical Services Facility" means a general hospital with an emergency department or a
freestanding emergency department, as defined in Section 25-1.5-114(5), C.R.S.
“Emergency Medical Service Provider” means a person who holds a valid emergency medical service
provider certificate or license issued by the Health Department as provided in Article 3.5 of Title 25,
C.R.S.
“Emergency Medical Treatment and Labor Act (EMTALA)”, means the federal Emergency Medical
Treatment and Labor Act of 1986, found at 42 U.S.C. § 1395dd (2020).
“Facility” for the purposes of this Chapter 11 means:
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A. Pursuant to Section 27-65-102(15), C.R.S., a public hospital or a licensed private hospital,
Behavioral Health Entity, institution, or residential child care facility that provides treatment for
persons with mental health disorders.
B. Any facility, as defined in part 1.2 of these rules, or unit(s) designated by the BHA pursuant to
Title 27, Article 65, C.R.S. and this Chapter.
“Facility Personnel” or “Community- Based Personnel” means:
A. A professional person as defined in this Chapter;
B. A registered professional nurse as defined in Section 12-255-104(11), C.R.S.;
C. A licensed marriage and family therapist, as defined in Section 12-245-501(3), C.R.S., licensed
professional counselor, as defined in Section 12-245-601(2), C.R.S., or licensed addiction
counselor, as defined in Section 12-245-801(10), C.R.S.; or,
D. A licensed clinical social worker licensed as defined in Section 12-245-401(7), C.R.S.
“Gravely Disabled” means a condition in which a person, as a result of a mental health disorder, is
incapable of making informed decisions about or providing for the person’s essential needs without
significant supervision and assistance from other people. As a result of being incapable of making these
informed decisions, a person who is gravely disabled is at risk of substantial bodily harm, dangerous
worsening of any concomitant serious physical illness, significant psychiatric deterioration, or
mismanagement of the person’s essential needs that could result in substantial bodily harm. A person of
any age may be “Gravely Disabled”, but the term does not include an person whose decision-making
capabilities are limited solely by the person’s developmental disability.
“I mmediate Screening” means the determination of whether a person meets criteria for an emergency
mental health hold.
“Imminent Danger” means a situation in which a person’s risk status is believed to immediately indicate
actions that could lead to a person’s harm of self or others.
“Independent Professional Person” means a professional who evaluates a minor’s condition as an
independent decision-maker and whose recommendations are based on the standard of what is in the
best interest of the minor. The professional person may be associated with the admitting facility if the
professional person is free to independently evaluate the minor’s condition and need for treatment and
has the authority to refuse admission to any minor who does not satisfy the statutory standards specified
in Section 27-65-104(2), C.R.S.
“Individual” for the purposes of this Chapter 11, has the same meaning as respondent as defined in
Section 27-65-102(29), C.R.S.
“Intervening Professional”, a person who is statutorily permitted to enact an emergency mental health
hold, means a person who is of the following:
A. A professional person as defined in Section 27-65-102(27), C.R.S.;
B. A physician assistant licensed pursuant to Section 12-240-113, C.R.S.;
C. An a dvanced practice registered nurse, as defined in Section 12-255-104(1), C.R.S.;
D. A registered professional nurse, as defined in Section 12-255-104(11), C.R.S., who has specific
mental health training as identified by the BHA;
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E. A clinical social worker licensed pursuant to Part 4 of Article 245 of Title 12, C.R.S.;
F. A marriage and family therapist licensed pursuant to Part 5 of Article 245 of Title 12, C.R.S.;
G. A professional counselor licensed pursuant to Part 6 of Article 245 of Title 12, C.R.S.;
H. An addiction counselor licensed pursuant to Part 8 of Article 245 of Title 12, C.R.S.
“Involuntary Medication” means psychiatric medication administered without a person's consent.
“Involuntary Transportation Form” means the report and application allowing for immediate transport of a
person, in need of an immediate screening for treatment, to a clinically appropriate facility.
“Involuntary Transportation Hold” means the ability to transport a person in need of an immediate
screening to determine if the person meets criteria for seventy-two (72) hour treatment and evaluation.
The involuntary transportation hold does not extend or replace the timing or procedures related to a
seventy-two (72) hour treatment and evaluation hold or a person’s ability to voluntarily apply for mental
health services.
"Lay Person" means a person identified by another person who is detained on an involuntary emergency
mental health hold pursuant to Section 27-65-106, C.R.S., certified for short-term treatment pursuant to
Section 27-65-109, C.R.S., or certified for long-term care and treatment pursuant to Section 27-65-110,
C.R.S., who is authorized to participate in activities related to the person’s involuntary emergency mental
health hold, short-term treatment, or long-term treatment, including court appearances, discharge
planning, and grievances. The person may rescind the lay person’s authorization at any time.
"Mental H ealth Disorder" includes one or more substantial disorders of the cognitive, volitional, or
emotional processes that grossly impairs judgment or capacity to recognize reality or to control behavior.
An intellectual or developmental disability is insufficient to either justify or exclude a finding of a mental
health disorder pursuant to the provisions of Article 65 of Title 27, C.R.S.
"Minor", for this Chapter 11, means a person under eighteen (18) years of age; except that the term does
not include a person who is fifteen (15) years of age or older who is living separately and apart from the
person’s parent or legal guardian and is managing the person’s own financial affairs, regardless of the
person’s source of income, or who is married and living separately and apart from the person’s parent or
legal guardian.
“Objects to Hospitalization” means that a minor, with the necessary assistance of hospital staff, has
written the minor’s objections to continued hospitalization and has been given an opportunity to affirm or
disaffirm such objections forty-eight (48) hours after the objections are first written.
"Patient Representative" means a person designated by a mental health facility to process patient
complaints or grievances or to represent patients who are minors pursuant to Section 27-65-104(4),
C.R.S.
“P etitioner ”, pursuant to Section 27-65-102(25), C.R.S., means any person who files any petition in any
proceeding in the interest of any person who allegedly has a mental health disorder or is allegedly gravely
disabled.
"Physician", for the purposes of this Chapter 11, means a person licensed to practice medicine in this
state pursuant to Article 240 of Title 12, C.R.S.
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“Placement Facility” means a public or private behavioral health provider that has a written agreement
with a designated facility to provide care and treatment to any individual undergoing mental health
evaluation or treatment by a designated facility. A placement facility may be but is not limited to, a general
hospital, nursing care facility, adult residential facility or licensed residential child care facility.
"Professional Person" has the same meaning as described in Section 27-65-102(27), C.R.S.
“Protection and Advocacy for Individuals with Mental Illness Act (PAIMI Act)”, means the federal
Protection and Advocacy for Persons with Mental Illness Act of 1986, Pub. L. No. 99-319 (1986).
“Psychiatric Medication” is a medication being used to treat psychiatric illness for the individual including,
but not limited to, anti-psychotics, antidepressants, and other medications that may have other medical
uses but are accepted within the medical profession for psychiatric use as well.
“Qualified Medication Administration Person” or “QMAP” means a person who passed a competency
evaluation administered by the Department of Public Health and Environment before July 1, 2017, or
passed a competency evaluation administered by an approved training entity on or after July 1, 2017, and
whose name appears on the Department of Public Health and Environment’s list of persons who have
passed the requisite competency evaluation.
“R esidential Child Care Facility” has the same meaning as set forth in Section 26-6-903(29) C.R.S. a
residential child care facility may be eligible for designation by the commissioner pursuant to Article 65 of
Title 27, C.R.S.
“Respondent”, for the purposes of Chapter 11, has the same meaning as described in Section 27-65-
102(29), C.R.S.
"Secure Transportation Provider” means a provider licensed pursuant to Section 25-3.5-310, C.R.S. to
provide public or private secure transportation services.
“Secure Treatment Facility” for the purposes of these rules, means the state operated mental health
hospitals.
“Subsequent Hold” means additional, up to 72-hour hold, when appropriate placement options could not
be found during the initial hold period and the person continues to meet criteria for an emergency mental
health hold.
“Therapy or Treatments Using Special Procedures” for the purposes of this part 11.10, means a therapy
that requires informed consent specific to additional requirements of the treatment, including but not
limited to electroconvulsive therapy, feeding tubes for eating disorder treatment, and behavior
modifications using transcranial magnetic stimulation.
“Transitional Measures” means physical guidance, prompting techniques of short duration, or an initial
temporary approved physical positioning of an individual at the onset or in response to a re-escalation
during a physical management, for the purpose of quickly and effectively gaining physical control of that
individual in order to prevent harm to self or others.
11.3 27 -65 Designation Requirement
A. These rules are established to create standards for agencies seeking a 27-65 designation to
provide involuntary treatment services pursuant to Article 65 of Title 27, C.R.S.
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B. All agencies providing involuntary treatment services pursuant to Article 65 of Title 27, C.R.S.
shall meet the standards in this Chapter 11. If the facility requires a BHE license, the facility shall
also comply with Chapter 2 and the other Chapters specific to any endorsements held by the
facility. If the facility requires approval as a behavioral health safety net provider, the facility shall
also comply with Chapter 12.
C. Any facility licensed by a state agency to include the Colorado Department of Public Health and
Environment or the division of child welfare within the Colorado Department of Human Services
providing involuntary mental health services whether inpatient or outpatient, shall seek a 27-65
designation.
D. In order to provide involuntary services described in this Chapter 11, a facility, other than an
emergency medical services facility, must receive a designation based on their compliance with
the service standards described in this Chapter.
E. A designated facility must also comply with regulations specific to the involuntary services it
provides, which may include:
1. Involuntary short-term and long-term care and treatment designation (part 11.16 of this
Chapter); and/or,
2. Involuntary outpatient care and treatment (part 11.17 of this Chapter).
11.3.1 27 -65 Designation General Standards
A. The 27-65 designated facility shall only provide services for which it holds/has a 27- 65
designation, approval, and/or another BHA license.
B. Facility designation applies only to the physical location(s) listed on the 27-65 designation
certificate from BHA and not to any other non-designated physical locations operated by the
facility.
1. Psychiatric units within a medical hospital and units that are separate from a main
building must be designated separately for involuntary services.
2. Locations serving individuals under certification on an outpatient basis pursuant to
Section 27-65-111, C.R.S. must also be designated.
C. The 27-65 designated facility shall ensure all operations, locations, and services, including
contracted services or personnel, comply with laws, regulations, and standards as required by 2
CCR 502-1.
D. Any 27-65 designated facility, must develop, implement, and every three (3) years review the
following policies and procedures, unless such a facility has an active BHE license or safety net
approval and has implemented policies and procedures listed below that address 27-65
designated services:
1. The governing body shall have policies and procedures regarding administrative and/or
clinical oversight of the 27-65 designated services and requirements.
2. Personnel needed for services and ratios;
3. Training schedules and demonstration of training for personnel;
4. Emergency and crisis protocol;
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5. Record protection, sharing, and retention protocol;
6. Disclosure of intervention, treatment, and/or medication;
7. Policies and procedures regarding the use/non-use of seclusion, restraint, and/or
physical management pursuant to part 11.9 of this Chapter;
8. Continuity and transfer of care upon admittance and discharge from the facility;
9. The change to voluntary status process for an individual at the facility;
10. Communication of rights of individuals;
11. Facility rules and how they are communicated to individuals receiving services, including
visitation expectations;
12. How the facility will manage and maintain the statutory rights individuals have to keep
and use their own clothes and possessions, including cell phones and money;
13. Critical incident reporting; and
14. Facility process for removal and reinstatement of individual rights.
E. Any additional details regarding applicable policies and procedures in this Chapter must be
followed in addition to those in this part.
11.3.2 Critical Incident Reporting
A. A critical incident includes but is not limited to the following:
1. Breach of confidentiality: any unauthorized disclosure of protected health information as
described in HIPAA, incorporated in part 1.2 of these rules; 42 C.F.R. Part 2, as
incorporated in part 1.2 of these rules; and/or Sections 27-65-101 through -131, C.R.S.
2. D eath: including the death of an individual inside of or outside of the facility’s physical
location while an individual is receiving services or where an individual has attempted to
receive services from the facility within the past thirty (30) calendar days.
3. Elopement: absconding from a mental health hold, certification, emergency/involuntary
commitment, or a secure facility where an individual is being held as a result of a court
order. This includes any unauthorized absence of a minor, when a minor cannot be
accounted for or when there is reasonable suspicion to believe the minor has absconded.
4. Any instance in which an individual cannot be located following a search of the facility,
the facility grounds, and the area surrounding the facility, and:
a. There are circumstances that place the individual’s health, safety, or welfare at
risk; or,
b. The individual has been missing for eight (8) hours.
5. Medication diversion: any medication diversion as defined in part 1.2 of these rules. If the
diverted drugs are injectable, the facility shall also report the full name and date of birth of
any individual who diverted the injectable drugs, if known.
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6. Medication error: medication error that resulted or could have resulted in harm to the
individual.
7. Medical emergency: any suicide attempt/self-injury, other form of serious injury, health
emergency, overdose or serious illness of an individual which occurred on facility
premises or in the presence of facility personnel.
8. Any instance involving physical, sexual, or verbal abuse of an individual, as described in
Sections 18-3-202, 18-3-203, 18-3-204, 18-3-206, 18-3-402, 18-3-404, or 18-3-405, 18-3-
405.3, 18-3-405.5, and 18-9-111 (exempting, however, the phrase “intended to harass”),
C.R.S. by another individual, personnel, or a visitor to the facility.
9. Any instance that results in any of the following serious injuries to an individual:
a. Brain or spinal cord injuries;
b. Life-threatening complications of anesthesia or life-threatening transfusion errors
or reactions; or,
c. Second- or third-degree burns involving twenty percent (20%) of more of the
body surface area of an adult or more fifteen percent (15%) or more of the body
surface area of a minor.
10. Any instance involving caretaker neglect of an individual, as defined in Section 26-3.1-
101(2.3), C.R.S.
11. An y instance involving misappropriation of an individual’s property, meaning patterns of
loss or single incidences of deliberately misplacing, exploiting, or wrongfully using, either
temporarily or permanently, an individual’s belongings or money without the individual’s
consent.
12. Any occurrence involving the malfunction or intentional or accidental misuse of care
equipment that occurs during treatment or diagnosis of an individual and that significantly
or adversely affects or, if not averted, would have significantly adversely affected an
individual.
B. Critical incidents must be reported to the BHA within one (1) business day after the incident.
Critical incidents must also be reported to the BHA within one (1) business day of when the
facility determines that a reportable incident has occurred and the BHA requests such reporting.
Critical incidents must be reported to the BHA within one (1) business day on a BHA-created form
posted on the BHA website.
C. The BHA may conduct scheduled or unscheduled site reviews for specific monitoring purposes
and investigation of critical incidents reports in accordance with:
1. BHA policies and procedures,
2. Regulations that protect the confidentiality and individual rights in accordance with
Sections 27-65-101 through -131, C.R.S.; HIPAA, as incorporated by reference in part
1.2 of these rules; and, 42 C.F.R. Part 2, as incorporated by reference in part 1.2 of these
rules,
3. C ontrolled substance licensing, Section 27-81-113, C.R.S., Section 27-80-212, C.R.S.,
and Section 18-18-503, C.R.S.
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D. The BHA shall have access to relevant documentation required to determine compliance with
these rules.
E. The facility must:
1. Establish written policies and procedures for reporting and reviewing all critical incidents
occurring at the facility;
2. Submit critical incidents reports to the BHA using state prescribed forms that can be
obtained from the BHA’s website. This is not in lieu of other reporting mandated by state
statute or federal guidelines;
3. Make available a report with the investigation findings for review by the BHA, upon
request; and,
4. Maintain critical incidents reports for a minimum of three (3) years following the incident
unless it would violate any other federal or state law.
F. Nothing in this part shall be construed to limit or modify any statutory or common law right,
privilege, confidentiality, or immunity.
11.4 27-65 Designation Approval Procedures
11.4.1 Application Process
A. Entities applying for 27-65 designation shall submit an application to the BHA on a state approved
form, available on the BHA website.
B. Facilities providing twenty-four (24) hour inpatient or acute crisis care, must apply for a separate
27-65 designation based on the unique physical address of each site. If two or more buildings or
units share a physical address, each building or unit must be designated separately for 27-65
services.
C. T he BHA will provide written notice to the applicant within thirty (30) calendar days of receipt of a
complete application.
D. The BHA will act on an application within ninety (90) calendar days of receipt of the completed
application. The applicant may be approved for 27-65 designation, granted provisional approval,
or the application may be denied.
E. An applicant that is found to be in compliance with these rules shall be approved as a facility
designated to provide mental health services effective for up to a one (1) year period.
F. A basis for denial of a 27-65 designation application includes a health care or residential child
care facility’s withdrawal, revocation, loss of its license to operate.
G. If the application for 27-65 designation is denied, the reason(s) for denial listing deficiencies in the
application shall be provided in a certified letter to the address of the applicant as shown on the
application or as subsequently furnished in writing by the applicant. If an applicant disagrees with
the decision, the applicant, if within sixty (60) days of receiving notice of the decision, may
request a hearing to review the denial pursuant to Sections 24-4-105 and 24-4-106, C.R.S. (see
part 2.24.5 of these rules); or upon remedying the noted deficiencies, may re-apply for 27-65
designation in accordance with this part 11.4.
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11.4.2 Provisional 27-65 Designation
A. Provisional approval may be granted for a period not to exceed ninety (90) calendar days if, after
initial inspection and review of an application:
1. The applicant is in substantial compliance with these rules and is temporarily unable to
conform to all the minimum standards required under these rules. No provisional 27-65
designation shall be issued to an applicant if the operation of the facility may adversely
affect individual health, safety, or welfare;
2. Compliance will be achieved within the ninety (90) day duration of the provisional license;
and
3. The applicant has a reasonable plan or schedule in writing for achieving compliance and
provides a written copy of the plan to the BHA.
B. The applicant shall provide proof that attempts are being made to conform and comply with
applicable rules.
C. A second provisional approval for a period not to exceed ninety (90) calendar days may be
granted under the same criteria if necessary to achieve compliance.
D. If the applicant is not able to come into compliance within one hundred and eighty (180) calendar
days from the date of initial provisional license granted, the application may be denied with a right
to request a hearing as described in part 11.4.1.G of this rule.
11.4.3 27 -65 Re-Designation
A. A facility seeking 27-65 designation renewal shall provide the Department with a completed 27-65
designation application at least sixty (60) calendar days prior to the expiration of the existing 27-
65 designation.
B. 27-65 designation renewal applications received by the BHA after the current 27-65 designation
expiration date has passed shall be returned to the facility by certified first class mail and/or
through electronic means with written notification that the 27-65 designation is no longer in effect.
Applicants may reapply for an initial 27-65 designation in accordance with part 11.4.1 of these
rules.
C. 27-65 designation renewal applications that are received by the BHA fewer than sixty (60)
calendar days prior to the expiration of their existing 27-65 designation is a basis from which the
BHA may deny the renewal application. If the BHA denies the renewal application for being
untimely, the BHA will provide the facility with notice of the decision by certified first class mail. If
the facility disagrees with the decision, it may request a hearing as described in part 11.4.1.G of
this rule. Alternatively, any facility that submits its renewal application fewer than sixty (60)
calendar days prior to the expiration of the current 27-65 designation and does not receive a new
27-65 designation prior to that date and/or notice that the BHA decided to deny the renewal
application may reapply for an initial 27-65 designation in accordance with part 11.4.1 of these
rules.
D. F ailure of a facility seeking renewal of a designation to accurately answer or report any
information requested by the BHA shall be considered good cause to deny the 27-65 designation
renewal application.
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E. Facilities designated to provide care and treatment to persons with mental health disorders
pursuant to Section 27-65-101 through -131, C.R.S., shall receive an annual review for
compliance.
F. Facilities shall be notified in writing of non-compliance areas and the need for a plan of action as
outlined in part 2.23.H.2 of these rules. A probationary 27-65 designation may be granted.
G. A facility in compliance with applicable BHA rules and state and federal regulations shall be
granted 27-65 designation effective through the expiration date, for a period not to exceed one (1)
year.
11.4.4 Conditional 27-65 Designation
A. A conditional 27-65 designation may be granted to a facility out of compliance with applicable
BHA or state and federal regulations prior to issuance of a renewal designation or during a
current designation period. The facility will be notified in writing of non-compliance areas and the
need for a plan of action (see part 2.23.H.2 of these rules).
B. A conditional 27-65 designation will replace the current 27-65 designation for a period not to
exceed ninety (90) calendar days.
C. Administrative and treatment activities may be limited by a conditional 27-65 designation as set
forth in the conditional designation while the facility addresses corrective actions.
D. A c onditional 27-65 designation may be re-issued for an additional period not to exceed ninety
(90) calendar days if substantial progress continues to be made and it is likely that compliance
can be achieved by the date of expiration of the second conditional license.
E. If the facility fails to comply with or complete a plan of action in the time or manner specified, or is
unwilling to consent to the conditional 27-65 designation, the modification to a conditional 27-65
designation shall be treated as a revocation of the 27-65 designation and the facility shall be
notified by certified mail of the deficiencies and reason for action, the BHA may then institute
proceedings to effect the revocation per Section 24-4-104(3), C.R.S.
11.4.5 Change in Designation
A. If a facility makes a change in its designation status or decides to drop its 27-65 designation, it
shall notify the BHA in writing no later than thirty (30) calendar days prior to the desired effective
date. The facility shall submit a written plan for the transfer of care for the persons with mental
health disorders if the facility will no longer treat those individuals. This plan shall be submitted no
later than ten (10) business days prior to the effective date.
11.4.6 R ule Waivers
A. Rule waivers may be applied for as described in part 2.22 of these rules.
11.4.7 Enforcement and Adverse Actions
A. 27-65 designated facilities are subject to enforcement measures outlined in part 2.24 of these
rules and intermediate restrictions as outlined in part 2.24.4 of these rules.
B. Appeals of adverse actions shall be conducted in accordance with the state administrative
procedure act, Section 24-4-101 through -109, C.R.S.
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11.5 Data Reporting Requirements for All 27-65 Designated Facilities [Effective July 1, 2024]
A. Each facility designated for 27-65 services by the BHA, pursuant to Article 65 of Title 27, C.R.S.,
shall file an annual report with the BHA. The report shall be submitted in the format and
timeframe required by the BHA. This data shall include individuals on emergency mental health
holds and/or individuals on short-term or long-term certifications that are being treated in
placement facilities under the auspices of the 27-65 designated facility.
B. For each 27-65 designated facility, the annual report shall include:
1. Facility name;
2. County, and address of the facility; and
3. Type of facility as defined in Section 27-65-102(15), C.R.S.
C. The facility must maintain confidentiality over the data sets. The reports generated from these
data sets are also confidential; but the BHA may release aggregated information contained in the
reports so long as the total number of individuals in any aggregate data group (including county
or facility name) is greater than thirty (30). If the total number in such a data group is less than or
equal to thirty (30), the BHA may release this information by redacting such number.
11.5.1 D ata Reporting General Standards
A. Facilities must submit their annual data report to the BHA by July 1 of each year for the most
recent, complete calendar year covering January 1 through December 31. The report must meet
the requirements in this part 11.5 of these rules.
B. The BHA will annually request from the Department of Public Health and Environment a list of
licensed facilities that may provide emergency services pursuant to Article 65 of Title 27, C.R.S.
the facility list shall include, but is not limited to:
1. General hospitals;
2. Hospital units;
3. Psychiatric hospitals; and,
4. Community clinics.
C. If a facility on the list provided by the Department of Public Health and Environment does not
report to the BHA, the BHA will contact the facility to confirm that the facility did not provide
involuntary care to a person pursuant to Title 27, Article 65, C.R.S. during the reporting cycle.
1. If a facility is found to have provided involuntary care to a person pursuant to Title 27,
Article 65, C.R.S. and did not submit an annual report, an annual report will be requested.
2. If a facility refuses to provide the statutorily required report, the BHA may submit a
complaint to the office of the ombudsman for behavioral health access to care.
D. T he facility must maintain confidentiality over the data sets. The reports generated from these
data sets are also confidential; but the BHA may release aggregated information contained in the
reports so long as the total number of persons in any aggregate data group (including county or
facility name) is greater than thirty (30). If the total number in such a data group is less than or
equal to thirty (30), the BHA may release this information by redacting such number.
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E. The data report requirements, by service type, shall include the following types below in this part
11.5.
11.5.2 Seventy-Two (72) Hour Treatment and Evaluation (Emergency Mental Health Holds)
A. The facility is required to maintain a data set sufficient to report the following disaggregated
numbers to the BHA annually by July 1, for the most recent, complete calendar year covering
January 1 through December 31 and shall include as permitted by HIPAA, as incorporated by
reference in part 1.2 of these rules; 42 C.F.R. Part 2, as incorporated by reference in part 1.2 of
these rules ; and Section 27-65-101 through-131, C.R.S.:
1. For each individual on an involuntary emergency mental health hold, the facility shall
report the individual’s:
a. Client ID;
b. Date of birth;
c. Gender;
d. Race and ethnicity; and
e. County of residence.
2. Who initiated the involuntary emergency mental health hold? (Each hold can only meet
the requirements of one category listed below):
a. Certified peace officer;
b. Court; or
c. Intervening professional.
3. If applicable, what kind of intervening professional initiated the involuntary emergency
mental health hold?
a. P rofessional person;
b. Physician assistant;
c. Advanced practice registered nurse;
d. Registered professional nurse;
e. Licensed clinical social worker;
f. Licensed marriage and family therapist;
g. Professional counselor; or
h. Licensed addiction counselor.
4. The reason(s) for the involuntary emergency mental health hold (each hold can meet the
requirements of multiple categories listed below):
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a. Danger to self;
b. Danger to others; or
c. Gravely disabled.
5. Disposition of the involuntary emergency mental health hold (each hold can only meet the
requirements of one category listed below):
a. Released without need for further mental health services;
b. Referred for further mental health care and treatment on a voluntary basis;
c. Certified for short-term treatment pursuant to Section 27-65-109, C.R.S.;
d. Transferred to another designated facility while still on the seventy-two (72) hour
hold; or
e. Placed on a subsequent hold due to placement issues.
6. The length of time the individual had to wait for placement in a facility.
7. The challenges encountered while finding placement for the individual, which may include
but is not limited to:
a. Medical complications;
b. Historical aggression/combativeness;
c. Intellectual and developmental disorders;
d. Infectious disease;
e. No bed available; and/or
f. Other important barriers to placement.
8. If applicable, the reason(s) for the subsequent involuntary emergency mental health hold,
which may include but is not limited to:
a. Medical complications;
b. Historical aggression/combativeness;
c. Intellectual and developmental disorders;
d. I nfectious disease;
e. No bed available; and/or
f. Other circumstances that prompted subsequent involuntary emergency mental
health hold.
9. The total number of involuntary transportation holds received by the facility, as well as
total numbers by outcome of the required screening, including at least:
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a. Total number of involuntary transportation hold screenings resulting in the
placement of an involuntary emergency mental health hold;
b. Total number of involuntary transportation hold screenings resulting in a referral
for further mental health care and treatment on a voluntary basis; and
c. Total number of involuntary transportation hold screenings resulting in a release
without need for further mental health services.
11.5.3 Short and Long-Term Certifications
A. The facility is required to maintain a data set sufficient to report the following disaggregate
numbers to the BHA annually by July 1, for the most recent, complete calendar year covering
January 1 through December 31 and shall include as permitted by HIPAA, as incorporated by
reference in part 1.2 of these rules; 42 C.F.R. Part 2, as incorporated by reference in part 1.2 of
these rules; and Section 27-65-101 through-131, C.R.S.:
1. For each individual, who was on a certification, the facility shall report the individual’s:
a. Client ID;
b. Date of birth;
c. Gender;
d. Race and ethnicity; and
e. County of residence.
2. Type of certification (each certification can only meet the requirements of one category
listed below):
a. S hort -term;
b. Extended short-term;
c. Long-term; or
d. Extended long-term.
3. Status of certification:
a. Inpatient; or
b. Outpatient.
4. Who initiated the certification (each certification can only meet the requirements of one
category listed below):
a. Court order; or
b. Professional person.
5. Reason(s) for the certification (each certification can meet the requirements of multiple
categories listed below):
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a. Danger to self;
b. Danger to others; or
c. Gravely disabled.
6. Start date of certification.
7. End date of certification.
8. Start time of certification.
9. End time of certification.
10. The services that were provided during the certification.
11. Outcome of the certification (each certification can only meet the requirements of one
category listed below):
a. Certification extended;
b. Successfully discharged and referred for further mental health care and
treatment on a voluntary basis;
c. Voluntarily discharged;
d. Transferred for continued involuntary treatment;
e. Unable to locate individual for treatment;
f. Discontinued with treatment compliance concerns;
g. Unable to transfer to another facility;
h. Discontinued due to lack of payment to treatment providers; or
i. Other circumstances of the outcome of the certification.
12. Employment status:
a. Unemployed;
b. Employed (full time);
c. Employed (part time);
d. Student;
e. Military service; or
f. Disability.
13. Housing status:
a. Independent living;
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b. Lives with parent/guardian/caregiver;
c. Unhoused;
d. Shelter;
e. Temporary housing;
f. Halfway house;
g. Alternative care facility;
h. Nursing home;
i. Group home; or
j. Residential child care facility.
11.5.4 Voluntary Individuals
A. The facility is required to maintain a data set sufficient to report the following disaggregate
numbers to the BHA annually by July 1 for the most recent, complete calendar year covering
January 1 through December 31, a record of each individual who accessed mental health
treatment voluntarily pursuant to Section 27-65-103, C.R.S., each individual’s record and data
report shall include as permitted by HIPAA, as incorporated by reference in part 1.2 of these
rules; 42 C.F.R. Part 2, as incorporated by reference in part 1.2 of these rules; and Section 27-
65-101 through-131, C.R.S.:
1. Client ID;
2. Date of birth;
3. Gender;
4. Race and ethnicity; and
5. County of residence.
11.5.5 Involuntary Medications
A. In addition to the reporting of involuntary medications pursuant to part 11.8.5, the facility is
required to maintain data sets sufficient to report the following disaggregate numbers to the
Department annually by July 1 for the most recent, complete calendar year covering January 1
through December 31, a record of each individual who was given involuntary psychiatric
medication pursuant to Section 27-65-106, C.R.S., each individual’s record and data report shall
include as permitted by HIPAA, as incorporated by reference in part 1.2 of these rules; 42 C.F.R.
Part 2, as incorporated by reference in part 1.2 of these rules; and Section 27-65-101 through-
131, C.R.S.:
1. C lient ID;
2. Date the procedure was initiated;
3. Date of birth;
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4. Gender;
5. Race and ethnicity;
6. Type of order:
a. Emergency; or
b. Court-ordered.
7. Type of medication (specified use of involuntary medication):
a. Antipsychotics - typical;
b. Antipsychotics - atypical;
c. Antidepressants;
d. Mood stabilizers; or
e. Anxiolytics/hypnotics.
11.5.6 Involuntary Treatment
A. The facility is required to maintain data sets sufficient to report the following disaggregate
numbers to the Department annually by July 1 for the most recent, complete calendar year
covering January 1 through December 31, a record of each individual who underwent involuntary
treatments pursuant to Section 27-65-106, C.R.S., each individual’s record and data report shall
include as permitted by HIPAA, as incorporated by reference in part 1.2 of these rules; 42 C.F.R.
Part 2, as incorporated by reference in part 1.2 of these rules; and Section 27-65-101 through-
131, C.R.S.:
1. Client ID;
2. Date of birth;
3. Gender;
4. Race and ethnicity; and
5. Type of treatment:
a. Seclusion;
b. Restraint; or
c. Both seclusion and restraint.
6. Date, time, and length of seclusion and/or restraint episode per individual.
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11.5.7 Electroconvulsive Therapy (ECT) Procedures
A. The facility is required to maintain data sets sufficient to report the following disaggregate
numbers to the Department annually by July 1 for the most recent, complete calendar year
covering January 1 through December 31, a record of each individual who underwent
electroconvulsive therapy, each individual's record and data report shall include as permitted by
HIPAA, as incorporated by reference in part 1.2 of these rules; 42 C.F.R. Part 2, as incorporated
by reference in part 1.2 of these rules; and Section 27-65-101 through-131, C.R.S.:
1. Client ID;
2. Date of birth;
3. Gender;
4. Race and ethnicity;
5. Date, time, and length of ECT; and
6. Status:
a. Voluntary ECT; or
b. Involuntary ECT.
11.5.8 Imposition of Legal Disability or Deprivation of a Right
A. The facility is required to maintain data sets sufficient to report the following disaggregate
numbers to the BHA annually by July 1 for the most recent, complete calendar year covering
January 1 through December 31, a record of each individual with an imposition of legal disability
or deprivation of a right during treatment pursuant to Section 27-65-127, C.R.S., each individual’s
record and data report shall include as permitted by HIPAA, as incorporated by reference in part
1.2 of these rules; 42 C.F.R. Part 2, as incorporated by reference in part 1.2 of these rules; and
Section 27-65-101 through-131, C.R.S.:
1. C lient ID;
2. Date of birth;
3. Gender;
4. Race and ethnicity; and
5. Specific right deprived.
11.5.9 Data Requirements for Emergency Medical Services Facilities [Effective July 1, 2024]
A. The data reporting required in this section is subject to limitations set forth in HIPAA, as
incorporated by reference in part 1.2 of these rules; 42 C.F.R. Part 2, as incorporated by
reference in part 1.2 of these rules; and Section 27-65-101 through-131, C.R.S.
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B. An emergency medical services facility, as defined in part 11.2 of these rules, providing care to
an individual pursuant to Article 65 of Title 27, C.R.S. is required to maintain a data set sufficient
to report the following disaggregate numbers to the BHA annually pursuant to Section 27-65-
106(9), C.R.S., in the format and timeframe required by the BHA as provided on the BHA
website.
C. For each facility, the annual report shall include:
1. The name, county, and address of each facility site where the service was provided.
2. Gender;
3. Race and ethnicity;
4. County of residence;
5. If the individual arrived at the facility through an emergency transportation hold;
6. A record of each individual who had an involuntary emergency mental health hold
resolved (this includes release without need for further mental health services, referral for
voluntary treatment, or transferred to from the facility) at the facility;
7. The outcome of each individual involuntary emergency mental health hold resolved at the
facility (each hold can only meet the requirements of one category listed below):
a. Released without the need for further mental health services;
b. Referred for voluntary treatment; or
c. T ransferred to a 27-65 designated facility for continued involuntary services.
8. Who initiated the involuntary emergency mental health hold (each hold can only meet the
requirements of one category listed below):
a. Certified peace officer;
b. Court; or
c. Intervening professional.
9. The reason for the involuntary emergency mental health hold (each hold can meet
requirements of multiple categories below):
a. Dangerous to self;
b. Dangerous to others; or
c. Gravely disabled.
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11.6 Personnel Requirements for 27-65 Designated Facilities
11.6.1 Safety
A. Any personnel who are physically or mentally unable to adequately and safely perform duties that
are essential functions may not be assigned duties as a direct care personnel or volunteer at a
27-65 designated facility. Facilities shall outline criteria in their policies and procedures for
determining whether a person is able to safely perform duties in its policies and procedures.
B. The facility shall not employ or allow any personnel who are under the influence of a controlled
substance, as defined in Sections 18-18-203 through -207, C.R.S. or who are under the influence
of alcohol in the workplace. This does not apply to personnel using controlled substances under
the direction of a physician and in accordance with their health care provider’s instructions, as
long as it does not pose a safety risk to the person, other personnel, or individuals.
C. The facility shall employ sufficient personnel to ensure that the provision of services meets the
needs of individuals. The facility shall:
1. Ensure that each shift has a minimum of two (2) personnel, whenever one (1) or more
individuals are present in the milieu;
2. Mai ntain individual-to-personnel ratios not exceeding a one to six (1:6) trained staff
member(s) to individual ratio at all times; and
3. Inpatient staffing ratios do not apply to outpatient certification services.
D. If the facility is a hospital, the facility must comply with staffing requirements pursuant to Section
25-3-128, C.R.S. in lieu of compliance with part 11.6.1.C.
E. The facility shall ensure that, at minimum, one of the following qualified personnel is available to
administer medications at all times:
1. Licensed practical nurse, registered nurse, advanced practice registered nurse,
physician, physician’s assistant, pharmacist, or qualified medication administration
person (QMAP).
11.6.2 Leadership Personnel Requirements and Responsibilities
A. Facility director
1. The facility director is responsible for the following:
a. Overall direction and responsibility for the individuals, program, facility, and fiscal
management;
b. Overall direction and responsibility for supervision of personnel;
c. The selection and training of a capable personnel member who can assume
responsibility for management of the facility in the director’s absence; and
d. The establishment of relationships and maintaining contact with allied facilities,
services, and mental health resources within the community.
2. Qualifications of a facility director:
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a. The facility director shall have, at minimum, received a bachelor’s degree from an
accredited college or university and have three (3) years of verified experience in
the human services field, one of which was in a supervisory or administrative
position; or,
b. The facility director shall have, at minimum, received a master’s degree from an
accredited college or university and have two (2) years of verified experience in
the human services field, one of which was in a supervisory or administrative
position.
3. Assistant or acting facility director:
a. In each facility, there shall be a specifically designated personnel member
capable of acting as a substitute for the facility director during their absence. The
duties and responsibilities of the acting facility director shall be clearly defined
within the facility’s policies and procedures in order to avoid confusion and
conflict among other personnel and individuals.
b. If the facility director is regularly absent from the facility for more than fifty percent
(50%) of their working hours, an assistant or acting director shall be appointed
who meets the qualifications outlined in part 11.6.2.A.2 of this section.
B. Clinical director
1. The clinical director is responsible for assuring that there is adequate training and
supervision for personnel, that multidisciplinary personnel members are practicing within
their scope, and that ethical standards are upheld.
2. Q ualifications of a clinical director:
a. The clinical director shall possess a master’s degree or doctoral degree in a
mental health related field or a bachelor’s degree in a mental health related field
plus five (5) years of related work experience.
b. The clinical director shall possess a valid clinical license to practice medicine
and/or behavioral health services in the state of Colorado.
11.6.3 Personnel Training Requirements for 27-65 Designated Facilities
A. In addition to trainings identified in part 2.5.I of these rules, facilities designated for 27-65 services
under these rules shall develop policies and procedures for personnel training curriculum and
schedules in order to meet the following requirements. Facilities may choose to use an annual
certification of competency in lieu of training which shall be stored in the personnel file; the facility
shall develop appropriate policies, procedures and testing to assure and demonstrate personnel
competency. Training shall be conducted in a trauma-informed, culturally, and linguistically
competent manner.
B. All personnel supervising or providing direct care and treatment for individuals with mental health
disorders shall receive annual training or annual facility certification of competency on the
provisions of these rules and the requirements of Section 27-65-101 through -131, C.R.S.
C. Al l personnel who order or administer involuntary medications (including prescribers, nursing
personnel, and QMAPs) shall receive annual training or annual facility certification of competency
on Chapter 11 of these rules and the legal rationale underlying involuntary medication of
individuals.
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D. All supervisory and direct care personnel shall receive annual training or annual facility
certification of competency in the recognition and response to common side effects of psychiatric
medications. These personnel shall be trained to respond to emergency drug reactions in
accordance with the facility's policies.
E. All personnel who administer seclusion, restraint, and physical management techniques shall
receive training and/or certification at minimum pursuant to this part 11.9.3.
F. All program administrators and program supervisory personnel shall receive annual training or
annual facility certification of competency on alternative or representative medical decision
making, including, but not limited to advance directives, medical durable powers of attorney, and
proxy decision making, and guardianships.
G. Specific personnel of placement facilities, as determined by the 27-65 designated facility and its
policies and procedures, shall receive annual facility training or annual certification of competency
on the provisions of these rules and the requirements of Section 27-65-101 through-131, C.R.S.
the 27-65 designated facility is responsible for ensuring that this annual training occurs at
placement facilities and documenting all relevant placement facility training.
11.7 Individual Records
11.7.1 General Procedures for Individual Records
A. The professional person and/or the facility providing an evaluation, care, and/or treatment shall
keep records detailing all care and treatment received by the individual, and the records must be
made available, upon the individual’s written authorization, to the individual’s attorney or the
individuals personal physician in accordance with federal and state laws. The records are
permanent records and must be retained in accordance with Section 27-65-123(4), C.R.S.
B. E xcept as provided in this part 11.7.1.B, all information obtained and records prepared in the
course of providing any services to any individual pursuant to any provision of Article 65 of Title
27, C.R.S., are confidential and privileged matter. The information and records may be disclosed
only:
1. In communications between qualified professional personnel in the provision of services
or appropriate referrals;
2. When the individual designates other persons to whom information or records may be
released; but, if an individual is a ward or conservatee and the ward’s or conservatee’s
guardian or conservator designates, in writing, persons to whom records or information
may be disclosed, the designation is valid in lieu of the designation by the recipient;
except that nothing in this section compels a physician, psychologist, social worker,
nurse, attorney, or other professional personnel to reveal information that has been given
to the individual in confidence by members of an individual’s family or other informants;
3. To the extent necessary to make claims on behalf of a recipient of aid, insurance, or
medical assistance to which recipient may be entitled;
4. If the BHA has promulgated rules for the conduct of research, such rules must include,
but are not limited to, the requirement that all researchers must sign an oath of
confidentiality. All identifying information concerning individuals, including names,
addresses, telephone numbers, and social security numbers, must not be disclosed for
research purposes;
5. T o the courts, as necessary for the administration of Article 65 of Title 27, C.R.S.;
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6. To persons authorized by an order of court after notice and opportunity for hearing to the
individual to whom the record or information pertains and the custodian of the record or
information pursuant to the Colorado rules of civil procedure;
7. To family members upon admission of an individual with a mental health disorder for
inpatient or residential care and treatment. The only information that may be released
pursuant to this part 11.7.1.B.7 is the location and fact of admission of the person with a
mental health disorder who is receiving care and treatment. The disclosure of location is
governed by HIPAA and 42 C.F.R. Part 2 and the procedures in Section 27-65-124,
C.R.S. and is subject to review pursuant to Section 27-65-124, C.R.S.; and/or,
8. To family members or a lay person actively participating in the care and treatment of a
person with a mental health disorder, regardless of the length of the participation. This
disclosure is governed by HIPAA, as incorporated by reference in part 1.2 of these rules;
and 42 C.F.R. Part 2, as incorporated by reference in part 1.2 of these rules; and the
procedures in Section 27-65-124 (2) and is subject to review pursuant to Section 27-65-
124, C.R.S. The information released pursuant to this subpart is limited to one (1) or
more of the following:
a. T he diagnosis;
b. The prognosis;
c. The need for hospitalization and anticipated length of stay;
d. The discharge plan;
e. The medication administered and side effects of the medication; and
f. The short-term and long-term treatment goals.
9. In accordance with state and federal law, to the facility designated pursuant to the federal
“Protection and Advocacy for Mentally Ill Individuals Act”, 42 U.S.C. Sec. 10801 et seq.,
and as the governor's protection and advocacy system for Colorado.
C. Nothing in part 11.7.2 of these rules precludes the release of information to a parent or legal
guardian concerning the minor.
1. Nothing in Article 65 of Title 27, C.R.S., renders privileged or confidential any information,
except written medical records and information that is privileged pursuant to Section 13-
90-107, C.R.S., concerning observed behavior that constitutes a criminal offense
committed upon the premises of any facility providing services pursuant to Article 65 or
any criminal offense committed against any individual while performing or receiving
services pursuant to Article 65 of Title 27, C.R.S.
2. This section does not apply to physicians or psychologists eligible to testify concerning a
criminal defendant’s mental condition pursuant to Section 16-8-103.6, C.R.S.
D. Al l facilities shall maintain and retain permanent records, including all applications as required
pursuant to Section 27-65-106(3), C.R.S.
1. Outpatient or ambulatory care facilities shall retain all records for a minimum of seven (7)
years after discharge from the facility for individuals who were eighteen (18) years of age
or older when admitted to the facility, or until twenty-five (25) years of age for individuals
who were under eighteen (18) years of age when admitted to the facility.
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2. Inpatient or hospital care facilities shall retain all records for a minimum of ten (10) years
after discharge from the facility for individuals who were eighteen (18) years of age or
older when admitted to the facility, or until twenty-eight (28) years of age for individuals
who were under eighteen (18) years of age when admitted to the facility.
3. Nothing in this section prohibits or limits the sharing of information by a state institution of
higher education police department to authorized university administrators pursuant to
Section 23-5-141, C.R.S.
11.7.2 Request for Release of Information Procedures
A. This section provides for the release of information only and is not deemed to authorize the
release of the written medical record without authorization by the individual or as otherwise
provided by law.
1. When a family member requests the location and fact of admission of a person with a
mental health disorder pursuant to Section 27-65-123(1)(g), C.R.S., the treating
professional person or the professional person’s designee, who must be a professional
person, shall decide and document the rationale in the individual’s record to whether to
release or withhold such information. The location must be released if consistent with
HIPAA, as incorporated by reference in part 1.2 of these rules, and 42 C.F.R. Part 2, as
incorporated by reference in part 1.2 of these rules, unless the treating professional
person or the professional person’s designee determines, after an interview with the
individual, that release of the information to a particular family member would not be in
the best interests of the individual.
a. An y decision to withhold information requested pursuant to Section 27-65-123(1),
C.R.S., is subject to administrative review pursuant to this section upon request
of a family member or the individual.
2. The treating facility shall make a record of the information given to a family member.
3. For the purposes of request for release of information in this section, an adult person
having a similar relationship to an individual with a mental health disorder as a spouse,
lay person, parent, child, or sibling of an individual with a mental health disorder may also
request the location and fact of admission concerning an individual with a mental health
disorder.
4. When a family member requests information concerning an individual with a mental
health disorder, the treatment professional person or the professional person’s designee,
shall determine whether the individual is capable of making a rational decision in
weighing the individual’s confidentiality interests and the care and treatment interests
implicated by the release of information. The treating professional person or the
professional person’s designee shall then determine whether the individual consents or
objects to the release of information.
B. For purposes of this section, the treating professional person’s designee shall be a professional
person.
C. I nformation must be released or withheld in the following circumstances:
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1. If the treating professional person or the professional person’s designee makes a finding
that the individual is capable of making a rational decision concerning the individual’s
interests and the individual consents to the release of information, the treating
professional person or the professional person’s designee shall order the release of the
information unless the professional person or the professional person’s designee
determines that the release would not be in the best interest of the individual with a
mental health disorder.
2. If the treating professional person or the professional person’s designee makes a finding
that the individual with a mental health disorder is capable of making a rational decision
concerning the individual’s interests and the individual objects to the release of
information, the treating professional person or the professional person’s designee shall
not order the release of information.
3. If the treating professional person or the professional person’s designee makes a finding
that the individual with a mental health disorder is not capable of making a rational
decision concerning the individual’s interests, the treating professional person or the
professional person’s designee may order the release of the information if the
professional person or the professional person’s designee determines that the release
would be in the best interests of the individual.
4. An y determination of individual capacity:
a. Must be used only for the limited purpose of this section.
b. A decision by a treating professional person or the professional person’s
designee concerning the capability of an individual with a mental health disorder
is subject to administrative review upon the request of the individual.
c. A decision by a treating professional or the professional person’s designee to
order the release or withholding of information is subject to administrative review
upon the request of either a family member or the individual with a mental health
disorder.
d. The director of the treating facility shall make a record of any information given to
a family member.
D. Procedures for administrative and judicial review of information release/withholding when
requested:
1. When administrative review is requested, the director of the facility providing care and
treatment to an individual with a mental health disorder, shall cause an objective and
impartial review of the decision to withhold or release information.
2. The director of the facility shall conduct the review if the director is a professional person.
a. If the director is not available or if the director cannot provide an objective and
impartial review, the review must be conducted by a professional person
designated by the facility director.
3. T he review must include, but is not limited to, an interview with the individual with a
mental health disorder.
4. The facility providing care and treatment shall document the review of the decision
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5. If an individual with a mental health disorder objects to the release or withholding of
information, the individual and the individual's attorney, if any, must be provided with
information concerning the procedures for administrative review of a decision to release
or withhold information. The individual must be informed of any information proposed to
be withheld or released, and to whom, and be given a reasonable opportunity to initiate
the administrative review process before information concerning the individual’s care and
treatment is released.
6. A family member whose request for information is denied must be provided with
information concerning the procedures for administrative review of a decision to release
or withhold information.
7. An individual with a mental health disorder may file a written request for review by a
court, under Section 27-65-124, C.R.S., of a decision made upon administrative review to
release information to a family member requested and proposed to be released.
8. If judicial review is requested by the individual, under Section 27-65-124, C.R.S., the
court shall hear the matter within ten (10) days after the request, per Section 27-65-124,
C.R.S., and the court shall give notice to the individual with a mental health disorder and
the individual's attorney, the treating professional person, and the person who made the
decision upon administrative review of the time and place of the hearing.
a. T he hearing must be conducted in the same manner as other civil proceedings
before the court per Section 27-65-124, C.R.S.
9. Unless specifically stated in an order by the court, an individual does not forfeit any legal
right or suffer legal disability by reason of the provisions of Article 65 of Title 27, C.R.S.
10. In order to allow an individual with a mental health disorder an opportunity to seek judicial
review, the treating facility or the treating professional person or the professional person's
designee shall not release information requested until five (5) days after the
determination upon administrative review of the director or the director's designee is
received by the individual.
11. Once judicial review is requested, the treating facility or the treating professional person
or the professional person's designee shall not release information except by court order.
12. If the individual with a mental health disorder indicates an intention not to appeal a
determination upon administrative review that is adverse to the individual concerning the
release of information, the information may be released less than five (5) days after the
determination upon review is received by the individual.
11.7.3 Documentation in Individual Records
A. 27 -65 designated involuntary emergency services facilities shall be exempt from completing a
comprehensive assessment as described in part 2.12.3 of these rules, an initial assessment as
described in part 2.12.2 of these rules and a service plan as described in part 2.13.1 of these
rules.
B. Screening shall follow requirements as outlined in part 2.12.1 of these rules and must also
contain the following:
1. Substance use in the past 24 hours:
a. What, how much, when;
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2. Current medications; and
3. Psychiatric advance directives, psychiatric and/or medical assessment documentation.
C. Crisis assessments must be completed in full on a BHA-created form, available on the BHA
website, within 24 hours of admission when determining involuntary hold.
1. The elements from this form can be integrated into a facility’s electronic health record
system.
D. The BHA-created standardized evaluation form pursuant to 27-65-106(6)(b), C.R.S., available on
the BHA website must be documented in full in the individual record.
E. If the treating professional person at the designated facility pursues short-term or long-term
certification of an individual, all corresponding court documents must also be part of the individual
record.
F. Safety planning documentation must contain the following:
1. Emergency services facilities will develop crisis safety plans with individuals who are
detained or assessed/evaluated and are not placed on emergency mental health holds
prior to discharge or transfer.
2. Safety planning must be done in collaboration with the individual in crisis and their family
members and/or other social supports (if desired by the individual).
G. Discharge instructions and care coordination instructions must contain the following in both the
individual’s clinical record and available as instructions for the individual:
1. A s ummary of why the individual was detained or evaluated for an emergency mental
health hold;
2. Detailed information as to why the evaluating professional determined the individual no
longer meets the criteria for an emergency mental health hold pursuant to Section 27-65-
106, C.R.S. or certification pursuant to Section 27-65-109, C.R.S.;
3. Whether the individual may receive services on a voluntary basis pursuant to parts
11.14.2.I through 11.14.2.l of these rules;
4. If the individual’s medications were changed or the individual was newly prescribed
medications during the emergency mental health hold, a clinically appropriate supply of
medications, as determined by the judgment of a licensed health-care provider, for the
individual until the individual can access another provider or follow-up appointment.
Facility must assist in care coordination for the follow-up appointment, if needed;
5. A safety plan for the individual and, if applicable, the individual’s lay person where
indicated by the individual’s mental health disorder or mental or emotional state;
6. Notification to the individual’s primary care provider, if applicable and/or known;
7. A referral to appropriate services, if such services exist in the community, if the individual
is discharged without food, housing, or economic security. Any referrals and linkages
must be documented in the individual’s record;
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8. The phone number to call or text the Colorado Crisis Services hotline and information on
the availability of peer support services;
9. Information on how to establish a psychiatric or medical advance directive if one is not
presented;
10. Medications that were changed during the emergency mental health hold, including
previously prescribed upon admission, and which medications, if any, were changed or
discontinued at the time of discharge;
11. A list of any screening or diagnostic tests conducted during the emergency mental health
hold, if requested;
12. A summary of therapeutic treatments provided during the emergency mental health hold;
if requested;
13. Any laboratory work, including blood samples or imaging that was completed or
attempted, if requested;
14. The person’s vital signs upon discharge from the emergency mental health hold, if
requested;
15. A copy of any psychiatric advance directive presented to the facility, if applicable; and
16. How to contact the discharging facility if needed.
H. The facility shall document in the individual's record whether the individual accepted the
discharge instructions.
I. The facility shall provide the discharge instructions to the individual's parent or legal guardian if
the individual is under eighteen (18) years of age, and to the individual's lay person, when
possible and if consistent with state and federal law.
J. U pon discharge, the facility shall discuss with the individual, the individual's parent or legal
guardian, or the individual's lay person the statewide care coordination infrastructure established
in Section 27-60-204, C.R.S. to facilitate a follow-up appointment for the individual within seven
(7) calendar days after the discharge. Facilities shall comply with part 11.7.3.J of this Chapter,
when the statewide care coordination infrastructure created in Section 27-60-204, C.R.S. is fully
operational, as determined by the BHA. The BHA shall immediately notify facilities when the
statewide care coordination infrastructure is available to assist individuals with discharge.
K. The facility shall, at a minimum, attempt to follow-up with the individual, the individual's parent or
legal guardian, or the individual's lay person within forty-eight (48) hours after discharge.
L. The facility is encouraged to utilize peer support professionals, as defined in Section 27-60-
108(2)(b), C.R.S., when performing follow-up care with individuals and in developing a continuing
care plan pursuant to this part 11.7.3.G.1 through 3. The facility may facilitate follow-up care
through contracts with community-based behavioral health providers or the Colorado Behavioral
Health Crisis Hotline. If the facility facilitates follow-up care through a third-party contract, the
facility shall obtain authorization from the individual to provide follow-up care, any denial of
authorization from the individual shall be documented in the individual record.
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M. If the individual is enrolled in Medicaid, the facility is not required to meet the requirements of this
part 11.7.3.J through 11.7.3.M and instead, the facility shall notify the individual's relevant
Managed Care Entity, as defined in Section 25.5-5-403(4), C.R.S., of the individual's discharge
and need for ongoing follow-up care prior to the individual's discharge.
N. If the facility contracts with a Behavioral Health Entity and/or a safety net provider, as defined in
Section 27-50-101(7), C.R.S., to provide behavioral health services to an individual on or
following an emergency mental health hold, the facility shall work with the Behavioral Health
Entity and/or safety net provider in order to meet the requirements of this part 11.7.3.J through
11.7.3.M.
O. The facility shall encourage the individual to designate a family member, friend, or other persons
as a lay person to participate in the individual's discharge planning and shall notify the individual
that the individual is able to rescind the authorization of a lay person at any time. If the individual
designates a lay person and has provided necessary authorization, the facility shall attempt to
involve the lay person in the individual's discharge planning. The facility shall notify the lay person
that the individual is being discharged or transferred.
P. I nvoluntary emergency services facilities must ensure that an individual and authorized caregiver
and/or family member(s) receive follow-up by phone or telehealth within forty-eight (48) hours,
conducted by any member of the responding team or by an associated hospital follow-up
program. Purpose of the follow-up appointment shall be documented in the individual’s clinical
record.
11.8 Psychiatric Medications
11.8.1 Informed Consent
A. In all instances where prescription medications are to be ordered as a part of a mental health
treatment program, the following information in these part 11.8.1.A through 11.8.1.D shall be
provided, consistent with federal and state law, to the individual and legal guardian(s) and
communicated both written and verbally. For individuals, between the ages of fifteen (15) and
eighteen (18), the following information may be provided to the individuals’ parent(s) or legal
guardian(s). When an individual has designated another to act concerning medication issues
pursuant to a medical durable power of attorney, advanced directive, or proxy, the information
shall be provided to that person also. The facility shall have policies and procedures for
documenting in the clinical record that the required information was given to the individual,
parent, or guardian and consent obtained before initial administration of medication(s).
1. T he name(s) of the medication being prescribed;
2. The usual uses of the medication(s);
3. The reasons for ordering the medication(s) for this individual;
4. A description of the benefits expected;
5. The common side effects and common discomforts, if any;
6. The major risks, if any;
7. The probable consequences of not taking the medication(s);
8. Any significant harmful drug or alcohol interactions, or food interactions;
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9. Appropriate treatment alternatives, if any;
10. That the individual may withdraw agreement to take the medication at any time; and
11. Ensure that medication will not interfere or negatively interact with any of the individual’s
other prescribed medication(s).
B. If an individual has established an advance directive concerning psychiatric medication and the
advance directive is still in effect, the physician or advanced practice registered nurse shall follow
the directive unless contraindicated in a psychiatric emergency. The rationale for overriding an
advance directive shall be clearly documented in the individual’s clinical record.
C. The provider with prescriptive authority or their designee shall offer to answer inquiries regarding
the medication(s).
D. No individual shall be threatened with or subjected to adverse consequences by facility personnel
solely because of a failure to accept psychiatric medication voluntarily.
11.8.2 Prescribing, Handling, & Administration of Psychiatric Medication(s)
A. All psychiatric medication(s) shall be administered on the written order of a professional person
authorized by statute to order such medications. Verbal medication orders may be given
according to facility policies.
B. The facility shall have written policies and procedures regarding part 11.8.1 of these rules for
informed consent, and the following:
1. D ocumentation of the administration of medication, medication variances/errors, and
adverse medication reactions related to medication administration;
2. Notification to a professional person authorized by statute to order such medications in
case of medication errors and/or medication reactions/events;
3. Discontinuance of medication;
4. Disposal of medications;
5. Acceptance of verbal, fax, or electronically transmitted medication orders; and
6. Medication shortages and substitutions.
C. Facilities shall ensure all clinical staff are aware of and have access to the medication formulary.
D. Facilities shall ensure their providers have access to the medications on the medication formulary
when prescribing medications to treat behavioral health disorders.
E. Facilities shall note in the individual’s clinical record all prescription medications administered to
the individual by a facility including:
1. The name and dosage of medication;
2. The reason for ordering the medication;
3. The time, date and dosage when medication(s) is administered;
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4. The name and credentials of the person who administered the medication;
5. The name of the prescribing physician or advanced practice registered nurse to order
such medication; and
6. If the medication is administered as an emergency medication or a court-ordered
medication.
11.8.3 Involuntary Psychiatric Medications
A. These rules for involuntary psychiatric medications do not apply to refusal of non- psychiatric
medications or medical emergencies. If an individual refuses medications intended to treat
general medical conditions and that refusal is likely to cause or precipitate a medical emergency,
those professionals who are authorized to order and administer medications may take action in
accordance with generally accepted medical practice in an emergency situation.
B. Psychiatric emergency conditions: individuals who are detained pursuant to Sections 27- 65-106, -
107, -108.5, -109, or -110, C.R.S., and refuse psychiatric medication may be administered
psychiatric medication(s) ordered up to twenty-four (24) hours without consent under a psychiatric
emergency condition. The least intrusive means should be used to address the psychiatric
emergency.
C. An emergency condition exists if:
1. The individual is determined to be in immediate and substantial danger of harming self or
others, as evidenced by symptoms which have in the past reliably predicted
dangerousness in that particular individual; or,
2. By a recent overt act, including, but not limited to, a credible threat of bodily harm, an
assault on another person or self-destructive behavior that demonstrates an immediate
and substantial threat to self or others.
D. A reasonable attempt to obtain voluntary acceptance of psychiatric medication shall be made
prior to the use of involuntary medication.
E. Continuation of a psychiatric emergency:
1. If the psychiatric emergency has abated because of the effect of psychiatric medications
and the authorized practitioner is of the opinion that psychiatric medication is necessary
to keep the emergency in abeyance beyond seventy-two (72) hours, then within that
seventy-two (72) hours the following steps shall be taken:
a. T
he facility shall send a written request for a court hearing for an order to
administer the medication involuntarily;
b. A documented concurring consultation with another authorized practitioner shall
be obtained. The consultation shall include an examination of the individual and a
review of the clinical record including an assessment as to whether the
psychiatric emergency condition continues to exist; and
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c. If a concurring consultation is not obtained within seventy-two (72) hours, then
emergency psychiatric medication shall be discontinued until such concurring
consultation is obtained and documented, except in cases where life threatening
consequences could result from an abrupt medication discontinuation. Under
these circumstances, the individual shall be safely taken off the medication
according to standards of medical practice, with corresponding clinical
documentation.
2. In no case shall an individual receive emergency psychiatric medication(s) involuntarily
for a period exceeding ten (10) days without an order from a court of competent
jurisdiction, including continuation orders from the court.
3. The individual shall be notified of the right to contact their attorney and/or the court of
competent jurisdiction at the time the written request for court-ordered medication is
made. This notification shall be documented in the clinical record. If an individual chooses
to exercise this right, the 27-65 designated facility shall aid the individual, if necessary, in
accomplishing the foregoing.
F. The specific facts outlining behaviors supporting the finding of the emergency condition shall be
detailed in the clinical record. Every twenty-four (24) hours thereafter until such time a final court
order is issued, the emergency is resolved, or the individual accepts psychiatric medications
voluntarily, the facility shall document the behaviors that substantiated the need to continue the
emergency medication, and the physician shall reorder the psychiatric medications.
G. D uring the course of emergency medication administration, the individual shall be offered the
medication on a voluntary basis each time the medication is given. If the individual voluntarily
consents to take the medication(s), and the attending physician determines that the individual will
likely continue to accept the medication on a voluntary basis and no longer requires involuntary
medications, this shall be documented in the record and the involuntary medication procedures
shall be terminated.
H. If the individual again refuses to voluntarily accept medication(s) and their clinical condition
returns to an emergency situation, pursuant to part 11.8.3.C of these rules, the emergency
psychiatric medication procedures may be re-instituted.
11.8.4 Non-Emergency Involuntary Medications (Court Ordered Medications)
A. In non-emergency situations in which an individual, who is detained pursuant to Sections 27- 65-
106, -107, -108.5, -109, -110, or -111, C.R.S., would benefit from the administration of a
psychiatric medication, but the individual does not consent, the facility shall petition the court to
obtain permission to administer such medication. The following conditions must be documented
in the petition:
1. The individual is incompetent to effectively participate in the treatment decision;
2. Treatment by psychiatric medication is necessary to prevent a significant and likely long-
term deterioration in the individual's mental condition or to prevent the likelihood of the
individual causing serious harm to self or others;
3. A less intrusive appropriate treatment alternative is not available; and
4. The individual's need for treatment by psychiatric medication is sufficiently compelling to
override any bonafide and legitimate interest of the individual in refusing treatment.
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B. The petition shall specify what class or name of psychiatric medication is being recommended as
potentially beneficial to the individual.
C. No psychiatric medications shall be administered without the individual's consent until a court
order is received authorizing involuntary use, except under emergency conditions under part 11.8
of these rules.
11.8.5 Involuntary Medication Data Reporting
A. In addition to the involuntary medication data reporting requirements pursuant to 11.5.5, the 27-
65 designated facility shall maintain a log of all cases where involuntary medications were
administered.
B. The record must contain, at a minimum, the following:
1. Individual's name and identifying number;
2. Specified use of involuntary medication;
3. Physician or other professional authorized by law ordering involuntary medication;
4. Date/time each involuntary medication was administered and reason for use of
involuntary medication;
5. Date/time involuntary medication was discontinued; and
6. Reason for discontinuation of involuntary medication(s).
C. If the facility uses a medication administration record or another mechanism which meets the
criteria listed in this part 11.8.5.B, can correlate this information as required in this part 11.8.5.D,
and places the information in the clinical record, that mechanism may be used in lieu of a
separate log.
D. T he facility shall have the ability to determine, at a minimum:
1. The aggregate number of individuals receiving emergency and involuntary psychiatric
medications during a specified period of time; and
2. The start and stop dates for each individual's involuntary medication treatment.
E. If the facility is licensed as a BHE, the facility must incorporate the use of this data into the quality
improvement program in accordance with part 2.17 of these rules.
11.9 Seclusion, Restraint, and Physical Management
11.9.1 General Provisions
A. The following rules covering seclusion, restraint, and physical management apply to all facilities
that use seclusion, restraint, and/or physical management. If a facility has decided to use
seclusion, restraint, and/or physical management, the facility shall use seclusion, restraint, and/or
physical management only in accordance with the rules in this part 11.9.
B. These rules do not supersede any requirements under Section 26-20-101 through-111, C.R.S.
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C. If any provision of this part 11.9 conflicts with any provision concerning the use of seclusion,
restraint, and/or physical management on an individual with an intellectual or developmental
disability as stated in Article 10.5 of Title 27, C.R.S., Article 10 of Title 25.5, C.R.S. or any rule
adopted pursuant to those Articles, the provisions of those Articles or rules prevail.
D. Individuals being detained under Sections 27-65-106 through -110, C.R.S., may be secluded or
restrained involuntarily under the conditions in this part; otherwise, there must be a signed
informed consent for such an intervention as subject to part 2.11 of this rule.
E. A facility may only use seclusion, restraint, and/or physical management:
1. In cases of emergency, as defined at Section 26-20-102(3), C.R.S., to be a serious,
probable, imminent threat of bodily harm to self or others where there is the present
ability to affect such bodily harm; and,
2. After less restrictive alternatives, including but not limited to after all attempts to verbally
direct or de-escalate the individual have failed; or
3. After a determination that such alternatives would be inappropriate or ineffective under
the circumstances.
F. A fa cility that uses seclusion, restraint, and/or physical management pursuant to the provisions of
part 11.9.1.E of this section, may only use such seclusion, restraint, and/or physical
management:
1. For the purpose of preventing the continuation or renewal of an emergency;
2. For the period of time necessary to accomplish its purpose; and
3. In the case of physical restraint, with no more force than is necessary to limit the
individual's freedom of movement.
G. In addition to the circumstances described in this part 11.9.1.F, a facility that is designated by the
commissioner of the BHA in the State Department to provide treatment pursuant to Sections 27-
65-106, 27-65-109, or 27-65-110, C.R.S., to an individual with a mental health disorder, as
defined in Section 27-65-102(22), C.R.S., may use seclusion to restrain an individual with a
mental health disorder when the seclusion is necessary to eliminate a continuous and serious
disruption of the treatment environment.
H. Seclusion, restraint, and/or physical management must never be used:
1. As a punishment or disciplinary sanction,
2. As a means of coercion,
3. As part of an involuntary service plan or behavior modification plan,
4. F or convenience,
5. For the purpose of retaliation, or
6. For the purpose of protection, unless:
a. The restraint or seclusion is ordered by a court; or
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b. In an emergency, as provided for in this part 11.9.1.F.1 above.
I. Physical management for individuals under the age of eighteen (18) must always be considered
as restraint and follow the restraint order rules pursuant to part 11.9.13 of this Chapter.
11.9.2 Policies and Procedures Regarding Seclusion, Restraint, and Physical Management
A. Facilities shall have and shall implement written policies and procedures that describe the
situations in which the use of seclusion, restraint, and/or physical management are considered
appropriate in the facilities and personnel who can order their use. The policies and procedures
must include the requirements in this part 11.9 and Section 26-20-101 through -111, C.R.S. these
policies and procedures must also include:
1. For a facility that does not authorize the use of seclusion, restraint, and/or physical
management of any type, a policy statement noting the prohibition against the use of
seclusion, restraint, and/or physical management and the procedures that personnel will
utilize in lieu of seclusion, restraint, and/or physical management.
2. For a facility that utilizes seclusion, restraint, and/or physical management, a policy
statement regarding the review process for the use of seclusion, restraint, and/or physical
management. The review process must include a provision for terminating the seclusion,
restraint, and/or physical management episode when the reviewer does not concur with
the order for continuation.
a. If the reviewer is not an authorized practitioner, then the order must be
discontinued by an authorized practitioner.
3. Personnel shall ensure that no individual endures harm or harassment when secluded
and/or restrained.
4. A policy statement that a facility shall ensure that the care and treatment are skillfully and
humanely administered with full respect for the individual’s dignity, pursuant to Section
27-65-101(1)(a), C.R.S.
5. Protocols for when the use of restraint, seclusion, and/or physical management is
appropriate, and the restrictions on the use of these techniques, the facility may impose
more, but not fewer, restrictions on the use of these techniques than is required by this
Chapter.
6. Details on the type of physical management interventions that personnel are approved to
use.
7. Details on how seclusion, restraint, and/or physical management will be altered to include
any necessary accommodations the individual may need, including but not limited to,
changing emergency interventions to not restrain hands and ability to communicate for
those individuals that speak sign language.
11.9.3 Personnel Training
A. The facility shall ensure that all personnel involved in utilizing seclusion, restraint, and/or physical
management are trained in the use of seclusion, restraint, and/or physical management as
described in this part 11.9.
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B. The facility shall ensure that personnel are trained to explain, where possible, the use of
seclusion, restraint, and/or physical management to the individual who is to be secluded,
restrained, or physically managed and to the individual’s designated representative, if
appropriate.
C. Training must be standardized and evaluated every three (3) years to ensure incorporation of
evidence-based best practices for seclusion, restraint, and/or physical management.
D. Training must be provided to personnel within the first month of their orientation period and
annually thereafter unless training is needed sooner.
E. Personnel shall obtain certification in cardiopulmonary resuscitation (CPR), including periodic
recertification as needed to maintain certification.
F. Training must include at minimum, but is not limited to:
1. The safe use of seclusion, restraint, and/or physical management including content
related to the risks of positional asphyxia, aspiration, traumatization, and recognize and
respond to signs of physical distress of an individual who is secluded, restrained, and/or
physically managed;
2. Address concepts related to prevention and non-physical interventions such as de-
escalation and mediation;
3. Educate personnel of how their culture, language, biases, values, and perceptions
influence their response and escalation of person involved; and
4. U nderstanding and recognizing underlying behavioral health and physical health
conditions, medications, and their potential effects as well as how age, developmental
level, cultural background, language, history of physical or sexual abuse, and prior
experience with seclusion, restraint, and/or physical management will influence an
individual’s responses to seclusion, restraint, and physical management.
G. Personnel must demonstrate knowledge and application of seclusion, restraint, and physical
management training on an annual basis when working with persons over the age of twenty-one
(21), and on a semi-annual basis when working with youth twenty (20) years old and younger.
11.9.4 Standards of Care Upon Admission
A. At admission, the facility shall inform both the individual and the individual’s legal representative,
as applicable, of the facility’s policy regarding the use of seclusion, restraint, and physical
management during an emergency behavioral health episode for individuals in a treatment
program. This must, as is reasonable under the circumstances, be communicated, if feasible, in a
language and modality accessible to the individual.
B. Upon an individual’s admission, personnel shall collaborate with the individual and the individual’s
legal representative, when applicable, to formulate strategies that may minimize the potential for
a behavioral health emergency event that requires interventions of seclusion, restraint, and/or
physical management.
C. A fa cility electing to utilize seclusion, restraint, and/or physical management shall assess each
individual upon admission regarding:
1. Assault and trauma history;
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2. Seclusion, restraint, and/or physical management history;
3. Individual’s risk factors for a behavioral emergency, and individually identified strategies
to avoid seclusion, restraint, and/or physical management; and
4. The facility shall ascertain any applicable behavioral health advance directives.
11.9.5 Use of Physical Management
A. Physical management for individuals under the age of eighteen (18) must always be considered
as restraint and follow the restraint order rules pursuant to part 11.9.13 of this Chapter.
B. Physical management shall only be used on an emergency basis for a maximum of one (1)
minute, when the situation places the individual or others at imminent risk of serious physical
harm after all attempts to verbally direct or de-escalate the person have failed.
1. If physical management is used for longer than one (1) minute, the intervention is
restraint, pursuant to Section 26-20-102(6), C.R.S., and personnel must follow the
restraint order rules pursuant to part 11.9.7 of this Chapter.
C. To ensure the safety of each individual and personnel, each facility shall designate emergency
physical management techniques to be utilized during emergency situations.
D. The term “physical management” does not include briefly holding an individual in order to comfort
them.
E. T he physical management continuum may include:
1. Utilizing transitional measures;
2. Placing one’s hands on an individual to physically guide and/or physically control the
individual;
3. Use of an approved restraint method specified in the facility’s policies and procedures to
maintain safety of the individual;
4. Placing an individual into an approved prolonged restraint method specified in the
facility’s policies and procedures; or
5. Physical management may be used to move or escort an individual into seclusion.
a. Seclusion, in itself, is not a form of physical management.
F. Physical management must be documented in the clinical record to include the following:
1. Documentation of the behavioral necessity for physical management and any de-
escalation techniques attempted prior to utilizing physical management.
2. Documentation of the approved physical management method utilized.
11.9.6 Use of Seclusion
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A. If an order for seclusion is verbal, the verbal order must be received by a registered nurse or
other trained licensed personnel, such as a licensed practical nurse while the emergency safety
intervention is being initiated by personnel or immediately after the emergency safety situation
begins.
1. The physician or other authorized practitioner permitted to order seclusion must verify the
verbal order in a signed written form in the individual’s record. Signatures must be
entered into the record no more than twenty-four (24) hours after the event.
2. The physician or other authorized practitioner to order seclusion must be available to
personnel for consultation, at least by telephone, throughout the period of the emergency
safety intervention.
B. Within one (1) hour of the initiation of the original order of seclusion an authorized practitioner,
such as a registered nurse or physician assistant, trained in the use of emergency safety
interventions and permitted to assess the physical and psychological well-being of the individual,
shall conduct a face-to-face assessment of the physical and psychological well-being of the
individual including but not limited to:
1. The individual’s physical and psychological status;
2. The individual’s behavior;
3. The appropriateness of the intervention measures; and
4. Any complications resulting from the intervention.
C. When the one (1) hour assessment described in this part 11.9.6.B is conducted by a registered
nurse or a physician assistant, that personnel must consult with the attending physician when the
assessment is completed.
D. Results of the one (1) hour assessment must determine if continued emergency interventions
need to be re-ordered by the authorized practitioner.
1. Assessment results and continuation order, if applicable, must be contained in the clinical
record.
E. Seclusion occurs any time an individual is placed alone in a room and not allowed to leave.
F. Seclusion must be used only when other less restrictive methods have failed.
1. Documentation of less restrictive methods and the outcome must be contained in the
clinical record.
G. Seclusion must not be used for punishment, for the convenience of personnel, or as a substitute
for a program of care and treatment.
H. Seclusion rooms must be lighted, clean, safe, and have a window for personnel to observe.
I. Seclusion rooms must be a minimum of one hundred (100) square feet, unless the facility is
licensed as a hospital and the seclusion room size is in compliance with applicable CDPHE
regulations.
J. Relief periods from seclusion must be offered for reasonable access to toilet facilities.
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11.9.7 Use of Restraint
A. If an order for restraint is verbal, the verbal order must be received by a registered nurse or other
trained licensed personnel, such as a licensed practical nurse, while the emergency safety
intervention is being initiated by personnel or immediately after the emergency safety situation
begins.
1. The physician or other authorized practitioner permitted to order restraint must verify the
verbal order in a signed written form in the individual’s record. Signatures must be
entered into the record no more than twenty-four (24) hours after the event.
2. The physician or other authorized practitioner to order restraint must be available to
personnel for consultation throughout the period of the emergency safety intervention.
B. An individual in physical restraint must be released from such restraint within fifteen (15) minutes
after the initiation of physical restraint, except when precluded for safety reasons pursuant to part
11.9.1 of this section.
C. Within one (1) hour of the initiation of the original order for the emergency safety intervention, an
authorized practitioner, such as a registered nurse or physician assistant, trained in the use of
emergency safety interventions and permitted to assess the physical and psychological well-
being of the individual, shall conduct a face-to-face assessment of the physical and psychological
well-being of the individual including but not limited to:
1. T he individual’s physical and psychological status;
2. The individual’s behavior;
3. The appropriateness of the intervention measures; and
4. Any complications resulting from the intervention.
D. When the one (1) hour assessment described in this part 11.9.7.C is conducted by a registered
nurse or a physician assistant, that personnel must consult with the attending physician when the
assessment is completed.
E. Results of the one (1) hour assessment must determine if continued emergency interventions
need to be reordered by the authorized practitioner.
1. Assessment results and continuation order, if applicable, must be contained in the clinical
record.
F. The decision to restrain must be based on a current clinical assessment and may also be based
on other reliable information including information that was used to support the decision to take
the individual into custody for treatment and evaluation. The fact that an individual is being
evaluated or treated under Sections 27-65-106 through 27-65-111 [effective July 1, 2024], C.R.S.,
must not be the sole justification for the use of restraint.
G. Restraint includes chemical restraint, mechanical restraint, and physical restraint.
H. Mechanical restraints may be used only for the purpose of preventing such bodily movement that
is likely to result in imminent injury to self or others. Mechanical restraint must not be used solely
to prevent unauthorized departure.
I. R estraint of an individual by a chemical spray is not permissible.
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J. The type of restraint must be appropriate to the type of behavior to be controlled, the physical
condition of the individual, the age of the individual, and the type of effect restraint may have
upon the individual.
K. Restraint must be applied only if alternative interventions have failed. Justification for immediate
use of restraint without first attempting alternative interventions must be documented in the
clinical record; however, alternative techniques are not required if the alternatives would be
ineffective or unsafe when the individual’s behavior could cause harm to self or others.
L. The term “restraint” as used in this section, does not include restraints used while the facility is
engaged in transporting an individual from one facility location to another facility location when it
is within the scope of that facility’s powers and authority to conduct such transportation pursuant
to Section 26-20-101 through -111, C.R.S.
M. No physical or mechanical restraint of an individual may place excess pressure on the chest or
back of that individual, cover the individual’s face, or inhibit or impede the individual’s ability to
breathe.
11.9.8 Chemical Restraint
A. If an order for chemical restraint is verbal, the verbal order must be received by a registered
nurse or other trained licensed personnel, such as a licensed practical nurse, while the
emergency safety intervention is being initiated by personnel or immediately after the emergency
safety situation begins.
1. T he physician or other authorized practitioner permitted to order chemical restraint must
verify the verbal order in a signed written form in the individual’s record. Signatures must
be entered into the record no more than twenty-four (24) hours after the event.
2. The physician or other authorized practitioner to order chemical restraint must be
available to personnel for consultation, throughout the period of the emergency safety
intervention.
B. An order for a chemical restraint, along with the reasons for its issuance, must be recorded in
writing at the time of its issuance.
C. An order for a chemical restraint must be signed at the time of its issuance by such authorized
practitioner, who is present at the time of the emergency.
D. An order for a chemical restraint, if authorized by telephone, must be transcribed and signed at
the time of its issuance by personnel with the authority to accept telephone medication orders
who is present at the time of the emergency.
E. Personnel trained in the administration of medication shall make notations in the record of the
individual as to the effect of the chemical restraint and the individual’s response to the chemical
restraint.
11.9.9 E xplanation to Individual in Seclusion/Restraint
A. In any situation in which seclusion/restraint is utilized, information must be given to the
secluded/restrained individual, and the individual’s legal representative when applicable, as soon
as possible after they have been secluded or restrained. The individual must be given a clear
explanation of:
1. The reasons for use of such intervention;
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2. The observation procedure, the desired effect; and
3. The circumstances under which the procedure will be terminated.
B. That the explanation has been given to the individual and the individual’s legal representative,
when applicable, must be documented in the clinical record.
C. As soon as possible, upon termination of seclusion and/or restraint, personnel shall debrief with
the individual and assess for any traumatic stress that may have been triggered as a result of
seclusion/restraint.
11.9.10 Observation & Care of Individuals in Seclusion and/or Restraint
A. An individual who is in seclusion/restraint must be observed in-person by trained facility
personnel at no more than ten (10) feet physical distance from the individual.
1. Such observation, along with the behavior of the individual, must be documented every
fifteen (15) minutes.
B. Unless contraindicated by the individual's condition, such observation must include consistent
efforts to interact personally with the individual throughout the episode.
C. Ongoing provisions must be made for nursing care, hygiene, diet, and motion of any restrained
limbs throughout the episode.
D. Facility personnel must maintain a continuous line-of sight throughout the episode with the
individual held in mechanical restraints.
E. F or individuals held in mechanical restraints, facility personnel must observe the individual at
least every fifteen (15) minutes to ensure that:
1. The individual is properly positioned;
2. The individual’s blood circulation is not restricted;
3. The individual’s airway is not obstructed; and
4. The individual’s other physical needs are met, pursuant to this part 11.9.10.
F. For individuals held in mechanical restraints, the facility shall offer relief periods of at least ten
(10) minutes as often as every two (2) hours, so long as relief from the mechanical restraint is
determined by personnel to be safe pursuant to part 11.9.1 of this section.
G. Personnel must document relief periods both offered and granted.
H. The individual must have access to food at least every four (4) hours.
I. The individual must have access to fluids and toileting upon request or during offered relief
periods but must at minimum be offered every two (2) hours.
1. During such relief periods, personnel shall ensure proper positioning of the individual and
provide movement of limbs, as necessary.
J. Personnel must provide assistance for use of necessary toileting methods.
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1. Appropriate toileting does not include the use of adult diapers if not typically used by the
individual when not restrained or secluded.
2. If the individual typically uses adult diapers they are to be changed immediately if soiled.
K. Personnel shall maintain the individual’s dignity and safety during relief periods.
L. Cameras and other electronic monitoring devices must not replace face-to-face observations.
M. To the extent that the duties specified in Section 26-20-101 through -111, C.R.S. are more
protective of individual’s rights or are in conflict with the provisions in this part 11.9, the provisions
of Section 26-20-101 through -111, C.R.S. shall apply.
11.9.11 Continued Use of Seclusion and/or Restraint
A. Personnel must document efforts to assure that the use of seclusion/restraint are as brief as
possible.
B. The original order of seclusion/restraint of an individual must not exceed one (1) hour without an
order for continued seclusion/restraint from an authorized practitioner. A verbal order, including
telephone or other electronic orders, may be used if followed by a written order from the
authorized practitioner.
C. Seclusion/restraint must not be ordered on an “as needed” basis.
D. A ne w written order is required every four (4) hours and shall include a documented examination
by an authorized practitioner.
E. Continued seclusion/restraint in excess of twenty-four (24) hours shall require an administrative
review.
1. The administrative reviewer shall be a different authorized practitioner with the authority
and knowledge necessary to review clinical information and reach a determination that
the extension of a seclusion and/or restraint episode beyond twenty- four (24) hours is
clinically necessary.
2. If the administrative reviewer does not concur with the order for continuation of
seclusion/restraint, the order must be discontinued and the authorized practitioner in
charge of treatment shall be notified of such discontinuation.
F. An administrative review must be initiated at the conclusion of each twenty-four (24) hour period
of continuous use of seclusion/restraint.
11.9.12 Documentation Requirements
A. Each facility must ensure that an appropriate notation of the use of seclusion, restraint and/or
physical management is documented in the record of the individual who was secluded,
restrained, and/or physically managed and must be completed before the end of the shift of the
personnel involved in the seclusion, restraint and/or physical management episode(s). Each
facility shall document the following in the individual’s record:
1. S pecifics of the episode including identified triggers, precipitating events, the individual's
specific behavior(s) and the nature of the danger;
2. Type of restraint, if utilized;
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3. Specific date and times of initiation and discontinuation of seclusion, restraint and/or
physical management and total length of time individual is secluded, restrained, and/or
physically managed;
4. A description of specific non-physical and least restrictive interventions that were
attempted prior and the individual’s response;
5. Identification of personnel involved in the initiation and application of the seclusion,
restraint and/or physical management;
6. Notification to an authorized practitioner within one (1) hour of the seclusion/restraint
intervention;
7. Care provided while the individual was secluded, restrained, and/or physically managed,
including:
a. Observations conducted;
b. Assessments of position, respiration, circulation, and range of motion;
c. Documentation of ongoing 15-minute observation and care checks, as subject to
applicable rules, along with relief periods both offered and granted for food, fluid,
and/or toileting;
d. Interventions provided to promote comfort and safety as well as expedite release;
e. The individual’s response to these interventions; and
f. The effect of the restraint or seclusion on the individual;
8. Documentation that the individual, and the individual’s legal representative if applicable,
was given a clear explanation of the reasons for use of such intervention, the observation
procedure, the desired effect, and the circumstances under which the intervention will be
terminated including criteria for release and individual understanding of that criteria; and,
9. D ocumentation that personnel debriefed the incident with the individual and assessed for
trauma, processed the traumatic event, and identified triggers.
B. Any administrative reviewer shall document the clinical justification for the continued use of
seclusion/restraint in the individual's chart. The justification must include:
1. Documentation that the authorized practitioner ordering the continuous use of
seclusion/restraint in excess of four (4) hours has conducted a face-to-face evaluation of
the individual within the previous four (4) hours;
2. Documentation of the ongoing behaviors or findings that warrant the continued use of
seclusion/restraint and other assessment information as appropriate;
3. Documentation of a plan for ongoing efforts to actively address the behaviors that
resulted in the use of seclusion/restraint;
4. A determination of the clinical appropriateness of the continuation of seclusion/restraint;
and
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5. A summary of the information considered by the reviewer and the result of the
administrative review with the date, time and signature of the person completing the
review.
C. Information regarding use of seclusion/restraint must be readily accessible to authorized persons
for review. The facility shall have the ability to gather data as follows:
1. Each seclusion/restraint episode including date and time the episode started and ended,
specific to each individual over the period of one complete calendar year from January 1
through December 31.
11.9.13 Additional Procedures and Requirements for Seclusion/Restraint of a Youth
A. Procedures for youth must include the following in addition to the requirements found in this part
11.9, unless otherwise required in this part 11.9.13.
B. This part 11.9.13 does not apply to adult individuals over the age of twenty-one (21).
C. An emergency safety intervention must be performed in a manner that is safe, proportionate, and
appropriate to the severity of the behavior, and the youth’s chronological and developmental age;
size; gender; physical, medical, and psychiatric condition; and personal history (including any
history of physical or sexual abuse).
1. Physical management is always considered restraint for an individual under age eighteen
(18) and must follow the restraint order rules pursuant to this part 11.9 of this Chapter.
D. O rders for seclusion/restraint must be by an authorized practitioner in the facility to order
seclusion/restraint and trained in the use of emergency safety interventions. Federal regulations
at 42 C.F.R. Part 441.151, the federal regulations issued by the United States Secretary of Health
and Human Services found at 42 C.F.R. Part 441.151 (Feb. 2023), which are hereby incorporated
by reference. No later editions or amendments are incorporated. These regulations are available
at no cost from the U.S. Department of Health and Human Services, Substance Abuse and
Mental Health Services Administration, Office of Communications, 5600 Fishers Lane, Rockville,
MD 20857 or at https://www.ecfr.gov/current/Title-42. These regulations are also available for
public inspection and copying at the Behavioral Health Administration, 710 S. Ash Street, Unit
C140, Denver, CO 80246, during regular business hours. This requires that inpatient psychiatric
services for individuals under age twenty-one (21) be provided under the direction of a physician.
1. If the individual’s treatment team assigned physician is available, only they can order
seclusion/restraint. If they are not available, then another team physician may make the
order.
E. A physician or other authorized practitioner must order the least restrictive emergency safety
intervention that is most likely to be effective in resolving the emergency safety situation based on
consultation with personnel.
F. If the order for seclusion/restraint is verbal, the order must be received by a registered nurse or
other trained licensed personnel, such as a licensed practical nurse, while the emergency safety
intervention is being initiated by personnel or immediately after the emergency safety situation
begins.
1. The physician or other authorized practitioner permitted to order restraint or seclusion
must verify the verbal order in a signed written form in the youth’s record. Signatures
must be entered into the record no more than twenty-four (24) hours after the event.
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2. The physician or other authorized practitioner to order restraint or seclusion must be
available to personnel for consultation, at least by telephone, throughout the period of the
emergency safety intervention.
G. Each order for seclusion/restraint must be limited to no longer than the duration of the emergency
safety situation.
H. Under no circumstances may the total order time exceed:
1. Four (4) hours for persons ages eighteen (18) to twenty-one (21);
2. Two (2) hours for persons ages nine (9) to seventeen (17); or
3. One (1) hour for persons under the age of nine (9).
I. Within one (1) hour of the initiation of the order of the emergency safety intervention a physician,
or other authorized practitioner trained in the use of emergency safety interventions and permitted
to assess the physical and psychological well-being of the youth, must conduct a face - to - face
assessment of the physical and psychological well-being of the individual including but not limited
to:
1. The youth’s physical and psychological status;
2. The youth’s behavior;
3. The appropriateness of the intervention measures; and
4. Any complications resulting from the intervention.
J. R esults of the one (1) hour assessment must be documented in the individual’s record.
K. Notification of parent(s) and/or legal guardian(s), when applicable:
1. The facility must notify the parent(s) and/or legal guardian(s) of the individual who has
been in seclusion or restraint as soon as possible after the initiation of each emergency
safety intervention.
2. The facility shall document in the individual’s record that the parent(s) or legal guardian(s)
have been notified of the emergency safety intervention, including date and time of the
notification and the name of personnel providing the notification.
11.10 Therapy or Treatment Using Special Procedures
11.10.1 Informed Consent for Therapy/Treatment Using Special Procedures
A. Therapies using stimuli such as electroconvulsive therapy (ECT), use of feeding tubes for eating
disorder treatment, and transcranial magnetic stimulation (TMS), require special procedures for
consent and shall be governed by this part 11.10 of these rules.
B. Prior to the administration of a therapy listed in part 11.10.1.A of these rules, written informed
consent shall be obtained and documented in the clinical record reflecting agreement by both the
individual being treated and their legal guardian, if one has been appointed or alternative decision
maker if one exists.
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1. If the individual undergoing treatment using special procedures is a minor, fifteen (15)
years of age or older, the clinical record shall reflect informed consent by both the minor
and their guardian(s).
a. If the minor is unable to consent to the special procedure due to their mental
illness, as determined by an evaluation of capacity, this shall be documented in
the clinical record.
(1) The tool used to determine capacity shall be administered by an
authorized practitioner within their scope of practice and be maintained in
the clinical record.
(2) An evidence-based standardized tool for assessing decision-making
capacity shall be utilized.
2. If the minor is fourteen (14) years of age or younger, written informed consent from the
parent, legal custodian or legal guardian shall be obtained in addition to the requirements
listed in part 11.10.1.E, and maintained in the clinical record.
C. In the case of electroconvulsive therapy (ECT), a consent form shall be used, and procedures set
forth in Sections 13-20-401 through 13-20-403, C.R.S. shall be followed. An informed consent for
ECT means:
1. It is freely and knowingly given and expressed in writing; and
2. The consent agreement entered into by the individual or other person(s) shall not include
exculpatory language through which the individual or other person(s) is made to waive, or
appear to waive, any of their legal rights, or to release the facility or any other party from
liability for negligence.
D. Electroconvulsive treatment (ECT) may be performed on a minor who is sixteen (16) years of age
or older, but under eighteen (18) years of age only if two individuals licensed to practice medicine
in Colorado and specializing in psychiatry approve the treatment, and the parent or guardian of
the minor consents to the treatment.
1. The minor aged sixteen (16) to eighteen (18) must have a diagnosis consistent with ECT
best practices.
E. ECT may be performed on a minor who is fifteen (15) years of age or younger when:
1. Two individuals licensed to practice medicine in Colorado, and specializing in psychiatry,
approve the treatment. One (1) of the individuals must also specialize in child and
adolescent psychiatry;
2. Other less invasive treatments have failed;
3. ECT is performed by at least one (1) physician, or physician’s designee, who is trained
and credentialed in ECT; and
4. The minor’s parent, legal custodian, or legal guardian consents to the treatment; or
a. A court issues an order for treatment pursuant 27-65-113, C.R.S.
F. Electroconvulsive treatment (ECT) requires a concurring consultation by a licensed psychiatrist
prior to administration of the treatment. Such consultation shall be noted in the clinical record.
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G. The facility shall document that the following has been explained to the individual:
1. The reason for such treatment information;
2. The nature of the procedures to be used in such treatment, including their probable
frequency and duration;
3. The probable degree and duration of improvement or remission expected with or without
such treatment;
4. The nature, degree, duration, and probability of the side effects and significant risks of
such treatment, commonly known by the medical profession, the possible degree and
duration of memory loss, the possibility of permanent irrevocable memory loss, and the
remote possibility of death;
5. The reasonable alternative treatments, if any, and why the professional person is
recommending the specific treatment;
6. That the individual has the right to refuse or accept the proposed treatment and has the
right to revoke their consent for any reason at any time, either orally or in writing;
7. That there is a difference of opinion within the medical profession on the use of some
treatments;
8. An offer to answer any inquiries concerning the recommended special procedures; and
9. The number of treatments expected over a specified period of time to achieve maximum
benefit.
H. Informed consent for the special procedure shall be renewed each time the prescribed course of
treatments determined through clinical assessment have been completed
I. Feeding tubes for eating disorder treatment may be used within a designated facility when:
1. Informed written consent is required pursuant to this Section 11.10 from both patient and
patient’s parent, legal guardian, or custodian if the patient is fifteen (15) years of age or
older; or
a. If the patient, fifteen (15) years of age or older, does not consent or objects to
continued use of an involuntary feeding tube, patient may seek review pursuant
to Section 27-65-104(6) C.R.S.
2. If the patient is fourteen (14) years of age or younger, only written informed consent from
the parent, legal guardian, or custodian is required.
11.10.2 Involuntary Treatment Using Special Procedures
A. In the event the individual or the legal guardian refuses to or cannot consent, treatments
referenced in part 11.10.1.A of these rules using special procedures shall be administered only
under the following circumstances:
1. With a prior court order for the treatments using special procedure; or,
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2. In an emergency in which the life of the individual is in immediate danger because of the
individual's condition. In an emergency situation in which the individual is unable to grant
informed consent and sufficient time does not exist to petition the court for an order prior
to the administration of the specific therapy, the individual's physician, in consultation with
the director of the facility or their designee, may, after careful and informed deliberation
and under procedures adopted by the facility, order a special procedure without consent.
B. Policies and procedures:
1. Each designated facility shall adopt written policies and procedures for administration of
special procedures in accordance with these rules and applicable statutes.
11.11 Continuity of Care & Transfer of Care
11.11.1 Continuity of Care
A. Each facility shall adopt and implement a written policy for continuity of care. The policy shall
include at a minimum the following:
1. Access to all necessary care and services within the facility, and coordination with any
other current mental health care providers or other systems of care or support as
appropriate;
2. Coordination of care with the individual's previous mental health care providers or
medical providers as appropriate, including retrieval of psychiatric and medical records;
3. C oordination of the individual's care with family members, guardians, and other
interested parties as appropriate and in a manner that reflects the individual's culture;
and/or
4. The facility shall facilitate access to proper medical care and shall be responsible for
coordinating mental health treatment with medical treatment provided to the individual.
11.11.2 Transfer of Care: Non-Emergent
A. The individual shall only be transferred to another 27-65 designated or placement facility when
adequate arrangements for care by the receiving facility have been made and documented in the
clinical record. Transfer coordination shall include at least one discharge planning conference,
face-to-face or by telephone, with participants from both facilities and the individual and their
guardian, whenever possible.
B. At least twenty-four (24) hours advance notice of transfer shall be given to individuals under
certification, unless knowingly waived in writing by the individual and guardian, if applicable and
as appropriate, except in cases of a medical emergency. Notice of such transfer shall also be
provided to the court of competent jurisdiction and the individual's attorney.
C. The transferring facility shall ask the individual to indicate two (2) persons to whom notification of
transfer should be given and shall notify such persons within twenty-four (24) hours of notification
to the individual. Such notification shall be made by the transferring facility with the appropriate
written authorization. Actions taken under part 11.11 of these rules, shall be documented in the
clinical record.
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11.12 Requirements for Placement Facilities
A. Facilities with a 27-65 designation may provide mental health services directly or through the use
of a placement facility contract. Whenever a placement facility is used there must be a written
agreement with the 27-65 designated facility. In either case, the 27-65 designated facility is
responsible for assuring an appropriate treatment setting for individuals and services provided in
accordance with these rules. Whenever a placement facility is used, the 27-65 designated facility
shall be responsible for the care provided by the placement facility as well as placement facility
compliance with these rules. Policies and procedures must be in place outlining the 27-65
designated facility’s responsibilities and procedures for oversight of placement facilities as
outlined in this section.
B. Emergency departments are not eligible to be placement facilities. Only the following Colorado
licensed facilities are eligible to be placement facilities:
1. Nursing homes;
2. Residential child care facilities providing mental health services;
3. Non-psychiatric hospitals providing inpatient medical services;
4. Alternative care facilities; and
5. Mental health transitional living homes.
C. All agreements between 27-65 designated facilities and placement facilities and all supplemental
agreements and amendments shall be submitted in writing to the BHA no later than ten (10)
business days after the effective date of the agreement or amendment.
D. W henever a 27-65 designated facility uses a placement facility, the agreement shall include:
1. An annual training plan for placement facility personnel that provides at a minimum
training regarding mental health disorders, these rules, Article 65 of Title 27, C.R.S., and
appropriate, safe behavioral interventions. The implementation of the training plan shall
be monitored regularly by the 27-65 designated facility;
2. A requirement that supervision of direct care personnel be provided by: professional
persons licensed in Colorado to practice medicine or licensed Colorado psychologists
employed by or under contract with the designated facility; designated professional
persons licensed in Colorado to practice medicine; or licensed Colorado psychologists
employed by the placement facility to be responsible for direct care supervision provided
that the placement facility and the designated facility are operated by the same corporate
facility;
3. A requirement that assures the necessary availability and supervision of placement
facility personnel in order to carry out the contract; and
4. A requirement that the placement facility adheres to these rules through the placement
facility agreement.
E. Placement facility agreements shall be executed and signed at least every two years and
submitted to the BHA when the 27-65 designated facility submits its application for continued
designation.
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F. A placement facility can be used by a 27-65 designated facility, at its discretion under the
provisions of these regulations, in order to provide care to any individual undergoing mental
health evaluation or treatment. 27-65 designated facilities shall not place individuals in a
placement facility unless all of the applicable provisions of these rules are met and placement in
such facilities are appropriate to the clinical needs of each individual. When a placement facility is
required, the least restrictive facility possible and available must be used, consistent with the
clinical needs of the individual.
G. A placement facility shall not provide services beyond the scope of its license.
11.13 Procedures for Involuntary Transportation Holds
A. This Section 11.13 is meant to provide a summary of the obligations and standards set forth in
Section 27-65-101 through -131, C.R.S., with regard to involuntary transportation holds. This
section is only enforceable with regard to designated facilities.
B. An individual may be placed on an involuntary transportation hold pursuant to Section 27- 65-107,
C.R.S. if the certified peace officer or emergency medical services provider believes the individual
is experiencing a behavioral health crisis or is gravely disabled, and as a result, without
professional intervention, the individual may be a danger to self or others.
1. The certified peace officer or emergency medical services provider may then take the
individual into protective custody and transport the individual to an outpatient mental
health facility, or a facility designated by the commissioner or other clinically appropriate
facility designated by the commissioner.
2. If such a service is not available, the individual may be taken to an emergency medical
services facility.
C. The involuntary transportation form to be completed in full (on the BHA-provided M 0.5 form
available on the BHA website) prior to transportation shall include:
1. The circumstances under which the individual’s condition was called to the certified
peace officer’s or emergency medical services (EMS) provider’s attention and further
stating sufficient facts obtained from personal observations or obtained from others whom
the certified peace officer or emergency medical services provider reasonably believes to
be reliable, to establish that the individual is experiencing a behavioral health crisis or is
gravely disabled and, as a result it is believed that without professional intervention the
individual may be a danger to the individual’s self or others;
2. The name of the individual and date and time the individual was placed on the involuntary
transportation hold;
3. The name of the facility to which the individual will be transported; and
4. The signature of the certified peace officer or EMS provider placing the involuntary
transportation hold.
D. A copy of the involuntary transportation form must be given to the individual who was placed on
the involuntary transportation hold.
E. A copy of the involuntary transportation form must be given to the facility and made part of the
individual’s medical record.
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F. An individual may not be placed on a transportation hold if an intervening professional or certified
peace officer has assessed the individual during the same emergency event and determined the
individual does not meet the criteria for an emergency mental health hold.
G. If a behavioral health crisis response team is known to be available in a timely manner, the
certified peace officer or emergency medical services provider shall access the behavioral health
crisis response team prior to transporting an individual involuntarily.
H. Individuals may not be transported involuntarily for longer than six (6) hours.
I. Once the individual is presented to an outpatient mental health facility or facility designated by the
commissioner, an intervening professional shall screen the individual immediately. If an
intervening professional is not immediately available, the individual must be screened within
immediately, but no more than eight (8) hours pursuant to Section 27-65-107(4)(a)(I), C.R.S.,
after the individual’s arrival at the facility to determine if the individual meets criteria for an
emergency mental health hold.
J. Once the screening is completed and if the individual meets criteria, the intervening professional
shall first pursue voluntary treatment and evaluation. If the individual refuses or the intervening
professional has reasonable grounds to believe the individual will not remain voluntarily, the
intervening professional may place the individual under an emergency mental health hold
pursuant to Section 27-65-106, C.R.S.
11.13.1 Individual Rights for Involuntary Transportation
A. The following rights must be explained to the individual prior to transporting them involuntarily and
provided in written form:
1. To not be detained under an emergency transportation hold pursuant to this Section for
longer than fourteen (14) hours, to not be transported for longer than six (6) hours, and to
receive a screening within eight (8) hours after being presented to the receiving facility.
Section 27-65-107(4)(a)(I), C.R.S., does not prohibit a facility from holding the individual
as authorized by state and federal law, including the federal “Emergency Medical
Treatment and Labor Act,” 42 U.S.C. Sec. 1395dd, or if the treating professional
determines that the individual's physical or mental health disorder impairs the individual’s
ability to make an informed decision to refuse care and the provider determines that
further care is indicated.
2. To request a phone call to an interested party prior to being transported. If the certified
peace officer or EMS provider believes access to a phone poses a physical danger to the
individual or someone else, the receiving facility shall make the call on the individual’s
behalf immediately upon arrival at the receiving facility.
3. T
o wear the individual’s own clothes and keep and use personal possessions that the
individual had in the individual’s possession at the time of detainment. A facility may
temporarily restrict an individual’s access to personal clothing or personal possessions
until a safety assessment is completed. If the facility restricts an individual’s access to
personal clothing or personal possessions, the facility shall have a discussion with the
individual about why the individual’s personal clothing or personal possessions are being
restricted. A licensed medical professional or a licensed mental health professional shall
conduct a safety assessment as soon as possible. The licensed professional shall
document in the individual’s medical record the specific reasons why it is not safe for the
individual to possess the individual’s personal clothing or personal possessions.
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4. To keep and use the individual’s cell phone, unless access to the cell phone causes the
individual to destabilize or creates a danger to the individual’s self or others, as
determined by a provider, facility personnel, or security personnel involved in the
individual’s care.
5. To have appropriate access to adequate water and food and to have the individual’s
nutritional needs met in a manner that is consistent with recognized dietary practices.
6. To be treated fairly, with respect and recognition of the individual’s dignity and
individuality.
7. To file a grievance with the BHA, the Department of Public Health and Environment
(CDPHE), or the Office of the Ombudsman for Behavioral Health Access to Care
established pursuant to Section 27-80-303, C.R.S.
B. An individual’s rights may only be denied if access to the item, program, or service causes the
individual to destabilize or creates a danger to the individual’s self or others, as determined by a
licensed mental health provider or professional person involved in the individual’s care or
transportation. Denial of any right must be entered into the individual’s treatment record or BHA-
approved form, available on the BHA website. Information pertaining to a denial of rights
contained in the individual’s treatment record must be made available, upon request, to the
individual, the individuals attorney, or the individual’s lay person.
11.13.2 I ndividual Rights for Receiving Individuals on Involuntary Transportation Holds
A. An individual detained pursuant to this section at an outpatient mental health facility or facility
designated by the commissioner, must receive a copy of a form with the individual rights
described in this part 11.13.1 on it if they were not provided a copy of the rights prior to transport.
1. If an individual detained pursuant to this part 11.13 is transported to an emergency
medical services facility, the involuntary transportation hold expires upon the facility
receiving the person for screening by an intervening professional.
B. The receiving emergency medical services facility must offer to make a phone call on the
individual’s behalf if the transporting EMS professional or certified peace officer determined that
access to a phone prior to transport could pose a physical danger to the individual’s self or
others.
C. A facility may temporarily restrict an individual's access to personal clothing or personal
possessions until a safety assessment is completed. If the facility restricts an individual's access
to personal clothing or personal possessions, the facility shall have a discussion with the
individual about why the individual's personal clothing or personal possessions are being
restricted and document this in the clinical record.
D. T he individual may keep and use their cell phone, unless access to the cell phone causes the
individual to destabilize or creates a danger to the individual's self or others, as determined by a
provider, facility personnel, or security personnel involved in the individual's care. If a cell phone
is restricted, the reason for this must be explained to the individual and documented in the clinical
record.
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1. An individual's rights may only be denied if access to the item, program, or service
causes the individual to destabilize or creates a danger to the individual's self or others,
as determined by a licensed provider involved in the individual's care or transportation.
Denial of any right must be entered into the individual’s treatment record or BHA-
approved form, available on the BHA website. Information pertaining to a denial of rights
contained in the individual's treatment record must be made available, upon request, to
the individual, the individual's attorney, or the individual's lay person.
a. If an individual speaks sign language and their rights to their cell phone has been
denied, when communicating outside the facility they must have access to
communication devices that provide written/video/closed caption.
2. Once the screening is completed and if the individual meets criteria, the intervening
professional shall first pursue voluntary treatment and evaluation. If the individual refuses
or the intervening professional has reasonable grounds to believe the individual will not
remain voluntarily, the intervening professional may place the individual under an
emergency mental health hold pursuant to Section 27-65-106, C.R.S.
E. If the individual is placed on an emergency mental health hold, they must be advised of and
provided with a copy of the associated individual rights as described in part 11.14.3 of this
Chapter.
11.14 Pr ocedures for Emergency Mental Health Holds
11.14.1 General Procedures
A. This section 11.14 is meant to provide a summary of the obligations and standards set forth in
Section 27-65-101 through -131, C.R.S., with regard to emergency mental health holds. This
section is only enforceable with regard to designated facilities.
B. An individual may be placed on an emergency mental health hold for seventy-two (72) hours
pursuant to Section 27-65-106, C.R.S., if the individual has a mental health disorder and, as a
result of the mental health disorder, is an imminent danger to the individual’s self or others or is
gravely disabled.
1. The certified peace officer may take the individual into protective custody and transport
the individual to a facility designated by the commissioner for an emergency mental
health hold. If such a facility is not available, the certified peace officer may transport the
individual to an emergency medical services facility. The certified peace officer may
request assistance from a behavioral health crisis response team for assistance in de-
escalating and preparing the individual for transportation, or an emergency medical
services provider in transporting the individual; or,
2. When an intervening professional reasonably believes that an individual appears to have
a mental health disorder and, as a result of the mental health disorder, appears to be an
imminent danger to the individual's self or others or appears to be gravely disabled, the
intervening professional may cause the individual to be taken into protective custody and
transported to a facility designated by the commissioner for an emergency mental health
hold. If such a facility is not available, the certified peace officer may transport the
individual to an emergency medical services facility. The intervening professional may
request assistance from a certified peace officer, a secure transportation provider, or a
behavioral health crisis response team for assistance in detaining and transporting the
individual, or assistance from an emergency medical services provider in transporting the
individual.
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C. The emergency mental health hold form, available on the BHA website, shall be completed by an
intervening professional or certified peace officer and include the following:
1. The circumstances under which the individual’s condition was brought to the attention of
the intervening professional or certified peace officer;
2. A description of facts, either through direct observation by the intervening professional or
peace officer or obtained from others believed to be reliable, establishing that the
individual has a mental health disorder, and as a result of the mental health disorder, is
an imminent danger to self or others, is gravely disabled, or is in need of immediate
evaluation for treatment;
3. Date/time the individual was placed on the emergency mental health hold; and
4. Who brought the individual’s condition to the attention of the intervening professional or
certified peace officer.
D. A copy of the emergency mental health hold form must be given to the individual who was placed
on the emergency mental health hold.
E. A copy of the emergency mental health hold form must be given to the facility and made part of
the individual’s record.
F. Once the individual is receiving care and treatment in a designated involuntary short-term
treatment facility, the individual shall receive treatment and care for the duration of their
emergency mental health hold.
G. T he individual must be released before seventy-two hours have elapsed if, in the opinion of the
professional person overseeing treatment, the individual no longer requires evaluation and
treatment.
H. At the expiration of the emergency mental health hold, the individual must be:
1. Released;
2. Referred for further care and treatment on a voluntary basis; or
3. Certified for short-term treatment pursuant to Section 27-65-109, C.R.S.
11.14.2 Court Orders for Screening & Evaluation
A. Pursuant to Section 27-65-106(1)(c), C.R.S., any individual may petition the court in the county in
which the individual resides or is physically present requesting an evaluation of the individual’s
condition and alleging that the individual appears to have a mental health disorder and, as a
result of the mental health disorder, appears to be a danger to the individual’s self or others or
appears to be gravely disabled.
B. A court may order that an individual be taken into custody and placed in a designated facility for
seventy-two (72) hour treatment and evaluation.
C. Pursuant to Section 26-65-106(4)(a), C.R.S., the petition for a court-ordered evaluation must
contain the following:
1. N ame and address of the petitioner, and the petitioner’s interest in this case;
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2. Name of the individual for whom evaluation is sought, and if known, the address, age,
gender, marital status, occupation, and any animals or dependent children in the
individual’s care;
3. Allegations of fact indicating the individual may have a mental health disorder and, as a
result of the mental health disorder, is a danger to self or others or is gravely disabled;
4. The name and address of every person responsible for the care, support, and
maintenance of the individual, if available; and
5. The name, address, and telephone number of the attorney, if any, who has most recently
represented the individual. If there is not attorney, there shall be a statement as to
whether, to the best knowledge of the petitioner, the individual meets criteria established
by the legal aid agency operating in the county or city and county for it to represent the
individual.
D. Upon receipt of a petition, the court shall identify a facility designated by the commissioner, an
intervening professional, or a certified peace officer to provide screening of the individual to
determine whether probable cause exists to believe the allegations.
E. Following the screening, the facility, intervening professional, or certified peace officer designated
by the court shall file a report with the court and may initiate an emergency mental health hold at
the time of screening. The report must include a recommendation as to whether probable cause
exists to believe that the individual has a mental health disorder and is a danger to self or others
or is gravely disabled. The report must also specify whether the individual will voluntarily receive
evaluation or treatment.
F. A c opy of the confidential screening report must be provided to the individual and the individual’s
attorney or personal representative.
G. If the court determines that the individual has a mental health disorder and is a danger to self or
others or is gravely disabled, and efforts have failed to obtain cooperation from the individual to
receive treatment voluntarily, the court must issue an order for a certified peace officer or secure
transportation provider to take the individual into custody and transport the individual to a
designated facility for seventy-two (72) hour evaluation and treatment.
1. At the time the individual is taken into custody, a copy of the petition and the order for
evaluation must be given to the individual and promptly to the one lay person designated
by the individual and to the person in charge of the facility named in the order or the
individual’s lay person designee. If the individual refuses to accept a copy of the petition
and the order for evaluation, such refusal must be documented in the petition and the
order for evaluation.
H. When an individual is transported to an emergency medical services facility or a facility
designated by the commissioner, the facility may detain the individual under an emergency
mental health hold for evaluation for a period not to exceed seventy-two (72) hours from the time
the emergency mental health hold was placed or ordered. Nothing in this section prohibits an
emergency medical services facility from involuntarily holding the individual in order to stabilize
the individual as required pursuant to the federal "Emergency Medical Treatment and Labor Act",
42 U.S.C. Sec. 1395dd, or if the treating professional determines that the individual's physical or
mental health disorder impairs the individual's ability to make an informed decision to refuse care
and the provider determines that further care is indicated.
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1. If, in the opinion of the person in charge of the evaluation, the individual can be properly
cared for without being detained, the individual shall be provided services on a voluntary
basis.
2. If the person in charge of the evaluation determines the individual should be released, the
person in charge of the evaluation may terminate the emergency mental health hold.
I. Each individual detained for an emergency mental health hold pursuant to part 11.14 of this
Chapter, shall receive an evaluation as soon as possible after the individual is presented to the
facility and shall receive such treatment and care as the individual’s condition requires for the full
period that the individual is held.
J. The evaluation may include an assessment to determine if the individual continues to meet the
criteria for an emergency mental health hold and requires further mental health care in a facility
designated by the commissioner. The evaluation must state whether the individual should be:
1. Released;
2. Referred for further care and treatment on a voluntary basis; or
3. Certified for short-term treatment pursuant to Section 27-65-109, C.R.S.
K. Each evaluation must be completed using a standardized form approved by the commissioner
available on the BHA website (the elements from this form can be integrated into a facility’s
electronic health record system) and may be completed by a professional person; a licensed
advanced practice registered nurse with training in psychiatric nursing; or a licensed physician
assistant, a licensed clinical social worker, a licensed professional counselor, or a licensed
marriage and family therapist who has two years of experience in behavioral health safety and
risk assessment working in a health-care setting.
1. If the professional person conducting the evaluation does not hold two (2) years’
experience, they may conduct the evaluation and a professional person that holds the
required experience must review, provide clinical consultation as needed, and provide
their signature to the evaluation.
L. If the personnel conducting an evaluation pursuant to part 11.14 of this Chapter is not a
professional person and the evaluating personnel recommends the detained individual be
certified for short-term treatment pursuant to Section 27-65-109, C.R.S., the evaluating personnel
shall notify the facility of the recommendation. A certification may only be initiated by a
professional person.
M. If an individual is evaluated at an emergency medical services facility and the evaluating
professional determines that the individual continues to meet the criteria for an emergency mental
health hold pursuant to part 11.14 of this Chapter, the emergency medical services facility shall
immediately notify the BHA if the facility cannot locate appropriate placement. Once notified, the
BHA shall support the emergency medical services facility in locating an appropriate placement
option on an inpatient or outpatient basis, whichever is clinically appropriate.
N. If an appropriate placement option cannot be located pursuant to this part 11.14.2.N and the
individual continues to meet the criteria for an emergency mental health hold pursuant to part
11.14 of these rules and the individual has been medically stabilized, the emergency medical
services facility may place the individual under a subsequent emergency mental health hold.
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1. If the facility places the individual under a subsequent emergency mental health hold, the
facility shall immediately notify the BHA, the individual's lay person, and the court, and
the court shall immediately appoint an attorney to represent the individual.
2. The facility may notify the court where the individual resides by mail.
a. Once the court is notified, the emergency medical services facility is not required
to take any further action to provide the individual with an attorney unless
specified in part 11.14.3 of this Chapter.
3. The emergency medical services facility shall notify the BHA after each emergency
mental health hold is placed.
4. If the individual has been recently transferred from an emergency medical services facility
to a facility designated by the commissioner and the designated facility is able to
demonstrate that the facility is unable to complete the evaluation before the initial
emergency mental health hold is set to expire, the designated facility may place the
individual under a subsequent emergency mental health hold and shall immediately notify
the BHA and lay person.
O. The BHA shall maintain data on the characteristics of each individual placed on a subsequent
emergency mental health hold pursuant to this part 11.14.2. The BHA may contract with facilities
coordinating care or with providers serving within the safety net system developed pursuant to
Section 27-63-105, C.R.S., to meet the requirements of this part 11.14.
11.14.3 I ndividual Rights for Emergency Mental Health Holds
A. The following rights apply to anyone receiving evaluation, care, or treatment pursuant to Article
65 of Title 27, C.R.S. and must be explained to the individual and provided in written form:
1. Nothing in Article 65 of Title 27, C.R.S., limits the right of any individual to make a
voluntary application at any time to any public or private facility or professional person for
mental health services, including but not limited to evaluation, care, and/or treatment,
either by direct application in-person or by referral from any other public or private facility
or professional person.
a. Subject to Section 15-14-316(4), C.R.S., a ward, as defined in Section 15-14-
102(15), C.R.S., may be admitted to a hospital or institutional care and treatment
for a mental health disorder with the guardian’s consent for as long as the ward
agrees to such care and treatment. The guardian shall immediately notify in
writing the court, that appointed the guardian, of the admission.
b. Medical and legal status of all voluntary individuals receiving treatment for mental
health disorders in inpatient or custodial facilities must be reviewed at least once
every six (6) months.
c. V oluntary individuals are afforded all rights and privileges customarily granted by
hospitals to individuals they serve.
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d. Any individual receiving an evaluation or treatment pursuant to Article 65 of Title
27, C.R.S., is entitled to medical and psychiatric care and treatment, with regard
to services listed in Section 27-65-101, C.R.S., and services listed in rules
authorized by Section 27-66-102, C.R.S., suited to meet the individual’s specific
needs, delivered in such a way as to keep the individual in the least restrictive
environment, and delivered in such a way as to include the opportunity for
participation of family members in the individuals program of care and treatment
when appropriate.
2. To be told the reason for the individual’s detainment and the limitations of the individual’s
detainment, including a description of the individual’s right to refuse medication, unless
the individual requires emergency medications, and that the detainment does not mean
all treatment during detainment is mandatory;
3. To request a change to voluntary status;
4. To be treated fairly, with respect and recognition of the individual’s dignity and
individuality, by all employees of the facility with whom the individual comes in contact;
5. To not be discriminated against on the basis of age, race, ethnicity, religion, culture,
spoken language, physical or mental disability, socioeconomic status, sex, sexual
orientation, gender identity, or gender expression;
6. T o retain and consult with an attorney at any time;
a. Except that, unless specified in this part 11.14.2.N of this Chapter, the facility is
not required to retain an attorney on behalf of the individual but must allow the
individual to contact an attorney;
7. To continue the practice of religion;
8. Within twenty-four (24) hours after the individual's request, to see and receive the
services of a patient representative who has no direct or indirect clinical, administrative,
or financial responsibility for the individual;
9. To have reasonable access to telephones or other communication devices and to make
and to receive calls or communications in private;
a. Facility personnel shall not open, delay, intercept, read, or censor mail or other
communications or use mail or other communications as a method to enforce
compliance with facility personnel;
10. To wear the individual’s own clothes, keep and use the individual’s own personal
possessions (including but not limited to personal medical devices and/or auxiliary aids),
and keep and be allowed to spend a reasonable sum of the individual’s own money.
a. A facility may temporarily restrict an individual’s access to personal clothing or
personal possessions, until a safety assessment is completed.
b. If the facility restricts an individual’s access to personal clothing or personal
possessions, the facility shall have a discussion with the individual about why the
individual’s personal clothing or personal possessions are being restricted.
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c. A licensed medical professional or a licensed mental health professional shall
conduct a safety assessment as soon as possible. The licensed professional
shall document in the individual’s medical record the specific reasons why it is
not safe for the individual to possess the individual’s personal clothing or
personal possessions.
d. The facility shall periodically conduct additional safety assessments to determine
whether the individual may possess the individual's personal clothing or personal
possessions, with the goal of restoring the individual’s rights established
pursuant to this section.
11. To have the individual's information and records disclosed to family members and a lay
person pursuant to Section 27-65-123, C.R.S.;
12. To have the individual's treatment records remain confidential, except as required by law;
13. To not be fingerprinted, unless required by law;
14. To have appropriate access to adequate water, hygiene products, and food and to have
the individual's nutritional needs met in a manner that is consistent with recognized
dietary practices;
15. To have appropriate access to non-psychiatric medications necessary to maintain an
individual's health, including but not limited to pain medications that may be controlled
substances, as ordered and/or overseen by a physician or other authorized medical
practitioner of record;
16. T o keep and use the individual's cell phone, unless access to the cell phone causes the
individual to destabilize or creates a danger to the individual's self or others, as
determined by a provider, facility personnel member, or security personnel involved in the
individual’s care;
17. To not be photographed, except upon admission for identification and administrative
purposes. Any photographs must be confidential and must not be released by the facility
except pursuant to a court order. Nonmedical photographs must not be taken or used
without appropriate consent or authorization;
18. To have personal privacy to the extent possible during the course of treatment;
19. To have frequent and convenient opportunities to meet with visitors in accordance with
the facility’s current visitor guidelines. Each individual may see the individual’s attorney,
clergyperson, or physician at any time;
20. An individual’s rights may only be denied if the item, program, or service causes the
individual to destabilize or creates a danger to the individual’s self or others, as
determined by a licensed provider involved in the individual’s care. Denial of any right
must in all cases be entered into the individual’s treatment record. Information pertaining
to a denial of rights contained in the individual’s treatment record must be made
available, upon request, to the individual, or the individual’s attorney; and,
21. An y person receiving evaluation, care, or treatment pursuant to Article 65 of Title 27,
C.R.S., must be given the opportunity to exercise the persons right to register and to vote
in primary and general elections.
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a. The facility or facility providing evaluation, care, or treatment shall assist the
individual, upon the individual’s request, to obtain voter registration forms and
mail ballots and to comply with any other prerequisite for voting.
11.14.4 Additional Considerations
A. The facility shall develop written policies that include the procedures for managing individual
funds or property that include at minimum:
1. A written inventory of all personal belongings shall be conducted upon admission. This
inventory shall be signed and reviewed by facility personnel and the individual and shall
be maintained in the individual’s clinical record.
2. A process for storing all inventoried items in a secure location during the individual’s stay
in the facility.
3. A process for returning all inventoried property to the individual upon discharge or
sending the property with the individual if they are transferred to another facility for care
and treatment. The individual and facility personnel shall sign the inventory form
indicating that all items were returned or that all items were present in the bag for
transport.
B. For the purpose of Article 65 of Title 27, C.R.S., the treatment by prayer in the practice of religion
of any church that teaches reliance on spiritual means alone for healing is considered a form of
treatment.
C. An y individual receiving an evaluation or treatment pursuant to Article 65 of Title 27, C.R.S., may
petition the court pursuant to Section 13-45-102, C.R.S., for release to a less restrictive setting
within or without a treating facility or release from a treating facility when adequate medical and
psychiatric care and treatment are not administered;
1. If at any time during an emergency mental health hold of an individual who is confined
involuntarily the facility personnel requests the individual to sign in voluntarily and the
individual elects to do so, the following advisement shall be given orally and in writing and
an appropriate notation shall be made in the individual’s medical record by the
professional person or the professional person’s designee (this does not apply to an
individual on an emergency mental health hold in an emergency medical services
facility):
“NOTICE
The decision to sign in voluntarily should be made by you alone and should be free from
any force or pressure implied or otherwise. If you do not feel that you are able to make a
truly voluntary decision, you may continue to be held at the hospital involuntarily. As an
involuntary individual, you will have the right to protest your confinement and request a
hearing before a judge.”
11.14.5 I ndividual Rights for Receiving Individuals on Emergency Mental Health Holds
A. Each person receiving evaluation, care, or treatment pursuant to any provision of Article 65 of
Title 27, C.R.S., has the individual rights specified in part 11.14.3 of this Chapter and shall be
provided with a written copy and advised of such rights by the facility.
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B. A facility may temporarily restrict an individual's access to personal clothing or personal
possessions until a safety assessment is completed. If the facility restricts an individual's access
to personal clothing or personal possessions, the facility shall have a discussion with the
individual about why the individual's personal clothing or personal possessions are being
restricted and document this in the chart.
C. The individual may keep and use their cell phone, unless access to the cell phone causes the
individual to destabilize or creates a danger to the individual's self or others, as determined by a
provider, facility personnel member, or security personnel involved in the individual's care. If a cell
phone is restricted, the reason for this must be explained to the individual and documented in the
chart.
D. An individual's rights may only be denied if access to the item, program, or service causes the
individual to destabilize or creates a danger to the individual's self or others, as determined by a
licensed provider involved in the individual's care or transportation. Denial of any right must be
entered into the individual's treatment record or BHA-approved form available on the BHA
website. Information pertaining to a denial of rights contained in the individual's treatment record
must be made available, upon request, to the individual, the individual's attorney, or the
individual's lay person.
1. O nce the screening is completed and if the individual continues to meet criteria for an
emergency mental health hold, the intervening professional shall first pursue voluntary
treatment and evaluation. If the individual refuses or the intervening professional has
reasonable grounds to believe the individual will not remain voluntarily, the intervening
professional may keep the individual under an emergency mental health hold pursuant to
Section 27-65-106, C.R.S.
11.14.6 Procedures for Subsequent Emergency Mental Health Holds
A. If the facility places the individual under a subsequent emergency mental health hold, the facility
shall immediately notify the BHA, the individual's lay person, and the court, and the court shall
immediately appoint an attorney to represent the individual. The facility may notify the court
where the individual resides by mail.
11.14.7 Procedures for Individuals Who Meet Criteria for an Emergency Mental Health Hold but
Require Inpatient Medical Treatment Prior to Placement
A. If an individual meets criteria for an emergency mental health hold but requires medical treatment
prior to being placed psychiatrically, they may receive treatment on a medical unit of the same
hospital under the following conditions:
1. Unless the medical unit is designated for 27-65 services by the BHA, the hospital must
follow the hospital’s policies and procedures for ensuring individual safety while receiving
medical services.
2. R easonable efforts shall be made to ensure ligature risk is minimized in the individual’s
room on the medical unit; these efforts shall be documented in the individual’s clinical
record.
11.15 Additional Procedures for Minors
A. This section 11.15 is meant to provide a summary of the obligations and standards set forth in
Section 27-65-101 through -131, C.R.S., with regard to minors. This section is only enforceable
with regard to designated facilities.
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11.15.1 Consent and Rights of a Minor
A. Notwithstanding any other provision of law, a minor who is fifteen (15) years of age or older,
whether with or without the consent of a parent or legal guardian, may consent to receive mental
health services to be rendered by a facility, a professional person, or mental health professional
licensed pursuant to Parts 3, 4, 5, 6, or 8 of Article 245 of Title 12, C.R.S., in any practice setting.
1. Such consent is not subject to disaffirmance because of age.
2. The professional person or licensed mental health professional rendering mental health
services to a minor may, with or without the consent of the minor, advise the minor’s
parent or legal guardian of the services given or needed.
B. Any individual receiving evaluation or treatment pursuant to any of the provisions of Article 65 of
Title 27, C.R.S., is entitled to a written copy of all the corresponding designated service
individual’s rights enumerated and a minor child shall receive written notice of the minor’s rights
as provided. The list of rights must be prominently posted in all evaluation and treatment facilities.
Minor’s rights include:
1. To refuse to sign the admission consent form; and,
2. T o revoke consent of treatment at a later date;
a. If minor’s consent is revoked after admission, a review of the minor’s need for
hospitalization must be initiated immediately
3. Nothing in part 11.15 of these rules limits a minor’s right to seek release from the facility
pursuant to any other provision of law.
4. Services shall be suited to meet the individual’s needs, delivered in such a way as to
keep the individual in the least restrictive environment, and delivered in such a way as to
include the opportunity for participation of family members in the individual’s program of
care and treatment, when appropriate.
11.15.2 Hospitalization Treatment Procedures for Minors
A. The following treatment procedures apply to any minor receiving evaluation, care, or treatment
pursuant to Article 65 of Title 27, C.R.S. and must be explained to the individual and provided in
written form:
1. A minor who is fifteen (15) years of age or older or a minor’s parent or legal guardian, on
the minor’s behalf, may make a voluntary application for hospitalization.
2. An application for hospitalization on behalf of a minor who is under fifteen (15) years of
age and who is a ward of the Department must not be made unless a guardian ad litem
has been appointed for the minor or a petition for the same has been filed with the court
by the facility having custody of the minor; except that such an application for
hospitalization may be made under emergency circumstances requiring immediate
hospitalization, in which case the facility shall file:
a. A p etition for appointment of a guardian ad litem within seventy-two (72) hours
after application for admission is made,
b. And the court shall immediately appoint a guardian ad litem.
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c. Procedures for hospitalization of a minor may proceed pursuant to this section
once a petition for appointment of a guardian ad litem has been filed, if
necessary.
3. Whenever an application for hospitalization is made, an independent professional person
shall interview the minor and conduct a careful investigation into the minor’s background,
using all available sources, including, but not limited to, the minor’s parents or legal
guardian, the minor’s school, and any other social service facilities.
4. Prior to admitting a minor for hospitalization, the independent professional person shall
make the following findings:
a. That the minor has a mental health disorder and is in need of hospitalization;
b. That a less restrictive treatment alternative is inappropriate or unavailable; and,
c. That hospitalization is likely to be beneficial, improve condition and/or prevent
further regression.
5. An interview and investigation by an independent professional person is not required for
a minor who is fifteen (15) years of age or older and who, upon the recommendation of
the minor’s treatment professional person, seeks voluntary hospitalization with the
consent of the minor’s parent or legal guardian.
6. A need for voluntary continued hospitalization must be formally reviewed every two (2)
months and must fulfill the requirements of Section 19-1-115(8), C.R.S., when the minor
is fifteen (15) years of age or older and consenting to hospitalization.
a. R eview must be conducted by an independent professional person who is not a
member of the minor’s treatment team; or if the minor, minor’s physician, and the
minor’s parent or legal guardian do not object to the need for continued
hospitalization, the review required may be conducted internally by hospital
personnel.
b. The independent professional person shall determine whether the minor
continues to meet the criteria specified in part 11.15.2.A.1 through part
11.15.2.A.4 of this Chapter and whether continued hospitalization is appropriate
and shall, at a minimum, conduct an investigation pursuant to this part
11.15.2.A.1 through part 11.15.2.A.4 of these rules.
c. Ten (10) days prior to the review, the patient representative at the mental health
facility shall notify the minor of the date of the review and shall assist the minor in
articulating to the independent professional person the minor’s wishes
concerning continued hospitalization.
7. Every six (6) months the review required pursuant to part 11.15.2.A.6 of this Chapter of
this section shall be conducted by an independent professional person who is not a
member of the minor’s treating team and who has not previously reviewed the minor
pursuant to part 11.15.2.A.6 of this Chapter.
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11.15.3 Objection to Hospitalization Process for Minors
A. When a minor does not consent to or objects to continued hospitalization, the need for such
continued hospitalization must, within ten (10) days, be reviewed pursuant to part 11.15.2.A.6 of
this Chapter by an independent professional person who is not a member of the minor’s
treatment team and who has not previously reviewed the minor pursuant to part 11.15.3.A of this
Chapter.
1. The minor shall be informed of the results of the review within three (3) days after the
review’s completion.
a. If the conclusion reached by the professional person is that the minor no longer
meets the standards for hospitalization specified in part 11.15.2.A.1 through part
11.15.2.A.4 of this Chapter, the minor shall be discharged with clinically indicated
discharge planning and notice to parent, guardian, or caregiver, as appropriate.
B. If twenty-four (24) hours after being informed of the results of the review specified in part
11.15.3.A of this Chapter, a minor continues to affirm the objection to hospitalization, the facility
director or the director’s duly appointed representative shall advise the minor that the minor has
the right to retain and consult with an attorney at any time and that the director or the director’s
duly appointed representative shall file, within three (3) days after the request of the minor, a
statement requesting an attorney for the minor or, if the minor is under fifteen (15) years of age, a
guardian ad litem. The minor, the minor’s attorney (if any) and the minor’s parent, legal guardian,
or guardian ad litem (if any) shall be given written notice that a hearing upon the recommendation
for continued hospitalization may be had before the court or a jury upon written request directed
to the court pursuant to part 11.15.3.D of this Chapter.
C. W henever the statement requesting an attorney is filed with the court, the court shall ascertain
whether the minor has retained an attorney, and, if the minor has not, the court shall, within three
(3) days, appoint an attorney to represent the minor, or if the minor is under fifteen (15) years of
age, a guardian ad litem. Upon receipt of a petition filed by the guardian ad litem, the court shall
appoint an attorney to represent the minor under fifteen years of age.
D. The minor or the minor’s attorney or guardian ad litem may, at any time after the minor has
continued to affirm the minor’s objection to hospitalization pursuant to part 11.15.3.B of this
Chapter, file a written request that the recommendation for continued hospitalization be reviewed
by the court or that the treatment be on an outpatient basis. If review is requested, the court shall
hear the matter within ten (10) days after the request, and the court shall give notice of the time
and place of the hearing to the minor; the minor’s attorney (if any), the minor’s parents or legal
guardian; the minor’s guardian ad litem (if any), the independent professional person, and the
minor's treatment team. The hearing must be held in accordance with Section 27-65-113, C.R.S.;
except that the court or jury shall determine that the minor is in need of care and treatment if the
court or jury makes the following findings:
1. T hat the minor has a mental health disorder and is in need of hospitalization;
2. That a less restrictive treatment alternative is inappropriate or unavailable; and,
3. That hospitalization is likely to be beneficial.
E. At the conclusion of the hearing, the court may enter an order confirming the recommendation for
continued hospitalization, discharge the minor, or enter any other appropriate order.
F. A minor may not again object to hospitalization pursuant to this part 11.15.3 until ninety (90) days
after conclusion of proceedings.
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G. In addition to the rights specified in Section 27-65-119, C.R.S. for individuals receiving evaluation,
care, or treatment, a written notice specifying the rights of minor children under this section must
be given to each minor upon admission to hospitalization.
H. A minor who no longer meets the standards for hospitalization specified in this part 11.15 must be
discharged.
11.16 Involuntary Short-Term and Long-Term Care and Treatment Designation (Inpatient
Services)
11.16.1 Applicability
A. The involuntary short-term and long-term care and treatment designation allows facilities to
provide care and treatment to individuals on involuntary mental health holds, short-term
certifications, and long-term certifications on an inpatient basis.
B. Facilities designated for involuntary short-term and long-term services must be in compliance with
the following rules:
1. Parts 2.7 through 2.13 and parts 2.23 through 2.25 of these rules with the following
exception:
a. Part 2.7.A.3 of these rules
2. Parts 11.1 through 11.15 and 11.16 of this Chapter.
C. Facilities that may become designated to provide involuntary short-term and long-term care and
treatment include acute treatment units (ATU). Crisis stabilization units (CSU), residential child
care facilities, and hospitals. ATUs must become designated to meet the requirements of their
service endorsement.
D. T his section 11.16 is meant, in part, to provide a summary of the obligations and standards set
forth in Section 27-65-101 through -131, C.R.S., with regard to involuntary short-term care and
treatment. This section is only enforceable with regard to designated facilities.
11.16.2 Procedures for Emergency Mental Health Holds
A. With every emergency mental health hold and petition to court for involuntary treatment resulting
in a change of legal status, the facility shall advise an individual of their rights set forth in part
11.16.5 of this Chapter, and there shall be evidence of such advisement in the individual’s clinical
record.
B. Procedures for emergency mental health holds may be found in part 11.14 of this Chapter.
11.16.3 Procedures for Short-Term Certifications on an Inpatient Basis
A. An individual may be certified for not more than three (3) months for short-term treatment under
the following conditions:
1. The professional personnel of the facility detaining the individual on an emergency
mental health hold has evaluated the individual and has found that the individual has a
mental health disorder and, as a result of the mental health disorder, is a danger to the
individual’s self or others or is gravely disabled;
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2. The individual has been advised of the availability of, but has not accepted, voluntary
treatment; but, if reasonable grounds exist to believe that the individual will not remain in
a voluntary treatment program, the individual’s acceptance of voluntary treatment does
not preclude certification;
3. The facility or community provider that will provide short-term treatment has been
designated by the commissioner to provide such treatment; and,
4. The individual, the individual’s legal guardian, and the individual’s lay person, if
applicable, have been advised of the individual’s right to an attorney and right to contest
the certification for short-term treatment. [effective July 1, 2024]
B. The facility is responsible for ensuring the individual receive all court paperwork (or ensuring the
attorney has provided it).
C. The facility or court shall ask the individual to designate a lay person whom the individual wishes
to be informed regarding certification. If the individual is incapable of making such a designation
at the time the certification is delivered, the individual must be asked to designate a lay person as
soon as the individual is capable.
D. In addition to the certification, the individual must be given a written notice that a hearing upon the
individual’s certification for short-term treatment may be had before the court or a jury upon
written request directed to the court pursuant to Section 27-65-109(6), C.R.S.
E. T he notice of certification must be signed by a professional person who participated in the
evaluation. The notice of certification must:
1. State facts sufficient to establish reasonable grounds to believe that the individual has a
mental health disorder and, as a result of the mental health disorder, is a danger to the
individual’s self or others or is gravely disabled;
2. Be filed with the court within forty-eight (48) hours, excluding Saturdays, Sundays, and
court holidays, after the date of the certification;
3. Be filed with the court in the county in which the individual resided or was physically
present immediately prior to being taken into custody;
4. Provide recommendations if the certification should take place on an inpatient or
outpatient basis [effective July 1, 2024]; and
5. Within twenty-four (24) hours after the date of certification, copies of the certification must
be personally delivered from the evaluating facility to the individual, the BHA, and a copy
must be kept by the evaluating facility as part of the individual’s record, if applicable.
F. Upon certification of the individual, the facility designated for short-term treatment has custody of
the individual.
G. T he individual or the individual’s attorney may at any time file a written request that the
certification for short-term treatment or the treatment be reviewed by the court or that the
treatment be on an outpatient basis.
1. If the individual requests the review, the court shall hear the matter within ten (10) days
after the request, and the court shall give notice to the individual and the individual’s
attorney and the certifying and treating professional person of the time and place of the
hearing.
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2. The hearing must be held in accordance with Section 27-65-113, C.R.S.
3. At the conclusion of the hearing, the court may enter or confirm the certification for short-
term treatment, discharge the individual, or enter any other appropriate order.
a. Upon the release of any individual in accordance with Section 27-65-112, C.R.S.,
the facility shall notify the clerk of the court within five (5) days after the release.
4. If the professional person in charge of the evaluation and treatment believes that a period
longer than three (3) months is necessary to treat the individual, the professional person
shall file with the court an extended certification at least thirty (30) days prior to the
expiration date of the original certification.
5. An extended certification for treatment must not be for a period of more than three (3)
months.
6. The individual is entitled to a hearing on the extended certification under the same
conditions as an original certification. The attorney initially representing the individual
shall continue to represent the individual unless the court appoints another attorney.
H. An individual certified for short-term treatment may be discharged upon the signature of the
treating medical professional and the medical director of the facility.
I. A fa cility or program shall make the individual’s discharge instructions available to the individual,
the individual's attorney, and the individual’s legal guardian, if applicable, within seven (7) days
after discharge, if requested.
1. A facility or program that is transferring an individual to a different treatment facility or to
an outpatient provider shall provide all treatment records to the facility or provider
accepting the individual at least twenty-four (24) hours prior to the transfer.
11.16.4 Procedures for Long-Term Certifications on an Inpatient Basis
A. The facility is responsible for ensuring the individual receives all court paperwork (or ensuring the
attorney has provided it).
B. Whenever an individual has received an extended certification for treatment pursuant to Section
27-65-109(10), C.R.S., the professional person in charge of the certification for short-term
treatment or the BHA may file a petition with the court at least thirty (30) days prior to the
expiration date of the extended certification for long-term care and treatment of the individual
under the following conditions:
1. The professional personnel of the facility or facility providing short-term treatment has
analyzed the individual’s condition and has found that the individual has a mental health
disorder and, as a result of the mental health disorder, is a danger to the individual’s self
or others or is gravely disabled;
2. T he individual has been advised of the availability of, but has not accepted, voluntary
treatment; but, if reasonable grounds exist to believe that the individual will not remain in
a voluntary treatment program, the individual’s acceptance of voluntary treatment does
not preclude an order pursuant to this section; and
3. The facility that will provide long-term care and treatment has been designated by the
commissioner to provide the care and treatment.
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C. Every petition for long-term care and treatment must include a request for a hearing before the
court filed thirty (30) calendar days prior to the expiration of six (6) months after the date of
original certification and provide a recommendation as to whether the certification for long-term
care and treatment should take place on an inpatient or outpatient basis.
1. A copy of the petition must be delivered personally to the individual for whom long-term
care and treatment is sought and electronically delivered to the individual’s attorney of
record simultaneously with the filing.
D. Within ten (10) days after receipt of the petition, the individual or the individual’s attorney may
request a hearing before the court or a jury trial by filing a written request with the court.
E. The court or jury shall determine whether the conditions of this part 11.16.4, are met and whether
the individual has a mental health disorder and, as a result of the mental health disorder, is a
danger to the individual’s self or others or is gravely disabled.
F. The court shall issue an order of long-term care and treatment for a term not to exceed six (6)
months, discharge the individual for whom long-term care and treatment was sought, or enter any
other appropriate order.
G. An or der for long-term care and treatment must grant physical custody of the individual to the
BHA for placement with a facility or facility designated by the commissioner to provide long-term
care and treatment. The BHA may delegate the physical custody of the individual to a facility
designated by the commissioner and the requirement for the provision of services and care
coordination.
H. When a petition contains a request that a specific legal disability be imposed or that a specific
legal right be deprived, the court may order the disability imposed or the right deprived if the court
or a jury has determined that the individual has a mental health disorder or is gravely disabled
and that, as a result, the individual is unable to competently exercise the specific legal right or
perform the function for which the disability is sought to be imposed.
1. Any interested person may ask leave of the court to intervene as a co petitioner for the
purpose of seeking the imposition of a legal disability or the deprivation of a legal right.
I. An original order of long-term care and treatment or any extension of such order expires on the
date specified, unless further extended as provided in this part 11.16.4.
J. If an extension is being sought, the professional person in charge of the evaluation and treatment
shall certify to the court at least thirty (30) days prior to the expiration date of the order in force
that an extension of the order is necessary for the care and treatment of the individual subject to
the order in force, and a copy of the certification must be simultaneously delivered to the
individual and electronically delivered to the individual’s attorney of record.
1. At least twenty (20) days before the expiration of the order, the court shall give written
notice to the individual and the individual’s attorney of record that a hearing upon the
extension may be had before the court or a jury upon written request to the court within
ten (10) days after receipt of the notice.
2. If a hearing is not requested by the individual within such time, the court may proceed ex
parte.
3. If a hearing is timely requested, the hearing must be held before the expiration date of the
order in force.
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4. If the court or jury finds that the conditions of this part 11.16 continue to be met and that
the individual has a mental health disorder and, as a result of the mental health disorder,
is a danger to others or to the individual’s self or is gravely disabled, the court shall issue
an extension of the order.
5. Any extension must not exceed six (6) months, but there may be as many extensions as
the court orders pursuant to this section.
K. An individual certified for long-term care and treatment may be discharged from the facility upon
the signature of the treating professional person and medical director of the facility, and the
facility shall notify the BHA prior to the individual’s discharge.
1. The facility shall make the individual’s discharge instructions available to the individual,
the individual’s attorney, the individual’s lay person, and the individual’s legal guardian, if
applicable, within one (1) week after discharge, if requested.
L. A facility that is transferring an individual to a different facility or to an outpatient program shall
provide all treatment records to the facility or provider accepting the individual at least twenty-four
(24) hours prior to the transfer.
11.16.5 I ndividual Rights for Short-Term and Long-Term Care Treatment
A. The facility shall furnish all persons receiving evaluation, care, or treatment under any provisions
of Article 65 of Title 27, C.R.S., with a written copy of the rights listed under part 11.14.3 of this
Chapter (translated into a language or modality accessible that the individual understands if
feasible) upon admission. If the individual is not able to read the rights, the individual shall be
read the rights in a language that the individual understands, if feasible, or provided access to a
modality to assist in understanding. Minors must receive a separate written notice of individual
rights as outlined in Section 27-65-104, C.R.S.
B. The facility shall post the following list of rights (in the predominant languages of the community in
which it operates and explained, if feasible, in a language or modality accessible to the individual)
in prominent places frequented by individuals and their families receiving services and the facility
shall assist the individual in exercising the below rights, in addition to the rights found in part
11.14.3 of this Chapter:
1. To meet with or call a personal clinician, spiritual advisor, counselor, crisis hotline, family
member, workplace, childcare provider, or school at all reasonable times;
2. T o receive and send sealed correspondence, as well as to be given the assistance of
facility personnel if the individual is unable to write, prepare, or mail correspondence.
Facility personnel shall not open, delay, intercept, read, or censor mail or other
communications or use mail or other communications as a method to enforce compliance
with facility personnel;
a. To have access to letter-writing materials, including postage, and to have
personnel members of the facility assist the individual if the individual is unable to
write, prepare, and mail correspondence;
3. To have the individual’s behavioral health orders for scope of treatment or psychiatric
advance directive reviewed and considered by the court as the preferred treatment option
for involuntary administration of medications unless, by clear and convincing evidence,
the individual’s directive does not qualify as effective participation in behavioral health
decision making;
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4. To have frequent and convenient opportunities to meet with visitors and to see the
individual’s attorney, clergyperson, or physician at any time;
a. The facility may not deny visits by the individual’s attorney, religious
representative or physician at any reasonable time.
b. The facility will provide privacy to maintain confidentiality of communication
between an individual and spouse or significant other, family member(s),
personnel, attorney, physician, certified public accountant and religious
representative, except that if disclosure is required by law, then such privacy may
be terminated;
5. To have personal privacy to the extent possible during the course of treatment; and,
6. To have access to a representative within the facility who provides assistance to file a
grievance.
7. An individual may be photographed upon admission for identification and the
administrative purposes of the facility. The photographs are confidential and must not be
released by the facility except pursuant to court order.
a. Nonmedical photographs shall not be taken or used without appropriate consent
or authorization.
C. Facilities providing care and treatment to minors shall post the minor’s rights information of
section 11.15.1, in addition to the following list of rights (in languages and modality appropriate for
understanding) in prominent places frequented by individuals and their families receiving
services.
11.16.6 I ndividual Rights Restrictions for Short-Term and Long-Term Care Treatment
A. As set forth in Section 27-65-119, C.R.S., an individual’s statutory rights, and rights listed in parts
11.14.3 and 11.16.5 of this Chapter, may be limited or denied if access to the right would
endanger the safety of the individual or another person in close proximity and may only be denied
by a person involved in the individual’s care.
1. A person involved in the individual’s care means a person that is either providing care
directly to the individual or directing the care of the individual.”
B. Any individual whose rights are denied or violated pursuant to this section has the right to file a
complaint against the facility with the BHA and the Department of Public Health and Environment.
C. Except as otherwise provided in part 11.16.6.A of this Chapter, each denial of an individual’s right
shall be made on a case-by-case basis and the reason for denying the right shall be documented
in the individual record and shall be made available, upon request, to the individual, the
individual’s legal guardian, or the individual’s attorney.
D. Except as otherwise provided in part 11.16.6.A of this Chapter, restrictions on rights in parts
11.14.3.A.9, 11.14.3.A.10, 11.14.3.A.15, 11.14.3.A.17, and 11.14.3.A.19 and part 11.16.5.B.1 of
this Chapter, shall be evaluated for therapeutic necessity on an ongoing basis and the rationale
for continuing the restriction shall be documented at least every seven (7) calendar days.
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E. A facility shall not intentionally retaliate or discriminate against a person or employee for
contacting or providing information to any official or to an employee or any state protection and
advocacy facility, or for initiating, participating in, or testifying in a grievance procedure or in an
action for any remedy authorized pursuant to this this section.
1. Under Section 27-65-119(6), C.R.S., any facility that violates this commits an unclassified
misdemeanor and shall be fined not more than one thousand dollars.
11.16.7 Individual Rights Restrictions in Secure Treatment Facilities
A. A facility, through a professional person treating individuals in a secure treatment setting may limit
or deny rights listed in this Chapter for good cause based upon the safety and security needs of
the personnel and other individuals in the facility. Safety and security policies applicable to the
unit shall be incorporated into the individual’s service plan. The following procedures shall be
adhered to:
1. The BHA shall approve of safety and security policies for each facility unit that places any
limit on the rights set forth in part 11.16 of this Chapter, as well as the policy and criteria
for placement of an individual committed under Article 65 of Title 27, C.R.S., in secure
treatment facilities.
2. T he safety and security policies for each facility unit shall be posted in the unit. The
secure facility personnel shall provide a copy of the unit policy upon an individual’s
request.
3. Any good cause restriction of rights based upon the safety and security policy of the
facility unit shall be noted in the individual’s record. The order for restriction shall be
signed by the professional person providing care and treatment and shall be reviewed at
least every thirty (30) days.
4. No safety or security policy may limit an individual’s ability to send or receive sealed
correspondence. However, to prevent the introduction of contraband into the secure
treatment facility, the policy may require that the individual open the correspondence in
the presence of unit personnel.
5. No safety or security policy may limit an individual’s right to see their attorney, clergy, or
physician at reasonable times. However, the safety and security policy may provide that
advance notice be given to the secure treatment facility for such visits so that the secure
facility can adequately personnel for the private visit and take any measures necessary to
ensure the safety of the visit.
6. For the purposes of this rule, placement of individuals in secure treatment facilities on
units that are locked at night:
a. I ndividuals transferred to a secure treatment facility from the Department of
Corrections, who are serving sentences in the Department of Corrections, may
be placed on units in which the bedroom doors are locked during sleeping hours.
b. Individuals who are newly admitted to a secure treatment facility may be placed
on units in which the bedroom doors are locked during sleeping hours, for a time
period not to exceed sixty (60) calendar days. After sixty (60) calendar days,
these individuals will not be placed on a unit with locked doors during sleeping
hours unless an individualized assessment is made, and the treatment team
determines that the individual is imminently dangerous to self or to others; this
must be documented in the individual’s record.
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c. Sleeping hours shall begin no earlier than 9:00 p.m., end no later than 8:00 a.m.,
and shall not exceed 8-1/2 hours.
d. Individuals shall be provided an effective means of calling for assistance when in
a locked room during sleeping hours. The secure treatment facility shall provide
personnel to promptly assist an individual with their individual needs including,
but not limited to, personnel assigned to a day hall where personnel will be able
to hear and respond to individuals who knock on their room doors. An intercom
call system may also be used. Personnel shall monitor each individual’s well-
being through visual observation checks every fifteen (15) minutes.
e. As set forth in Section 27-65-127, C.R.S., an individual's rights may be limited or
denied under court order by an imposition of legal disability or deprivation of a
right.
f. Information pertaining to the denial of any right shall be made available, upon
request, to the individual or their attorney.
11.16.8 Admissions Requirements & Disclosures
A. The facility shall develop written admission criteria based on the facility’s ability to meet the
individual’s needs. Admission criteria shall be based upon a comprehensive assessment of the
individual’s mental health, physical health, substance use, and capacity for self- care. The
assessment shall determine the level of intervention and supervision required, including
medication management, behavioral health services and stabilization prior to return to the
community.
B. Ac ute treatment units shall not admit individuals with a mental health disorder into a locked
setting unless there is no less restrictive alternative and unless they are otherwise in compliance
with the requirements of Article 65 of Title 27, Colorado Revised Statutes.
C. Individuals may be admitted to a locked setting as a voluntary or involuntary individual. If
voluntary, the individual shall sign a form that documents the following information:
1. The individual is aware that the facility is locked.
2. The individual may exit the facility with personnel assistance and/or permission.
3. The individual may leave the facility at any point in time, unless they present as a danger
to self or others, or is gravely disabled as defined in Section 27-65-102(17), C.R.S.
4. An individual who is imminently suicidal or homicidal shall only be admitted to the locked
facility, upon completion of the facility’s assessment and the facility’s determination that
the individual’s safety and the safety of others can be maintained by the facility. If an
individual is admitted and facility personnel determine that their behavior cannot be safely
and successfully treated at the ATU, then personnel shall make arrangements to transfer
the individual to the nearest hospital for further assessment and disposition.
D. A fa cility shall not admit or keep any individual who meets the following exclusion criteria:
1. Is consistently incontinent unless the individual or personnel is capable of preventing
such incontinence from becoming a health hazard.
2. Is under the age of eighteen (18) unless the facility has a separate locked unit dedicated
to minors.
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3. Is bedridden with limited potential for improvement.
4. Has a communicable disease or infection that is:
a. Reportable under the Colorado Department of Public Health and Environment's
regulations (6 CCR 1009-1 (01/14/2025) and 6 CCR 1009-2 (05/15/2023)) which
are hereby incorporated by reference. No later editions or amendments are
incorporated. The rules are available at no cost from the Colorado Secretary of
State website. The 6 CCR 1009-1 (01/14/2025) regulation is available at
https://www.coloradosos.gov/CCR/GenerateRulePdf.do?ruleVersionId=11781&fil
eName=6%20CCR%201009-1. The 6 CCR 1009-2 (05/15/2023) regulation is
available at
https://www.coloradosos.gov/CCR/GenerateRulePdf.do?ruleVersionId=10788&fil
eName=6%20CCR%201009-2. Individuals may inspect a copy at the Behavioral
Health Administration, 710 S. Ash Street, Unit C140, Denver, CO 80246, during
regular business hours); and
b. Potentially transmittable in a facility unless the individual is receiving medical or
drug treatment for the condition and the admission is approved by a physician.
5. Has acute withdrawal symptoms, is at risk of withdrawal symptoms, or is incapacitated
due to a substance use disorder and facility does not have appropriate
capacity/endorsements to address issues of withdrawal.
E. The facility shall maintain a current list of individuals and their assigned room.
11.16.9 Required Disclosures to Individuals Upon Admission
A. There shall be written evidence of consent to treat, and the following upon admission to the
individual or individual’s legal representative, as appropriate. Acknowledgements shall specify the
understanding between the parties regarding, at a minimum:
1. Charges;
2. Services included in the rates and charges;
3. Types of services provided by the facility, those services which are not provided, and
those which the facility will assist the individual in obtaining;
4. Transportation services;
5. Therapeutic diets;
6. A physically safe and sanitary environment;
7. Personal services;
8. Protective oversight;
9. Presence and purpose of any video monitoring;
10. Social and recreational activities;
11. A provision that the facility must give individuals thirty (30) calendar days’ notice of
closure;
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12. Management of personal funds and property;
13. Facility rules, established pursuant to part 11.16.11 of this Chapter;
14. Staffing levels based on individual needs; and
15. Types of daily activities, including examples of such activities that will be provided.
11.16.10 Environment and Safety
A. All individuals being treated under these regulations shall receive such treatment in a clean and
safe environment with opportunities for privacy.
B. A facility shall only place an individual in a bedroom with video monitoring due to good cause and
safety or security reasons which must be noted in the individual record. Individuals shall be
notified in writing when placed in bedrooms with video monitoring capabilities.
C. Each facility shall maintain reasonable security capabilities to guard against the risk of
unauthorized departures. The least restrictive method to prevent an unauthorized departure shall
be used.
D. An unlocked facility may place an individual in seclusion to prevent an unauthorized departure
when such departure carries an imminent risk of danger for the individual or for others. Under
those circumstances, the seclusion procedures in part 11.9 of these rules shall be followed.
11.16.11 Facility rules
A. The facility shall establish written policies, which shall list all possible actions that may be taken
by the facility if any policy is knowingly violated by an individual. Facility policies may not violate
or contravene any rule herein, or in any way discourage or hinder an individual’s rights.
B. T he facility shall prominently post its policies in writing, which shall be available at all times to
individuals. Such policies shall address at least the following:
1. Smoking;
2. Cooking;
3. Visitors;
4. Telephone usage including frequency and duration of calls;
5. Use of common areas, including the use of television, radio;
6. Consumption of alcohol and/or illicit drugs;
7. Dress; and
8. Pets, which shall not be allowed in the facility; however, in no event shall such rules
prohibit service or guide animals.
11.16.12 Employment of Individuals Receiving Services in 27-65 Designated Facilities
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A. All labor, employment or jobs involving facility operation and maintenance which are of an
economic benefit to the facility, shall be treated as work and shall be compensated according to
applicable minimum wage or prevailing wage rates.
B. Maintaining a minimum standard of cleanliness and personal hygiene and personal
housekeeping, such as making one's bed or cleaning one's area, shall not be treated as work and
shall not be compensated.
C. Individuals shall not be forced in any way to perform work.
D. Privileges or release from a designated facility shall not be conditioned upon the performance of
work.
E. Vocational programs and training programs must comply with all applicable federal and state
laws.
F. Vocational programs are not subject to the provisions in part 11.16.12.A of this section unless the
program is of economic benefit to the facility.
G. All work assignments, together with a specific consent form, and the hourly compensation
received, shall be noted in the individual’s record.
11.16.13 Medical/Dental Care
A. The facility shall ensure the availability of emergency medical and dental care to meet the
individual needs of each individual. The obligation to ensure the availability of emergency medical
services shall not be construed as the obligation to pay for such services; however, the facility
shall secure these services regardless of source of payment. The facility shall have and adhere to
a written plan for providing emergency medical and dental care to include at least:
1. A qu alified licensed independent practitioner responsible for the completion of physical
examinations within twenty-four (24) hours of admission. Subsequent physical
examinations shall be completed at least annually, and as frequently as needed. This
information shall be included in the clinical record.
a. If the individual refuses to complete a physical examination, documentation must
be held in the clinical record of facility efforts.
2. The availability of a qualified licensed independent practitioner or emergency medical
facility on a twenty-four (24) hour, seven (7) days a week basis.
3. Emergency medical or dental treatment, when indicated, shall be accessed immediately
upon determination that an emergency exists.
4. Whenever indicated, an individual shall be referred to an appropriate specialist for either
further assessment or treatment. The facility shall be responsible for securing an
appropriate assessment to determine the need for further specialty consultation. This
information shall be contained in the clinical record.
B. Each designated facility must maintain a facility placement agreement with one or more medical
hospitals pursuant to part 11.12 of this Chapter.
C. If an individual on an emergency mental health hold or certification requires inpatient medical
care at a hospital, the designated facility shall be responsible for the care and treatment provided
by the medical hospital per part 11.12 of this Chapter.
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D. The designated facility shall communicate with the hospital upon the individual being admitted to
the medical unit regarding the individual’s psychiatric treatment needs, safety considerations, and
managing ligature risk while the individual is hospitalized medically consistent with state and
federal law.
11.16.14 Physical Health Assessment Policy
A. The facility shall develop policies and procedures that identify when a physical health assessment
by a qualified licensed independent practitioner will be required, including the following indicators:
1. Within twenty-four (24) hours of admission;
2. A significant change in the individual’s condition;
3. Evidence of possible infection (open sores, etc.);
4. Injury or accident sustained by the individual that might cause a change in the individual’s
condition;
5. Known exposure of the individual to a communicable disease; or
6. Development of any condition that would have initially precluded admission to the facility.
11.16.15 Medication Storage, Disposition, and Disposal
A. All personal medication must be surrendered to the facility to be logged in and stored by the
facility. Individuals are not allowed to self-administer medication in the facility.
B. Personal medication shall be returned to the individual or individual’s legal representative, upon
discharge or death, except that return of medication to the individual may be withheld if specified
in the individual’s service if a physician or other authorized medical practitioner has determined
that the individual lacks the decisional capacity to possess or administer such medication safely.
C. Med ications shall be labeled with the individual’s full name, pursuant to Article 280 of Title 12,
C.R.S.
D. Any medication container that has a detached, excessively soiled, or damaged label shall be
returned to the issuing pharmacy for re-labeling or disposed of appropriately.
E. All medication shall be stored in a manner that ensures the safety of all individuals.
F. Medication shall be stored in a central location, including refrigerators, and shall be kept under
lock and shall be stored in separate or compartmentalized packages, containers, or shelves for
each individual in order to prevent intermingling of medication.
G. Individuals shall not have access to medication that is kept in a central location.
H. Medications that require refrigeration shall be stored separately in locked containers in the
refrigerator. If medication is stored in a refrigerator dedicated to that purpose, and the refrigerator
is in a locked room, then the medications do not need to be stored in locked containers.
I. Prescription and over the counter medication shall not be kept in stock or bulk quantities unless
such medication is administered by a licensed medical practitioner.
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J. Medication disposal procedures include:
1. The return of medication shall be documented by the facility.
2. Medication that has a specific expiration date shall not be administered after that date
and shall be disposed of appropriately.
11.16.16 Medication Administration
A. The facility must ensure that medications are administered only by licensed or certified personnel
allowed to administer medications under their own scopes of practice, or an unlicensed personnel
who are qualified medication administration persons (QMAPs) acting within their own scope of
practice.
B. When using QMAPs to administer medication, the facility shall ensure compliance with 6 CCR
1011-1 Chapter 24 (July 19, 2017), which is hereby incorporated by reference. No later editions
or amendments are incorporated. The rule is available at no cost from the Colorado Secretary of
State at https://www.sos.state.co.us. Individuals may inspect a copy at the Behavioral Health
Administration, 710 S. Ash Street, Unit C140, Denver, CO 80246, during regular business hours.
C. Facilities shall follow psychiatric medication standards as outlined in part 11.8.2 of this Chapter
and the following:
1. Only a licensed nurse may accept telephone orders for medication from a physician or
other authorized practitioner. All telephone orders shall be evidenced by a written and
signed order and documented in the individual’s record and the facility’s medication
administration record.
2. These rules apply to medications and treatment which do not conflict with state law and
regulations pertaining to acute treatment units and which are within the scope of services
provided by the facility, as outlined in the individual agreement or the facility rules.
3. The facility shall be responsible for complying with professional person or advanced
practice registered nurse orders associated with the administration of medication or
treatment. The facility shall implement a system that obtains clarification from the
physician, as necessary and documents that the physician:
a. Has been asked whether refusal of the medication or treatment should result in
physician notification.
b. Has been notified, where such notification is appropriate.
c. Has provided documentation of such notification shall be made in the individual’s
clinical record.
d. C oordinates with external providers or accepts responsibility to perform the care
using facility personnel.
e. Trains personnel regarding the parameters of the ordered care as appropriate.
f. Documents the delivery of the care, including refusal by the individual, of the
medication or treatment.
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11.16.17 Administration of Oxygen
A. Individuals may administer oxygen, if the individual is able to manage the administration themself
and personnel shall assist with the administration as needed for safety, when prescribed by a
physician and if the facility follows appropriate safety requirements regarding oxygen herein.
B. Oxygen tanks shall be secured upright at all times to prevent falling over and secured in a
manner to prevent tanks from being dropped or from striking violently against each other.
C. Tank valves shall be closed except when in use.
D. Transferring oxygen from one container to another shall be conducted in a well-ventilated room
with the door shut. Transfer shall be conducted by trained personnel or by the individual for whom
the oxygen is being transferred, if the individual is capable of performing this task safely. When
the transfer is being conducted, no person, except for a person conducting such transfer, shall be
present in the room.
E. Tanks and other oxygen containers shall not be exposed to electrical sparks, cigarettes, or open
flames.
F. Tanks shall not be placed against electrical panels or live electrical cords where the cylinder can
become part of an electric circuit.
G. T anks shall not be rolled on their side or dragged.
H. Smoking shall be prohibited in rooms where oxygen is used or stored. Rooms in which oxygen is
used shall be posted with a conspicuous “no smoking” sign.
I. Tanks shall not be stored near radiators or other heat sources. If stored outdoors, tanks shall be
protected from weather extremes and damp ground to prevent corrosion.
11.16.18 Serious Illness, Serious Injury, or Death
A. Facility policy shall describe the procedures to be followed by the facility in the event of serious
illness, serious injury, or death of individuals receiving services, including incident reporting
requirements.
B. The policy shall include a requirement that the facility notify an emergency contact, if one has
been provided, when the individual’s injury or illness warrants medical treatment or face-to-face
medical evaluation. In the case of an emergency room visit or unscheduled hospitalization, a
facility must notify an emergency contact immediately.
11.16.19 Service Provisions for Short-Term and Long-Term Care Treatment
A. Facilities providing short-term and long-term care treatment shall have detailed policies and
procedures specific to therapeutic programming provided to individuals while in the facility’s care.
B. P rogramming shall be trauma-informed, person-centered, and appropriate for the individual’s
diagnosis.
C. Programming shall be documented in the individual’s treatment plan.
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D. Programming shall be facilitated by appropriate personnel for the type of therapeutic treatment
provided.
E. Programming can include the following, but is not limited to:
1. Intensive case management;
2. Assertive community treatment;
3. Peer recovery support services;
4. Individual therapy;
5. Group therapy;
6. Therapeutic activities;
7. Educational and vocational training or activities;
8. Housing and transportation assistance; and/or
9. Transitional assistance.
11.16.20 Content of Records
A. Records shall be kept in conformity with part 2.11 of these rules, applicable federal and state
laws, and the following:
1. Demographic and medical information;
2. A cover sheet to contain the following information;
a. Individual’s full name, including maiden name if applicable;
b. Individual’s sex, date of birth, gender identity, marital status and social security
number, where needed for Medicaid or employment purposes;
c. Individual’s current address of residence;
d. Date of admission;
e. Name, address and telephone number of relatives or legal representative(s), or
other person(s) to be notified in an emergency;
f. Name, address and telephone number of individual’s primary physician, and
case manager if applicable, and an indication of religious preference, if any, for
use in emergency;
g. I ndividual’s diagnoses, at the time of admission;
h. Current record of the individual’s allergies;
3. Medication administration record; and
4. Physician’s orders.
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B. Initial and comprehensive assessments shall comply with the requirements of parts 2.12.2 and
2.12.3 of these rules and must be completed within twenty-four (24) hours of admission.
C. Service plans shall comply with the requirements of part 2.13.1 of these rules, and the following:
1. The service plan shall contain specific criteria required for discharge from treatment or to
progress to less restrictive treatment alternatives.
2. If an individual is discharged during an emergency mental health hold without certification
by the facility, and a service plan has not been completed, then pertinent information
shall be included in the discharge summary.
3. A physician or other legal prescriber shall be responsible for the component of the plan
requiring medication management services.
4. For individuals certified to short-term or long-term treatment, the service plan shall be
reviewed, and revised, if necessary, at least monthly by the personnel responsible for the
plan, the treating professional person, any additional personnel involved in care as the
facility determines is necessary for the review, the individual, and the legal guardian. This
review shall be documented in the record and include progress toward meeting the
criteria for termination of treatment and the need for continued involuntary treatment if the
individual is certified. If the monthly review is delayed, the reason for such delay shall be
noted in the record and the review shall be completed as promptly as possible.
D. T reatment progress notes shall include the following:
1. Documentation of all treatment procedures including, but not limited to: brief physical
restraint, seclusion, mechanical restraint, medications voluntary and involuntary, and
other therapies or interventions.
2. Information regarding the serious injury of or by the individual and the circumstances and
outcome.
3. Documentation of all transfers, whether permanent or temporary, and reasons for
transfer.
4. Legal status and all legal documents related to treatment under Section 27-65-101
through -131, C.R.S.
5. Consultations and/or case reviews.
6. Pertinent information from outside facilities or persons or from the individual.
7. Correspondence to and from relevant facilities and persons.
8. Consent forms as appropriate for alternative treatments or voluntary treatment.
9. Use or non-use of psychiatric and medical advance directives.
E. Discharge information provided to the individual shall include the requirements of part 2.10.A.6.
Of these rules, and the following:
1. Specific recommendations regarding prevention of re-hospitalization based on the
individual’s unique challenges and needs.
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F. Discharge summaries shall comply with the requirements of part 2.10.A.6 of these rules, this part
11.16.20, and the following:
1. Documentation that notice of discharge was provided to the individual or individual’s legal
representatives as follows:
a. At least twenty-four (24) hours in advance of discharge or transfer, in accordance
with the rules governing the care and treatment of persons with a mental health
disorder in parts 11.14 and 11.16 of this Chapter.
b. In cases of a medical or psychiatric emergency, the emergency contact shall be
notified as soon as possible.
2. Documentation of discharge coordination with the individual, and, with permission, the
individual’s family, legal representative, or appropriate facility.
3. For transfers between facilities, documentation of appropriate clinical information and
coordination of services between the two facilities, including mode of transportation.
4. Information if the discharge is being made against the advice of the treating professional
person.
11.16.21 Management of Personal Funds and Personal Property
A. The facility shall comply with part 2.26.D.3 of these rules related to management of personal
funds and personal property.
11.16.22 Transportation of Individuals
A. Whenever transportation of an individual is required, the treating personnel of the facility shall
assess the individual for danger to self or others and potential for escape. Whenever clinically
and safely appropriate, the individual may be transported by other means such as ambulance,
care van, private vehicle, and restraints shall not be used, unless consistent with state and
federal law, authorized as necessary, and ordered by the treating professional person. If the
treating personnel assesses the individual as dangerous to self or others or as an escape risk,
the personnel may request transportation by a secure transportation provider or the local sheriff's
department.
11.16.23 Se cure Transportation Providers
A. Facilities may utilize a secure transportation provider.
B. “ Class A” secure transportation services are licensed pursuant to CDPHE regulations to use
physical restraint during secure transport based on associated regulations.
C. “ Class B” secure transportation services are not licensed pursuant to CDPHE regulations to use
physical restraint during secure transport.
D. For individuals receiving involuntary care in a 27-65 designated facility, when transportation to a
medical appointment outside of the 27-65 designated facility is required, a personnel from the 27-
65 designated facility who is trained in facility transportation policies and procedures shall
accompany and remain with the individual for the duration of the appointment at the outside
facility. The individual may be left in an emergency medical services facility’s care without a
designated facility personnel only if the individual is in a secure area (such as a psychiatric
emergency department) and/or if there is trained security personnel present with the individual at
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all times; these provisions for safety/security must be noted in the designated facility’s individual
chart.
11.16.24 Secure Transport Requests
A. Any requests for transportation from the sheriff's department shall be filed with the court of
appropriate jurisdiction and shall include:
1. Statements from the treating Colorado licensed physician or psychologist supporting the
need for transportation by the sheriff's department;
2. Recommendations concerning the use of mechanical restraints and the impact that
handcuffs or shackles would have on the individual;
3. Recommendations for soft restraints, not handcuffs or shackles, if the findings of the
assessment support the use of mechanical restraint;
4. Recommendations concerning the placement and management of the individual during
the time they will be absent from the 27-65 designated facility due to court hearings;
5. Recommendations of considerations for management of the individual based on the
individual's age, physical abilities, culture, medical and psychiatric status and/or stability.
B. Notice of the request for transportation by the sheriff's department shall be given to the individual
and their attorney at least twenty-four (24) hours prior to the time it is filed with the court. This
notice shall not be required during the time an emergency mental health hold is in effect or in an
emergency situation with an individual under certification or when the individual signs a waiver
which has been clearly explained.
C. R equesting transportation by the sheriff's department does not require a finding of danger to self
or others or an escape risk if the sheriff's department is willing to transport the individual without
the use of mechanical restraints.
11.16.25 Termination of Certification for Short-Term and Long-Term Treatment
A. Prior to July 1, 2024, an original or extended certification for short-term treatment issues pursuant
to Section 27-65-109, C.R.S., or an order or extension for certification for long-term care and
treatment pursuant to Section 27-65-110, C.R.S., terminates as soon as the professional person
in charge of treatment of the individual determines the individual has received sufficient benefit
from the treatment for the individual to end involuntary treatment. Beginning July 1, 2024, an
original or extended certification for short-term treatment issues pursuant to Section 27-65-109,
C.R.S., or an order or extension for certification for long-term care and treatment pursuant to
Section 27-65-110, C.R.S., terminates as soon as the professional person in charge of treatment
of the individual and the BHA determine the individual has received sufficient benefit from the
treatment for the individual to end involuntary treatment.
B. W henever a certification or extended certification is terminated, the professional person in charge
of providing treatment shall notify the court in writing within five (5) days after the termination.
C. Before termination, an individual who leaves a facility may be returned to the facility by order of
the court without a hearing or by the superintendent or director of the facility without a court order.
D. After termination, an individual may be returned to the facility only in accordance with Article 65 of
Title 27, C.R.S.
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E. Facilities designated for involuntary care and treatment of individuals are required to notify the
BHA whenever an individual certification is terminated. 27-65 designated facilities must submit
required documentation directly to the BHA using the prescribed BHA method available on BHA’s
website.
11.17 Involuntary Outpatient Care & Treatment Designation
11.17.1 Applicability
A. The involuntary outpatient care and treatment designation allows facilities to provide care and
treatment to individuals on short-term and long-term certifications on an outpatient basis.
B. Facilities designated for involuntary outpatient care and treatment must be in compliance with the
following rules:
1. Parts 2.7 through 2.13 and parts 2.23 through 2.25 of these rules with the following
exception
a. Part 2.7.A.3 of these rules
2. Parts 11.1 through 11.15 and 11.17 of this Chapter.
C. This section 11.17 is meant, in part, to provide a summary of the obligations and standards set
forth in Section 27-65-101 through -131, C.R.S., with regard to involuntary outpatient care and
treatment. This section is only enforceable with regard to designated facilities.
11.17.2 Procedures for Certification to Outpatient Treatment
A. An individual who has been treated as an inpatient under a short-term or long-term certification
for mental health treatment at a designated facility may be treated on an outpatient basis if the
following conditions are met:
1. A pr ofessional person who has evaluated the individual and who is on the personnel of
the inpatient designated facility determines that while the individual continues to meet the
requirements for certification, professional judgment is that with appropriate treatment
modalities in place the individual is unlikely to act dangerously in the community.
2. Certification on an outpatient basis is the appropriate disposition suited to the individual's
needs.
3. The designated facility that will hold the certification on an outpatient basis has
documentation of the results of a physical examination within the last year, or
documented attempts to obtain information.
B. In addition to the requirements in Chapter 4 of these rules, the outpatient treatment provider shall
develop a service plan for the individual receiving treatment on an outpatient basis with the goal
of the individual finding and sustaining recovery. The service plan must include measures to keep
the individual or others safe, as informed by the individual's need for certification. The service
plan may include, but is not limited to:
1. Intensive case management;
2. Assertive community treatment;
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3. Peer recovery support services;
4. Individual or group therapy;
5. Day or partial-day programming activities;
6. Intensive outpatient programs;
7. Educational and vocational training or activities; and
8. Housing and transportation assistance.
C. The individual, the individual's legal guardian, the individual’s patient representative or the
individual's lay person, or any party at any court hearing may contest an individual's treatment
regimen, including court-ordered medications, at any court hearing related to the individual's
certification for treatment.
D. Primary oversight of outpatient certifications at designated facilities must be provided by a
professional person. The professional person assigned to the individual’s case must also be
available for clinical supervision and/or consultation to personnel providing clinical services to the
individual at the designated facility in which the individual is receiving outpatient certification
treatment.
E. Primary clinical services at the designated facility, including but not limited to individual therapy,
must be provided by a licensee or authorized practitioner receiving clinical supervision and/or
consultation from the assigned professional person.
11.17.3 Enforcement of Outpatient Certification [Effective July 1, 2024]
A. The facility responsible for providing services to an individual on a certification on an outpatient
basis shall proactively reach out to the individual to engage the individual in treatment on a
weekly basis and including visits to the individual’s known places or residence. Documentation of
all visits and attempts must be included in the clinical record.
B. If
the individual refuses treatment or court-ordered medication and is decompensating
psychiatrically, the court may order a certified peace officer or secure transportation provider to
transport the individual to an appropriate, least restrictive designated facility in collaboration with
the BHA and the provider holding the certification.
1. The individual does not need to be imminently dangerous to the individual's self or others
for the facility to request, and the court to order, transportation to a facility for the
individual to receive treatment and court-ordered medications.
C. The facility responsible for providing services to an individual on a certification on an outpatient
basis shall provide the court information on the facility's proactive outreach to the individual and
the professional person's and psychiatric advanced practice registered nurse's basis for medical
opinion.
D. If an individual is placed in a more restrictive setting, the individual has the right to judicial review
within ten (10) days after filing a written request.
E. In addition to any other limitation on liability, an agency or facility providing care to an individual
placed on short-term or long-term certification on an outpatient basis is only liable for harm
subsequently caused by or to an individual who:
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1. Has been terminated from certification despite meeting statutory criteria for certification
pursuant to Sections 27-65-109 or 27-65-110, C.R.S.; and,
2. Provided services to the individual not within the scope of the individual's professional
license or was reckless or grossly negligent in providing services.
3. A provider is not liable if an individual's certification is terminated, despite meeting criteria
for certification, if the provider is unable to locate the individual despite proactive and
reasonable outreach.
F. An individual certified for short-term treatment on an outpatient basis may be discharged upon the
signature of the approved professional person overseeing the individual's treatment, and the
professional person shall notify the BHA prior to the discharge.
G. A facility or program shall make the individual’s discharge instructions available to the individual,
the individual's attorney, and the individual’s legal guardian, if applicable, within seven (7) days
after discharge, if requested.
1. A facility or program that is transferring an individual to a different treatment facility or to
an outpatient provider shall provide all treatment records to the facility or provider
accepting the individual at least twenty-four (24) hours prior to the transfer.
H. T he individual, their legal guardian, the patient representative or lay person, or any party may
object to the individual’s treatment, including court-ordered medications, at any court hearing
related to the individual’s certification to treatment.
11.17.4 Individual Rights for Involuntary Outpatient Treatment [Effective July 1, 2024]
A. The facility shall provide all individuals receiving evaluation, care, or treatment on a certified
outpatient basis, with a written copy of the rights listed under part 11.14.3 of this Chapter, in
addition to this part 11.17.4.B (translated into a language that the individual understands if
feasible) upon admission and upon each renewal of certification. If the individual is not able to
read the rights, the individual shall be read the rights in a language that they understand.
B. The facility shall post the following list of rights (in languages predominantly used by the
population of individuals served), in addition to those enumerated in part 11.14.3 of this Chapter
in prominent places frequented by individuals and their families receiving services:
1. To request a change to voluntary status. A change to voluntary status may be denied by
the supervising professional person or an advanced practice registered nurse with
training in psychiatric nursing responsible for the individual’s treatment if the professional
person or advanced practice registered nurse with training in psychiatric nursing
determines reasonable grounds exist to believe that the individual will not remain in a
voluntary treatment program;
a. If a discrepancy exists for the determination of voluntary status between the
professional person and the advanced practice nurse with training in psychiatric
nursing, the determination for the individual to change to voluntary status must
defer to the assessment from the professional person.
2. To be treated fairly, with respect and recognition of the individual's dignity and
individuality, by all employees of the treatment facility with whom the individual comes in
contact;
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3. To appropriate treatment, which must be administered skillfully, safely, and humanely. An
individual shall receive treatment suited to the individual's needs that must be determined
in collaboration with the individual;
4. To not be discriminated against on the basis of age, race, ethnicity, religion, culture,
spoken language, physical or mental disability, socioeconomic status, sex, sexual
orientation, gender identity, or gender expression;
5. To retain and consult with an attorney at any time;
6. Within forty-eight (48) hours after the individual's request, to see and receive the services
of a patient representative, including a peer specialist;
7. To have the individual's behavioral health orders for scope of treatment or psychiatric
advance directive reviewed and considered by the court as the preferred treatment option
for involuntary administration of medications unless, by clear and convincing evidence,
the individual's directive does not qualify as effective participation in behavioral health
decision-making;
8. To have the individual's information and records disclosed to adult family members and a
lay person pursuant to Section 27-65-123, C.R.S.;
9. To have access to a representative within the facility who provides assistance to file a
grievance; and
10. To have the right to file a motion with the court at any time to contest the certification.
c. As s et forth in Section 27-65-127, C.R.S., an individual's rights, as set forth in Section 27-65-101
through -131, C.R.S. and this Chapter, may be limited or denied under court order by an
imposition of legal disability or deprivation of a right.
d. Information pertaining to the denial of any right shall be made available, upon request, to the
individual or their attorney.
11.17.5 Service Planning [Effective July 1, 2024]
A. Service plans shall comply with the requirements of part 2.13.1 of this Chapter, and the following:
1. The service plan shall contain specific criteria required for discharge from treatment or to
progress to less restrictive treatment alternatives;
2. A physician or other legal prescriber shall be responsible for the component of the plan
requiring medication management services; and,
3. For individuals certified to short-term or long-term treatment, the service plan shall be
reviewed, and revised, if necessary, at least monthly by the personnel responsible for the
plan, the treating professional person, the individual and the legal guardian. This review
shall be documented in the record and include progress toward meeting the criteria for
termination of treatment and the need for continued involuntary treatment if the individual
is certified. If the monthly review is delayed, the reason for such delay shall be noted in
the record and the review shall be completed as promptly as possible.
4. T he service plan may include, but is not limited to:
a. Intensive case management services;
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b. Assertive community treatment;
c. Peer recovery services;
d. Individual and/or group therapy;
e. Day or partial-day programming activities;
f. Intensive outpatient programs;
g. Educational and/or vocational training and activities; or
h. Housing and transportation assistance
Chapter 12: Behavioral Health Safety Net Provider Approval
12.1 Authority and Applicability
A. Chapter 12 establishes standards for behavioral health safety net providers, including
comprehensive community behavioral health providers and essential behavioral health safety net
providers, and the behavioral health safety net approval process. The statutory authority to
promulgate these rules is set forth in Sections 27-50-107(3)(c), 27-50-301(5), 27-50-304(7), and
27-50-502(1) through (5), C.R.S. Chapter 12 additionally establishes standards for additional
competencies related to serving priority populations where behavioral health safety net providers
may be eligible for enhanced rates. The statutory authority to promulgate these rules is set forth
in Section 27-50-502(6), C.R.S.
B. To be eligible for enhanced service delivery payments set forth in Section 27-50-502(2),(3),
C.R.S., a behavioral health safety net provider must be approved by the BHA. This approval does
not guarantee enhanced service delivery payments.
C. Approved behavioral health safety net providers shall be subject to the following rule compliance
timeline:
1. U pon these rules going into effect, the BHA shall take immediate action pursuant to
Section 27-50-505, C.R.S. on rule violations that impact the health, safety, and welfare of
individuals receiving services provided by an approved safety net provider.
2. All approved safety net providers shall be in full compliance of these rules by July 1,
2024.
D. Provider participation in the behavioral health safety net system is voluntary. The rules in this
Chapter must be followed, as applicable, by all entities and persons that are seeking to be or are
approved behavioral health safety net providers to be eligible for public funding as part of the
state of Colorado’s Behavioral Health Safety Net System created pursuant to Section 27-50-301
through -304, C.R.S.
12.2 Approval
A. Approval by the BHA as a behavioral health safety net provider shall be predicated upon the
following:
1. Evidence of current licensure in good standing by the BHA, Department of Public Health
and Environment, Department of Regulatory Agencies, and/or other state agency where
applicable, unless otherwise exempt from licensing by state or federal rule or statute.
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a. Behavioral health providers, including but not limited to federally qualified health
centers, that are exempt from licensure but require federal recognition shall
provide documentation to demonstrate current recognition.
2. Compliance with the requirements of this Chapter 12.
a. Part 12.4 of this Chapter shall apply only to essential behavioral health safety net
providers.
b. Part 12.5 of this Chapter shall apply only to comprehensive community
behavioral health providers.
12.3 Safety Net Standards
12.3.1 General Requirements
A. The behavioral health safety net provider shall ensure all operations, locations, and services,
including contracted services and/or personnel, comply with applicable federal and state laws,
regulations, and standards.
B. The behavioral health safety net provider shall provide services in conformity with endorsement-
specific requirements as found in Chapters 3 through 10 of these rules, for all services delivered
by the provider as part of the behavioral health safety net provider’s approval. This must include:
1. Appropriate personnel, including but not limited to authorized practitioners, licensees,
peer support professionals, and others, with qualifications, responsibilities and
experience that correspond to the size and capacity of the provider.
C. When determining personnel needs, the behavioral health safety net provider must consider how
they will comply with the no refusal requirements set forth in part 12.4.3.D for essential behavioral
health safety net providers and part 12.5.3.D. For comprehensive community behavioral health
providers.
D. T he behavioral health safety net provider shall provide services in alignment with the following
competencies of the behavioral health safety net system:
1. Proactively engaging priority populations, with adequate care coordination throughout the
care continuum;
2. Incorporating and demonstrating trauma-informed care practices throughout the care
experience;
3. Promoting person-centered care and cultural and linguistic competence;
4. Utilizing evidence-based and evidence-informed programming to promote quality
services; and
5. Demonstrating competency in de-escalation techniques.
12.3.2 Policies and Procedures
A. The behavioral health safety net provider’s policies and procedures must demonstrate how the
agency will provide care in alignment with the required competencies of behavioral health safety
net providers set forth in part 12.3.1 of this Chapter.
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B. The behavioral health safety net provider shall have written policies and procedures that address:
1. The rights of individuals seeking or receiving care
a. The policy must ensure that each individual or, when applicable, the individual’s
designated representative, has the right to:
(1) Participate in all decisions involving the individual’s care or treatment;
(2) Be informed about whether the agency is participating in teaching
programs, and to provide informed consent prior to being included in any
clinical trials relating to the individual’s care;
(3) Refuse any drug, test, procedure, service or treatment and to be
informed of risks and benefits of this action;
(4) Receive care and treatment, in compliance with state statute, that is free
from discrimination on the basis of physical or mental disability, race,
ethnicity, socio-economic status, religion, gender expression, gender
identity, sexuality, culture, and/or languages spoken; recognizes an
individual's dignity, cultural values and religious beliefs; as well as
provides for personal privacy to the extent possible during the course of
treatment;
(5) Be informed of, at a minimum, the first names and credentials of the
personnel that are providing services to the individual. Full names and
qualifications of the service providers must be provided upon request to
the individual or the individual’s designated representative or when
required by DORA;
(6) G ive informed consent for all treatment and services. Personnel must
obtain informed consent for treatment they provide to the individual;
(7) Register grievances with the agency and the BHA and be informed of the
procedures for registering these grievances including contact
information;
(8) Be free of abuse and neglect;
(9) Be free from the improper application of restraints or seclusion;
(10) Expect that the agency in which the individual is admitted can meet the
identified and reasonably anticipated care, treatment, and service needs
of the individual;
(11) Receive care from the agency in accordance with the individual’s needs;
(12) Have the confidentiality of their individual records maintained as required
by applicable federal and state law;
(13) Receive care in a safe setting;
(14) Be notified if referrals to other providers are to entities in which the
agency has a direct or indirect financial benefit, including a benefit that
has financial value, but is not a direct monetary payment;
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(15) Formulate medical and psychiatric advance directives and have the
agency comply with such directives in compliance with applicable state
statute.
2. When admitting, discharging, triaging, and denying services to individuals:
a. Essential behavioral health safety net providers must ensure their policies and
procedures align with the requirements of parts 12.4.2 and 12.4.3 of this Chapter
b. Comprehensive community behavioral health providers must ensure their
policies and procedures align with the requirements of parts 12.5.2 and 12.5.3 of
this Chapter
3. How an agency will respond in a crisis to promote the safety of individuals, personnel and
community members, including when an individual demonstrates physical aggression or
agitation.
4. How telehealth services are deployed, how individual preference for in-person services
are addressed, and when based on diagnosis or other need, telehealth services are not
appropriate.
5 Safety of personnel and individuals when delivering services in-home and in-community.
6. Personnel training requirements, which must include training in:
a. De-escalation techniques;
b. Culturally and linguistically appropriate service delivery in accordance with the
requirements of part 12.3.4 of this Chapter;
c. Trauma-informed care practices and service delivery.
7. P ersonnel background checks
a. The agency must obtain, prior to hire or contract of new personnel, unless the
personnel is a volunteer whose service does not involve unsupervised direct
contact with individuals receiving services, a name-based criminal history record
check for each prospective personnel or volunteer.
(1) If the prospective personnel has lived in Colorado for more than three (3)
years at the time of application, the agency shall obtain a name-based
criminal history report conducted by the Colorado Bureau of Investigation
(CBI).
(2) If the prospective personnel has lived in Colorado for three (3) years or
less at the time of application, the agency shall obtain a name-based
criminal history report for each state in which the prospective personnel
has lived during the past three (3) years, conducted by the respective
states’ bureaus of investigation or equivalent state-level law enforcement
agency, or a national criminal history report conducted by the federal
bureau of investigation.
b. The agency shall bear the cost of obtaining a name-based criminal history record
check for each prospective personnel.
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c. If an agency contracts with a staffing agency for the provision of services, it shall
require that the staffing agency meet the requirements of this part 12.3.2.B.7.
d. When determining whether a prospective personnel is eligible for hire if the
criminal history record check reveals the person has a conviction or plea of guilty,
active deferred judgment, or nolo contendere, the agency shall have a policy that
includes:
(1) Written criteria and procedures for evaluating which convictions or
complaints make prospective personnel unacceptable for hire, or for
existing personnel, unacceptable for retention, including:
(a) Factors to be considered when determining whether a
prospective personnel is eligible for hire or contract when their
name-based criminal history record check reveals a conviction or
plea of guilty, active deferred judgment, or nolo contendere,
including, but not limited to:
1. The nature and seriousness of the offense;
2. The nature of the position and how the offense relates to
or may impact the duties of the position; experience in
the criminal justice system is not necessarily a
disqualifier and, in certain circumstances, an agency
may determine that some lived experiences would
benefit a particular position;
3. The length of time since the conviction or plea;
4. W hether such conviction is isolated or part of a pattern;
and,
5. Whether there are mitigating or aggravating
circumstances involved.
8. Clinical supervision
a. The agency must ensure that all personnel providing behavioral health services,
with the exception of peer support professionals, receive clinical supervision, as
defined in this part 12.3.2.B.8.
b. The agency will develop policies and procedures for supervision that address the
following:
(1) Supervisee’s mandatory disclosure statement that clearly states they are
under supervision and by whom;
(2) Requirements for regular evaluation of the supervisee’s progress with a
rubric that is tied to the responsibilities assigned;
(3) Documentation and frequency of supervisor reviews and feedback
provided;
(4) Maximum number of supervisees a supervisor oversees; and
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(5) How supervision/consultation is covered by personnel with comparable
credentials when the usual supervisor is not available.
c. Clinical supervisors must at minimum:
(1) Meet the standard qualifications for clinical supervision as defined by
their professional practice board.
(2) Deliver clinical supervision within the supervisor’s professional practice
license and ethical standards for:
(a) Those that are licensed or seeking professional licensure; or
(b) When supervising personnel that are not seeking or not eligible
for professional licensure, such as group living workers, the
supervisor must follow standards in the Colorado Mental Health
Practice Act, as defined in Article 245 of Title 12, C.R.S.
(3) Dedicate time between the supervisor and supervisee to instruct, model,
and encourage self-reflection by the personnel receiving supervision
regarding acquisition of clinical and administrative skills. Clinical
supervisor will determine skills through observation, evaluation,
feedback, and mutual problem-solving.
(4) Address ethics and ethical dilemmas as aligned with the appropriate
professional practice board.
(5) Provide professional direction based on experience, expertise, and/or for
ethical or safety concerns.
(6) Ensure that safety and crisis management plans are followed and that
clinical supervisors are available to personnel for assistance in crisis
situations and processing of the crisis event afterwards.
(7) D ocument date, duration, and the content of supervision session for their
supervisee(s), which may include a professional development plan. All
documents pertaining to clinical supervision must be provided to the
supervisee and the BHA upon request.
d. Personnel-specific clinical supervision requirements
(1) Licensees and authorized practitioners will be provided with clinical
supervision and/or consultation at minimum upon request of the licensee
or authorized practitioner or at times of individual emergency.
(2) Candidates will be provided with clinical supervision at a rate that will
meet their licensing requirements for the license they are pursuing or at a
minimum of one (1) hour every two (2) weeks, whichever provides a
higher level of clinical supervision.
(3) All clinical documentation completed by a counselor-in-training and/or
intern still in pursuit of their clinical degree must be reviewed and co-
signed by a clinical supervisor able to supervise pursuant to their scope
of practice.
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(4) Personnel not seeking or not eligible for licensure, but that are providing
clinical services, will be provided clinical supervision at a frequency that
ensures treatment to individuals is appropriate, safe, and in line with
assessment treatment needs and the individual’s treatment goals.
9. Critical incident reporting
a. A critical incident includes but is not limited to the following:
(1) Breach of confidentiality: any unauthorized disclosure of protected health
information as described in HIPAA, as incorporated by reference in part
1.2 of these rules; 42 C.F.R. Part 2, as incorporated by reference in part
1.2 of these rules, and/or Section 27-65-101 through -131, C.R.S.
(2) Death: including the death of an individual inside of or outside of the
agency’s physical location while an individual is receiving services or
where an individual has attempted to receive services from the agency
within the past thirty (30) calendar days.
(3) Elopement: absconding from a mental health hold, certification,
emergency/involuntary commitment, or a secure facility where an
individual is being held as a result of a court order. This includes any
unauthorized absence of a child, when a child cannot be accounted for
or when there is reasonable suspicion to believe the child has
absconded.
(4) An y instance when an individual cannot be located following a search of
the agency, the agency grounds, and the area surrounding the agency,
and:
(a) There are circumstances that place the individual’s health,
safety, or welfare at risk; or
(b) The individual has been missing for eight (8) hours.
(5) Medication diversion: any medication diversion as defined in part 1.2 of
these rules. If the diverted drugs are injectable, the agency shall also
report the full name and date of birth of any individual who diverted the
injectable drugs, if known.
(6) Medication error: medication error that resulted or could have resulted in
harm to the individual.
(7) Medical emergency: any suicide attempt/self-injury, other form of serious
injury, health emergency, overdose, or serious illness which occurred on
agency premises or in the presence of agency personnel.
(8) Any instance involving physical, sexual, or verbal abuse of an individual,
as described in Sections 18-3-202, 18-3-203, 18-3-204, 18-3-206, 18-3-
402, 18-3-404, 18-3-405, 18-3-405.3, 18-3-405.5, and 18-9-111
(exempting, however, the phrase “intended to harass”), C.R.S. by
another individual, personnel, or a visitor to the agency.
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(9) Any instance that results in any of the following serious injuries to an
individual:
(a) Brain or spinal cord injuries;
(b) Life-threatening complications of anesthesia or life-threatening
transfusion errors or reactions; or,
(c) Second- or third-degree burns involving twenty (20%) percent of
more of the body surface area of an adult or more fifteen (15%)
percent or more of the body surface area of a child.
(10) Any instance involving caretaker neglect of an individual, as defined in
Section 26-3.1-101(2.3), C.R.S.
(11) Any instance involving misappropriation of an individual’s property,
meaning patterns of loss or single incidences of deliberately misplacing,
exploiting, or wrongfully using, either temporarily or permanently, an
individual’s belongings or money without the individual’s consent.
(12) Any occurrence involving the malfunction or intentional or accidental
misuse of care equipment that occurs during treatment or diagnosis of an
individual and that significantly or adversely affects or, if not averted,
would have significantly adversely affected an individual.
b. Critical incidents must be reported to the BHA within one (1) business day after
the incident. Critical incidents must also be reported to the BHA within one (1)
business day of when the agency determines that a reportable incident has
occurred and the BHA requests such reporting.
c. T he BHA may conduct scheduled or unscheduled site reviews for specific
monitoring purposes and investigation of critical incidents reports in accordance
with:
(1) BHA policies and procedures,
(2) Regulations that protect the confidentiality and individual rights in
accordance with Section 27-65-101 through -131, C.R.S.; HIPAA; as
incorporated by reference in part 1.2 of these rules; and, 42 C.F.R. Part
2, as incorporated by reference in part 1.2 of these rules,
(3) Controlled substance licensing; Section 27-81-113; Section 27-80-212,
C.R.S., and Section 18-18-503, C.R.S.
d. The BHA shall have access to relevant documentation required to determine
compliance with these rules.
e. The agency must:
(1) Establish written policies and procedures for reporting and reviewing all
critical incidents occurring at the agency;
(2) Submit critical incident reports to the BHA using state prescribed forms
available on the BHA website. This is not in lieu of other reporting
mandated by state statute or federal guidelines;
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(3) Make available a report with the investigation findings for review by the
BHA, upon request; and,
(4) Maintain critical incident reports for a minimum of three (3) years
following the incident.
f. Nothing in this part shall be construed to limit or modify any statutory or common
law right, privilege, confidentiality, or immunity.
12.3.3 Care Coordination
A. Behavioral health safety net providers shall work with the individual to identify the individual’s
service and support needs and preferences and shall carry out care coordination as defined in
part 1.1 of these rules to facilitate access to those services and supports.
B. Care coordination must, to the extent possible, be carried out in accordance with the individual's
expressed preferences and with involvement of the individual's family, parent, legal
representative, advocate, caregiver, and other supports identified by the individual.
C. Care coordination activities may include, as appropriate for the needs and preferences of the
individual:
1. Development of person and family-centered service plans that:
a. Promote integrated whole person care across the spectrum of health services.
b. Address each individual’s priorities, goals, and the barriers they face.
c. Address access to acute and chronic physical and behavioral health care, peer
support networks, social services including income supports, health insurance,
housing, educational systems, and employment opportunities as necessary to
facilitate wellness and recovery of the whole person in alignment with an
individual’s assessed needs and expressed goals.
2. F acilitating access to needed resources and services to carry out the service plan. This
may include, but is not limited to:
a. Conducting application assistance, referrals, and warm hand-offs to access
resources and care;
b. Providing accessible, culturally and linguistically appropriate resources and
information, including access to resource directories such as OWNPATH;
c. Coordinating with partners to provide specialized services, risk stratification,
discharge planning, transition planning, prior authorization, insurance appeal,
and medication reconciliation;
d. Identifying the information, social service, and health care systems that an
individual will need to access in order to navigate systems, manage their care,
and achieve whole person health;
e Equipping the individual with information through means that are accessible and
appropriate for the individual based on their needs and preferences and as
required by federal and state statute;
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f. Collaborating with other systems and entities providing care coordination
services to the individual;
(1) If care coordination activities necessary to meet the individual’s needs
and fulfill the service plan are being carried out by an alternate entity, the
behavioral health safety net provider shall document the responsibilities
of each entity within the record and update the record in response to
changes in the individual's needs and/or preferences, and the alternate
entity’s involvement.
g. Providing outreach, planning, problem-solving, advocacy, education, and self-
management support;
3. Deliberate and coordinated planning to prevent disengagement from services, identifying
and mitigating risks for individuals, including identifying and implementing prevention
strategies to proactively mitigate risk, and connecting individuals to supports to promote
ongoing maintenance and prevention.
a. Risks may include, but are not limited to, risk of grave disability, risk of danger to
self or others, risk of institutionalization, risk of incarceration, risk of overdose,
risk of housing and income instability including loss of benefits, and risk for out of
home placement for a youth.
b. Risk assessment must involve the individual and their service providers, be done
on an ongoing basis, and be addressed within the service plan.
c. Wh en a risk for disengagement is identified, the service plan must address
prevention of and response to an individual disengaging from services including
missing appointments.
4. Monitoring an individual’s progress, engagement, and satisfaction with treatment and
recovery in alignment with outcomes identified by the individual.
12.3.4 Culturally and Linguistically Appropriate Services
A. To ensure the provision of culturally and linguistically appropriate services, the behavioral health
safety net provider shall:
1. Ensure all methods and procedures used to assess and evaluate an individual are able to
be provided in the preferred language and/or communication method of frequently
encountered limited English proficiency (LEP) groups.
2. Develop and maintain general knowledge about the racial, ethnic, and cultural groups in
the service area, including each group's diverse cultural health beliefs and practices,
preferred languages, health literacy, and other needs in order to inform the provision of
culturally and linguistically appropriate services and improve access and quality of
services for these groups.
3. Collect and maintain updated information to help understand the composition of the
communities in the service area, including the primary spoken languages in order to
inform the provision of culturally and linguistically appropriate services and improve
access for these communities.
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4. Be able to provide oral and written notice to individuals with limited English proficiency in
the preferred language and/or communication method of frequently encountered limited
English proficiency (LEP) groups of the agency to inform them of their right to receive
language assistance services and how to do so. Language assistance services must be
free of charge to the individual, be accurate and timely, and protect the privacy and
independence of the individual receiving services.
5. Provide documents or messages vital to an individual’s ability to access services (for
example, registration forms, sliding scale fee discount schedule, after-hours coverage,
signage) in languages common in the community served, taking account of literacy and
developmental levels and the need for alternative formats. Such materials shall be
provided at intake.
6. Provide interpretation and translation services in a manner that meets the needs of the
individual.
a. In order to ensure complete, accurate, impartial, and confidential communication,
family, friends, or other individuals shall not be required, suggested, or used as
interpreters. An individual shall not be required to provide their own interpreter.
Behavioral health safety net providers shall not rely on an adult accompanying an
individual with limited English proficiency (LEP) to interpret or choose to facilitate
communication except:
(1) In an em ergency involving an imminent threat to the safety or welfare of
an individual or the public, where there is no qualified interpreter for the
individual with limited English proficiency immediately available.
(2) Where the individual with limited English proficiency specifically requests
that the accompanying adult interpret or facilitate communication, the
accompanying adult agrees to provide such assistance, and reliance on
that adult for such assistance is appropriate under the circumstances.
(a) Personnel should suggest that a trained interpreter be present in
these instances to ensure accurate interpretation and should
document the offer and declination in the individual’s record.
(3) Minor children must not be used as interpreters, nor be allowed to
interpret for their parents when the minor is the individual receiving
services, unless there is an emergency involving an imminent threat to
the safety or welfare of an individual or the public when no other
interpreter is available.
b. To the extent interpreters are used, and an interpreter is not provided by the
individual, the interpreters must be trained to function in a medical and/or
behavioral health setting, adhere to accepted interpreter ethics principles,
including individual confidentiality and be able to interpret effectively, accurately,
and impartially.
7. P rovide auxiliary aids and services needed for effective communication, that are
Americans with Disabilities Act (ADA) compliant and responsive to the needs of
individuals with disabilities (e.g., sign language interpreters, videophones).
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8. Implement strategies to recruit, support, and promote personnel that is representative of
the demographic characteristics, including primary spoken languages of the communities
in the agency’s service area.
9. Behavioral health safety net providers are responsible for training personnel on
interpretation and translation services available to facilitate services. This includes
training personnel on the procedures to access and use such services.
12.4 Essential Behavioral Health Safety Net Providers
12.4.1 Requirements
A. Essential behavioral health safety net providers shall provide at least one of the following
services.
1. Emergency and/or crisis behavioral health services;
2. Behavioral health outpatient services;
3. Behavioral health high-intensity outpatient services;
4. Behavioral health residential services;
5. Withdrawal management services;
6. Behavioral health inpatient services;
7. Integrated care services;
8. Hospital alternatives; and/or
9. Additional services that the BHA determines are necessary in a region or throughout the
state.
B. For services which a BHA endorsement exists in Chapters 3 through 10 of these rules, services
shall be provided in conformity with the rules of the endorsement.
C. When providing services to children and families, essential behavioral health safety net providers
shall provide services to children and families in conformity with the standards set forth in Chapter
8 of these rules.
D. T he essential behavioral health safety net provider shall provide clinical services during times that
ensure accessibility and meet the needs of the individual population to be served, including
evening and/or weekend hours.
1. These extended hours may include services provided via telehealth, if appropriate.
E. Essential behavioral health safety net providers offering outpatient behavioral health services
must have in-person service offerings in addition to any telehealth services the agency may elect
to provide.
12.4.2 Priority Populations
A. Essential behavioral health safety net providers must serve all priority populations as defined in
Section 27-50-101(17), C.R.S., unless:
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1. The agency’s approval limits the agency’s scope and responsibility to a specific subset of
priority population(s); and
2. The provisions in the agency’s contract with the BHA or its designee limit the agency’s
scope and responsibility to a specific subset of priority populations.
B. When an essential behavioral health safety net provider is approved to serve a subset of priority
populations, the agency shall ensure that corresponding admission and exclusion criteria are:
1. Outlined in the agency’s policy developed pursuant to part 12.3.2.B.2 of this Chapter;
2. Approved by the BHA or its designee;
3. Publicly available on the provider's website; and
4. Applied uniformly.
C. The essential behavioral health safety net provider shall have personnel with scope of practice
and training to meet the needs of priority populations within the scope of the services and priority
populations that the essential behavioral health safety net provider is approved to provide.
12.4.3 Screening, Triage, and Care Coordination in Alignment with No Refusal Requirements
A. When an individual attempts to initiate treatment with an essential behavioral health safety net
provider, the essential behavioral health safety net provider shall complete an initial screening
and triage process to identify the needs of the individual, and to determine the urgency and
appropriateness of care with the essential behavioral health safety net provider.
B. S creenings must collect at least the following information from an individual seeking services:
1. Identifying information;
2. Primary complaint/reason for seeking services;
3. Current behavioral health symptoms, including severity, duration, mental status, and
changes or impairments in functioning due to symptoms;
4. Medical concerns/chronic health issues, including pregnancy and postpartum status; and,
5. Evaluation of imminent risk, including:
a. Suicide risk;
b. Danger to self or others;
c. Urgent or critical medical conditions, including withdrawal or overdose risk; or
d. Other immediate risks, including threats from another person.
6. Preliminary determination of level of care needed;
7. Health-related social needs and associated risk factors related to social determinants of
health, including but not limited to:
a. Food security;
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b. Housing stability and security;
c. Personal safety;
d. Access to health services including preventative health care;
e. Physical health concerns for which the individual is not receiving adequate
treatment.
8. Whether an individual is part of an identified priority population and which one.
C. The essential behavioral health safety net provider shall use these standard criteria for
determining whether an agency’s clinical scope of practice or treatment capacity are appropriate
to meet the needs of the individual, or if the agency will instead provide care coordination to
support the individual in accessing alternate services. These criteria are:
1. The individual’s presenting problem or behavioral health diagnosis is outside the scope of
practice of the agency and its personnel, including the age range with which the agency
works, or the modalities and interventions in which personnel are trained in.
2. The agency is approved pursuant to part 12.4.2 of this Chapter to serve a subset of
priority populations, and the individual does not fall within the priority population(s).
3. The individual presents with the need for a level of care the agency does not provide.
4. The agency cannot provide services within an appropriate time frame per the individual’s
needs and the agency’s capacity.
D. In ac cordance with Section 27-50-301(4), C.R.S., unless it is determined, pursuant to the criteria
in part 12.4.3.c of this Chapter, that an individual’s needs fall outside the scope and capacity of
the essential behavioral health safety net provider, the essential behavioral health safety net
provider shall not refuse to treat an individual based on the individual's:
1. Insurance coverage, lack of insurance coverage, or ability to pay;
2. Clinical acuity level related to the individual's behavioral health condition or conditions,
including whether the individual has been certified for short-term treatment or long-term
care and treatment pursuant to Article 65 of Title 27, C.R.S.;
3. Readiness to transition out of the Colorado Mental Health Hospital at Pueblo, the
Colorado Mental Health Hospital at Fort Logan, or any other mental health institute or
licensed facility providing inpatient psychiatric services or acute care hospital providing
stabilization because the individual no longer requires inpatient care and treatment;
4. Involvement in the criminal or juvenile justice system;
5. Current involvement in the child welfare system;
6. Co-occurring mental health and substance use disorders, physical disability, or
intellectual or developmental disability, irrespective of primary diagnosis, co-occurring
conditions, or if an individual requires assistance with activities of daily living or
instrumental activities of daily living, as defined in Section 12-270-104(6), C.R.S.;
a. E ssential behavioral health safety net providers shall not deny services to
individuals who exhibit inappropriate sexual behaviors.
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7. Displays of aggressive behavior, or history of aggressive behavior, as a symptom of a
diagnosed mental health disorder or substance use disorder;
8. Clinical presentation or behavioral presentation in any previous interaction with a
provider;
9. Place of residence; or
10. Disability, age, race, creed, color, sex, sexual orientation, gender identity, gender
expression, marital status, national origin, ancestry, or tribal affiliation.
E. If the individual’s needs exceed the treatment capacity or clinical scope of practice needed to
serve the individual, the essential behavioral health safety net provider shall provide a warm
handoff to a provider or entity able to provide care for the individual that is within its scope of
service, which may include the BHA or its designee.
1. Essential behavioral health safety net providers must also provide warm handoffs for
individuals who have health-related social needs that require alternative services outside
the scope of the behavioral health safety net system, such as services for housing, food
insecurity, and transportation. The essential behavioral health safety net provider shall
connect the individual to appropriate resources to initiate those services.
2. When referring an individual to an alternative provider, entity, or service, geographic
location and the individual’s ability to access the service location shall be considered.
F. T he essential behavioral health safety net provider shall track the following information for all
priority population individuals who were referred to alternative services pursuant to this part. This
information must be maintained in a single report that must be made available upon request by
the BHA or its designee. This report shall include:
1. Individual demographics, including to which priority population the individual belongs;
2. Standardized descriptions of the needs of the individual that could not be met and require
the individual to be referred to another provider;
3. The outcome and timeliness of the referral, i.e., the date of the referral and response
from the receiving agency; and
4. Whether the individual was discharged from a higher level of care to a lower level of care
and, if so, what level of care the referring provider was seeking to discharge the individual
from.
G. These processes must apply at the time of initial screening, and any time reassessment indicates
the individual’s needs have changed and fall outside of the scope of the agency.
1. When an essential behavioral health safety net provider initiates a transition in care for an
individual or family under the care of the agency, whether the transition is to an alternate
agency or an alternate level of care within the agency, the essential behavioral health
safety net provider must notify the individual or family via a live conversation and then
ensure that appropriate steps are taken to transition the individual or family.
2. R equirements to not refuse care based on these criteria apply to essential behavioral
health safety net providers as a whole. Refusal does not include transferring an individual
to an alternative level of care within an essential behavioral health safety net provider or
identifying new personnel to support the individual.
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12.4.4 Governance
A. Overall responsibility for the administration of an essential behavioral health safety net provider
shall be vested in a director who is a physician or a member of one of the licensed mental health
professions unless the essential behavioral health safety net provider is only providing recovery
support services. If the director is not a licensed physician or licensed mental health professional,
the essential behavioral health safety net provider shall employ or contract with at least one (1)
authorized practitioner or licensee to advise the director on clinical decisions.
B. Each essential behavioral health safety net provider from which services may be purchased shall:
1. Be under the control and direction of a county or local board of health, a board of
directors or board of trustees of a corporation, a for-profit or not-for-profit organization, a
regional mental health board, tribal organization, or a political subdivision of the state;
2. Enter into a contract developed pursuant to Section 27-50-203, C.R.S. and accept
publicly funded individuals.
12.5 Comprehensive Community Behavioral Health Providers
12.5.1 Requirements
A. Comprehensive community behavioral health providers shall, either directly or through formal
agreement with behavioral health providers in the community or region, ensure the provision of all
of the following services:
1. E mergency and Crisis Behavioral Health Services in conformity with Chapter 6 of these
rules;
2. Mental Health and Substance Use Outpatient Services in conformity with Chapter 4 of
these rules;
3. Behavioral Health High-Intensity Outpatient Services in conformity with Chapter 4 of
these rules;
4. Care Management pursuant to part 12.5.7 of this Chapter;
5. Outreach, Education, and Engagement Services pursuant to part 12.5.8 of this Chapter;
6. Mental Health and Substance Use Recovery Supports in conformity with Chapter 3 of
these rules;
7. Outpatient Competency Restoration pursuant to part 12.5.9 of this Chapter.
8. Screening, assessment, and diagnosis, including risk assessment, crisis planning, and
monitoring to key health indicators, in accordance with endorsement specific
requirements and part 12.5.3 of this Chapter.
B. When providing these services directly, the comprehensive community behavioral health provider
shall provide the services in conformity with endorsement specific requirements for the services,
found in Chapters 3 through 10 of these rules.
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C. When providing these services through formal agreement with another agency, the
comprehensive provider shall ensure that the agency providing the services holds the appropriate
license(s) and accompanying endorsements in good standing for those services, unless the
agency is otherwise exempt from licensure requirements.
D. Comprehensive community behavioral health providers shall provide services to children and
families in conformity with the requirements of Chapter eight (8) of these rules.
E. In addition to the requirements set forth in the endorsement Chapters three (3) through ten (10),
comprehensive community behavioral health providers shall comply with the following
requirements:
1. Outpatient requirements
a. The comprehensive community behavioral health provider’s requirement to
provide outpatient services does not include the requirement to provide minor in
possession (MIP) services.
b. The comprehensive community behavioral health provider shall provide
outpatient clinical services during times that ensure accessibility and meet the
needs of the individual population to be served, including evening and/or
weekend hours.
c. As necessary and appropriate for the needs of individuals, comprehensive
community behavioral health providers shall provide services in the home and
community and shall utilize telehealth methods to deliver care.
d. If an individual presents with an emergency or crisis need, appropriate action is
taken immediately, and subsequent outpatient follow-up is promptly coordinated
and delivered.
e. If an individual currently receiving services from a comprehensive community
behavioral health provider presents with an urgent need, clinical services,
including medication management, are provided within one (1) business day of
the time the request is made.
f. Comprehensive community behavioral health providers must be designated to
provide services to individuals on involuntary outpatient certifications pursuant to
part 11.18 of these rules.
2. Crisis/emergency
a. The comprehensive community behavioral health provider shall provide crisis
management services that are available and accessible twenty-four (24) hours a
day. These services may include:
(1) Walk-in crisis services; or
(2) Mobile crisis services.
12.5.2 Priority Populations
A. The comprehensive community behavioral health provider shall:
1. Serve all priority populations; and
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2. Have personnel with appropriate training and scope of practice to serve all priority
populations.
12.5.3 Screening, Triage, and Care Coordination in Alignment with No Refusal Requirements
A. When an individual attempts to initiate treatment with a comprehensive community behavioral
health provider, the comprehensive community behavioral health provider shall complete an initial
screening and triage process to determine urgency and appropriateness of care with the
comprehensive community behavioral health provider and the service needs of the individual.
B. Screenings must collect at least the following information from an individual seeking services:
1. Identifying information;
2. Primary complaint/reason for seeking services;
3. Current behavioral health symptoms, including severity, duration, mental status, and
changes or impairments in functioning due to symptoms;
4. Medical concerns/chronic health issues, including pregnancy and postpartum status; and,
5. Evaluation of imminent risk, including:
a. Suicide risk;
b. Danger to self or others;
c. Urgent or critical medical conditions, including withdrawal or overdose risk; or
d. Other immediate risks, including threats from another person.
6. Health-related social needs and risk factors related to social determinants of health,
including but not limited to:
a. Food security;
b. H ousing stability and security;
c. Personal safety;
d. Access to health services including preventative health care; or
e. Physical health concerns for which the individual is not receiving adequate
treatment.
C. The comprehensive community behavioral health provider shall use these standard criteria for
determining whether a comprehensive community behavioral health provider clinical scope of
practice or treatment capacity are appropriate to meet the needs of the individual, or if the
comprehensive community behavioral health provider will instead provide care coordination to
support the individual in accessing alternate services in the following circumstances:
1. The individual presents with the need for a level of care the comprehensive community
behavioral health provider does not provide.
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2. The comprehensive community behavioral health provider cannot provide services within
an appropriate time frame per the individual’s needs and the agency’s capacity.
D. In accordance with Section 27-50-301(4), C.R.S., unless it is determined, pursuant to the criteria
in part 12.5.3.C of this Chapter, that an individual’s needs fall outside the scope and capacity of
the comprehensive community behavioral health provider, the comprehensive community
behavioral health provider shall not refuse to treat an individual based on the individual's:
1. Insurance coverage, lack of insurance coverage, or ability to pay;
2. Clinical acuity level related to the individual's behavioral health condition or conditions,
including whether the individual has been certified for short-term treatment or long-term
care and treatment pursuant to Article 65 of Title 27, C.R.S.;
3. Readiness to transition out of the Colorado Mental Health Hospital at Pueblo, the
Colorado Mental Health Hospital at Fort Logan, or any other mental health institute or
licensed facility providing inpatient psychiatric services or acute care hospital providing
stabilization because the individual no longer requires inpatient care and treatment;
4. Involvement in the criminal or juvenile justice system;
5. Current involvement in the child welfare system;
6. Co-oc curring mental health and substance use disorders, physical disability, or
intellectual or developmental disability, irrespective of primary diagnosis, co-occurring
conditions, or if an individual requires assistance with activities of daily living or
instrumental activities of daily living, as defined in Section 12-270-104(6), C.R.S.;
a. Comprehensive community behavioral health providers shall not deny services to
individuals who exhibit inappropriate sexual behaviors.
7. Displays of aggressive behavior, or history of aggressive behavior, as a symptom of a
diagnosed mental health disorder or substance use disorder;
8. Clinical presentation or behavioral presentation in any previous interaction with a
provider;
9. Place of residence; or
10. Disability, age, race, creed, color, sex, sexual orientation, gender identity, gender
expression, marital status, national origin, ancestry, or tribal affiliation.
E. If the individual's needs exceed the treatment capacity or clinical scope of practice of a
comprehensive community behavioral health provider, based on the standard criteria in part
12.5.3.c of this Chapter, the comprehensive community behavioral health provider must ensure
that the individual has access to interim behavioral health services until the individual is
connected to the most appropriate agency for ongoing care. This may include use of providers
within the network of the BHA or its designee, or the regional managed care entity.
F. T he comprehensive community behavioral health provider shall obtain approval from the BHA or
its designee under which the agency is operating, or the regional managed care entity for
Medicaid individuals, prior to referring a priority population individual to alternative behavioral
health treatment services.
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1. Only an individual assessed to be experiencing a behavioral health crisis may be referred
to external emergency or crisis services without prior approval from the BHA or its
designee.
a. If an individual is referred to an external provider for crisis or emergency
behavioral health services, the agency shall work with the receiving provider to
coordinate follow-up care for the individual upon discharge.
G. If a referral of a priority population individual is approved by the BHA or its designee, the
comprehensive behavioral health provider must provide a warm hand off by assisting the client in
identifying a new provider, which may involve using the state’s care coordination and navigation
infrastructure.
H. For individuals who have health-related social needs that require alternative services outside the
scope of the safety net system, such as services for housing, food insecurity, and transportation,
the comprehensive community behavioral health provider will connect the individual to
appropriate resources to initiate those services. Approval by the BHA or its designee is not
required in this instance.
I. The comprehensive community behavioral health provider shall track the following information for
all priority population individuals who were referred to external behavioral health services
pursuant to this part 12.5.3 of this Chapter. This information must be maintained in a single report
that must be made available upon request by the BHA or it’s designee. This report shall include:
1. I ndividual demographics, including to which priority population the individual belongs;
2. Standardized descriptions of the needs of the individual that could not be met and require
the individual to be referred to another provider;
3. The outcome and timeliness of referral, i.e., the date of the referral and response from
the receiving agency; and
4. Whether the individual was discharged from a higher level of care to a lower level of care
and, if so, what level of care the referring provider was seeking to discharge the individual
from.
J. These processes must apply at the time of initial screening, and any time reassessment indicates
the individual’s needs have changed and fall outside of the scope of the agency.
1. When an agency initiates a transition in care for an individual or family under the care of
the agency, whether the transition is to an alternate agency or an alternate level of care
within the agency, the agency must notify the individual or family face to face, on a
telephone call, or two-way video conference and then ensure that appropriate steps are
taken to transition the individual or family.
2. Requirements to not refuse care based on these criteria apply to the comprehensive
community behavioral health provider as a whole. Refusal does not include transferring
an individual to an alternative level of care within the comprehensive community
behavioral health provider or assigning new personnel to support the individual.
12.5.4 A ccess Plan
A. Comprehensive community behavioral health providers shall establish an access plan as part of
their quality management program.
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B. Access plans must be designed to improve treatment access and/or outcomes for one (1) or
more priority populations through an evidenced-based approach.
C. Comprehensive community behavioral health providers shall implement strategies from the
access plan to decrease the disparities in access and outcomes for priority populations.
D. Development, implementation, and evaluation of the access plan must include the collection
and/or analysis of available data related to populations and areas served by the agency to
evaluate outcomes for priority populations. Goals and outcome measures should be identified in
conjunction with individuals, families, and advocates who represent the identified priority
populations. These outcome measures may include but are not limited to:
1. Individual or family-reported measures such as satisfaction, achievement of
goals, ability to thrive, or quality of life;
2. System-reported outcomes such as access and engagement in care, preventable
hospitalizations and/or hospital readmission, rate of follow-up with individuals and
families, level of individual or family engagement, number of substantiated
complaints or appeals, and timeliness of transitions to appropriate levels of care;
or
3. Utilization measures such as number of individuals or families served,
characteristics of individuals who do not engage in services, number of
screenings completed, or number of referrals provided.
12.5.5 Governance
A. Each comprehensive community behavioral health provider shall:
1. Be under the control and direction of a county or local board of health, a board of
directors or board of trustees of a corporation, a for-profit or not-for-profit organization, a
regional mental health board, tribal organization, or a political subdivision of the state;
and
2. Enter into a contract developed pursuant to Section 27-50-203, C.R.S. and accept
publicly funded individuals.
B. Treatment programs of the comprehensive community behavioral health provider must be vested
in a director who is a physician or a member of one of the licensed mental health professions.
The director is not required to provide oversight or direction for recovery services. If the director is
not an authorized practitioner or licensee, the agency shall contract with at least one (1)
authorized practitioner or licensee to advise the director on clinical decisions.
C. The governing board of the comprehensive community behavioral health provider must either:
1. Be composed of at least 51% voting members that have lived experience with accessing
services for mental health and/or substance use disorders, which may include parents of
children with mental health and/or substance use disorders who have supported their
children in accessing services for mental health and/or substance use disorders; or
2. I
nclude at least two (2) voting members that have lived experience with accessing
services for mental health and/or substance use disorders, which may include parents of
children with mental health and/or substance use disorders who have supported their
children in accessing services for mental health and/or substance use disorders.
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a. In addition, the governing body shall demonstrate how it collects, considers, and
implements input and feedback from individuals and families currently receiving
services in governing body decisions.
12.5.6 Fee Schedule for Services Provided
A. The comprehensive community behavioral health provider shall waive charges or charge for
services on a sliding scale based on income and require that the agency not restrict access or
services because of an individual's financial limitations.
B. The comprehensive community behavioral health provider must ensure no individuals are denied
behavioral health care services, including but not limited to crisis management services, because
of an individual’s inability to pay for such service.
1. Any fees or payments required by the comprehensive community behavioral health
providers for such services must be reduced or waived to enable the comprehensive
community behavioral health providers if necessary to fulfill this requirement.
C. The comprehensive community behavioral health provider shall have a published sliding fee
discount schedule(s) that includes all services the comprehensive community behavioral health
provider proposes to offer pursuant to these criteria. Such fee schedule must be included on the
comprehensive community behavioral health provider’s website, posted in the comprehensive
community behavioral health provider’s waiting room, and readily accessible to individuals and
families. The sliding fee discount schedule must be communicated in languages/formats and/or
communication methods of frequently encountered limited English proficiency (LEP) groups of the
comprehensive community behavioral health provider.
D. T he fee schedules, to the extent relevant, conform to federal and state statutory or administrative
requirements that may be applicable to existing agencies; absent applicable state or federal
requirements, the schedule is based on locally prevailing rates or charges and includes
reasonable costs of operation.
E. The comprehensive community behavioral health provider has written policies and procedures
describing eligibility for and implementation of the sliding fee discount schedule. Those policies
are applied equally to all individuals seeking services.
12.5.7 Care Management
A. In addition to the requirements of part 12.3.3, comprehensive community behavioral health
providers shall be equipped to provide outreach-focused high intensity supports to individuals
who may have complex needs, be involved in multiple systems, and/or require additional support
to achieve whole person health.
B. Care management may include, as necessary to address the assessed needs of an individual,
and in alignment with the expressed preferences of the individual:
1. Convening persons involved in the individual’s services, including health care and
community-based service providers, family members and other persons identified by the
individual, to work collaboratively with the individual for the purpose of service planning
and coordination, in order to facilitate wellness, self-management, and recovery of the
whole person.
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a. This must occur when the individual is assessed to be at rising risk of adverse
outcomes, or when the individual experiences a significant change in status,
which may include a behavioral health crisis, change in health or housing status,
etc.
b. This may include team meetings or other structured discussions.
2. Facilitating access to necessary services and supports identified within the individual’s
service plan created pursuant to part 12.3.3 of this Chapter through supports including
but not limited to:
a. Application assistance;
b. Community-based outreach to the individual;
c. Self-management support including educating the individual about their
behavioral health conditions and daily living skills including but not limited to
medication use, personal hygiene, transportation use, shopping, and budgeting;
d. Accompanying the individual within the community or other setting to access
services which the individual may not be able to access independently.
3. Supporting an individual to develop psychiatric advance directives, with the support of
appropriate medical and behavioral health professionals, so the individual's preferences
for behavioral health treatment and recovery supports are known in the event of a
behavioral health crisis.
4. Providing support and outreach during care transitions.
a. T he agency shall have policies and procedures in place supporting discharge
planning and transitions between levels of care, including individuals who have
presented to or have been treated at an emergency department (ED) or hospital
for behavioral health needs.
b. The comprehensive community behavioral health provider shall be proactive in
identifying impending care transitions and shall implement these procedures any
time that the comprehensive community behavioral health provider is made
aware that a care transition is occurring.
c. Policies and procedures must address how the comprehensive community
behavioral health provider will provide services to individuals and families to
support successful care transitions, ensure continuity of services, and minimize
the time between discharge and follow-up. These services may include:
(1) Peer support;
(2) Medication management including completing medication reconciliation
and educating individuals, families or persons the individual identifies as
their caretaker, about changes to the individual’s medications or service
plan;
(3) Individual education to support self-management, including education
regarding warning signs for increasing support needs; and
(4) Outreach to promote engagement in follow-up care.
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d. Whenever possible, the comprehensive community behavioral health provider
shall work with the discharging facility ahead of discharge to facilitate a seamless
transition, in accordance with care coordination requirements in 12.3.3 in this
Chapter.
e. The comprehensive community behavioral health provider shall make and
document reasonable attempts to contact individuals who are discharged from a
facility within 24 hours of discharge. This may include community-based outreach
as applicable to the needs of the individual.
f. Policies and procedures must address transfer of medical records for services
received as permitted by HIPAA, as incorporated by reference in part 1.2 of
these rules; 42 C.F.R. Part 2, as incorporated by reference in part 1.2 of these
rules; and Section 27-65-101 through -131, C.R.S.
C. Documentation
1. Care management provided to an individual pursuant to this part 12.5.7 must be
documented in the individual’s record.
2. The service plan must identify person-centered goals related to mitigating risks and
managing assessed needs. The service plan must identify relevant outcome measures
and timeframes for assessing progress towards goals.
a. The comprehensive community behavioral health provider must document goal
progress within the individual’s record.
D. Personnel and training
1. C omprehensive community behavioral health providers shall have written policies and
procedures outlining the initial and ongoing training for personnel delivering the services
outlined in this part 12.5.7.
a. Training must include training specific to the particular needs of the populations
served by the personnel, including the provision of person-centered, trauma-
informed, harm reduction-focused, physically and programmatically accessible,
and culturally and linguistically appropriate services.
b. The training requirements of personnel may vary based on the populations
served by that personnel.
c. The written policies and procedures must identify the frequency of ongoing
training.
2. Comprehensive community behavioral health providers shall clearly document trainings
in the personnel file and ensure that personnel provide services only to populations for
which they are properly trained.
3. Personnel providing care coordination must have clearly defined scopes of work that do
not exceed their level of training and scope of practice.
12.5.8 Outreach, Education, and Engagement Services
A. General service provisions
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1. Comprehensive community behavioral health providers must complete an assessment of
the community behavioral health treatment needs of the population they serve.
2. If the agency is completing, or has completed, a community behavioral health
assessment for another government entity or project, or through a third-party, those
assessments may be used for the purpose of this part 12.5.8.A.1.
3. Assessments of community behavioral health treatment needs of applicable service and
populations in need by the BHA or a designee of the BHA may be used for the purpose of
this part 12.5.8.A.1.
a. If using previously completed assessment(s) for the purpose of this part
12.5.8.A.1, community behavioral health needs assessment must not be older
than three (3) years.
B. The community behavioral health treatment needs assessment must include, but is not limited to,
the following:
1. Feedback from community stakeholders that address social determinants of health;
2. Define the community the agency serves by gathering information including, but not
limited to, demographics of the community, data on access to care, client grievances and
complaints, social determinants of health, and priority population data; and
3. Assess unmet needs in behavioral health treatment levels of care in the community.
C. C omprehensive community behavioral health providers must re-assess at least once every three
(3) years to adapt to the changing needs of the community they serve.
D. Comprehensive community behavioral health providers must develop a strategic plan to provide
outreach, education, and engagement services. The strategic plan shall include the following:
1. Identified priority population(s) and/or treatment needs,
2. Plans for outreach, education, and engagement services in the community to meet the
priority population demographic. Plans must include:
a. How outreach, education, and engagement services will support efforts toward
screening, early intervention, and treatment.
b. Off-site events and intentional engagement with priority populations, that may
involve but is not limited to:
(1) Broad community involvement;
(2) Community partners that address social determinants of health in serving
priority populations in assessed area;
(3) Local law enforcement;
(4) Local public health departments; and.
(5) Cultural centers/organizations.
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c. How planned outreach, education, and engagement services can improve
behavioral health outcomes.
d. How data will be gathered and analyzed to measure outreach, education, and
engagement service outcomes as permitted by HIPAA, as incorporated by
reference in part 1.2 of these rules; 42 C.F.R. Part 2, as incorporated by
reference in part 1.2 of these rules; and Section 27-65-101 through -131, C.R.S.
E. Comprehensive community behavioral health providers must engage in outreach, education, and
engagement services according to the strategic plan developed pursuant to part 12.5.8.D of this
section.
F. Comprehensive community behavioral health providers must gather, analyze, and interpret data
received from efforts to measure outreach, education, and engagement service efforts into an
outcome report as permitted by HIPAA, 42 C.F.R. Part 2; and Section 27-65-101, et. Seq.
G. At the time of license renewal, or at any other additional time requested by the BHA,
comprehensive community behavioral health providers must submit the outcomes report and an
updated strategic plan for the following licensure year including a summary of outreach,
education, and engagement efforts of the previous year and developed goals created from those
efforts.
12.5.9 Outpatient Competency Restoration Services
A. A pplication process
1. Comprehensive community behavioral health providers must complete the application
process with outpatient competency restoration services program within the Office of Civil
and Forensic Mental Health (OCFMH) and appear on the OCFMH approved outpatient
competency restoration list prior to BHA approval.
B. Qualification and training
1. Comprehensive community behavioral health providers must ensure that all personnel
providing restoration services meet all qualifications as an approved provider of
outpatient competency restoration services within OCFMH.
2. Comprehensive community behavioral health providers must meet all training
requirements set forth in any contracts between them and OCFMH to provide outpatient
competency restoration services and must ensure all personnel providing restoration
services attend any additional trainings as required by OCFMH, via contract, and the
BHA.
C. Standards for conducting services
1. Comprehensive community behavioral health providers must provide competency
restoration services in an outpatient setting to adult and juvenile individuals that are
involved with the criminal justice system and deemed by the court to be incompetent to
proceed.
2. An agency must provide care coordination and collaborate with community and state
partners when referrals are needed to assist in removing barriers to successful
restoration to competency.
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3. An agency must provide written notice within a minimum of thirty (30) calendar days in
advance to individuals, OCFMH, and the BHA of intention to no longer provide outpatient
competency restoration services. Responsibility for continuity of care must remain with
the agency currently serving the individual until the transfer is complete.
4. If an agency provider is removed from the approved provider list held by the outpatient
competency restoration services program within OCFMH, the BHA may take action to
suspend and/or revoke the safety net approval pursuant to part 12.7 of this Chapter.
12.6 Procedures for Approval and BHA Oversight
12.6.1 Initial Approval
A. Applicants seeking approval as a behavioral health safety net provider will be approved in
accordance with the requirements set forth in this section.
B. The applicant shall initially notify the BHA of their intent to seek approval by submitting a letter of
intent. The letter of intent must indicate the provider’s intent to seek approval as an essential
behavioral health safety net provider and/or comprehensive community behavioral health provider
as well as the services the provider intends to provide.
C. The applicant shall provide the BHA with a complete application including all information and
attachments specified in the application form available to access on the BHA’s website and any
additional information requested by the BHA.
1. An a pplication may be considered abandoned if the applicant fails to complete the
application within twelve (12) months and fails to respond to the BHA. The BHA may
administratively close the application process.
2. After an administrative closure, the applicant may file a new application.
D. With the submission of an application for approval as a behavioral health safety net provider, or
within ten (10) days after a change in ownership or management of a behavioral health safety net
provider, each owner and manager shall submit a complete set of the owner's and manager's
fingerprints to the Colorado Bureau of Investigation (CBI) for the purpose of conducting a
fingerprint-based criminal history record check. The CBI shall forward the fingerprints to the
Federal Bureau of Investigation (FBI) for the purpose of conducting fingerprint-based criminal
history record checks. Each owner and each manager shall pay the CBI the costs associated with
the fingerprint-based criminal history record check. Upon completion of the criminal history record
check, the CBI shall forward the results to the BHA. The BHA 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.
1. An e ntity that holds a current license to operate from the BHA or CDPHE, and/or is
currently recognized as a federally qualified health center are exempt from this
requirement.
E. The applicant shall provide the following information:
1. Evidence of current licensure in good standing by the Department of Public Health and
Environment, Department of Regulatory Agencies, Department of Human Services, or
other state agency where applicable, unless otherwise exempt from licensing per
applicable state or federal rule or statute.
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a. For applicants, including but not limited to federally qualified health centers, that
are exempt from licensure but require federal recognition, the applicant shall
provide documentation to demonstrate current recognition.
b. Applicants with an existing license from the BHA shall indicate their licensure
status within the application. Evidence of licensure by the BHA does not need to
be provided by the applicant for approval.
2. The legal name of the applicant and all other names used by it to provide services. The
applicant has a continuing duty to submit notification to the BHA for all name changes at
least thirty (30) calendar days prior to the effective date of the change.
3. Contact information for the applicant must include a mailing address, telephone number,
and e-mail address. If applicable, the applicant’s website and facsimile number are to be
provided.
4. The identity, address, and telephone number of all persons and business entities with a
controlling interest in the applicant, including but not limited to:
a. A non-profit corporation shall list the governing body and officers.
b. A for-profit corporation shall list the names of the officers and stockholders who
directly or indirectly own or control five (5) percent or more of the shares of the
corporation.
c. A s ole proprietor shall include proof of lawful presence in the United States.
d. A partnership shall list the names of all partners.
e. The chief executive officer of the facility or agency.
f. If the addresses and telephone numbers provided above are the same as the
contact information for the applicant 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.
5. Proof of professional liability insurance. Behavioral health safety net providers must
maintain such coverage for the duration of the approval term and must notify the BHA of
any change in the amount, type, or provider of professional liability insurance coverage
during the license term.
6. 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.
7. The address(es) of the physical location where services are delivered, as well as, if
different, where records are stored for BHA review.
8. A copy of any management agreement pertaining to operation of the entity that sets forth
the financial and administrative responsibilities of each party.
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9. If an applicant leases one (1) or more building(s) to operate under the approval, a copy of
the lease or leases must 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.
10. A statement, on the applicant’s letterhead, if available, signed and dated, submitted with
the application stating whether any of the actions listed in this part 12.6.1.E.10 of these
rules 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 approval.
The BHA may, based upon information received in the statement, request additional
information from the applicant beyond the ten-year (10) time frame.
a. For initial approval as a behavioral health safety net provider, whether one (1) or
more individuals or entities identified in the response to part 12.6.1.E.4 has a
controlling or ownership interest in the business entity and has been the subject
or party to any of the following:
(1) A civil judgment or criminal conviction resulting from conduct or an
offense in the operation, management, or ownership of an 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.
(2) A d isciplinary action imposed by a governmental entity in another state
that registers or licenses agencies including but not limited to: a sanction,
probation, civil penalty, or a denial, suspension, revocation, or
modification of a license or registration.
(3) Limitation, denial, revocation, or suspension by any federal, state, or
local authorities of any health care related license.
(4) The refusal to grant or renew a license for operation of an agency, or
contract for participation or certification for Medicaid, Medicare, or other
public health or social services payment program.
b. For a change of ownership of an agency, whether any of the new owners have
been the subject of, or a party to, one (1) of more of the following events:
(1) 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 an agency or other entity related to substandard care or
health care fraud.
(2) Limitation, denial, revocation, or suspension of a state license or federal
certification by another jurisdiction.
11. Any statement regarding the information requested in part 12.6.1.E.10 of this Chapter
must include the following, as applicable:
a. If the event is an action by a governmental agency, as described in part
12.6.1.E.10.b: 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.
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b. 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. For the purposes of this rule, “crimes of moral turpitude” include the
following felony, misdemeanor, or municipal offenses or equivalent out-of-state or
federal offenses:
(1) Any of the offenses against the person set forth in Article 3 of Title 18 of
the Colorado Revised Statutes. Examples of such offenses include, but
are not limited to, any assault, menacing, or unlawful sexual behavior;
(2) Any of the offenses against property set forth in Article 4 of Title 18 of the
Colorado Revised Statutes. Examples of such offenses include, but are
not limited to, any arson, theft, trespass, or criminal mischief;
(3) Any of the offenses involving fraud set forth in Article 5 of Title 18 of the
Colorado Revised Statutes;
(4) Computer crime as set forth in Article 5.5 of Title 18 of the Colorado
Revised Statutes;
(5) Any of the offenses involving the family relations set forth in Article 6,
Part 4 (wrongs to children), when committed intentionally and knowingly
or recklessly; Part 6 (harboring a minor); or Part 8 (domestic violence) of
Title 18 of the Colorado Revised Statutes;
(6) An y of the offenses constituting wrongs to at-risk adults set forth in,
Article 6.5 of Title 18 of the Colorado Revised Statutes;
(7) Any of the offenses relating to morals set forth in Article 7 of Title 18 of
the Colorado Revised Statutes. Examples of such offenses include, but
are not limited to, prostitution, indecent exposure, and criminal invasion
of privacy;
(8) Any other offense in any jurisdiction whatsoever that is committed
intentionally, knowingly, or recklessly, and involves violence, coercion,
threats, cruelty, fraud, deception, or deprivation of legally recognized
rights; and,
(9) Any conspiracy, solicitation, or criminal attempt to commit any of the
above offenses, or participation as an accessory to any of the above
offenses.
c. If the event is 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.
F. Each application must be signed under penalty of perjury by an authorized corporate officer,
general partner, or sole proprietor of the agency as appropriate.
G. BHA shall conduct a preliminary assessment of the application and notify the applicant of any
application defects.
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1. The applicant shall respond within fourteen (14) calendar days to written notice of any
application defect.
H. BHA will provide written notice to the applicant within thirty (30) calendar days of receipt of a
complete application.
I. BHA will act on an application within ninety (90) calendar days of receipt of the completed
application.
J. The duration of the initial approval will be two (2) years from the date of issuance.
1. BHA may conduct annual inspections during the two (2) year approval duration, in
addition to any other inspections indicated in Section 12.6.6.G.
12.6.2 Provisional Approval
A. Where an applicant for an initial approval fails to fully conform to the applicable statutes and
regulations but the BHA determines the applicant is in substantial compliance with these rules
and regulations and is temporarily unable to conform to all the minimum standards, a provisional
approval may be granted. No provisional approval may be issued to an applicant if the operations
may adversely affect individual health, safety, or welfare.
1. A provisional approval will be valid for ninety (90) days.
2. A second provisional approval, for another ninety (90) days, may be issued if the BHA
determines that it is likely that compliance can be achieved by the date of expiration of
the second provisional approval.
3. The second provisional approval may be issued for the same duration as the first. The
BHA may not issue a third or subsequent provisional approval to the entity.
4. During the term of the provisional approval, the BHA shall conduct any review it deems
necessary to determine if the agency meets the requirements for a regular approval.
5. If
the BHA determines, prior to expiration of the provisional approval, that the agency is in
compliance with all applicable rules, it may issue a regular approval. The regular approval
will be valid for one (1) year from the date of issuance of the regular approval, unless
otherwise acted upon pursuant to part 12.7 of this Chapter.
12.6.3 Renewal of Approval
A. An agency seeking renewal must provide the BHA with a renewal application, signed under
penalty of perjury by an authorized corporate officer, general partner, or sole proprietor of the
agency as appropriate at least sixty (60) calendar days prior to the expiration of the existing
approval. Renewal applications shall contain the information required in part 12.6.1.E of this
Chapter unless the information has been previously submitted and no changes have been made
to the information currently held by the BHA.
B. Failure of the agency to accurately answer or report any of the information requested by the BHA
will be considered good cause to deny the renewal application.
C. The BHA shall conduct a preliminary assessment of the renewal application and notify the agency
of any application defects.
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1. The agency shall respond within fourteen (14) calendar days to written notice of any
application defect.
D. The duration of the renewal approval will be two (2) years from the date of issuance.
1. The BHA may conduct annual inspections during the two (2) year approval duration, in
addition to any other inspections indicated in section 12.6.6.G.
12.6.4 Change of Ownership/Management
A. If an agency undergoes a change in ownership without following the procedures outlined in this
part 12.6.4, their existing approval will be terminated. Termination of the approval may not occur
until after a hearing and in compliance with the provisions and procedures specified in Section
24-4-101 through -109, C.R.S.
B. When an agency initiates a change of ownership, the agency must submit notification to inform
the BHA of the change.
C. Each agency undergoing a change of ownership shall submit an application, as prescribed in part
12.6.1 of this Chapter at least thirty (30) calendar days before a change of ownership.
1. The application must include supporting documentation for change of ownership.
D. The BHA will consider the following criteria in determining whether there is a change of ownership
of an agency that requires a new approval. The transfer of fifty percent (50%) of the ownership
interest referred to in this part 12.6.4.D may occur during the course of one (1) transaction or
during a series of transactions occurring over a five (5) year period.
1. So le proprietors:
a. The transfer of at least fifty percent (50%) of the ownership interest in an 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.
b. Change of ownership does not include forming a corporation from the sole
proprietorship with the proprietor as the sole shareholder or forming a limited
liability company from sole proprietorship.
2. Partnerships:
a. 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 ownership to one (1) or more new owners.
b. Change of ownership does not include dissolution of the partnership to form a
corporation with the same persons retaining ownership in the new corporation.
3. Corporations:
a. Merger of two (2) or more corporations resulting in the creation of a new
corporate entity will be considered a change of ownership if the consolidation
includes a transfer of at least fifty percent (50%) of the ownership to one or more
new owners.
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b. Formation of a corporation from a partnership, a sole proprietorship, or a limited
liability company will be considered a change of ownership if the change includes
a transfer of at least fifty percent (50%) of the ownership to one (1) or more new
owners.
c. The transfer, purchase, or sale of shares in the corporation such that at least fifty
percent (50%) of the ownership of the corporation is shifted to one (1) or more
new owners will be considered a change of ownership.
4. Limited liability companies:
a. The transfer of at least fifty percent (50%) of the ownership interest in the
company will be considered a change of ownership.
b. The termination or dissolution of the company and the conversion thereof into
any other entity will be considered a change of ownership if the conversion also
includes a transfer of at least fifty percent (50%) of the ownership to one (1) or
more new owners.
c. 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.
5. Non-profits:
a. T he transfer of at least fifty percent (50%) of the controlling interest in the
nonprofit is considered a change of ownership.
6. Management contracts, leases, or other operational arrangements:
a. If the agency enters into a lease arrangement or management agreement
whereby the owner retains no authority or responsibility for the operation and
management of the agency, the action will be considered a change of ownership
that requires a new approval.
7. Legal structures:
a. The conversion of an agency’s legal structure, or the legal structure of a business
entity that has an ownership interest in the agency is a change of ownership if
the conversion also includes a transfer of at least fifty percent (50%) of the
agency’s ownership interest to one (1) or more new owners.
E. The existing agency is responsible for correcting all rule violations and deficiencies in any current
plan of action before the change of ownership becomes effective. In the event that such
corrective actions cannot be accomplished in the time frame specified, the prospective agency
shall be responsible for all uncorrected rule violations and deficiencies including any current plan
of action submitted by the previous agency unless the prospective agency submits a revised plan
of action, approved by the BHA, before the change of ownership becomes effective.
F. Wh en the BHA issues an approval to the new owner, the previous owner must return its approval
to the BHA within five (5) calendar days of the new owner’s receipt of its approval.
12.6.5 Rule Waivers
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A. Any agency or applicant that has applied for or been approved as a behavioral health safety net
provider has the right to apply for a waiver of any rule or standard set forth in these rules which, in
their opinion, poses an undue hardship on the applicant, agency, or community.
B. Nothing contained in these provisions abrogates the agency’s obligation to meet minimum
requirements under local safety, fire, electrical, building, zoning, and similar codes.
C. Nothing herein authorizes a waiver of any statutory requirement under state or federal law, except
to the extent permitted therein.
D. Upon application to the BHA, a waiver may be granted in accordance with this part 12.6.5. Absent
the existence of a current waiver issued pursuant to this part, behavioral health safety net
providers are expected to comply at all times with all applicable regulations except in instances
where they are granted a provisional approval in accordance with part 12.6.2 of this Chapter.
E. Waiver applications must be submitted to the BHA in writing.
1. The BHA will only consider one (1) regulation per waiver application.
2. The waiver application must provide the BHA information related to:
a. T he regulation the agency or applicant is requesting to waive;
b. The reason why the waiver is being requested;
c. A proposed alternate compliance plan;
d. Any other information relevant to the waiver request that would inform the BHA’s
decision in either granting or denying the waiver.
3. The waiver application must be signed by an authorized representative of the agency or
applicant, who is the primary contact person and the person responsible for ensuring that
accurate and complete information is provided to the BHA.
F. In making its determination, the BHA may consider any information it deems relevant, including
but not limited to:
1. Critical incident and complaint investigation reports, licensure or certification survey
reports, anticipated impact of the waiver on individual safety and quality of care if any,
and findings of these reports related to the agency and/or the operator or owner thereof.
2. When determining whether a waiver should be granted, the BHA shall prioritize the
impact of the waiver on the health, safety, and welfare of individuals over any alleged
undue hardship.
G. The BHA shall act on a waiver application within ninety (90) calendar days of receipt of the
completed application. An application will not be deemed complete until the applicant has
provided all information and documentation requested by the BHA.
H. T he BHA may specify terms and conditions under which any waiver is granted, including which
terms and conditions must be met in order for the waiver to remain effective. The term for which
each waiver granted will remain effective must be specified at the time of issuance but may not
exceed the term of the current approval.
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1. At any time, upon reasonable cause, the BHA may inspect an agency with an active
waiver to ensure that the terms and conditions of the waiver are being observed, and/or
that the continued existence of the waiver is otherwise appropriate.
2. Within thirty (30) calendar days of the termination, expiration, or revocation of a waiver,
the agency shall submit to the BHA an attestation of compliance with the regulation to
which the waiver pertained.
I. The BHA will institute termination of a waiver upon a change of ownership of the agency, as
defined in part 12.7.4. However, to prevent such termination, the prospective new owner may
submit a waiver application to the BHA prior to the effective date of the change of ownership.
Provided the BHA receives the new application by prior to the effective date of the change of
ownership, the waiver will be deemed to remain effective until such time as the BHA acts on the
application. Termination of the waiver may not occur until after a hearing and in compliance with
the provisions and procedures specified in Section 24-4-101 through -109, C.R.S.
1. Except as otherwise provided in this part 12.6.5, a waiver may not be granted for a term
that exceeds the current approval term.
2. If an agency wishes to maintain a waiver beyond the stated term, it must submit a new
waiver application to the BHA not less than ninety (90) calendar days prior to the
expiration of the current term of the waiver or with an approval renewal.
J. Notwithstanding anything in this part 12.6.5 to the contrary, the BHA may revoke a waiver if it
determines that:
1. The waiver's continuation jeopardizes the health, safety, or welfare of individuals served
by the agency;
2. The waiver application contained false or misleading information;
3. The terms and conditions of the waiver have not been complied with;
4. The conditions under which a waiver was granted no longer exist or have changed
materially; or,
5. A change in a federal or state statute or regulation prohibits, or is inconsistent with, the
continuation of the waiver.
K. Notice of the revocation of a waiver must be provided to the agency in accordance with the
Colorado Administrative Procedures Act and will not be effective until after a hearing in
compliance with the provisions and procedures specified in Section 24-4-101 through -109,
C.R.S.
12.6.6 Continuing Obligations and BHA Oversight
A. Ea ch agency must have and maintain electronic business communication tools, including but not
limited to, internet access and a valid e-mail address. The agency must use these tools to receive
and submit information.
B. The approval is only valid while in the possession of the agency to whom it is issued and may not
be subject to sale, assignment, or other transfer, voluntary or involuntary.
C. The agency must provide accurate and truthful information to the BHA during inspections,
investigations, applications, and oversight activities.
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D. When an agency is subject to inspection, certification, or review by other agencies, accrediting
organizations, or inspecting companies, the agency shall provide and/or release to the BHA, upon
request, any correspondence, reports, or recommendations concerning the agency that were
prepared by such organizations.
E. Each agency must submit notification to the BHA regarding any change in the information
required by part 12.6.1.E of this Chapter from what was contained in the last submitted approval
application.
1. Changes to the operation of the agency may not be implemented without prior approval
from the BHA. An agency shall, at least thirty (30) calendar days in advance, submit
notification to the BHA regarding any of the following proposed changes.
a. Change in license category or classification.
b. Change in the scope of services, including the addition or removal of an
endorsement, a service, or a physical location.
c. Change in legal name of the agency and all other names used by it to provide
services.
F. The BHA and any duly authorized representatives thereof have the right to enter upon and into
the premises of any approved agency or applicant for an agency approval in order to determine
the state of compliance with the statutes and regulations and must initially identify themselves to
the person in charge of the agency at the time.
G. T he BHA may use the following measures to ensure an agency’s full compliance with the
applicable statutory and regulatory criteria.
1. The BHA may conduct an unscheduled or unannounced review of a current agency
based upon, but not limited to, the following criteria:
a. Routine compliance inspection,
b. Reason exists to question the agency’s continued fitness to conduct or maintain
operations in accordance with the approval requirements,
c. A complaint alleging non-compliance with approval requirements,
d. Discovery of previously undisclosed information regarding an agency or any of its
owners, officers, managers, or other employees if such information affects or has
the potential to affect the agency’s provision of services, or
e. The omission of relevant information from documents requested by the BHA or
indication of false information submitted to the BHA.
2. Plan of action
a. If after review or pursuant to a complaint, it is determined that an agency is not in
compliance with these rules, the agency shall be notified in writing, within thirty
(30) business days of the specific deficiency/deficiencies.
b. After any review, the BHA may request a plan of action from an agency or
require an agency’s compliance with a BHA directed plan of action.
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c. If the agency does not agree with any or all of the findings regarding non-
compliance, the agency has ten (10) business days from the receipt of non-
compliance notice to dispute the findings by submitting evidence to the BHA.
d. The agency shall receive a written response within thirty (30) business days of
the review of submitted evidence.
e. If the submitted information is sufficient, the agency shall be determined in
compliance with these rules.
f. If the agency continues to be found out of compliance with these rules, the
agency shall have thirty (30) business days from the date of receipt of the review
findings to submit a plan of action.
g. The plan of action must be in the format prescribed by the BHA and included, but
not be limited to, the following:
(1) A description of how the agency will correct each identified deficiency.
(a) If deficient practice was cited for specific personnel, 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 individuals and/or other individuals
having the potential to be affected.
(2) A d escription of how the agency will monitor the corrective action to
ensure each deficiency is remedied and will not reoccur, and
(3) A completion date that is no later than ninety (90) calendar days from the
issuance of the deficiency list, unless otherwise required or approved by
the BHA. The completion date is the date that the entity deems it can
achieve compliance.
h. A completed plan of action must be:
(1) Signed by the agency’s director, administrator, or manager, and
(2) Submitted to the BHA within thirty (30) calendar days after the date of
the BHA’s written notice of deficiencies.
(a) If an extension of time is needed to complete the plan of action,
the agency shall request an extension in writing from the BHA
prior to the plan of action due date. The BHA may grant an
extension of time.
i. The BHA has discretion to approve, impose, modify, or reject a plan of action.
(1) If the plan of action is accepted, the BHA shall notify the agency by
issuing a written notice of acceptance, served either in-person or by first-
class mail.
(2) If the plan of action is unacceptable, the BHA shall notify the agency in
writing, and the agency shall re-submit the changes within the time frame
prescribed by the BHA in the notice.
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(3) If the agency fails to comply with the requirements or deadlines for
submission of a plan or fails to submit requested changes to the plan, the
BHA may reject the plan of action and impose disciplinary sanctions as
set forth in part 12.7 of this Chapter.
(4) If the agency fails to implement the actions agreed to by the action date
in the approved plan of action, the BHA may impose enforcement
sanctions as set forth below in part 12.7.
H. The agency must provide, upon request, access to or copies of the following to the BHA for the
performance of its regulatory oversight responsibilities:
1. Individual records.
2. Reports and information including but not limited to, staffing reports, census data,
statistical information, and other records, as determined by the BHA.
I. Oversight and enforcement activities may include review of endorsements and/or separate
physical locations as necessary for the BHA to ensure the health, safety, and welfare of
individuals.
12.7 Enforcement and Adverse Actions
12.7.1 Denial
A. The BHA may deny an agency’s approval as a behavioral health safety net provider for reasons
including but not limited to, the following:
1. T he agency has not fully complied with all local, state, and federal laws and regulations
applicable to the approval;
2. The application or its accompanying documents contain a false statement of material
fact;
3. The agency fails to respond to BHA requests for additional information in the time frame
indicated in the request;
4. The agency refuses any part of an inspection;
5. The agency fails to comply with federal financial participation requirements;
6. The agency fails to comply with state and federal data and financial reporting
requirements;
7. The agency has failed to cooperate with the investigation of any local, state, or federal
regulatory body or law enforcement agency; or
8. The agency 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 individual(s) served.
B. If the BHA denies an application for approval, it shall provide the agency with a written notice,
served either in-person or by first-class mail, explaining the basis for the denial and affording the
agency the opportunity to respond and request a hearing.
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C. Appeals of denials must be conducted in accordance with the State Administrative Procedure Act,
Section 24-4-101 through -109, C.R.S.
12.7.2 Revocation of Approval
A. The BHA may revoke an existing approval if an agency fails or refuses to comply with the
statutory and/or regulatory requirements applicable to its approval. Failures to comply include:
1. Making a false statement of material fact about individuals served by the agency, its
personnel, capacity, or other operational components verbally or in any public document,
or in a matter under investigation by the BHA or another governmental entity,
2. Preventing, interfering with, or attempting to impede in any way the work of a
representative or agent of the BHA in investigating or enforcing the applicable statutes or
regulations,
3. Falsely advertising or in any way misrepresenting the agency’s ability to provide services
for the individuals served based on its license type or status,
4. Failing to provide reports and documents required by regulation or statute in a timely and
complete fashion,
5. Failing to comply with or complete a plan of action in the time or manner specified,
6. Falsifying records or documents,
7. K nowingly using or disseminating misleading, deceptive, or false information,
8. Accepting commissions, rebates, or other forms of remuneration for referrals or other
treatment decisions, or
9. Exercising undue influence or coercion over an individual to obtain certain 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 an individual.
B. Revocation must not occur until after a hearing and in compliance with the provisions and
procedures specified in Article 4 of Title 24 and in Section 27-50-505, C.R.S.
12.7.3 Intermediate Restrictions
A. The BHA may impose the following intermediate restrictions or conditions on an agency that has
sought enhanced service payments in accordance with Section 27-50-505(3), C.R.S.:
1. Retaining a consultant to address corrective measures including deficient practice
resulting from systemic failure;
2. Monitoring by the BHA for a specific period;
3. Providing additional training to personnel, owners, or operators of the agency;
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.
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B. The agency may appeal any intermediate restriction or condition to the BHA in accordance with
the Colorado Administrative Procedures Act Section 24-4-101, et seq., C.R.S.
12.7.4 Right to Appeal
A. Any agency adversely affected or aggrieved by these rules or by the BHA’s decisions in regard to
implementation of these rules, has the right to appeal to the Colorado Department of Personnel
and Administration, Office of Administrative Courts, and may subsequently seek judicial review of
the BHA’s action in accordance with Section 24-4-101 through -109, C.R.S.
B. The following actions may be submitted to an administrative law judge for an evidentiary hearing:
denial or revocation of an approval.
C. After written notification from the BHA of intended action, the agency has twenty-one (21)
calendar days to submit a written appeal. The appeal must be received by the BHA within twenty-
one (21) days from the date the written notification of action letter was sent by the BHA.
D. In all cases except waiver denials, the BHA will file a notice of charges with the Office of
Administrative Courts to begin the administrative process. In waiver denials, if the applicant for
the waiver requests an appeal, the request for appeal must be forwarded to the Office of
Administrative Courts. Once the appellant’s request is forwarded to the office of administrative
courts, the BHA may file a notice of charges.
E. S ubsequent to an evidentiary hearing at the Office of the Administrative Courts and the issuance
of a final agency decision, a party may seek to appeal the final agency decision through judicial
review in accordance with Section 24-4-106, C.R.S.
The following sections 21.000 through 21.290.58 and sections 21.400 through 21.400.6 of these rules are
applicable to agencies approved or designated by the BHA prior to January 1, 2024, pursuant to Section
27-81-106, C.R.S.; Sections 27-50-101 through 27-50-903; Sections 27-65-101 through 27-65-131; or
Sections 27-66-101 through 27-66-110, C.R.S. until such time that such agencies’ approval or
designation expires and/or is up for renewal. Upon renewal, Chapters 1 - 11 above shall apply.
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Chapter 13: Controlled Substance Services
13.1 Definitions
“Administer” means the direct application of a controlled substance, whether by injection, inhalation,
ingestion, or any other means to the body of an individual.
“Approved Private Treatment Facility” means a private agency meeting the definition set forth in Section
27-81-102(2), C.R.S., and standards prescribed and approved under Section 27- 81-106, C.R.S., and
shall be referred to as “approved treatment facility”.
“Approved Public Treatment Facility” means an agency operating under the direction and control of or
approved by BHA and meeting the definition set forth in Section 27-81-102(3), C.R.S., and standards
prescribed and approved under Section 27-81-106, C.R.S., and shall be referred to as “approved
treatment facility.”
“Compound” means to produce or create by combining two or more substances.
“Controlled Substance” means a drug whose general availability is restricted or any substance that is
strictly regulated or outlawed because of its potential for abuse or dependence. Controlled substances
include narcotics, stimulants, depressants, hallucinogens, and cannabis.
“Corrective Action” means a time limited remedial measure applied to agencies that are out of compliance
during a one (1) year licensing period.
“Diversion” means the transfer of any controlled substance from a licit to an illicit channel of distribution or
use.
“Maintenance Treatment” means the dispensing of a controlled substance, such as methadone or
buprenorphine, at stable dosage levels for a period in excess of twenty-one (21) days in the supervised
treatment of an individual for opioid use disorder.
“Medically Supervised Withdrawal” means the process through which an individual who is physically
dependent on alcohol, illicit drugs, prescription medications, or a combination of these substances is over
a period of time withdrawn from the substances of dependence and the process may include the use of
controlled substances to manage the symptoms of withdrawal under the supervision of a qualified
practitioner.
“Office-based opioid treatment” or “OBOT” means the prescribing of medications for the treatment of
opioid use disorders by a federally authorized primary care or general health care provider outside of
programs required to be licensed pursuant to Section 27-80-201 et seq., C.R.S.
“Physical dependence” means a state of adaptation that is manifested by a drug class specific withdrawal
syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the
drug, and/or administration of an antagonist.
“Practitioner” means:
A. A physician or other person licensed, registered or otherwise permitted to distribute, dispense, or
to administer a controlled substance in the course of professional practice.
B. A pharmacy, hospital or other institution licensed, registered, or otherwise permitted to distribute,
dispense, or to administer a controlled substance in the course of its professional practice in this
state.
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13.2 Authority and Applicability
A. These rules are established to create standards for agencies seeking a controlled substance
license.
B. All agencies providing controlled substance licensed services as defined within 13.3 shall meet
the standards in this Chapter 13. Controlled substance licensed agencies shall require a BHE
license, and the agency shall comply with Chapter 2 and corresponding Chapters of these rules
applicable to levels of care provided.
13.3 Controlled Substance License Requirements
A. Agencies shall apply for and obtain a controlled substance license if they dispense, compound, or
administer (pursuant to Section 27-80-204, C.R.S.) a controlled substance in order to treat a
substance use disorder or to manage the withdrawal symptoms of a substance use disorder, from
stock medication. All applicants for a controlled substance license must demonstrate compliance
with these rules and all applicable state and federal statutes and regulations, including but not
limited to the 72-hour emergency rule and others pertaining to controlled substances. The 72-
hour emergency rule means the regulation issued by the Drug Enforcement Administration (DEA)
found at 21 C.F.R. § 1306.07 (Apr. 2024), which is hereby incorporated by reference, no later
editions or amendments are incorporated. This regulation is available at no cost from the DEA at
8701 Morrissette Drive, Springfield, VA 22152 or at https://www.ecfr.gov/current/title-21. This
regulation is also available for public inspection at the Colorado Department of Human Services,
Behavioral Health Administration, 710 S. Ash st, Suite C140, Denver, CO 80246, during regular
business hours.
B. An office-based opioid treatment (OBOT) provider that does not dispense, compound, or
administer a controlled substance from stock medication on-site is not required to obtain a
controlled substance license pursuant to this part 13.3.
C. In accordance with 21 C.F.R. § 1306.07(c), as incorporated by reference in Section 13.3.a.
administering or dispensing of narcotic drugs: BHA CSL rules are not intended to impose
limitations on a physician or authorized hospital staff to administer or dispense narcotic drugs in a
hospital to maintain or detoxify a person as an incidental adjunct to medical or surgical treatment
of conditions other than addiction, or to administer or dispense narcotic drugs to persons with
intractable pain in which no relief or cure is possible or none has been found after reasonable
efforts.
13.3.1 Licensing Procedures
A. Treatment facilities meeting all the requirements of Colorado Revised Statutes Part 1 of Article
280 of Title 12; Part 3 of Article 18 of Title 18; Section 27-81-106, C.R.S.; the requirements of the
controlled substance license rules; and all applicable state and federal regulations including those
that apply to controlled substances shall be issued a controlled substance license.
B. A controlled substance license issued by BHA shall be obtained annually for each approved
treatment facility that dispenses, compounds, or administers a controlled substance to treat
substance use disorders or the withdrawal symptoms of a substance use disorder.
C. A separate controlled substance license is required for each approved treatment facility site
where controlled substances are dispensed, compounded, or administered, in order to treat
substance use disorders or the withdrawal symptoms of a substance use disorder.
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D. Any approved treatment facility that receives a controlled substance license may dispense,
compound, or administer controlled substances only to the extent authorized by their license and
in conformity with Colorado Revised Statutes Part 1 of Article 280 of Title 12, and Article 18 of
Title 18.
E. Routine Monitoring: Controlled substance licensing visits shall be scheduled and conducted by
BHA during the approved agencies' normal business hours to the extent possible.
F. BHA shall conduct unscheduled site visits for specific monitoring purposes and investigation of
complaints or critical incidents involving approved agencies that have a controlled substance
license. These unscheduled visits shall be in accordance with the:
1. Controlled Substance License Rules;
2. BHA policies and procedures;
3. Department substance use disorder BHA Rules; and
4. Any statutes and regulations that protect the confidentiality of individual identifying
information.
G. BHA shall have access to all individual, agency, and personnel records and any other relevant
documentation required to determine compliance with these rules and to coordinate individual
placement and care.
H. A controlled substance license shall not be granted to an agency unless there is documentation
that the medical director or qualified practitioner dispensing, compounding or administering
controlled substances has not been convicted within the last two (2) years of a willful violation of
Part 1 of Article 180 of Title 12 of the Colorado Revised Statutes or any other state or federal law
regulating controlled substances
13.3.2 Initial License
A. Applicants for an initial controlled substance license to dispense, compound, or administer
controlled substances to treat a substance use disorder or to manage the withdrawal symptoms
of a substance use disorder shall submit a controlled substance license application that has been
affirmed and signed by a qualified practitioner, a copy of current policies and procedures
addressing the use of controlled substances to treat substance use disorders or withdrawal
symptoms of a substance use disorder, and the application fee of five hundred dollars ($500).
B. No approved treatment facility that is required to be licensed shall engage in any activity for which
a controlled substance license is required until the facility's application is granted, and a license is
issued to the facility by BHA.
C. Initial controlled substance license applications received by BHA that are not completed
according to instructions, do not include the application fee, or do not include the required policies
and procedures shall be returned to the applicant by certified mail with the submitted application
fee and a written explanation as to why their application is being returned.
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D. BHA shall review complete initial applications that have the required fee and appropriate policies
and procedures and BHA shall conduct an on-site inspection to determine that the applicant is in
compliance with these controlled substance license rules, treatment rules, and all state and
federal statutes and regulations. If the Governor or local government declares an emergency or
disaster BHA has discretion to modify the requirement for on-site inspections. If BHA modifies the
requirement for on-site inspections, the requirement shall only be modified as necessary because
of circumstances related to the disaster or emergency.
E. Initial applicants that have submitted satisfactory policies and procedures and other required
documentation shall be granted a one hundred and eighty (180) day provisional license.
F. BHA may conduct a site visit to determine that the provisionally licensed agency is in compliance
with these controlled substance license rules, treatment rules, and all state and federal statutes
and regulations. If, after the first provisional license, an agency has not demonstrated full
compliance, a second one hundred and eighty (180) day provisional license may be granted if
substantial progress continues to be made, and it is likely compliance can be achieved by the
date of expiration of the second provisional license. If, at the end of the first provisional license,
an agency demonstrates compliance, a full controlled substance license shall be issued. BHA will
not issue a third or subsequent provisional license to the applicant.
G. BHA shall conduct a site visit to determine compliance with all applicable state and federal laws
and regulations at the end of the second provisional license period. If at the end of the second
provisional license an agency demonstrates compliance, a full controlled substance license shall
be issued.
H. An applicant for licensure pursuant to these rules and regulations shall also be considered an
applicant for registration pursuant to Section 18-18-302, C.R.S.
I. Initial applicants that are found not to be in full compliance shall have their license applications
returned by certified mail with a written explanation as to why their application is being returned
and notification that their controlled substance license application has been denied as of ten (10)
days from the date the denial letter was mailed. Application fees shall not be refunded. If an
applicant disagrees with the decision, they may appeal (Part 2.24.5 of these Rules); or upon
remedying the noted deficiencies, may re-apply for an initial license in accordance with Chapter
13 of these rules.
13.3.3 License Renewal
A. A controlled substance license shall expire one (1) year from the date the license is granted. A
term shorter than one (1) year may be issued if agreed upon between the agency and BHA.
1. If a term shorter than one (1) year is issued, fees may be prorated to reflect the time
period of the license term.
B. Agencies wishing to continue their controlled substance license shall submit a license renewal
application to BHA thirty (30) days prior to the expiration date of their current controlled substance
license along with the required fee of five hundred dollars ($500). A copy of the agency’s DEA
narcotic treatment program registration and SAMHSA accreditation or certification as applicable
shall also be submitted with each annual renewal application for this program type.
C. Any treatment facility that currently has a controlled substance license issued by BHA may not
apply for renewal more than sixty (60) days before the expiration date of the current controlled
substance license.
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D. A controlled substance license renewal application that is received by BHA fewer than thirty (30)
calendar days prior to the expiration of their existing license may fail to receive their new license
prior to the expiration of their existing license. An agency that submits its renewal application
fewer than thirty (30) days prior to the expiration of the current license and does not receive a
new license prior to the current license expiration may reapply for an initial license in accordance
with Chapter 13 of these rules.
E. A controlled substance license renewal application that is received by BHA after the current
license expiration date shall be returned by certified mail with written notification that the license
is no longer in effect. Applicants may reapply for an initial license in accordance with Chapter 13
of these rules.
F. If the governor or local government declares an emergency or disaster BHA has discretion to
modify the requirement for on-site inspections. If BHA modifies the requirement for on-site
inspections, the requirement shall only be modified as necessary because of circumstances
related to the disaster or emergency.
G. An agency that is in full compliance shall be granted renewal of their annual controlled substance
license that shall be effective for one (1) year from the prior license’s expiration date.
13.3.4 Probationary License
A. At BHA’s discretion, a probationary license may be issued to an agency out of compliance with
applicable BHA, state, or federal regulations prior to issuance of a renewal license or during a
current license term. The agency will be notified in writing of non-compliance areas and the need
for a plan of action (see Part 2.24.3 of these rules).
B. A probationary license will replace the current license for a period not to exceed ninety (90)
calendar days.
C. Administrative and treatment activities may be limited by a probationary license while the agency
addresses corrective actions.
D. A second probationary license may be issued for a period not to exceed ninety (90) calendar
days if substantial progress continues to be made and it is likely that compliance can be achieved
by the date of expiration of the second probationary license.
E. If the agency fails to comply with or complete a plan of action in the time or manner specified, or
is unwilling to consent to the probationary license, BHA shall revoke the license and the agency
shall be notified by certified mail that the agency's license is revoked as of ten (10) days from the
date the letter was mailed. If an agency disagrees with the decision, the agency may appeal (see
Part 2.24.5 of these rules).
F. Upon remedying the noted deficiencies, an agency may re-apply for an initial license in
accordance with Part 13.5 of these rules.
13.3.5 License Denial, Revocation, Or Suspension
A. A controlled substance license may be denied, suspended, or revoked in accordance with Part
2.24 of these rules and upon finding that the agency:
1. Is not in compliance with the controlled substance license rules;
2. Has violated any provision of Part 1 of Article 280 of Title 12, And Article 18 of Title 18 of
the Colorado Revised Statutes;
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3. Has failed to implement BHA imposed corrective actions;
4. Has been negligent resulting in risk to individual and/or personnel health or safety;
5. Has failed to provide for adequate supervision of treatment personnel as outlined in Part
2.5.1 of these rules and defined by the supervisor's professional practice board;
6. Has furnished false or fraudulent information in an application;
7. Has, as a practitioner, been convicted of, or has had accepted by a court a plea of guilty
or nolo contendere to a felony under any state or federal law relating to a controlled
substance; or
8. Has had their federal registration to manufacture, conduct research on, distribute, or
dispense a controlled substance suspended or revoked.
B. BHA may limit revocation or suspension of a controlled substance license to the particular
controlled substance, which was the basis for revocation or suspension.
C. If BHA denies, suspends, or revokes a controlled substance license, all controlled substances
owned or possessed by the agency at the time of the denial or suspension or on the effective
date of the revocation order must be placed under seal. No disposition may be made of
substances under seal until the time for making an appeal has elapsed or until all appeals have
concluded, unless a court orders otherwise or orders the sale of any perishable controlled
substances and the deposit of the proceeds with the court, or if BHA orders otherwise. Upon a
revocation order becoming final, all controlled substances may be forfeited to the state.
D. BHA shall promptly notify the Drug Enforcement Administration and the appropriate professional
licensing agencies, if any, of all charges and the final disposition thereof and of all forfeitures of a
controlled substance.
13.4 Treatment Provisions Under A Controlled Substance License
13.4.1 Agency Policies And Procedures
A. Agencies shall develop and implement policies and procedures, as defined in this Part 13.4.1,
that address the use of controlled substances in the treatment of substance use disorders or the
withdrawal symptoms of a substance use disorder. These policies shall include, but are not
limited to, how individuals are assessed to be appropriate to receive a controlled substance to
treat their substance use disorder or the withdrawal symptoms of a substance use disorder.
These policies shall meet the requirements of all federal, state, and local laws pertaining to
controlled substances.
B. Medication assisted treatment using a controlled substance shall be provided to individuals with a
substance use disorder who are seeking treatment to manage symptoms of physical and
psychological withdrawal and cravings, and to reduce risk associated with drug use, including
overdose, death, and the spread of infectious diseases.
C. Approved agencies must only dispense, compound, or administer, controlled substances by or on
the order of a qualified practitioner who currently possesses and maintains a license to practice
medicine in the State of Colorado as provided by Article 240, of Title 12, C.R.S. The qualified
practitioner’s medical order must be documented in the individual’s treatment record.
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D. Approved agencies that dispense, compound, or administer controlled substances must also
have a current registration from the Drug Enforcement Administration for the state in which they
are licensed.
E. All controlled substances must be dispensed, compounded, or administered according to
applicable state and federal statutes, regulations and rules, controlled substance license rules,
and BHA rules.
F. Controlled substances must be dispensed, compounded, or administered in accordance with the
manufacturer’s specifications found on product labels and/or in printed instructions accompanying
the product.
G. Agencies shall maintain an individual dispensing record on each individual that receives
controlled substances at their facility. The dispensing record shall include:
1. Complete name of individual receiving the controlled substance;
2. Name of the controlled substance, strength, and dosage form;
3. Amount consumed;
4. Amount dispensed;
5. Date dispensed;
6. Amount and dosage form taken home by individual (if applicable); and
7. First initial and last name and the credentials of the individual who dispensed the
controlled substance medication.
H. Agencies shall ensure that all personnel are working within their scope of practice and shall only
allow licensed medical personnel to dispense, compound, or administer controlled substances.
I. Each approved treatment facility shall provide formal training and testing on an annual basis to all
personnel for the following:
1. State and federal requirements regarding controlled substances and confidentiality,
including BHA rules; and
2. Pharmacology of controlled substances dispensed, including but not limited to loss of
tolerance, dangerous drug or alcohol interactions, signs and symptoms of overdose,
purpose of its use.
13.4.2 Critical Incident Reporting
A. In addition to the provisions of Part 2.16 of these rules, theft, loss, misuse, diversion, or illicit
distribution of agency-dispensed or prescribed controlled substance medication shall also be
considered a critical incident and BHA critical incident reporting policy shall be followed. Critical
incidents must be reported to BHA within one (1) business day of when the agency determines
that a reportable incident has occurred or upon BHA request.
13.4.3 Medical Evaluations
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A. Individuals who wish to receive medication assisted treatment shall have medical evaluations
conducted by a qualified practitioner to determine physical dependence and to determine that
such individuals are appropriate for treatment with a controlled substance. Evaluations shall
include, but are not limited to:
1. A medical history that includes a detailed and comprehensive account of substance use
history, which includes all substances of misuse;
2. Evidence of current physical dependence (for OTPS, see Part 13.8.1.C.2); and
3. A pregnancy screen for females and pregnancy-capable individuals of childbearing age.
13.4.4 Informed Consent to Receive a Controlled Substance
A. All individuals receiving medication assisted treatment shall sign informed consent indicating they
are voluntarily agreeing to treatment with a controlled substance. The individual shall be informed
of what controlled substance they are receiving and the expected benefits and risks of medication
assisted treatment. All individuals receiving controlled substances must also be informed of the
risks of using other substances in combination with a controlled substance. Should an individual
change controlled substance medications over the course of treatment, the individual must sign a
new informed consent specific to each controlled substance they are receiving under the care of
the controlled substance license.
13.4.5 Security Controls and Operating Procedures
A. All agencies must follow the standards of physical security controls and operating procedures
required by the Federal Drug Enforcement Administration necessary to prevent diversion as
outlined in Title 21, Food and Drugs, Chapter II, Code of Federal Regulations, Sections 1301.71
through 1301.77 (September 2022), which are hereby incorporated by reference. No later
editions or amendments are incorporated. These regulations are available at no cost from the
U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control, 2401
Jefferson Davis Highway, Alexandria, VA 22301; or, the Colorado Department of Human
Services, Behavioral Health Administration, 710 S. Ash St. Suite C140, Denver, CO 80246; or at
any state publications depository library, during regular business hours.
13.4.6 Record Keeping
A. Agencies must follow the record keeping requirements of the Federal Drug Enforcement
Administration, Code of Federal Regulations (Title 21, Food and Drugs, Part 1304) to ensure
compliance with the requirements in Part 1 of Article 280 of Title 12, C.R.S. (September 2021),
which are hereby incorporated by reference. No later editions or amendments are incorporated.
These regulations are available at no cost from the U.S. Department of Justice, Drug
Enforcement Administration, Office of Diversion Control, 2401 Jefferson Davis Highway,
Alexandria, VA 22301; or the Colorado Department of Human Services, Behavioral Health
Administration, 710 S. Ash St. Suite C140, Denver, CO 80246; or at any state publications
depository library, during regular business hours.
B. Agencies must also keep inventories, records, and reports that are required by any other state or
federal law or standard regulating controlled substances.
13.4.7 Handling and Storage
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A. All agencies shall have adequate and proper facilities for the handling and storage of controlled
substances. All agencies must maintain proper control over such controlled substances to ensure
against their being illegally dispensed or distributed. Access to the storage area shall be restricted
to personnel specifically authorized to handle controlled substances. This includes restricting the
number and accessibility of keys or passwords.
B. Agencies shall also develop and implement policies on how controlled substances will be
obtained, stored, and accounted for. These policies shall include, but are not limited to:
1. What controlled substance the agency will be using for the substance use disorder they
are treating and how these controlled substances will be dispensed, compounded, or
administered, as well as who will be responsible for ordering the controlled substances;
2. Where the controlled substances will be stored;
3. How the controlled substances will be accounted for; and
4. Who will have access to the controlled substances.
13.4.8 Toxicology Screening Requirements
A. Agencies shall develop and implement toxicology screen policies and procedures that specify a
random sample collection protocol and these policies must include, but are not limited to:
1. How appropriate and approved samples for drug testing shall be collected and analyzed
in accordance with applicable state and federal statutes and regulations;
2. How toxicology screens shall be used to detect the presence of the approved controlled
substance, that is being dispensed, and its metabolite, for which laboratory analyses are
available;
3. How all individuals entering medication assisted treatment shall provide a toxicology
screen at time of admission and then as clinically indicated throughout the treatment
episode;
4. How an agency shall address an individual having illicit substances in a toxicology
screen, including unauthorized prescription medication; and
5. How the agency incorporates harm reduction, trauma-informed practices, and respect for
the gender identity of the individuals being screened.
13.5 Opioid Treatment Programs (OTP)
A. These parts 13.5 through 13.8 are applicable to agencies licensed as an Opioid Treatment
Program (OTP).
B. Agencies shall follow all federal requirements in accordance with 42 C.F.R. Part 8 (2024), which
are hereby incorporated by reference. No later editions or amendments are incorporated. These
regulations are available at no cost from the U.S. Department of Health & Human Services,
Substance Abuse & Mental Health Services Administration, Office of Communications, 5600
Fishers Lane, Rockville, MD 20857, or at https://www.ecfr.gov/. These regulations are also
available for public inspection and copying at the Colorado Department of Human Services,
Behavioral Health Administration, 710 S. Ash St. Suite C140, Denver, CO 80246, during regular
business hours.
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13.5.1 Definitions
“21 C.F.R. Part 1300, 1301, and 1304” means the federal regulations issued by the Drug Enforcement
Administration of the U.S. Department of Justice found at 21 C.F.R. Part 1301, 1302, and 1304 (Oct.
2021), which are hereby incorporated by reference. No later editions or amendments are incorporated.
These regulations are available at no cost from the U.S. Department of Justice, Drug Enforcement
Administration, Liaison and Policy Section, 8701 Morrissette Drive, Springfield, VA 22152 or at
https://www.ecfr.gov/. These regulations are also available for public inspection and copying at the
Colorado Department of Human Services, Behavioral Health Administration, 710 S. Ash St. Suite C140,
Denver, CO 80246, during regular business hours.
“42 C.F.R. PART 8” means the federal regulations issued by the United States Secretary of Health and
Human Services found at 42 C.F.R. Part 8 (Apr. 2024), as incorporated by reference in Section 13.5.B.
“Administrative Discharge” means a process whereby an OTP has determined immediate treatment
discharge is the most appropriate pathway for an individual for causes such as safety concerns for the
individual or others, incarceration or other confinement which does not permit the individual’s treatment
continuation, or for non-payment of fees. The timeframe for this typically involves a treatment transfer
and/or taper at a rate set forth by the program.
“Administrative Transfer” means a process whereby an OTP has determined treatment continuation for an
individual is unsafe for the individual receiving treatment or others and a program decides to transfer care
to another clinic of the individual’s choice. To avoid unnecessary medication taper, this individual is to be
transferred at a time frame that is determined by agreement with the receiving OTP.
“Comprehensive Metabolic Panel” means a blood test that measures proteins, enzymes, electrolytes,
minerals and other substances in the body. A qualified practitioner can use the results to diagnose,
screen for or monitor health conditions or side effects of medications, and make appropriate medical
referrals.
“Dilute urinalysis” for the purposes of these rules means a creatinine level less than twenty (20)
milligrams.
“Diversion Control Plan” or “DCP” means a written document that contains specific measures to reduce
theft, loss, misuse, or illicit distribution of agency-dispensed or prescribed controlled substance
medication.
“Guest Dosing” means a process where an individual in an OTP may be able to dose at another clinic,
either in the state or out of state, to maintain the continuity of care for their OTP.
“History Of Present Illness” means a chronological description of the development of the individual’s
present illness from the first sign and/or symptom or from the previous encounter to the present. It shall
include the following elements: location, quality, severity, duration, timing, context, modifying factors, and
associated signs and symptoms as applicable.
“Lock In” means a process where a program, along with the State authority, determines that an individual
is best served clinically at one (1) program. This determines where the individual is to go for their OTP.
“Lock Out” means a process where a program, along with the State authority, determines that it is in an
individual's best interest to be locked out of a program due to concerns of this individual not being safe to
themselves or others in a program and/or could be a threat to that program due to diversion or other
items.
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“Medical Director” means a physician licensed to practice medicine in the jurisdiction in which the OTP is
located and shall assume responsibility for all medical and behavioral health services performed by the
OTP, including their administration in accordance with 42 C.F.R. § 8.2., as incorporated by reference in
Section 13.5.
“Medication Unit” means an entity that is established as part of, but geographically separate from, an OTP
from which qualified practitioners, contractors working on behalf of the OTP, or community pharmacists
may dispense or administer medications for opioid use disorder (MOUD), collect samples for drug testing
or analysis, or provide other OTP services. Medication units can provide the same services as an OTP,
as used in 42 C.F.R. Part 8, as incorporated by reference in Section 13.5.
“Mobile Opioid Treatment Unit” for the purpose of this Chapter 13 has the same meaning as “Mobile
Narcotic Treatment Program” as used in 21 C.F.R. Part 1300.01, as incorporated by reference in this
Section 13.5.1. An OTP operating from a motor vehicle that serves as a mobile component (conveyance)
and is operating under the registration of the OTP and engages in maintenance and/or detoxification
treatment with narcotic drugs in schedules II-V, at a location or locations remote from, but within the same
state as, its registered location. Operating a mobile OTP is a coincident activity of an existing OTP, as
listed in § 1301.13(E).
“Motor Vehicle” means a vehicle propelled under its own motive power and lawfully used on public
streets, roads, or highways with more than three (3) wheels in contact with the ground. This term does not
include a trailer, as used in 21 C.F.R. Part 1300.01.
“OTP” means opioid treatment program.
“Review Of Systems” means an inventory of body systems obtained through a series of questions to
identify signs and/or symptoms the individual may be experiencing or has experienced.
“Special Exception Requests” are requests for take-home doses beyond what is allowed for an individual
who is prescribed a controlled substance at the time of the request. Requests must be sent to the state
authority for final approval.
“Split Dosing” means, in accordance with SAMHSA, the dispensing of a single dose of MOUD as
separate portions to be taken within a twenty-four (24) hour period. Split dosing is indicated among, but
not limited to, those individuals who: possess a genetic variant which increases methadone metabolism;
concurrently take other medications or drink alcohol that also induce hepatic enzymes leading to more
rapid metabolism of methadone; who are pregnant; or for whom methadone or buprenorphine are being
used to treat a concurrent pain indication in addition to the diagnosis of Opioid Use Disorder (OUD). This
leads to more stable, steady-state medication levels.
“Take-Home Dose” is a prescription of individually labeled bottles or containers of methadone and other
controlled substances, dose and quantity determined by prescribing qualified practitioner, and dispensed
to the individual. Each bottle or container is labeled with proper required DEA information.
“Take-Home Dose Callback” means a measure of dispensed controlled substance diversion control
wherein the OTP contacts and requests the individual to report back to the OTP within a reasonable
period (e.g., 24 to 36 hours) with all take-home doses dispensed by the OTP. This practice may be a
result of randomized individual selection or for-cause (when concerns of diversion are present) in nature.
The number of take-home doses remaining must correspond to the number expected based on
prescribed ingestion.
“Taper” refers to when an individual is being reduced on their dose for any reason, either of their own
accord or due to concerns that the medical director raises. Tapers are started with a medical order and
monitored by the medical personnel.
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“Torsades de Pointes” or simply Torsades, is a French term that literally means “twisting of the spikes.” It
refers to a specific, rare variety of ventricular tachycardia that exhibits distinct characteristics on the
electrocardiogram (ECG).
“Transfer” is when an individual transfers from one program to another without a break in treatment.
13.6 Opioid Treatment Program General Provisions
A. Opioid Treatment Programs (OTP) must provide treatment to individuals meeting criteria for
opioid use disorder according to the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5-TR) (2022)
B. Agencies applying to be licensed as an OTP must have the following:
1. Controlled substance license;
2. Drug Enforcement Administration (DEA) registration;
3. Substance Use and Mental Health Services Administration (SAMHSA) certification; and
4. Federal accreditation, when applicable.
C. In addition to OTP provisions beginning with 13.6., OTPs shall adhere to requirements listed
within 13.1 through 13.8.5.
13.6.1 Services for Pregnant and Postpartum Individuals
A. When prospective or currently enrolled individuals are pregnant or postpartum, the following
considerations shall be cared for through policies, procedures, and clinical documentation:
1. Agencies must provide admission to pregnant individuals within forty-eight (48) hours of
request for services or provide interim services until an admit date is available;
2. Confirmation of pregnancy for pregnancy-capable individuals upon OTP enrollment;
3. Agencies must not medically withdraw pregnant individuals receiving methadone or other
approved controlled substances without the approval of the Behavioral Health
Administration;
4. Prenatal care and other sex-specific services, including reproductive health services, for
pregnant and postpartum individuals shall be provided and documented either by the
OTP or by referral to appropriate healthcare practitioners; and
5. Evidence-based treatment protocols for the pregnant individual, such as split dosing
regimens, may be instituted after assessment by a qualified practitioner operating within
the OTP.
13.6.2 Admission Criteria
A. Agencies must follow all federal requirements in accordance with 42 C.F.R. Part 8 (2024), as
incorporated by reference in Section 13.5.B.
B. OTPS offering short-term or long-term detoxification treatment shall follow all applicable state and
federal laws, rules, and regulations regarding admission criteria.
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C. At time of admission, individuals shall be oriented to OTP policies and procedures, including, but
not limited to:
1. Benefits and risks of medication for Opioid Use Disorder;
2. Fee structure and payment options. This policy must include written acknowledgement of
understanding from the individual. The individual will be provided with a copy of this
document and a copy will be placed in the clinical record;
3. Conditions for dosing, counseling and toxicology sample collection. The policy must
include provisions for holding doses, evaluation of the “impaired” individual, treatment
stipulations and agreements, “refusal” or “inability” to provide specimens for toxicology
testing and unacceptable/unsafe behavior that limits the individual's ability to participate
in OTP;
4. Take-home treatment structure established by the OTP;
5. Special exception requests;
6. Consequences for violating policies; and
7. Written procedures and signed acknowledgements around the following shall include, but
not be limited to:
a. Behavioral agreements;
b. Office treatment lock-in;
c. Office treatment lock-out;
d. Reduction in take-home doses;
e. Administrative discharges;
f. Administrative transfers;
g. Guest dosing;
h. OTP transfer policy;
i. Taper protocol for any and all circumstances, including inability to pay;
j. Hospitalization while in OTP instructions, including clinic after-hours information;
k. Emergency procedures in case of a natural disaster, human-induced disaster, or
emergent closing of the clinic;
l. Use of prescription drug monitoring program in treatment;
m. Use of other prescription medications in treatment; and
n. Provisions around conditions for dosing.
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D. OTPs shall provide alternatives to admission denial due to lack of government-issued photo
identification. This is including, but not limited to, accepting various forms of suitable identification,
coordinating with BHA to establish a unique treatment identifier within the central registry system,
and direct referral to alternative MOUD (medications for opioid use disorder) treatment options.
E. Individuals re-admitted to treatment following treatment absences of six (6) months or more must
undergo medical evaluations, physical examinations, and/or laboratory tests as deemed
appropriate by an OTP medical director or qualified practitioner.
13.6.3 Prescribing, Dispensing, And Administering Approved Controlled Substances
A. An OTP medical director or a qualified practitioner shall order approved controlled substances
and document orders in individual records.
B. Exceptions to dosing regimens outlined in federal regulations shall require approval by BHA prior
to dosing.
C. Approved controlled substances must be administered by OTPs according to manufacturer's
specifications found on product labels and/or in printed instructions accompanying the product.
D. In circumstances where individuals must be administratively discharged from the agency OTP or
MOUD services, OTPs shall make a good faith documented effort to obtain appropriate consents
and coordinate transition of care to nearby MOUD treatment and other applicable services to
reduce the risk of opioid withdrawal and harm. When transfer effort is unsuccessful, OTPs shall
notify and coordinate with BHA before providing a safe medical taper due to inability or
unwillingness to pay. Pregnant individuals shall have the option to defer payment for treatment
and continue to receive MOUD.
E. OTP medical directors and leadership shall develop a medication induction protocol which
considers, on an individualized basis and among other factors, rate of dose adjustment and when
initiation of take-home dose protocol would be safe for the individual and community.
F. In an effort to prevent medication disruption, OTPs shall make a good faith effort to provide or
coordinate services for treatment-enrolled individuals in treatment settings outside of the agency,
including carceral settings.
13.6.4 Take-Home Dose Guidance
A. In accordance with 42 C.F.R. § 8.12(i)(2)(i-vi), as incorporated by reference in Section 13.5.B of
these rules, OTP decisions on dispensing MOUD to individuals for unsupervised use shall be
determined by an appropriately licensed OTP medical practitioner or the medical director. In
determining which individuals may receive unsupervised medication doses, the medical director
or program medical practitioner shall consider, among other pertinent factors that indicate that the
therapeutic benefits of unsupervised doses outweigh the risks, the following criteria:
1. Absence of active substance use disorders, other physical or behavioral health conditions
that increase the risk of individual harm as it relates to the potential for overdose, or the
ability to function safely;
2. Regularity of attendance for supervised medication administration;
3. Absence of serious behavioral problems that endanger the individual, the public, or
others;
4. Absence of known recent diversion activities;
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5. Whether take-home medication can be safely transported and stored; and
6. Any other criteria that the medical director or medical practitioner considers relevant to
the individual's safety and the public's health.
B. Buprenorphine products that are dispensed, compounded, and administered by an OTP do not
require time in treatment requirements as listed in this Part 13.6.4. However, an OTP is still
responsible for including all controlled substances dispensed, compounded, and administered in
their division control plan, including OTP directed buprenorphine take-home doses.
C. In accordance with 42 C.F.R. § 8.12(I)(3)(I-III), as incorporated by reference in Section 13.5.B,
such determinations and the basis for such determinations consistent with the criteria outlined in
13.6.4 of this section shall be documented in the individual's medical record. If it is determined
that an individual is safely able to manage unsupervised doses of MOUD, the dispensing
restrictions set forth in D.1 through D.3 of this section apply. The dispensing restrictions set forth
in paragraphs D.1 through D.3 of this section do not apply to buprenorphine and buprenorphine
products.
1. During the first fourteen (14) calendar days of treatment, take-home doses are limited to
a seven (7) day supply. It remains within the discretion of the qualified practitioner
operating within the OTP to determine the number of take-home doses up to seven (7)
days, but decisions must be based on the criteria listed in A.1-6. The rationale underlying
the decision to provide unsupervised doses of methadone must be documented in the
individual's clinical record.
2. From fifteen (15) calendar days of treatment, take-home doses are limited to a fourteen
(14) day supply. It remains within the discretion of the qualified practitioner operating
within the OTP to determine the number of take-home doses up to fourteen (14) calendar
days, but decisions must be based on the criteria listed in a.1-6. The rationale underlying
the decision to provide unsupervised doses of methadone must be documented in the
individual's clinical record.
3. From thirty-one (31) calendar days of treatment, take-home doses provided to an
individual are not to exceed a twenty-eight (28) day supply. It remains within the
discretion of the qualified practitioner operating within the OTP to determine the number
of take-home doses up to twenty-eight (28) days, but decisions must be based on the
criteria listed in A.1-6. The rationale underlying the decision to provide unsupervised
doses of methadone must be documented in the individual's clinical record.
D. In determining a safe amount of take-home doses for individuals transferring from one Colorado
OTP to another Colorado OTP, the receiving OTP shall determine and document the amount of
take-home doses provided by the previous OTP.
E. Individuals transferring from out of state must meet the Colorado state requirements for the take-
home doses they are requesting.
F. OTPs shall seek BHA and SAMHSA approval prior to providing take-home doses beyond limits
defined by 13.6.4 of this ruleset and 42 C.F.R. § 8.12(I)(3)(I-III) as incorporated by reference in
Section 13.5.
G. Take-home doses may be approved by OTPs for days clinics are closed, including Sundays and
state and federal holidays.
H. Take-home doses shall not be approved for individuals undergoing short-term supervised
withdrawal.
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I. Written agreements shall be developed and implemented for individuals approved for take- home
doses. Agreements must be part of the service plan and shall explain the rationale for approving
take-home medication, stipulate dose amounts, and set consequences for violating agreement
conditions.
J. Take-home doses shall be dispensed in medication containers that conform to state and federal
poison prevention packaging requirements, including childproof lids.
K. Labels must be affixed to containers with the following information:
1. OTP names, addresses, and telephone numbers;
2. Individual names;
3. Drug types;
4. Dose amounts, if not OTP medical director-authorized blind doses; and
5. Directions for use.
L. Take-home doses numbering six (6) or less shall be transported in a discrete and secure manner
agreed upon by OTPs and individuals.
M. Take-home doses numbering seven (7) or more shall be transported in locked, well-constructed
containers that resist tampering.
N. Take-home doses shall be securely and discretely stored in a manner that reduces the risk for
access by children and unauthorized persons.
O. OTPs must submit and obtain BHA approval for the following:
1. Take-home doses for individual supervised withdrawal lasting less than thirty (30)
consecutive calendar days
2. Take-home doses that do not conform to take-home dose requirements; and
3. Take-home doses for OTP individuals admitted to extended health care agencies,
licensed residential substance use disorder agencies, or carceral settings.
P. OTPs shall have policies and procedures for transporting methadone or other approved
controlled substances to individuals in residential treatment, carceral settings, or recovery
agencies, that include chain-of-custody documentation retained by the OTP and a secure plan for
storage from the facility.
Q. In the event of take-home medication theft, loss, or diversion, take-home dose replacement shall
not be provided until documented review and approval is given by a qualified practitioner within
the OTP. In-person dosing shall be continued in the event of take-home medication theft, loss,
misuse, or diversion.
R. OTPs shall offer either directly or through prescription, opioid antagonists for all individuals
receiving MOUD take-home doses.
13.6.5 Prescription Drug Monitoring Program (PDMP)
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A. Medical directors and other qualified health care professionals within the OTP shall utilize the
information obtained from the Colorado State Board of Pharmacy's Electronic Prescription Drug
Monitoring program (PDMP), developed pursuant to Section 12-280-403, C.R.S. The PDMP shall
be utilized at key decision-making points, including at intake and take-home dose consideration.
Documentation should include relevant recent prescription history and/or copy of results uploaded
to the clinical chart.
13.6.6 Diversion Control and Central Registry
A. OTPs shall maintain a current diversion control plan, which assigns responsibility to OTP medical
and administrative leadership and personnel for developing, performing, and monitoring
measures and functions described in OTP’s diversion control plan.
B. The diversion control plan shall include, at minimum, the following categories:
1. Program environment;
2. Dosing;
3. Take-home doses;
4. Take-home dose callbacks;
5. Prevention of multiple program enrollment; and
6. Misuse of prescription medication as outlined in SAMHSA federal OTP guidelines;
C. As a core function of diversion control, the following must occur:
1. Randomized take-home dose callbacks shall be performed and documented at a
minimum of two (2) per year for individuals whose take-home doses equal seven (7) or
greater and may coincide with random toxicology screens.
2. For-cause take-home dose callbacks shall be performed whenever take-home dose
diversion or misuse is suspected and OTPs shall develop written protocol to determine
consistently under which circumstances and how those take-home callbacks will be
conducted and documented.
D. OTPs shall prevent simultaneous enrollment of individuals in more than one (1) clinic by fully
participating in the behavioral health administration central registry, developed pursuant to
Section 27-80-215, C.R.S.
1. Prior to admitting applicants to treatment, OTPs shall initiate a clearance inquiry to BHA’s
central registry of OTP-enrolled individuals by submitting applicant information in BHA-
prescribed formats.
2. Applicant information must include:
a. Name:
b. Date of birth;
c. Proposed date of admission; and
d. Other information required by the individual clearance procedure.
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3. Applicants shall not be admitted to treatment when BHA’s central registry shows them as
currently enrolled in another OTP.
4. In the event that the central registry is inaccessible, not functioning, or BHA is closed, an
OTP shall contact another OTP within their geographic area to verify an individual’s
enrollment status.
5. OTPs must report clinic discharges to BHA’s central registry within three (3) business
days or immediately upon transfer.
E. By definition, mobile opioid treatment units and medication units operate under the license of an
OTP and therefore do not require a central registry account separate from the home OTP.
Individuals receiving services at either mobile or med units must be enrolled in the primary OTP’s
central registry. It is the OTP’s responsibility to prevent medication error and diversion across that
spectrum of service delivery.
13.6.7 Mobile Opioid Treatment Units and Medication Units
A. OTPs utilizing mobile opioid treatment units or medication units shall follow all applicable state
and federal regulations, including these BHA OTP rules as incorporated by reference in Part
13.5.1 of these rules.
B. OTPs are not required to obtain a separate behavioral health entity license or controlled
substance license for medication units or mobile opioid treatment units.
C. OTPs shall develop the following plans for mobile opioid treatment units or medication units:
1. Staffing plan;
2. Security plan;
3. Adequate handling and storage plan of controlled substances;
4. Contingency plans for mobile opioid treatment unit closure, including but not limited to,
adverse weather events, human-induced disasters, and unit breakdown for mobile
medication units only; and
5. Vehicle maintenance plan for mobile medication units only.
D. Mobile opioid treatment units and medication units shall comply with reporting requirements
determined by BHA pursuant to Part 2.16 of these rules.
E. OTPs shall submit current schedule of planned dosing stops for mobile medication units to BHA
prior to initiating care at those stops.
13.7 Personnel
13.7.1 OTP Medical Directors
A. An OTP must have a designated medical director who shall authorize and oversee other qualified
practitioners, other appropriately licensed and/or certified medical personnel and all medical
services provided.
B. The medical director must be available to the OTP for service provision or consultation.
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C. The medical director, qualified practitioners, and all other medical healthcare providers shall
currently possess and maintain licenses to practice medicine/nursing in compliance with the
credentialing requirements of their own profession in Colorado as provided by Article 240, Title
12, C.R.S. OTP medical directors shall assure appropriate credentials and training for other OTP
physicians and other qualified health care providers to dispense, compound or administer a
controlled substance in an OTP.
D. The medical director must complete an annual review of federal and state guidelines and rules to
ensure that the OTP agency is in compliance with all state and federal rules and regulations
regarding medical treatment for opioid use disorder.
E. The medical director shall sign an acknowledgment of review of all BHA-issued BHE and
controlled substance licensing violations and recommendations connected to the OTP.
F. OTPs utilizing a qualified practitioner shall have a plan that at minimum:
1. Identifies all qualified practitioners with prescriptive authority;
2. Identifies the number of hours practitioners with prescriptive authority are onsite weekly;
3. Establishes qualified practitioner supervision requirements, including review and
documentation of all medication orders for approved controlled substances and other
medications, which also includes subsequent dose adjustments and changes to take-
home doses; and
4. Addresses consultation requirements for when medical directors are not onsite.
G. OTP medical directors and qualified practitioners must ensure the following:
1. Medical evaluations are completed, including evidence of current physical dependence
and/or history of opioid use or exceptions to admission criteria that are documented prior
to initial dosing;
2. These medical evaluations are done at admission prior to initial dose;
3. The physical examinations and all appropriate laboratory tests are performed and
reviewed within fourteen (14) calendar days following treatment admission;
4. All medical professionals must educate individuals regarding risks and benefits of OTP
and document that individuals are entering voluntarily;
5. Other medical concerns shall be addressed by OTPs or referred to other medical
agencies when appropriate, as determined by an OTP medical director or a qualified
practitioner; and
6. All medical orders are properly signed or countersigned, including initial orders for
approved controlled substances and other medications, subsequent dose increases or
decreases, changes in take-home doses, emergency situations, and other special
circumstances by a qualified practitioner in an OTP, operating within scope of their
license.
H. Medical directors shall ensure that OTPs make documented efforts to outreach individuals
actively enrolled at the OTP who have missed three (3) or more consecutive doses.
13.7.2 OTP Sponsors
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A. OTP sponsors are responsible for the following:
1. Overall operation of the program, including, but not limited to:
a. Compliance with all applicable state and federal laws, rules, and regulations;
b. Medical and counseling personnel are qualified to provide opioid replacement
treatment;
c. Ensures an active medical director is assigned to the OTP and available for
supervision;
d. Individuals are enrolled on their own volition;
e. Full disclosure is made to individuals about opioids and their use in treatment
f. Written, informed consents for opioid replacement treatment are signed by
individuals eighteen (18) years of age and older;
g. Written, informed consents for all aspects of opioid replacement treatment
are signed by parents, legal guardians or other responsible adults designated by
appropriate state authorities for individuals under age eighteen (18) years old;
h. Written (OTP) policies and procedures are developed, implemented, and
maintained that are based on and in compliance with BHA rules;
i. All reasonable and clinically indicated efforts are made to coordinate treatment
with other healthcare and behavioral health providers. Documentation includes
obtaining individuals' consent to release information to communicate with those
practitioners;
j. Methadone and other controlled substances are disposed of in accordance with
the federal regulations; and
k. Printed acknowledgements are signed by individuals and kept in individual
records stating that they have been informed of the United States Department of
Transportation regulation against the use of OTP prescribed methadone
by commercial drivers and the possible loss of commercial driver's license if
taking methadone for an opioid use disorder is discovered.
13.7.3 Personnel Training
A. Training for new OTP personnel is documented in personnel records, including, but not limited to,
provisions of part 2.5.I of these rules and the following:
1. Federal OTP laws and regulations;
2. State OTP laws and regulations;
3. Agency OTP policies and procedures;
4. Clinical practices including, but not limited to:
a. Protocols around special exception requests;
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b. Take-home dose adjustment requests; and
c. Any take-home protocol such as holiday dosing, weekend dosing, hold doses,
hospitalization of individuals, incarceration, nursing home stays, and guest
dosing.
5. Pharmacology of methadone and other controlled substances, including, but not limited
to, loss of tolerance to opioids, dangerous drug or alcohol interactions, signs and
symptoms of overdose, and purpose of its use.
B. Annual training for OTP personnel, including, but not limited to:
1. Most current pharmacology of medications used, and clinical practices applicable to OTP,
including problems with interactions of medications ;
2. Review of federal and state regulations and rules;
3. Review of current agency OTP policies and procedures; and
4. Infectious disease risks and screening.
13.8 Service Delivery
13.8.1 Medical Evaluations
A. Individuals admitted to OTPs shall have medical evaluations conducted by a medical director or
qualified practitioner prior to the first dose.
B. In accordance with 42 C.F.R. § 8.12(F)(2)(B)(II), as incorporated by reference in Section 13.5, if
the practitioner is not a qualified practitioner operating within the OTP, the medical evaluation
must be completed no more than seven (7) days prior to OTP admission. Where the evaluation is
performed outside of the OTP, the written results and narrative of the examination, as well as
available lab testing results, must be transmitted, consistent with applicable privacy laws, to the
OTP, and verified by a qualified practitioner operating within the OTP.
C. Medical evaluations must include, at minimum, the following:
1. Past medical history, past substance use history, including required chronologies of
opioid use and dependence, choice of opioid, and route of administration;
2. Confirmation of evidence of current physical dependence, or diagnostic criteria for active
moderate to severe opioid use disorder (OUD), or OUD remission, or are at high risk for
disease recurrence or overdose;
3. Cardiovascular assessment for the risk of torsades de pointes; and
4. Other co-occurring conditions.
13.8.2 Physical Examinations
A. Physical examinations, informed by the results of history of present illness and comprehensive
review of systems, shall be conducted, evaluated, and documented in individual records by
medical directors or authorized OTP practitioners practicing within their scope, within fourteen
(14) consecutive calendar days following treatment admission and annually from date of
admission.
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B. In accordance with 42 C.F.R. § 8.12(F)(2)(B)(III), as incorporated by reference in part 13.5 of
these rules. The full exam can be completed by a qualified practitioner operating outside of the
OTP, if the exam is verified by a qualified practitioner operating within the OTP as being true and
accurate and transmitted in accordance with applicable privacy laws.
C. At a minimum, physical examinations shall consist of:
1. History of present illness;
2. Comprehensive review of systems; and
3. Vital signs (temperature, pulse, blood pressure, and respiratory).
D. When exam results indicate further testing or medical follow-up, the OTP shall make documented
efforts to educate the individual and make referrals to appropriate medical care.
13.8.3 Laboratory Tests
A. Admission laboratory tests shall be conducted either on-site or through referral, and results shall
be evaluated and documented in individual records within fourteen (14) consecutive calendar
days following treatment admission. When utilizing laboratory tests performed outside of the OTP
to comply with rule, the OTP must ensure tests are drawn not more than thirty (30) days prior to
admission to the OTP.
B. Screening for the following shall be documented and the following laboratory tests shall be
completed when clinically indicated:
1. Urine toxicology or other tests to determine current substance use;
2. Viral hepatitis, syphilis, tuberculosis, HIV/AIDS, sexually transmitted infections, and other
infectious diseases;
3. Complete blood count and differential;
4. Routine and microscopic urinalysis; and
5. Comprehensive metabolic panel (CMP).
C. The following laboratory tests shall be conducted with consent, every two (2) consecutive years
from date of admission when clinically indicated:
1. Viral hepatitis, syphilis, tuberculosis, HIV/AIDS, sexually transmitted infections, and other
infectious diseases; and
2. Complete blood count and differential;
3. Comprehensive metabolic panel (CMP).
D. When laboratory test results indicate further testing or medical follow-up, the OTP shall make
documented efforts to educate the individual and make referrals to appropriate medical care.
E. In accordance with 42 C.F.R. § 8.12 (f)(2)(b)(iii), as incorporated by reference in part 13.5 of
these rules, an individual’s refusal to undergo lab testing for co-occurring physical health
conditions should not preclude them from access to treatment, provided such refusal does not
have potential to negatively impact treatment with medications.
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13.8.4 Toxicology Screens/Urine Drug Screens
A. OTPs shall develop and implement policies and procedures that ensure a random sample
collection protocol that minimizes falsification and respectfully limits refusal to provide specimens
for testing, including offering alternative methods for testing.
1. Individuals shall have no notification prior to the day they are required to give a sample.
2. Individuals shall not be allowed to give a sample on days they normally attend the clinic
unless those days are coincidentally randomly assigned sample days.
B. OTPs shall develop and implement policies and procedures that establish treatment responses to
the following:
1. Evidence of unauthorized drugs in toxicology screens, including prescription medications;
2. Lack of all OTP-administered controlled substances in toxicology screens;
3. Dilute urine analysis;
4. Use of the prescription drug monitoring program; and
5. How the agency incorporates harm reduction and trauma-informed practices, and respect
for the gender identity of the individuals being screened.
C. Toxicology screens shall occur with the following frequencies:
1. One (1) toxicology screen at admission;
2. Eight (8) annual random toxicology screens;
3. An initial toxicology screen for individuals undergoing short-term supervised withdrawal;
4. An initial toxicology screen and at least one (1) random toxicology screen per month for
individuals undergoing long-term supervised withdrawal;
5. At least one (1) random toxicology screen during thirty (30) day reduction in take- home
doses due to diversion or other factors as indicated in 13.6.4 of this Chapter; and
6. If toxicology screening frequency is above standards listed in 13.8.4.C 1-5, the OTP shall
document medical or clinical necessity.
D. Refusal to provide samples for toxicology screens shall be considered to be positive toxicology
screens.
E. Dilute urinalysis will be reviewed and assessed.
F. The state authority will monitor drug trends and may require testing for additional substances that
pose a risk to health and safety of individuals receiving OTP services.
G. Results of OTP drug screening shall be utilized as a clinical tool for monitoring an individual’s
substance use patterns before and during treatment. The agency’s medical director shall ensure
that drug screen results are not to be utilized as the sole factor in the administrative discharge of
an individual from treatment in cases that do not involve negative drug screens for methadone
metabolite.
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13.8.5 Counseling Services
A. In accordance with 42 C.F.R. § 8.12(F)(5)(I)(II) & (III), as incorporated by reference in Part 13.5.1
of these rules, OTPs operating in Colorado shall follow the following standards of counseling
care:
1. OTPs must provide adequate substance use disorder counseling and psychoeducation to
each individual as clinically necessary and mutually agreed-upon, including harm
reduction education and recovery-oriented counseling. This counseling shall be provided
by a program counselor, qualified by education, training, or experience, to assess the
psychological and sociological background of individuals, and engage with individuals, to
contribute to the appropriate care plan for the individual and to monitor and update
individual progress;
2. OTPs must provide counseling on preventing exposure to, and the transmission of,
human immunodeficiency virus (HIV), viral hepatitis, and sexually transmitted infections
(STIs) and either directly provide services and treatments or actively link to treatment
each individual admitted or readmitted to treatment who has received positive test results
for these conditions from initial and/or periodic medical examinations;
3. OTPs must provide directly, or through referral to adequate and reasonably accessible
community resources, vocational training, education, and employment services for
individuals who request such services or for whom these needs have been identified and
mutually agreed-upon as beneficial by the individual and program staff;
4. Individual refusal of counseling shall not preclude them from receiving MOUD. OTPs
shall perform re-assessment of individual’s interest in counseling services at least every
one hundred and eighty (180) days and document as necessary in the individual's
service plan; and
5. As part of quality improvement planning, OTPs shall track, in addition to requirements
outlined in Chapter 2.17, OTP discharges, reasons for discharge, and progress to
retention improvement efforts.
Chapter 14: Recovery Support Services Organizations
14.1 Authority and Applicability
A. House Bill 21-1021 provides that it is in the best interest of the state to support the peer support
professional workforce through the creation of peer-run recovery support services organizations.
B. The general assembly authorized the Colorado Department of Human Services, in collaboration
with the Department of Health Care Policy and Financing, to promulgate rules establishing
minimum standards that recovery support services organizations must meet. § 27 -60-108(3)(A),
(C) C.R.S.
14.2 Definitions
“Licensed Mental Health Provider” means:
A. A mental health professional licensed or certified pursuant to Section 12-245-203(2), C.R.S.,
except for unlicensed psychotherapists pursuant to Section 12-245, C.R.S.
B. Advanced practice registered nurse registered pursuant to Section 12-255-111, C.R.S. with
training in substance use disorders or mental health.
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C. Physician assistant licensed pursuant to Section 12-240-113, C.R.S. with specific training in
substance use disorders or mental health.
D. Psychiatric technician licensed pursuant to Section 12-295-103(4), C.R.S.
E. Medical doctor or doctor of osteopathy licensed pursuant to Section 12-240-107, C.R.S.
14.3 License Requirement
A. Organizations shall apply for and obtain a recovery support services organization license if:
1. They are a peer-run organization providing peer support to individuals with behavioral
health disorder; and
2. The organization is seeking reimbursement through Medicaid.
B. All applicants for a recovery support services organization license shall demonstrate compliance
with these rules and all applicable state and federal regulations and statutes.
14.4 Annual License
A. Each approved recovery support services organization that provides peer support and seeks
reimbursement through Medicaid shall obtain a BHA-issued recovery support services
organization license annually.
B. Peer-run service providers are not required to seek RSSO licensure to provide services unless
they seek Medicaid reimbursement for peer support services rendered under a peer -run service
provider.
14.5 General Provisions
14.5.1 Service Provisions
A. Recovery support services organizations may provide a variety of nonclinical, recovery -focused
services and supports. These services shall include engaging individuals in peer -to-peer
relationships that support healing, personal growth, life skills development, self -care, and crisis-
strategy development to help achieve recovery, wellness, and life goals. These services may
include, but are not limited to:
1. Peer-run drop in centers;
2. Recovery and wellness centers;
3. Employment services;
4. Prevention and early intervention activities;
5. Peer mentoring for children and adolescents;
6. Warm lines; or
7. Advocacy services.
B. A peer support professional may provide services on behalf of a recovery support services
organization in a variety of clinical and nonclinical settings that may include, but are not limited to:
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1. Justice-involved settings;
2. Physical health settings, such as pediatrician or obstetric and gynecological health care
offices;
3. Emergency departments;
4. Services delivered via telehealth;
5. Agencies serving homeless communities;
6. Peer respite homes;
7. School-based health centers; or
8. Home and community-based settings.
C. Recovery support services organizations must have an established process by which the
organization coordinates its services with those rendered by other agencies, including treatment
agencies, to ensure an uninterrupted continuum of care to persons with behavioral health
disorders.
14.5.2 Staff Requirements and Training
A. Recovery support services organizations must employ or contract with a licensed mental health
provider pursuant to Section 12-245-203(2), C.R.S. to administer on-going supervision of peer
support professionals employed or contracted by recovery support services organizations. The
licensed mental health provider must be in good standing with their credentialing body and must
demonstrate in a manner determined by the behavioral health commissioner having received
formal training specific to:
1. Provision of peer support services;
2. Supervision of peer support professionals; and
3. Role of peer support professionals.
B. For peer support professionals with less than twelve (12) months experience, individual
supervision by the licensed mental health provider of sufficient length to address needs for a
minimum of thirty (30) minutes, two (2) times per month is required. For peer support
professionals with more than twelve (12) months experience, individual supervision by the
licensed mental health provider of sufficient length to address needs for a minimum of thirty (30)
minutes, once per month is required. Supervisors shall maintain documentation of all supervisory
sessions.
C. Recovery support services organizations must employ or contract with peer support professionals
who have successfully completed formal training covering all content areas outlined in “core
competencies for peer workers in behavioral health services – 2018” established by United States
Department of Health and Human Services’ Substance Abuse and Mental Health Services
Administration (SAMHSA) and does not include any later amendments or editions. These
regulations are available at no cost at https://www.samhsa.gov/ and are also available for public
inspection and copying at the Colorado Department of Human Services, Behavioral Health
Administration, 710 S. Ash St, Suite C410, Denver, CO 80246 during regular business hours.
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D. Peer support professionals must obtain a certification as a peer support professional and be in
good standing with their certifying body.
E. All staff employed or contracted by a recovery support services organization must comply with
background checks and employment verification processes outlined in 2 CCR 502 -1 Part 2.5 and
be verified at least annually.
14.5.3 Documentation Requirements
A. Recovery support services organizations shall comply with release of information requirements
pursuant to 2 CCR 502-1 Part 2.7.13.
B. Recovery support services organizations shall comply with consent requirements pursuant to 2
CCR 502-1 Part 2.7.a.7.
C. Recovery support services organizations shall maintain records of the services provided to
individuals by the RSSOs. The record shall be shared with BHA pursuant to a procedure
determined by the behavioral health commissioner. For each encounter in which services are
provided, the record shall contain:
1. Date of service;
2. Total contact time with person;
3. Session setting/place of service;
4. Reason for the encounter and description of services provided; and
5. Provider’s dated signature and relevant qualifying credential.
D. Recovery support services organizations shall have policies and procedures that address at a
minimum:
1. Experience and hiring requirements for peer support professionals and licensed mental
health providers;
2. The program's standards of practice and code of ethics;
3. Training for peer support professionals related to providing support services;
4. Training for licensed mental health providers related to the supervision of peers;
5. A description of each aspect of the program, including staff roles and responsibilities and
how the organization meets the description of “peer run”;
6. The program’s care coordination policy, including referral procedures;
7. The handling of grievances and complaints by individuals receiving services;
8. Reporting and reviewing critical incidents in accordance with 2 CCR 502-1 Part 2.16;
9. Compliance with confidentiality, HIPAA, and 42 C.F.R. Part 2; and
10. Methods for recording information required by 2 CCR 502-1 Part 14.5.3.
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14.5.4 Site Visits
A. Routine monitoring: recovery support services organization licensing visits shall be scheduled
and conducted by BHA during the RSSO’s normal business hours to the extent possible.
B. BHA shall conduct unscheduled site visits for specific monitoring purposes and investigation of
complaints or critical incidents involving approved organizations that have a recovery support
services organization license. These unscheduled visits shall be in accordance with the:
1. Recovery support services organization license rules;
2. BHA policies and procedures; and
3. Any statutes and regulations that protect the confidentiality of individual identifying
information, including HIPAA and 42 C.F.R. Part 2 as incorporated by reference in Part
1.2 of these rules.
C. BHA shall have access to all individual, organization, and staff records and any other relevant
documentation required to determine compliance with these rules and to coordinate individual
services.
D. Site inspection may be required at the sole discretion of BHA.
14.6 Ethical Standard
A. Recovery support services organizations shall ensure that peer support professionals adhere to
ethical standards. Violations of ethical standards include:
1. Performing duties outside of the scope of practice of a peer support professional;
2. Any breach of professional boundaries between a peer support professional and an
individual receiving services, including relationships of a sexual or romantic nature
between the peer support professional and individual receiving services;
3. Fraudulent activity, including but not limited to misrepresenting credentials and falsifying
records;
4. Failure to meet generally accepted standards of peer support professional practice; or
5. Any conduct described in 2 CCR 502-1 Part 2.24.
14.7 Critical Incident Reporting
A. Critical incident reporting shall occur in accordance with 2 CCR 502-1 Part 2.16.
14.8 Licensing Procedures
14.8.1 Initial Licenses
A. Applications for initial licenses for RSSOs shall be submitted and processed according to
procedures outlined in 2 CCR 502-1 Part 2.18.
B. The application fee for an RSSO license shall be two hundred dollars ($200).
C. No initial license shall issue prior to BHA inspection per 2 CCR Part 2.18.
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14.8.2 Provisional Licenses
A. Provisional licenses may be granted under the circumstances and through the processes
described in 2 CCR Part 2.19.
14.8.3 License Renewal
A. License renewal shall be conducted according to processes outlined in 2 CCR 502- 1 Part 2.20.
14.8.4 Conditional License
A. Conditional licenses may be granted under the circumstances and through the processes
described in 2 CCR 502-1 Part 2.24.3.
14.8.5 License Revocation, Denial, Suspension, Limitation, or Modification
A. A license may be revoked, denied, suspended, limited, or modified according to 2 CCR Part
2.24.2.
B. A license may be revoked, denied, suspended, limited, or modified if an individual providing
services under the organization’s auspices violates ethical standards outlined in 2 CCR 502-1
Part 2.24.2.a.
C. A recovery support services organization that has a limited, suspended, or modified license will
maintain that licensure status even if the recovery support services organization changes its
name but retains the same supervising licensed mental health provider.
14.8.6 Inactivation or Surrender of a License
A. No recovery support services organization license shall be inactivated except with BHA’s
approval. A recovery support services organization may request inactivation at any time. Approval
to inactivate a license will not be unreasonably denied. Inactivation or surrender of a license will
not avoid discipline if otherwise justified.
14.9 Appeal
A. Any recovery support services organization adversely affected or aggrieved by these rules or by
BHA's decisions in regard to implementation of these rules has the right to appeal a BHA action
in accordance with 2 CCR 502-1 Part 2.24.5.
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CHAPTER 15: DESIGNATION OF FACILITIES PROVIDING EATING DISORDER TREATMENT AND
RECOVERY SERVICES
15.1 Authority
A. Chapter 15 establishes the conditions that a provider must meet in order to be designated to
provide services for eating disorder treatment and recovery (EDTR). The statutory authority for
the promulgation of these regulations is set forth in Section 27-65-128, C.R.S., Section 27-65.5-
101, C.R.S., Section 26-1-107(5)(b), C.R.S., and Section 26-1-107(6)(g), C.R.S.
B. As of January 1, 2026, the Behavioral Health Administration (BHA) shall require all eating
disorder treatment and recovery facilities to hold an appropriate designation based on the level of
care the facility provides, including facilities that offer intensive outpatient treatment, partial
hospitalization, residential programs, and inpatient programs. Licensed clinicians who are not
facility-based and offer behavioral health therapy to individuals with an eating disorder on an
outpatient basis are not required to hold a designation.
C. Any facility providing involuntary eating disorder treatment and recovery services must also obtain
a 27-65 facility designation from BHA pursuant to Sections 27-65-101 through 27-65-132, C.R.S.
1. If there is any conflict between the Rules of this Chapter 15 and the requirements of
Article 65 of Title 27, C.R.S. and/or Chapter 11, the requirements of Chapter 11 and/or
the 27-65 designation shall supersede these Chapter 15 rules.
15.2 Definitions
“Administration” for the purpose of this Chapter 15 means assisting a person in the ingestion, application,
inhalation, or, using universal precautions, rectal or vaginal insertion of medication, including prescription
drugs, according to the legibly written or printed directions of the attending physician or other authorized
practitioner or as written on the prescription label and making a written record thereof with regard to each
medication administered, including the time and the amount taken, but “administration” does not include
judgment, evaluation, or assessments or the injections of medication, the monitoring of medication, or the
self-administration of medication, including prescription drugs and including the self -injection of
medication by the resident. “Administration” also means ingestion through placement and use of
gastrostomy tubes or naso-gastric tubes, if administered by a person authorized pursuant to Sections
25.5-10-204 (2)(j) and 27-10.5-103 (2)(i), C.R.S., as part of inpatient, residential or day programming
services provided through designated facilities and supervised by a licensed physician or nurse.
“Affiliate of an Entity,” for the purposes of this Chapter 15, means:
A. A person or entity that owns more than five percent of the ownership interest in the business
operated by the designee or the applicant for a license;
B. An executive, office member of the governing board, or employee of an entity; or
C. A relative of an entity who is otherwise involved in the management or operations of the facility or
agency.
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“Eating Disorder(s)” means a range of irregular eating patterns characterized by disturbance of eating or
eating-related behaviors that results in altered consumption or absorption of food as defined and updated
by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5- TR), as
incorporated by reference in Part 1.2 of these Rules; or, significantly impairs physical health, mental
health and/or psychosocial functioning. This does not include food restriction related to lack of food
availability, religious and/or spiritual practices, except as it impacts the health or safety of the individual,
or developmentally normal behaviors.
“Eating Disorder Treatment” means treatment to address the physical, mental, and behavioral aspects of
an individual’s struggles with an eating disorder. Eating disorder treatment may include, but is not limited
to, psychotherapy, psychiatric care and monitoring, medical care and weight monitoring, nutritional
support, medications, or any combination of these approaches.
“Eating Disorder Treatment Facility” means a facility that offers, but is not limited to, one or more of the
following levels of care for individuals with eating disorders: inpatient, residential services, partial
hospitalization, and/or intensive outpatient programs as these levels of care are described in Chapters 1
through 10 of these Rules.
“Facility” for the purposes of this Chapter 15, means an agency, general hospital, psychiatric hospital,
behavioral health entity, residential child care facility (RCCF), or similar, designated by BHA for the
purposes of providing eating disorder treatment and recovery services.
“Informed Consent” means an informed assent that is freely given. It is always preceded by the following:
A. An explanation of the nature and purpose of the recommended treatment or procedure in
layman's terms and in a form of communication understood by the individual or the individual’s
designated representative;
B. An explanation of the risks and benefits of a treatment or procedure, the probability of success,
mortality risks, and serious side effects;
C. An explanation of the alternatives with the risks and benefits of these alternatives;
D. An explanation of the risks and benefits if no treatment is pursued;
E. An explanation of the recuperative period, which includes a discussion of anticipated problems;
and
F. An explanation that the individual, or the individual’s designated representative, is free to
withdraw consent and to discontinue participation in the treatment regimen at any time with the
exception of an involuntary feeding tube pursuant to Part 15.16.4 of this Chapter 15.
“Medical emergency” for eating disorder treatment means an acute injury or illness that poses an
immediate risk to a person's life or long-term health.
“Medical necessity” means treatment that is recommended or ordered by a licensed Colorado health-care
provider. The following factors, at a minimum, must be considered when determining medical necessity or
the appropriate level of care for an individual diagnosed with an eating disorder:
A. The individual’s eating or compensatory behaviors;
B. The individual’s need for supervised meals and support interventions;
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C. Physical exam data and laboratory results, including but not limited to, the individual’s heart rate,
renal or cardiovascular activity, blood pressure, and degree of malnutrition;
D. The recovery environment; and
E. Co-occurring disorders the individual may have.
"Minor," for purposes relating to consent for mental health services and for this Chapter 15, means a
person under eighteen (18) years of age; except that the term does not include a person who is fifteen
(15) years of age or older who is living separately and apart from the person’s parent or legal guardian
and is managing the person’s own financial affairs, regardless of the person’s source of income, or who is
married and living separately and apart from the person’s parent or legal guardian.
"Patient Representative" means a person designated by a mental health facility to process patient
complaints or grievances or to represent patients who are minors pursuant to Section 27- 65-104(4),
C.R.S.
“Physical Activity,” for the purposes of this Chapter 15, means the free movement and motion of an
individual’s body.
“Physical Exercises” for the purposes of this Chapter 15, means the individual’s movement or
manipulation of their body in a specific manner or process to be carried out for a specific purpose in
response to a request, order, or direction.
“Transitional Measures” means physical guidance, prompting techniques of short duration, or an initial
temporary approved physical positioning of an individual at the onset or in response to a re- escalation
during a physical management, for the purpose of quickly and effectively gaining physical control of that
individual in order to prevent harm to self or others.
15.3 Designation Requirements
A. Facilities designated to provide eating disorder treatment and recovery shall be in compliance
with the requirements listed in this Chapter 15 and, if providing involuntary services Chapter 11 of
these Rules.
B. All providers providing eating disorder treatment and recovery services pursuant to Article 65.5 of
Title 27, C.R.S., shall meet the applicable standards in this Chapter 15. If the facility requires any
other license, designation, and/or endorsement type, the facility shall also comply with those
applicable standards.
15.4 Eating Disorder Designation Procedures
15.4.1 Application Process
A. Entities applying for eating disorder designation shall submit an application to BHA on a state-
approved form, available on BHA’s website.
B. Applicants providing eating disorder treatment and recovery pursuant to Section 65.5 of Title 27,
C.R.S., must apply for a separate eating disorder designation based on the unique physical
address of each site. If two or more buildings or units share a physical address, each building or
unit must be designated separately for eating disorder services.
C. BHA will provide written notice to the applicant within thirty (30) calendar days of receipt of a
complete application.
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D. BHA will act on an application within ninety (90) calendar days of receipt of the completed
application. The applicant may be approved for eating disorder designation, granted provisional
approval, or the application may be denied.
E. An applicant approved as a facility designated to provide eating disorder treatment and recovery
services, shall receive a designation, effective for up to a one (1) year period.
F. BHA may deny an application for an eating disorder treatment and recovery designation if the
applicant has been an affiliate of an entity, an affiliate of an agency, or an affiliate of a facility
which is the subject of a previous negative licensing action or is the subject of a pending
investigation by any Department that may result in a negative licensing action.
G. If the application for eating disorder designation is denied, the reason(s) for denial shall be
provided in a certified letter to the address of the applicant as shown on the application or to the
address subsequently furnished in writing by the applicant. If an applicant disagrees with the
decision, the applicant, if within sixty (60) days of receiving notice of the decision, may request a
hearing to review the denial pursuant to Sections 24-4-105 and 24-4-106, C.R.S.; or upon
remedying the noted deficiencies, may re-apply for an eating disorder designation in accordance
with this Part 15.4.
15.4.2 Provisional Designation
A. Provisional designation approval may be granted for a period not to exceed ninety (90) calendar
days if, after initial inspection and review of an application:
1. The applicant is in substantial compliance with these Rules and is temporarily unable to
conform to all the minimum standards required under these Rules. No provisional eating
disorder designation shall be issued to an applicant if the operation of the facility may
adversely affect individual health, safety, or welfare of individuals in care;
2. Compliance will be achieved within the ninety (90) day duration of the provisional
designation; and
3. The applicant has a reasonable plan or schedule in writing for achieving compliance and
provides a written copy of the plan to BHA.
B. The applicant shall provide proof that attempts are being made to conform and comply with
applicable rules.
C. A second provisional designation approval for a period not to exceed ninety (90) calendar days
may be granted under the same criteria if necessary to achieve compliance.
D. If the applicant is not able to come into compliance within one hundred and eighty (180) calendar
days from the date of initial provisional designation being granted, the application may be denied
with a right to request a hearing as described in Part 15.4.1.G of this Chapter 15.
15.4.3 Conditional Designation
A. A conditional eating disorder designation may be granted to a facility found to be out of
compliance with applicable BHA or state and federal regulations prior to issuance of a renewal
designation or during a current designation period. The facility will be notified in writing of non-
compliance areas and the need for a plan of action as described in Part 15.8 of this Chapter 15.
B. A conditional eating disorder designation will replace the current eating disorder designation for a
period not to exceed ninety (90) calendar days.
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C. Administrative and treatment activities may be limited by a conditional designation as set forth in
the conditional designation while the facility addresses corrective actions.
D. A conditional designation may be re-issued for an additional period not to exceed ninety (90)
calendar days if substantial progress continues to be made and it is likely that compliance can be
achieved by the date of expiration of the second conditional designation.
E. If the facility fails to comply with or complete a plan of action in the time or manner specified, or is
unwilling to consent to the conditional designation, the modification to a conditional designation
shall be treated as a revocation of the designation. The facility shall be notified by certified mail of
the deficiencies and the reason for action. BHA may then institute revocation proceedings
pursuant to Part 15.6.2 of this Chapter 15.
15.4.4 Change in Designation
A. If a facility makes a change in its designation status or decides to drop its designation, it shall
notify BHA in writing no later than thirty (30) calendar days prior to the desired effective date. The
facility shall submit a written plan for the transfer of care for the persons with eating disorders if
the facility will no longer treat those individuals. This plan shall be submitted no later than ten (10)
business days prior to the effective date.
15.4.5 Designation Renewal
A. A facility seeking eating disorder designation renewal shall provide BHA with a completed eating
disorder designation application at least sixty (60) calendar days prior to the expiration of the
existing eating disorder designation.
B. Eating disorder designation renewal applications received by BHA after the current designation
expiration date has passed shall be returned to the facility by certified first-class mail and/or
through electronic means with written notification that the eating disorder designation is no longer
in effect. Applicants may reapply for an initial eating disorder designation in accordance with Part
15.4.1 of this Chapter 15.
C. Eating disorder designation renewal applications that are received by BHA fewer than sixty (60)
calendar days prior to the expiration of their existing eating disorder designation is a basis from
which BHA may deny the renewal application.
1. If BHA denies the renewal application for being untimely, BHA will provide the facility with
notice of the decision by certified first-class mail. If the facility disagrees with the decision,
it may request a hearing as described in Part 15.4.1.G of this Chapter 15.
2. Any facility that submits its renewal application fewer than sixty (60) calendar days prior
to the expiration of the current eating disorder designation and does not receive a new
eating disorder designation prior to that date and/or notice that BHA decided to deny the
renewal application may reapply for an initial eating disorder designation in accordance
with Part 15.4.1 of this Chapter 15.
D. Failure of a facility seeking renewal of a designation to accurately answer or report any
information requested by BHA shall be considered good cause to deny the eating disorder
designation renewal application.
E. Facilities designated to provide care and treatment to persons with eating disorders pursuant to
Section 27-65.5-101, C.R.S. shall receive an annual review by BHA for compliance.
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F. Facilities shall be notified in writing of non-compliance areas and the need for a plan of action as
outlined in Part 15.8 of this Chapter 15. A conditional eating disorder designation may be granted.
G. A facility in compliance with applicable Rules of this Chapter 15 and state and federal regulations
may be granted an eating disorder designation effective through the expiration date, for a period
not to exceed one (1) year.
15.5 Change of Ownership/Management
A. If a designated eating disorder facility undergoes a change in ownership without following the
procedures outlined in this Part 15.5, its existing designation may be terminated. Termination of
the designation for this basis may not occur until after a hearing and in compliance with the
provisions and procedures specified in Sections 24-4-101 through -109, C.R.S.
B. When a designated eating disorder facility initiates a change of ownership, the facility must
submit notification to BHA within the specified time frame, and the prospective new facility shall
submit an application and supporting documentation for change of ownership within the same
time frame. The time frame for submission of the notification and the application, and supporting
documentation shall be at least thirty (30) calendar days before a change of ownership involving
any designation facility.
C. Each designated eating disorder facility undergoing a change of ownership shall submit an
application as prescribed in Part 15.4.1 of this Chapter 15.
D. The existing designated eating disorder facility is responsible for correcting all rule violations and
deficiencies in any current plan of action before the change of ownership becomes effective. In
the event that such corrective actions cannot be accomplished in the time frame specified, the
prospective facility shall be responsible for all uncorrected rule violations and deficiencies
including any current plan of action submitted by the previous facility unless the prospective
facility submits a revised plan of action, approved by BHA, before the change of ownership
becomes effective.
E. When BHA issues a designation to the new owner, the previous owner must return its designation
to BHA within five (5) calendar days of the new owner’s receipt of its designation.
15.6 Enforcement and Adverse Actions
15.6.1 Designation Denial
A. BHA may deny an application for an initial or renewal designation for reasons including but not
limited to the following:
1. The application or accompanying documents contain a false or misleading statement of a
material fact;
2. The facility/applicant fails to respond to BHA requests for additional information in the
time frame indicated in the request;
3. The facility/applicant refuses any part of an inspection;
4. The facility/applicant fails to comply with or successfully complete an acceptable plan of
action;
5. The facility/applicant has failed to cooperate with the investigation of any local, state, or
federal regulatory body or law enforcement agency;
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6. The facility/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 individual(s) served;
7. The facility/applicant was or is affiliated with a person or entity that is the subject of a
previous negative licensing action; or
8. The facility/applicant is the subject of a pending investigation by BHA that may result in
negative enforcement action.
B. If BHA denies an application for an initial or renewal designation, it shall provide the facility with a
written notice by certified mail to the applicant or designee at the address shown on the
application. The notice must explain the basis for the denial and afford the facility the opportunity
to respond.
C. Appeals of designation denials must be conducted in accordance with the State Administrative
Procedure Act, Sections 24-4-101 through -109, C.R.S., and Section 26-1-106, C.R.S.
15.6.2 Revocation or Suspension of Designation
A. BHA may limit, revoke, or suspend an existing designation if a facility fails or refuses to comply
with the statutory and/or regulatory requirements applicable to its designation or to other licenses,
endorsements, approvals, or designations the facility may have from BHA. BHA may limit the
overall designation, physical locations, or both, for failure or refusal to comply. Failures to comply
include, but are not limited to:
1. Making a false or misleading statement of material fact about individuals served by the
facility, its personnel, capacity, or other operational components verbally or in any public
document or in a matter under investigation by BHA or another governmental entity;
2. Preventing, interfering with, or attempting to impede in any way the work of a
representative or agent of BHA in investigating or enforcing the applicable statutes or
regulations;
3. Falsely advertising or in any way misrepresenting the facility’s ability to provide services
for the individuals served based on its designation type and/or status;
4. Failing to provide reports and documents required by regulation or statute in a timely and
complete fashion;
5. Failing to comply with or complete a plan of action in the time or manner specified;
6. Falsifying records or documents;
7. Knowingly using or disseminating misleading, deceptive, or false information;
8. Accepting commissions, rebates, or other forms of remuneration for referrals or other
treatment decisions;
9. Exercising undue influence or coercion over an individual to obtain certain 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 an individual; or
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10. Non-compliance with the requirements of Section 27-65.5-101, C.R.S., and any
applicable regulations promulgated pursuant to those statutes.
B. Except in the case of a summary suspension in accordance with Section 24-4-104(4)(a), C.R.S.,
suspension or revocation must not occur until after a hearing and in compliance with the
provisions and procedures specified in Section 24-4-101 through Section -109, C.R.S.
15.6.3 Right to Appeal
A. Any facility adversely affected or aggrieved by BHA’s decisions in regard to implementation of
these Rules has the right to appeal to the Colorado Department of Personnel and Administration,
Office of Administrative Courts, and may subsequently seek judicial review of BHA’s action in
accordance with Sections 24-4-101 through -109, C.R.S.
B. The following actions may be submitted to an Administrative Law Judge for an evidentiary
hearing: denial of a designation; denial of a designation renewal; provisional designation;
conditional designation; revocation; denial of a waiver; limitation of a designation; denial of a
modification; and imposition of an intermediate restriction or condition.
C. After written notification from BHA of intended action, the facility has twenty-one (21) calendar
days to submit a written appeal. The appeal must be received by BHA within twenty -one (21)
calendar days from the date the written notification of action letter was sent by BHA.
D. In all cases except waiver denials, BHA will file a Notice of Charges with the Office of
Administrative Courts to begin the administrative process. In waiver denials, if the applicant for
the waiver requests an appeal, the request for appeal must be forwarded to the Office of
Administrative Courts. Once the appellant’s request is forwarded to the Office of Administrative
Courts, BHA may file a Notice of Charges.
E. Subsequent to an evidentiary hearing at the Office of Administrative Courts and the issuance of a
final agency decision, a party may seek to appeal the final agency decision through judicial
review in accordance with Section 24-4-106, C.R.S.
15.6.4 Closure of a Facility
A. Each eating disorder treatment and recovery designation issued by BHA will become invalid if the
facility fails to timely renew the designation, ceases operation, or there is a final BHA action
suspending or revoking the designation. The designation certificate must be returned to BHA
within ten (10) calendar days of the event that invalidated it.
B. Emergency Closures
1. In the event of an emergency affecting the physical space of the facility that necessitates
the removal of individuals and personnel from the facility, the facility shall provide BHA
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 facility to provide services that meet the health and safety needs of the
individuals. Based on the extenuating circumstances, BHA may approve the continuation
of the designation during the time period that it takes to make the physical space
appropriate for individuals and personnel to return.
C. Permanent Closures
1. Each facility that surrenders its designation shall accomplish the following with regard to
any individual records that the entity is legally obligated to maintain:
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a. Within ten (10) calendar days prior to closure, inform BHA in writing of the
specific plan for storage and retrieval of individual records;
b. Unless noted otherwise within an endorsement chapter, within ten (10) calendar
days of closure, inform all individuals or designated representatives thereof, in
writing, how and where to obtain their individual records; and
c. Provide secure storage for any remaining individual records.
2. In the event of a facility closure, the facility shall be responsible for appropriate continuity
of care for each individual served by the facility.
15.7 Rule Waivers
A. This Part establishes procedures with respect to the waiver of regulations relating to facility
designation.
B. Any facility or applicant that has applied for or been issued a designation to operate an eating
disorder and treatment recovery facility has the right to apply for a waiver of any rule or standard
set forth in these Rules which, in their opinion, poses an undue hardship on the applicant, facility,
or community.
C. Nothing contained in these provisions negates the obligation of the facility/applicant to meet
minimum requirements under local safety, fire, electrical, building, zoning, and similar codes.
D. Nothing herein authorizes a waiver of any statutory requirement under state or federal law, except
to the extent permitted therein.
E. Upon application to BHA, a waiver may be granted in accordance with this Part 15.7. Absent the
existence of a current waiver issued pursuant to this part, designated facilities are expected to
comply at all times with all applicable regulations except in instances where they are granted a
provisional designation in accordance with Part 15.4 of this Chapter 15. Designated facilities must
comply with all applicable regulations unless and until a waiver is granted.
F. Waiver applications must be submitted to BHA in writing.
1. BHA will only consider one regulation per waiver.
2. The waiver application must provide BHA information related to:
a. The regulation the facility or applicant is requesting to waive;
b. The reason why the waiver is being requested;
c. A proposed alternate compliance plan; and
d. Any other information relevant to the waiver request that would inform BHA’s
decision in either granting or denying the waiver.
3. The waiver application must be submitted by an authorized representative of the facility
or applicant, who is the primary contact person and the person responsible for ensuring
that accurate and complete information is provided to BHA.
G. In making its determination, BHA may consider any information it deems relevant, including but
not limited to:
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1. Critical incident and complaint investigation reports, licensure or certification survey
reports, anticipated impact of the waiver on individual safety and quality of care if any,
and findings of these reports related to the facility and/or the operator or owner thereof.
2. When determining whether a waiver should be granted, BHA shall prioritize consideration
of the impact of the waiver on the health, safety, and welfare of individuals over any
alleged undue hardship.
H. BHA shall act on a waiver application within ninety (90) calendar days of receipt of the completed
application. An application will not be deemed complete until the facility or applicant has provided
all information and documentation requested by BHA.
I. BHA may specify terms and conditions under which any waiver is granted, including which terms
and conditions must be met in order for the waiver to remain effective. The term for which each
waiver granted will remain effective must be specified at the time of issuance, but may not exceed
the term of the current designation.
1. At any time, upon reasonable cause, BHA may inspect a facility with an active waiver to
ensure that the terms and conditions of the waiver are being observed, and/or that the
continued existence of the waiver is otherwise appropriate.
2. Within thirty (30) calendar days of the termination, expiration, or revocation of a waiver,
the facility shall submit to BHA an attestation of compliance with the regulation to which
the waiver pertained.
J. A waiver will automatically terminate upon a change of ownership of the facility, as outlined in
Part 15.5 of this Chapter 15. However, to prevent such automatic termination, the prospective
new owner may submit a waiver application to BHA prior to the effective date of the change of
ownership. Provided BHA receives the new application by this date, the waiver will be deemed to
remain effective until such time as BHA acts on the application.
1. Except as otherwise provided in this Part 15.7, a waiver may not be granted for a term
that exceeds the current designation term.
2. If a facility wishes to maintain a waiver beyond the stated term, it must submit a new
waiver application to BHA not less than ninety (90) calendar days prior to the expiration
of the current term of the waiver or with a designation renewal.
K. BHA may revoke a waiver if it determines that:
1. The waiver's continuation jeopardizes the health, safety, or welfare of individuals served
by the facility;
2. The waiver application contained false or misleading information;
3. The terms and conditions of the waiver have not been complied with;
4. The conditions under which a waiver was granted no longer exist or have changed
materially; or,
5. A change in a federal or state statute or regulation prohibits, or is inconsistent with, the
continuation of the waiver.
L. Notice of the revocation of a waiver must be provided to the facility in accordance with the
Colorado Administrative Procedures Act, Sections 24-4-101 through -109, C.R.S.
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M. A facility may appeal the decision of BHA regarding a waiver application or revocation, as
provided in the Colorado Administrative Procedure Act, Sections 24-4-101 through -109, C.R.S.
15.8 Continuing Obligations and BHA Oversight
A. Each facility must have and maintain electronic business communication tools, including but not
limited to internet access and a valid e-mail address. The facility must use these tools to receive
and submit information.
B. The designation is only valid while in the possession of the facility to whom it is issued and may
not be subject to sale, assignment, or other transfer, voluntary or involuntary, nor is a designation
valid for any premises other than those for which it was originally issued.
C. The facility must provide accurate and truthful information to BHA during inspections,
investigations, and licensing activities.
D. When a facility is subject to inspection, certification, or review by other agencies, accrediting
organizations, or inspecting companies, the facility shall provide and/or release to BHA, upon
request, any correspondence, reports, or recommendations concerning the facility that were
prepared by such organizations.
E. Each facility must submit notification to BHA of any change in the information required by Part
15.4 of this Chapter 15 from what was contained in the last submitted designation application.
1. Changes to the operation of the facility may not be implemented without prior approval
from BHA. A facility shall, at least thirty (30) calendar days in advance, submit notification
to BHA regarding any of the following proposed changes.
a. Change in designation or license category.
b. Change in the scope of services, including the addition or removal of a service or
a physical location.
c. Change in legal name of the facility and all other names used by it to provide
services.
F. BHA and any duly authorized representatives thereof have the right to enter upon and into the
premises of any facility or applicant for an eating disorder treatment and recovery designation in
order to determine the state of compliance with the statutes and regulations, and must initially
identify themselves to the person in charge of the facility at the time.
G. BHA may use the following measures to ensure a facility’s full compliance with the applicable
statutory and regulatory criteria.
1. BHA may conduct an unscheduled or unannounced review of a current facility based
upon, but not limited to, the following criteria:
a. Routine compliance inspection;
b. Reason exists to question the facility’s continued fitness to conduct or maintain
designated operations;
c. A complaint alleging non-compliance with designation requirements;
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d. Discovery of previously undisclosed information regarding a facility or any of its
owners, officers, managers, or other personnel if such information affects or has
the potential to affect the facility’s provision of services; or
e. The omission of relevant information from documents requested by BHA or
indication of false information submitted to BHA.
2. Plan of action
a. If after review or pursuant to a complaint, it is determined that a facility is not in
compliance with these Rules, the facility shall be notified in writing, within thirty
(30) calendar days of the specific deficiency/deficiencies.
b. After any review, BHA may request a plan of action from a facility or require a
facility’s compliance with a BHA-directed plan of action.
c. If the facility does not agree with any or all of the findings regarding non-
compliance, the facility has fourteen (14) calendar days from the receipt of the
non-compliance notice to dispute the findings by submitting evidence to BHA.
d. The facility shall receive a written response within thirty (30) calendar days of the
review of submitted evidence.
e. If the submitted information is sufficient, the facility shall be determined in
compliance with these Rules.
f. If the facility continues to be found out of compliance with these Rules, the facility
shall have thirty (30) calendar days from the date of receipt of the review findings
to submit a plan of action.
g. The plan of action must be in the format prescribed by BHA and include, but not
be limited to, the following:
(1) A description of how the facility will correct each identified deficiency.
(a) If deficient practice was cited for specific personnel, 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 individual (s) and/or other individuals
having the potential to be affected.
(2) A description of how the facility will monitor the corrective action to
ensure each deficiency is remedied and will not reoccur, and
(3) A completion date that is no later than ninety (90) calendar days from the
issuance of the deficiency list, unless otherwise required or approved by
BHA. The completion date is the date that the entity deems it can
achieve compliance.
h. A completed plan of action must be:
(1) Signed by the facility’s director, administrator, or manager, and
(2) Submitted to BHA within thirty (30) calendar days after the date of BHA’s
written notice of deficiencies.
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(a) If an extension of time is needed to complete the plan of action,
the facility shall request an extension in writing from BHA prior to
the plan of action due date. BHA may grant an extension of time.
i. BHA has discretion to approve, impose, modify, or reject a plan of action.
(1) If the plan of action is accepted, BHA shall notify the facility by issuing a
written notice of acceptance.
(2) If the plan of action is unacceptable, BHA shall notify the facility in
writing, and the facility shall resubmit the changes within the time frame
prescribed by BHA.
(3) If the facility fails to comply with the requirements or deadlines for
submission of a plan or fails to submit requested changes to the plan,
BHA may reject the plan of action and impose disciplinary sanctions as
set forth in Part 15.6 of this Chapter 15.
(4) If the facility fails to implement the actions agreed to by the action date in
the approved plan of action, BHA may impose enforcement sanctions as
set forth below.
H. The facility must provide, upon request, access to or copies of the following to BHA for the
performance of its regulatory oversight responsibilities:
1. Individual records.
2. Reports and information, including but not limited to staffing reports, census data,
statistical information, and other records, as determined by BHA.
I. Oversight and enforcement activities may include review of separate physical locations as
necessary for BHA to ensure the health, safety, and welfare of individuals.
15.9 General Eating Disorder Designation Provisions
15.9.1 Eating Disorder Designation General Standards
A. The facility shall only provide services for which it holds/has a designation, approval, and/or
another BHA license.
B. Facility designation applies only to the physical location(s) listed on the eating disorder
designation certificate from BHA and not to any other non-designated physical locations operated
by the facility.
C. The eating disorder facility shall ensure all operations, locations, and services, including
contracted services or personnel, comply with laws, regulations, and standards as required for
any additional BHA-issued licenses, designations, or approvals the facility may hold.
15.9.2 Critical Incident Reporting
A. A critical incident includes but is not limited to the following:
1. Breach of confidentiality: any unauthorized disclosure of protected health information as
described in HIPAA, 42 C.F.R. Part 2, as incorporated by reference in Part 1.2 of these
Rules, and/or Sections 27-65-101 through -131, C.R.S.
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2. Death: including the death of an individual inside of or outside of the facility’s physical
location while an individual is receiving services or where an individual has attempted to
receive services from the facility within the past thirty (30) calendar days.
3. Elopement: absconding from a mental health hold, certification, emergency/involuntary
commitment, or a secure facility where an individual is being held as a result of a court
order. This includes any unauthorized absence of a child, when a child cannot be
accounted for or when there is reasonable suspicion to believe the child has absconded.
4. Any instance when an individual cannot be located following a search of the facility, the
facility grounds, and the area surrounding the facility, and:
a. There are circumstances that place the individual’s health, safety, or welfare at
risk; or
b. The individual has been missing for eight (8) hours.
5. Medication diversion: any medication diversion as defined in Part 1.2 of these Rules shall
also include theft, loss, misuse, or illicit distribution of any prescription medication.
6. Medication error: a medication error that resulted or could have resulted in harm to the
individual.
7. Medical emergency: any suicide attempt/self-injury, other form of serious injury, health
emergency, overdose, or serious illness that occurred on facility premises or in the
presence of facility personnel.
a. This does not include the individual’s need for medical stabilization while
receiving eating disorder treatment and recovery services, such as electrolyte
imbalance, glucose level, or other medical conditions as a result of the eating
disorder.
(1) When an individual leaves the program to receive medical services and
returns after stabilization, a critical incident report to BHA is not required.
(2) When an individual leaves the program to receive medical services and
does not return, a critical incident report is required to be submitted to
BHA in accordance with Part 15.9.2 of this Chapter 15.
8. Any instance involving physical, sexual, or verbal abuse of an individual, as described in
Sections 18-3-202, 18-3-203, 18-3-204, 18-3-206, 18-3-402, 18-3-404, 18-3-405, 18-3-
405.3, 18-3-405.5, and 18-9-111 (exempting however, the phrase “intended to harass”),
C.R.S. by another individual, personnel, or a visitor to the facility.
9. Any instance that results in any of the following serious injuries to an individual:
a. Brain or spinal cord injuries;
b. Life-threatening complications of anesthesia or life-threatening transfusion errors
or reactions; or,
c. Second- or third-degree burns involving twenty percent (20%) or more of the
body surface area of an adult or more than fifteen percent (15%) of the body
surface area of a child.
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10. Any instance involving caretaker neglect of an individual, as defined in Section 26 -3.1-
101(2.3), C.R.S., or child abuse or neglect as defined in Section 19-1-103(1), C.R.S.
11. Any instance involving misappropriation of an individual’s property, meaning patterns of
loss or single incidences of deliberately misplacing, exploiting, or wrongfully using, either
temporarily or permanently, an individual’s belongings or money without the individual’s
consent.
12. Any occurrence involving the malfunction or intentional or accidental misuse of care
equipment that occurs during treatment or diagnosis of an individual and that significantly
or adversely affects or, if not averted, would have significantly adversely affected an
individual.
B. Critical incidents must be reported to BHA within one (1) business day after the incident. Critical
incidents must also be reported to BHA within one (1) business day of when the facility
determines that a reportable incident has occurred and BHA requests such reporting.
C. BHA may conduct scheduled or unscheduled site reviews for specific monitoring purposes and
investigation of critical incident reports in accordance with:
1. BHA policies and procedures,
2. Regulations that protect the confidentiality and individual rights in accordance with
Sections 27-65-101 through -131, C.R.S.; HIPAA; and 42 C.F.R. Part 2, as incorporated
by reference in Part 1.2 of these Rules.
D. BHA shall have access to the relevant documentation required to determine compliance with
these Rules.
1. Refusal to provide relevant information, documentation, or access to any part of the
facility may result in adverse licensing action.
E. The facility must:
1. Establish written policies and procedures for reporting and reviewing all critical incidents
occurring at the facility;
2. Submit critical incident reports to BHA using state-prescribed forms that can be obtained
from BHA’s website at: https://bha.colorado.gov/for-providers. This is not in lieu of other
reporting mandated by state statute or federal guidelines;
3. Make available a report with the investigation findings for review by BHA, upon request;
and,
4. Maintain critical incident reports for a minimum of three (3) years following the incident
unless it would violate any other federal or state law.
F. Nothing in this Part shall be construed to limit or modify any statutory or common law right,
privilege, confidentiality, or immunity.
15.9.3 Policies and Procedures
A. Any facility designated for eating disorder treatment and recovery must develop, implement, and
every three (3) years review the following policies and procedures listed below:
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1. The governing body shall have policies and procedures regarding administrative and/or
clinical oversight of the designated services and requirements.
2. Personnel needed for services and staffing ratios for direct care;
a. Required education and training; and
b. Background checks as listed in 15.10.2.
3. Training schedules and demonstration of training for personnel;
4. Emergency and crisis protocol(s);
5. Record protection, sharing, and retention protocol;
6. Disclosure of intervention, treatment, and/or medication;
7. Policies and procedures regarding the use or non-use of restraint, seclusion, and/or
physical management pursuant to Part 15.15 of this Chapter 15;
8. Continuity and transfer of care upon admittance and discharge from the facility;
9. Communication of rights of individuals;
10. Facility rules and how they are communicated to individuals receiving services, including
visitation and dress code expectations;
11. Weight monitoring procedures, including the prohibition of using body mass index (BMI)
as the only measure of medical necessity;
12. Critical incident reporting;
13. Treatment and care for transgender and gender non-conforming individuals, including
use of restroom facilities, preferred pronouns, and assessment of the individual’s related
gender identity needs;
14. Use of restroom facilities, bathing, supervision, and documentation of restroom activities,
including policies that prohibit requiring individuals to share a stall of a restroom or a
single-occupancy bathroom while in the act of using the restroom:
a. With another individual in care at any time; and
b. With personnel, unless medically indicated;
(1) Documentation showing the individual’s need for assistance in the
restroom shall be maintained as part of the clinical record as described in
Part 15.11 of this Chapter 15. The need for assistance shall be reviewed
at least every seven (7) calendar days and updated in the clinical record.
c. Policies and procedures must be in line with the Patient Bill of Rights as
described in Part 15.14 of this Chapter 15; and
15. Respect and accommodation of a patient’s sexual orientation, gender identity, religion,
and unless clinically contraindicated, personal dietary ethics;
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16. Meal times, dietary practices, and meal planning/preparation.
B. Any policies and procedures in subparts of this Chapter 15 must be followed in addition to those
listed in this part.
C. Weight monitoring policies and procedures shall reflect, at a minimum, the following
requirements:
1. How individuals shall be weighed without other individuals present in the same room,
when requested.
2. Individuals shall be allowed to wear their own clothing during a weigh-in or the facility
shall provide clothing that provides privacy and covers the individual's body.
a. If the facility provides the individual with alternative clothing, the clothing shall not
be transparent; and
b. Individuals shall not be required to remove their undergarments.
3. The facility shall not require physical exercises during a weigh-in.
a. If the treatment provider has sufficient cause to believe that the individual would
be at risk of harm without requiring a physical exercise, at which point the
treatment provider shall document the concern and need for further investigation
in the individual's clinical record.
(1) Utilizing physical exercise during a weigh-in may only be used to obtain
accurate weight information, as described in the facility’s policies and
procedures.
b. If the individual is asked to perform any physical exercises, they must be
provided a space with sufficient privacy that preserves the individual's dignity to
the greatest extent possible.
4. Only personnel with appropriate training or credentials, as described in the facility’s
policies, shall be allowed to monitor individual weigh-ins.
D. All policies and procedures listed in this Chapter 15 must be created and implemented within the
facility’s trauma-informed and trauma-aware framework as described in Part 15.9.4 of this
Chapter 15.
15.9.4 Trauma-Informed Care and Treatment
A. Any facility providing eating disorder treatment and care must implement a trauma -informed
treatment network and must create policies and procedures that support the implementation of a
trauma-informed treatment framework. The trauma-informed framework, utilizing an evidence-
based model, must include at a minimum:
1. Safety: Ensuring physical, social, emotional, and psychological safety of all individuals
receiving care;
2. Trustworthiness and Transparency: Prioritizing the therapeutic relationship between
personnel and individuals receiving services when personnel perform multiple functions
within the facility;
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3. Collaboration and Mutuality: Empowering individuals and their identified supportive others
to have their voice heard and their choice(s) considered in the decision-making process;
4. Cultural, Historical, and Gender issues: How the facility will promote access, cultural
affirmation, and anti-discrimination practice; and
5. Support and Self-help: Ways to build healthy relationships and interactions.
B. Facilities designated for eating disorder treatment and recovery must review the trauma- informed
framework and corresponding policies and procedures every three (3) years. Revisions to
framework and policies must reflect current best practices and be data-informed. Data used in the
revision process must include, but is not limited to:
1. The facility’s performance improvement plan;
2. The facility’s use of seclusion and/or restraint;
3. The facility’s internal critical incidents tracking; and
4. Satisfaction surveys from individuals and/or family members.
C. All personnel shall be trained in evidenced-informed, trauma-informed practices and the facility’s
trauma-informed framework as part of the initial orientation training in addition to the requirements
of Part 15.10.2 of this Chapter 15.
1. All personnel shall receive annual training on trauma-informed practices, the facility’s
framework, and applications of trauma-informed care for eating disorder treatment and
recovery.
D. Behavior Management
1. Each facility shall have written documentation of policies and procedures that describe
the trauma-informed model upon which the behavior management system is based and
who shall be responsible for any disciplinary measures.
2. The behavior management system shall be explained to the individual, the individual’s
legal guardian or legal custodian upon admission. The behavioral management system
must be explained in a manner that takes into account the individual’s developmental and
cognitive level.
3. The behavior management system shall include, at a minimum:
a. Positive and constructive components, such as talking with the individual about
the situation, positive reinforcement, skill training, and skill development;
b. Clear rules and expectations with predictable, consistent consequences or
interventions that will be used by the facility’s personnels to reinforce positive
behaviors and to address unsafe behaviors;
c. A continuum of de-escalation and redirection techniques;
d. A review process for addressing chronic or acute behavioral concerns when the
individual is not responding to the behavior management plan;
e. Individuals shall not be disciplined by other individuals in care; and
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f. Therapeutic services or clinically appropriate coping tools shall not be withheld
as part of the behavior management system.
4. The program will have a monitoring process of the behavior management system to
assure both consistency in implementation and for continuous quality improvement as
needed to address changing client needs and behaviors.
5. All interventions utilized as part of the behavior management system shall be
documented in the individual’s clinical record.
15.9.5 Quality Improvement Plan
A. The facility must develop and implement a quality improvement (QI) plan that is designed to
monitor and improve safety, quality of care, trauma-informed practices, and treatment outcomes
and meets the following criteria:
1. Utilizes a data-driven approach to identify patterns and trends in the data;
2. Analyzes the data to determine what improvements and changes must be implemented;
and
3. Is reviewed and/or modified no less than quarterly based on outcomes data.
B. The QI plan must be submitted to the Division of Quality and Standards, Licensing and
Designation of BHA, annually as part of the facility’s re-designation application.
15.10 Personnel And Safety Requirements For Eating Disorder Designated Facilities
15.10.1 General Building Safety
A. Each facility shall be in compliance with all applicable local zoning, housing, fire, and sanitary
codes and ordinances of the city, city and county, or county where it is situated.
B. The facility shall provide an interior environment that is clean and sanitary, maintained and in
good repair, free of hazards to health and safety.
1. Facilities shall have policies and procedures to ensure the facility is kept in good repair,
maintenance is conducted as needed or on a routine basis, and hazards are identified
and removed within a specified timeframe.
2. Items that could pose a threat to the health, safety, and welfare of an individual shall be
kept in a manner that is inaccessible to individuals in care.
C. The facility shall ensure the prominent posting of evacuation routes and exits in each physical
location.
D. The facility shall prominently post the hours of operation at the entrance of each physical location
and on the facility’s website.
E. There shall be separate identified room(s) to allow for private conversations and counseling
sessions.
F. Restroom stalls and bathroom facilities shall comply with the following standards:
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1. Facilities shall provide gender non-conforming and transgender individuals with the same
policies provided for cisgender individuals.
2. Individuals shall not be required by a facility to share a stall of a restroom or a single-
occupancy bathroom while in the act of using the restroom:
a. With another individual in care at any time; and
b. With personnel, unless medically indicated.
(1) Should an individual in care need assistance utilizing restroom facilities
from personnel, such as through the use of a gait belt for physical
stability, the facility shall document within the individual’s record the need
for medical assistance.
15.10.2 Personnel
A. Any personnel who are physically or mentally unable to adequately and safely perform duties that
are essential functions may not be assigned duties as direct care personnel or volunteer at an
eating disorder treatment and recovery facility. Facilities shall outline criteria in their policies and
procedures for determining whether a person is able to safely perform duties in its policies and
procedures.
B. The facility shall not employ or allow any personnel who are under the influence of a controlled
substance, as defined in Sections 18-18-203 through -207, C.R.S., or who are under the
influence of alcohol in the workplace. This does not apply to personnel using controlled
substances under the direction of a physician and in accordance with their health care provider’s
instructions, as long as it does not pose a safety risk to the person, other personnel, or
individuals.
C. The facility shall employ sufficient personnel to ensure that the provision of services meets the
needs of individuals. The facility shall:
1. Ensure each physical location must have at least one person trained in cardio- pulmonary
resuscitation (CPR) and first aid on-site and on-duty at all times when individuals are
present.
a. Telehealth-only service providers are exempt from this requirement.
D. If the facility administers medications to individuals while in care, the facility shall ensure that, at
minimum, one of the following qualified personnel is available to administer medications at all
times:
1. Licensed practical nurse, registered nurse, advanced practice registered nurse,
physician, physician’s assistant, pharmacist, or qualified medication administration
person (QMAP).
E. All personnel assigned to direct individual care must be qualified through either professional
credentials, education, training, and/or experience in the principles, policies, procedures, and
appropriate techniques for providing individual services.
1. Personnel providing individual services must be legally authorized to provide the service
in accordance with applicable federal, state, and local laws.
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2. Licensed, certified, and/or registered personnel must have an active license, certification,
or registration in the State of Colorado and may only provide services within their scope
of practice.
3. The facility shall verify the license, certification, or registration, and check for any
disciplinary action against personnel providing individual services, through the Colorado
Department of Regulatory Agencies or other state or federal agency no more than thirty
(30) days before official hire date prior to hire.
4. The facility shall create policies and procedures regarding supervision of all personnel
pursuant to Parts 15.10.2 and 15.10.3 of this Chapter 15.
F. The facility shall obtain, prior to hire or contract of new personnel or acceptance of persons for
volunteer service, if that volunteer service involves unsupervised direct contact with individuals
receiving services, a name-based criminal history record check for each prospective personnel or
volunteer.
1. If the prospective personnel has lived in Colorado for more than three (3) years at the
time of application, the facility shall obtain a name-based criminal history report
conducted by the Colorado Bureau of Investigation (CBI).
a. Designated facilities providing services to individuals under the age of 18 years
must also, prior to hiring or accepting new personnel, submit to the Federal
Bureau of Investigation (FBI) a complete set of fingerprints taken by a qualified
law enforcement agency to obtain any criminal record held by the FBI, for each
prospective personnel. Payment of the fee for the criminal record check is the
responsibility of the facility. No direct contact with children may take place until
the background check is cleared by the FBI.
2. If the prospective personnel has lived in Colorado for three (3) years or less at the time of
application, the facility shall obtain a name-based criminal history report for each state in
which the prospective personnel has lived during the past three (3) years, conducted by
the respective states’ bureaus of investigation or equivalent state-level law enforcement
agency, or a national criminal history report conducted by the federal bureau of
investigation.
3. The facility must conduct sex offender searches in the Colorado Bureau of Investigation
(CBI) sex offender registry and the national sex offender public website operated by the
United States Department of Justice for each operator, applicant for employment, current
employee, or any individual who has direct contact with children/youth or is associated
with the designation prior to the first day of employment or service at the facility.
a. Records of the checks must be maintained in the employee file and include the
following criteria at minimum:
(1) Known current names and prior names, or known aliases, of each
individual.
4. The facility shall bear the cost of obtaining such information.
5. If a facility contracts with a staffing agency for the provision of services, it shall require
that the staffing agency meet the requirements of Part 15.10.2 of this Chapter 15.
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6. When determining whether a prospective personnel is eligible for hire or contract, if the
criminal history record check reveals the person has a conviction or plea of guilty, active
deferred judgment, or nolo contendere, the facility shall follow its policy developed in
accordance with Part 15.10.2 of this Chapter 15.
7. All background check results shall be maintained as part of the personnel record and in
accordance with applicable state and federal laws.
G. The facility shall have written personnel policies developed in accordance with Part 15.10.2 of this
Chapter 15, including, but not limited to:
1. Line of authority/management hierarchy of personnel.
2. Job descriptions/responsibilities.
3. Written criteria and procedures for evaluating which convictions or complaints make
prospective personnel unacceptable for hire, or for existing personnel unacceptable for
retention, including:
a. Factors to be considered when determining whether prospective personnel are
eligible for hire when their criminal history record check reveals a conviction or
plea of guilty, active deferred judgment, or nolo contendere, including, but not
limited to:
(1) The nature and seriousness of the offense;
(2) The nature of the position and how the offense relates to or may impact
the duties of the position. Experience in the criminal justice system is not
necessarily a disqualifier and, in certain circumstances, a facility may
determine that some lived experiences would benefit a particular
position;
(3) The length of time since the conviction or plea;
(4) Whether such conviction is isolated or part of a pattern; and
(5) Whether there are mitigating or aggravating circumstances involved.
4. Conditions of employment, including but not limited to:
a. That personnel refrain from sexual or romantic relationships between supervisors
and supervisees and sexual or romantic relationships with individuals served.
5. Position qualifications and required credentials.
6. Orientation, training, and continuing education requirements for the populations served
and services provided.
a. Policies and procedures for professional development and ongoing training shall
be based on trauma-informed care and the facility’s policies around
implementation of their trauma-informed model.
7. Routine monitoring of personnel credentials and disciplinary actions.
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8. Requirements for self-reporting of new or current investigations, criminal charges,
indictments, or convictions that may affect the personnel’s ability to carry out their duties
or functions of the job.
9. Policies requiring all personnel to be free of communicable diseases that can be readily
transmitted in the facility.
a. All personnel who have direct contact with individuals must be required to have a
tuberculin skin test prior to direct contact with individuals. In the event of a
positive reaction to the skin test, evidence of a chest x-ray and other appropriate
follow-up may be required in accordance with community standards of practice.
b. Designated facilities providing telehealth services only are exempt from this
requirement.
H. The facility shall ensure that all personnel have access to and know about the facility’s policies,
procedures, and state and federal laws and regulations relevant to their respective duties.
I. All designated facilities shall ensure there is at least one patient representative and/or advocate
available during the hours of operations.
1. The patient representative is responsible for the following:
a. Primary contact for grievances received from individuals receiving care, or their
family members;
b. Address individual inquiries, concerns, or complaints;
c. Acting as a member of the multidisciplinary team; and
d. Ensuring the individual has the necessary support and information to make
informed decisions about their care.
J. The facility must maintain records on all personnel, including, but not limited to:
1. Date of hire;
2. Job description;
3. Results of criminal history record checks;
4. Documentation of professional credentials, education, and training;
5. Documentation of any disciplinary action taken against the person by a credentialing
body;
6. Documentation of orientation and training;
7. Evidence of review of the facility’s policies, procedures, and state and federal laws and
regulations relevant to their respective duties; and
8. Documentation of tuberculosis testing and results, or vaccination documentation, for
personnel who have direct contact with individuals.
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K. Treatment personnel, for the purpose of eating disorder treatment and recovery services, unless
otherwise noted, means the following behavioral health professionals trained in mental health
and/or substance use disorder identification and treatment and acting within their scope of
practice:
1. Authorized practitioners;
2. Licensees;
3. Candidates;
4. A registered nurse, licensed pursuant to Part 255 of Title 12, C.R.S.;
5. Counselors-in-training, students, and/or interns.
a. If utilizing counselors-in-training, students, and/or interns, the facility shall have
the following policies and procedures:
(1) Supervision of counselors-in-training, students, and/or interns;
(a) Total number of students and/or interns the facility can accept;
(b) How often supervision and consultation will be provided; and
(c) What services are appropriate for students and/or interns to
provide.
(2) Ensuring that all clinical documentation is reviewed and co-signed by a
clinical supervisor able to supervise pursuant to their scope of practice;
and
b. The use of counselors-in-training, students, and/or interns shall not be a
substitute for services provided by licensees or authorized practitioners.
15.10.3 Leadership Personnel Requirements and Responsibilities
A. Facility director
1. The facility director is responsible for the following:
a. Overall direction and responsibility for the individuals, program, facility, and fiscal
management;
b. Overall direction and responsibility for supervision of personnel;
c. The selection and training of a capable personnel member who can assume
responsibility for management of the facility in the director’s absence; and
d. The establishment of relationships and maintaining contact with allied facilities,
services, and mental health resources within the community.
2. Qualifications of a facility director:
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a. The facility director shall have at minimum, received a bachelor’s degree from an
accredited college or university and have three (3) years of verified experience in
the human services field, one of which was in a supervisory or administrative
position; or,
b. The facility director shall have at minimum, received a master’s degree from an
accredited college or university and have two (2) years of verified experience in
the human services field, one of which was in a supervisory or administrative
position.
3. Assistant or acting facility director:
a. In each facility, there shall be a specifically designated personnel member
capable of acting as a substitute for the facility director during their absence. The
duties and responsibilities of the acting facility director shall be clearly defined
within the facility’s policies and procedures in order to avoid confusion and
conflict among other personnel and individuals.
b. If the facility director is regularly absent from the facility for more than fifty percent
(50%) of their working hours, an assistant or acting director shall be appointed
who meets the qualifications outlined in this Part 15.10.3.
B. Clinical director
1. The clinical director is responsible for the following:
a. Assuring that there is adequate training and supervision for personnel;
b. Multidisciplinary personnel members are practicing within their scope;
c. Ethical standards are upheld;
d. Ensure services are provided in an appropriate, trauma-informed manner and as
indicated by screenings and assessments; and
e. Ensure clinical oversight of the facility’s personnel in accordance with Parts
15.10.2 and 15.10.3 of this Chapter 15.
2. Qualifications of a clinical director:
a. The clinical director shall possess a master’s degree or doctoral degree in a
mental health-related field or a bachelor’s degree in a mental health-related field
plus five (5) years of related work experience.
b. The clinical director shall possess a valid clinical license to practice medicine
and/or behavioral health services in the State of Colorado.
15.10.4 Personnel Training Requirements For Eating Disorder Designated Facilities
A. In addition to training identified in Part 15.10.2 of this Chapter 15, facilities designated for services
under these Rules shall develop policies and procedures for personnel training curriculum and
schedules in order to meet the following requirements. Training shall be conducted in a trauma-
informed, culturally competent, and linguistically competent manner.
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B. All supervisory and direct care personnel shall receive training or facility certification of
competency in the recognition and response to common side effects of psychiatric medications.
These personnel shall be trained to respond to emergency drug reactions in accordance with the
facility's policies.
C. All personnel who administer restraint, and/or physical management techniques shall receive
training and/or certification prior to direct care with individuals.
1. On an annual basis, the facility shall provide training and/or certification to refresh
restraint skills, prevention strategies, and de-escalation in accordance with the facility's
restraint model.
2. Facilities providing treatment and care to individuals under eighteen (18) years of age
shall complete refresher training and/or certifications on a semi-annual basis.
D. All program administrators and program supervisory personnel shall receive annual training or
annual facility certification of competency on alternative or representative medical decision
making, including, but not limited to, advance directives, medical durable powers of attorney,
proxy decision making, and guardianships.
E. The facility must ensure that all personnel complete an initial orientation on basic infection
prevention and control, safety, and emergency preparedness procedures.
F. The facility must ensure that all personnel receive the following training prior to working
independently with individuals, and on a periodic basis consistent with policies developed in
accordance with the following:
1. Training specific to the particular needs of the populations served, including the provision
of person-centered, trauma-informed, harm reduction-focused, physically and
programmatically accessible, and culturally and linguistically responsive services;
including, but not limited to:
a. Weight stigma;
b. Gender responsive care for individuals with disordered eating;
c. Developmentally (age and cognitive functioning) responsive care;
d. Neurodivergence; and
e. Inclusivity (racism).
2. Infection control;
3. Emergency preparedness, including de-escalation of potentially dangerous situations,
including but not limited to threats of violence, acts of violence, and abuse/mistreatment
of an individual;
4. Critical incident reporting;
5. Suicide prevention;
6. Individual rights of the population served;
7. Confidentiality, including individual privacy and records privacy, and security;
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8. Facility policies and procedures;
9. Mandatory reporting requirements for suspected abuse or neglect in accordance with
Section 19-3-304, C.R.S.; and
10. Understanding basic pharmacology and medications that are relevant to the treatment
type and population served by the facility.
G. Personnel providing residential/overnight services shall also be trained in the following:
1. The recognition and response to common side effects of medications used for behavioral
health disorders, and response to emergency drug reactions;
2. Behavior management and de-escalation techniques, including incidents involving harm
to self or others, and elopement; and,
3. Behavioral health and medical emergency response training, consistent with emergency
services policies required in Part 15.9.2.E.1 of this Chapter 15.
4. Personnel preparing or serving food shall complete food safety training.
a. At a minimum, this must include that personnel overseeing dietary services shall
have knowledge of foodborne disease prevention, including, but not limited to,
hygienic practices and food safety techniques pertaining to preparation, food
storage, and dishwashing.
15.11 Individual Records
15.11.1 General Procedures for Individual Records
A. Records shall be kept in conformity with Part 15.11 of this Chapter 15, applicable federal and
state laws, and shall contain, at a minimum, the following:
1. Demographic and medical information;
a. Individual’s full name, including any known aliases, if applicable;
b. Individual’s date of birth, sex/gender identity, marital status, and social security
number, where needed for Medicaid or employment purposes;
c. Individual’s current address of residence;
d. Date of admission;
e. Name, address, and telephone number of relatives or parent, legal custodian,
legal guardian or legal representative(s), or other person(s) to be notified in an
emergency;
f. Name, address, and telephone number of the individual’s primary physician, and
case manager if applicable, for use in emergency;
g. Religious preference, if any;
h. Individual’s diagnoses, at the time of admission;
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i. Current record of the individual’s allergies;
j. Screenings, assessments, reassessments, service plans, documentation of
informed consent, releases of information, documentation of services, treatment
progress notes, admission summary, and discharge summary;
(1) Treatment progress notes shall include the following:
(a) Documentation of all treatment procedures, including, but not
limited to: physical restraint, seclusion, mechanical restraint,
medications voluntary and involuntary, and other therapies or
interventions.
(b) Information regarding any serious injury of or by the individual
and the circumstances and outcome.
(c) Documentation of all transfers, whether permanent or temporary,
and reasons for transfer.
(d) Consultations and/or case reviews.
(e) Pertinent information from outside facilities or persons or from
the individual.
2. Medication administration record, if applicable;
3. Personal belongings inventory, including any prescribed medications, if applicable;
4. Records of required communications with outside sources; and
5. Physician’s orders.
B. Individual records must be available to an individual or their designated representative through
the facility or their designated representative at reasonable times and upon reasonable notice in
accordance with all applicable state and federal laws, including but not limited to the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) and 42 C.F.R. Part 2, as
incorporated by reference in Part 1.2 of these Rules.
1. If the service provider is deceased or unavailable, the current custodian of the record
shall designate a substitute service provider for purposes of compliance with these
regulations.
C. A statement of the eating disorder facility’s procedures for obtaining records, and the right to
appeal grievances regarding access to records to BHA, must be posted in conspicuous public
places on the premises and made available to each individual upon admission and discharge to
the facility.
D. An individual, whether currently receiving services or discharged from a facility, may inspect or
obtain a copy of their own record. The facility must act on the request to review the individual’s
record within a reasonable time, which must not exceed thirty (30) calendar days, except when an
extension is allowable in accordance with HIPAA, which is incorporated by reference in Part 1.2
of these Rules.
E. Facilities must not charge the individual or designated representative for inspection of the
individual's record.
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F. Records must be kept in accordance with all applicable state and federal laws and regulations.
G. Access to medical records contained within the individual’s records must be accessed in a
manner that is consistent with all applicable state and federal laws, including but not limited to the
Health Insurance Portability and Accountability Act of 1996 (HIPAA), which is incorporated by
reference in Part 1.2 of these Rules.
H. If there are changes/corrections, deletions, or other modifications to any portion of an individual
record, the person who is making the changes must note in the record the date, time, nature,
reason, correction, deletion, or other modification, and their name, to the change, correction,
deletion, or other modification.
I. The confidentiality of the individual record, including all medical, behavioral health, psychological,
and demographic information, must be protected in accordance with all applicable federal and
state laws and regulations, including during record use, storage, transportation, transmission, and
disposal.
J. When an eating disorder facility closes a physical location, it must maintain records of individuals
served in accordance with the requirements of this Part 15.11.
15.11.2 Admissions Requirements and Disclosures
A. The facility shall develop written admission criteria based on the facility’s ability to meet the
individual’s needs. Admission criteria shall be based upon:
1. A comprehensive assessment of the individual’s mental health;
2. A comprehensive assessment of the individual’s physical health;
3. The individual’s substance use; and
4. The individual’s capacity for self-care.
5. The assessment shall determine the level of intervention and supervision required,
including medication management, behavioral health services, and stabilization prior to
discharge.
B. An individual may only be admitted into a locked setting if there is no less restrictive appropriate
alternative setting.
1. Any eating disorder and recovery facility utilizing a locked setting shall also be a 27- 65
designated facility.
C. A facility shall not admit or keep any individual who meets the following exclusion criteria:
1. Is consistently incontinent unless the individual or personnel is capable of preventing
such incontinence from becoming a health hazard.
2. Has a communicable disease or infection that is:
a. Reportable under the Colorado Department of Public Health and Environment's
regulations 6 CCR 1009-1 and 6 CCR 1009-2, which are incorporated by
reference in Part 11.16.8.D.4.a of these Rules.
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b. Potentially transmittable in a facility unless the individual is receiving medical or
drug treatment for the condition and the admission is approved by a physician.
3. Has acute withdrawal symptoms, is at risk of withdrawal symptoms, or is incapacitated
due to a substance use disorder, and the facility does not have appropriate
capacity/endorsements to address issues of withdrawal.
4. The facility shall create policies for any other exclusionary criteria and procedures for
care coordination when appropriate.
D. There shall be written evidence of consent to treat, and the following upon admission to the
individual or the individual’s parent, legal custodian, legal guardian, or legal representative, as
appropriate. Acknowledgements shall specify the understanding between the parties regarding, at
a minimum:
1. Charges and fees;
2. Services included in the rates and charges;
3. Types of services provided by the facility, those services which are not provided, and
those which the facility will assist the individual in obtaining;
4. Transportation services;
5. Therapeutic diets;
6. A physically safe and sanitary environment;
7. Personal services;
8. Protective oversight;
9. Presence and purpose of any video monitoring;
10. Social and recreational activities;
11. A provision that the facility must give individuals thirty (30) calendar days’ notice of
closure;
12. Management of personal funds and property;
13. Facility rules, established pursuant to Part 15.12.1.C of this Chapter 15;
14. Staffing levels based on individual needs; and
15. Types of daily activities, including examples of activities that will be provided.
15.11.3 Request for Release of Information Procedures
A. The eating disorder and recovery facility must comply with all applicable state and federal laws
and regulations for release of information, including, but not limited to, Section 27- 65-123, C.R.S.,
42 C.F.R. Part 2, and HIPAA, which are incorporated by reference in Part 1.2 of these Rules.
B. When obtaining a consent or an authorization for the release of information, the signed release
must state, at a minimum:
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1. Person(s) or facility who may receive the information in the records;
2. The purpose of obtaining this information;
3. The information to be released;
4. That the release may be revoked by the individual, parent, legal custodian, or legal
guardian at any time; and
5. That the release of information is only valid for a time period specified, but such time
cannot exceed two (2) years from the date of signature.
C. Except as provided in this Part 15.11.3 C, all information obtained and records prepared in the
course of providing any services to any individual are confidential and privileged matter. The
information and records may be disclosed only:
1. In communications between qualified personnel in the provision of services or
appropriate referrals;
2. When the individual designates other persons to whom information or records may be
released, but,
a. If an individual is a ward or conservatee and the ward’s or conservatee’s
guardian or conservator designates, in writing, persons to whom records or
information may be disclosed, the designation is valid in lieu of the designation
by the recipient;
b. Except that nothing in this section compels a physician, psychologist, social
worker, nurse, attorney, or other personnel to reveal information that has been
given to the individual in confidence by members of an individual’s family or other
informants;
3. To the extent necessary to make claims on behalf of a recipient of aid, insurance, or
medical assistance to which the recipient may be entitled;
4. If BHA has promulgated rules for the conduct of research, such rules must include, but
are not limited to:
a. The requirement that all researchers must sign an oath of confidentiality;
b. All identifying information concerning individuals, including names, addresses,
telephone numbers, and social security numbers, must not be disclosed for
research purposes;
5. To family members upon admission of an individual with a mental health disorder for
inpatient or residential care and treatment.
a. The only information that may be released pursuant to this Part 15.11.3 C 7 is
the location and fact of admission of the person with a mental health disorder
who is receiving care and treatment. The disclosure of location is governed by
HIPAA and 42 C.F.R. Part 2, which are incorporated by reference in Part 1.2 of
these Rules, and/or,
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6. To family members actively participating in the care and treatment of a person with a
mental health disorder, regardless of the length of the participation. This disclosure is
governed by HIPAA and 42 C.F.R. Part 2, which are incorporated by reference in Part 1.2
of these Rules. The information released pursuant to this subpart is limited to one (1) or
more of the following:
a. The diagnosis;
b. The prognosis;
c. The need for hospitalization and anticipated length of stay;
d. The discharge plan;
e. The medication administered and side effects of the medication; and
f. The short-term and long-term treatment goals.
15.11.4 Screening and Assessment
A. Screening tools/approaches must be culturally and linguistically appropriate. Tools shall be
trauma-informed and should accommodate an individual's disability/disabilities (hearing disability,
cognitive limitations, visual impairment, etc.) as required.
B. The screening shall be completed no later than the time of admission and shall contain the
following:
1. Identifying information;
2. Primary complaint/reason for seeking services;
3. Current behavioral health symptoms, including severity, duration, mental status, and
changes or impairments in functioning due to symptoms;
4. Medical concerns/chronic health issues, including pregnancy and postpartum status; and
5. Evaluation of imminent risk, including:
a. Suicide risk;
b. Danger to self or others;
c. Urgent or critical medical conditions, including withdrawal or overdose risk; or
d. Other immediate risks, including threats from another person.
6. Substance use in the past 24 hours:
a. Substance name;
b. Amount used; and
c. Route of administration.
7. Current medications; and
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8. Advance directives, psychiatric and/or medical assessment documentation.
C. Screenings that identify an imminent risk must be reviewed by a licensee, an authorized
practitioner, or a licensure candidate, performing within the scope of their practice.
D. Screenings should be conducted in-person unless contraindicated. If contraindicated, screenings
may be conducted via audio-visual or audio-only telehealth. Clinical rationale must be
documented in the case of a telehealth screening.
E. Comprehensive assessment
1. The facility must complete a comprehensive best practices assessment that focuses on
person-centered care, which is signed and/or approved by a licensee, a licensure
candidate, or authorized practitioner performing within the scope of their practice.
2. Comprehensive assessments must be completed within the following timeframes:
a. Inpatient/residential: within 72 hours of admission
b. Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP): no
later than fourteen (14) days from the date of admission
c. Outpatient: no later than 60 calendar days from the date of admission.
3. Information gathered as part of screening may be incorporated into the comprehensive
assessment.
4. The facility must conduct assessments throughout the course of treatment, review
previous assessments, and update those assessments whenever there is a change in the
person's level of care or functioning. The assessments must occur, at minimum, every six
(6) months, unless otherwise indicated.
5. All methods and procedures used to assess and evaluate an individual must be
developmentally and age-appropriate, culturally and linguistically appropriate, and
trauma-informed. All methods and procedures used to assess and evaluate an individual
must be able to be provided in the preferred language and/or communication method of
frequently encountered limited English proficiency (LEP) groups of the facility.
6. The comprehensive assessment must be documented in the individual’s record and, at
minimum, include the following information, if available and applicable:
a. Identification and demographic data;
b. Primary complaint/reason for seeking services, including onset of symptoms and
severity of symptoms;
c. A diagnosis with sufficient supporting criteria, as well as any subsequent
changes in diagnosis;
d. Mental health history, including but not limited to:
(1) Suicidal risk and ideation, and
(2) Homicidal ideation.
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e. Substance use and substance use withdrawal history;
f. Physical and dental health status, including but not limited to human
immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS),
tuberculosis (TB), hepatitis A, B, or C, and other infectious diseases status and
risk evaluation;
(1) Assessments must apprise the individual, as applicable, of risk factors
associated with acquiring and transmitting HIV/AIDS, tuberculosis (TB),
hepatitis A, B, or C, and other infectious diseases. appropriate testing
and pre and post-test counseling must be offered on-site or through
referral.
(2) Current healthcare providers
(3) Screening the individual for current pregnancy status, where and when
applicable. Any contraindications shall be documented in the clinical
record.
(a) Individuals must be asked if they want access to
contraceptive/family planning care, and the individual must be
appropriately referred when requested by the individual.
(4) A list of current prescriptions and prescribing physicians, over-the-
counter medications, and any other substances the individual may be
taking, including doses and frequency; and
(5) Assessment of need for medical care (with referral and follow-up as
required).
g. History of involuntary treatment;
h. Determination regarding whether or not the individual has advance directives,
including medical and psychiatric;
i. Capacity for self-sufficiency and daily functioning;
j. Cultural factors that may impact treatment, including age, ethnicity,
linguistic/communication needs, gender, gender identity, sexual orientation,
relational roles, spiritual beliefs, socio-economic status, personal values, level of
acculturation and/or assimilation, and coping skills;
k. Education, vocational training, and military service;
l. Family and/or social relationships;
m. Trauma and trauma history;
n. Physical and/or sexual abuse or perpetration and current risk;
o. Legal issues that may impact behavioral health outcomes;
p. Issues specific to older adults, such as hearing loss, vision loss, strength,
mobility, and other aging issues;
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q. Issues specific to children, such as growth and development, daily activities,
legal guardians, and the need for family involvement and engagement in the
child's treatment;
r. Strengths, abilities, skills, and interests; and
s. Barriers to treatment.
15.11.5 Service Plans
A. The facility shall ensure the development and review of a written service plan for each individual
as follows:
1. The service plan must be completed within the following timeframes:
a. Inpatient/Residential: Within 72 hours of admission
b. PHP/IOP: 14 days from completion of the comprehensive assessment
c. Outpatient: 30 days from completion of the comprehensive assessment
2. The service plan must be reviewed and revised in writing when there is a change in the
individual’s level of functioning or service needs. Revisions must include documentation
of progress made in relation to planned treatment outcomes, changes in treatment focus,
and length of stay adjustments, as applicable.
3. The service plan must:
a. Meet the developmental and cultural needs of the individual in a trauma-
responsive manner.
b. Specify goals based on the initial and/or comprehensive assessment in a manner
understandable to the individual.
c. Identify the type, frequency, and duration of services.
d. Be individually directed, including the individual’s strengths and identities.
e. Include involvement of other identified family or supportive individuals, when
appropriate.
f. Specific criteria required for discharge from treatment or to progress to less
restrictive treatment alternatives.
4. The service plan must be signed by all parties involved in the development of the plan,
including the individual, and/or the individual’s parent or legal guardian in cases where
the individual is a minor, or the individual has a court-appointed legal guardian and has
not consented to services without the involvement of the legal guardian. Signatures must
include at least one of the following: a licensee, an authorized practitioner, or a licensure
candidate performing within the scope of their practice.
a. A copy of the service plan must be offered to the individual, or to the individual’s
parent or legal guardian, as appropriate.
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b. The facility must include documentation in the individual record in cases where
the plan is not signed by the individual or the individual's parent or legal guardian
if involved in the development of the plan, and in cases where offering the
service plan to a parent or legal guardian is contraindicated.
5. A physician or other legal prescriber shall be responsible for the component of the plan
requiring medication management services.
15.11.6 Discharge Planning
A. Discharge instructions and care coordination instructions must contain the following in both the
individual’s clinical record and available as instructions for the individual:
1. Documentation that the notice of discharge was provided to the individual, the individual’s
parent, legal custodian, legal guardian or the individual’s legal representatives as follows:
a. At least twenty-four (24) hours in advance of discharge or transfer.
b. In cases of a medical or psychiatric emergency, the emergency contact shall be
notified as soon as possible.
2. Documentation of discharge coordination with the individual, and, with permission, the
individual’s family member(s), legal custodian, legal representative, or appropriate facility.
3. For transfers between eating disorder designated facilities, documentation of appropriate
clinical information and coordination of services between the two facilities, including
mode of transportation.
4. Information if the discharge is being made against the advice of the treating authorized
practitioner.
B. The facility shall document in the individual's record whether the individual accepted the
discharge instructions.
C. The facility shall provide the discharge instructions to the individual's parent or legal guardian if
the individual is under eighteen (18) years of age, and to the individual's lay person, when
possible and if consistent with state and federal law.
D. Requirements for a discharge summary to facilitate continuity of individual care, including, but not
limited to:
1. The timeframe for discharge summary completion, which may not be more than fifteen
(15) calendar days after discharge.
2. Information to be included in the discharge summary to inform future providers of
treatment history, including, but not limited to:
a. Demographic information, including, but not limited to, name, date of birth,
gender identity, emergency contact information, insurance information, preferred
language, and any cultural factors to consider in treatment;
b. A brief summary of the episode of care, including, but not limited to, the
presenting issue, services received, diagnosis assigned or modified, and any
outstanding needs identified;
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c. Information on the individual’s status within the judicial system, including any
type of behavioral health certification or hold;
d. A summary of medications prescribed during treatment, including the individual's
responses to medications;
e. Medications recommended and prescribed at discharge; and
f. Documentation of referrals and recommendations for follow-up care.
3. This discharge information may be in narrative or abbreviated format and must be written
in a manner that can be readily understood by a receiving provider to allow for prompt
resumption of services.
4. Information and documentation to be provided to the individual upon discharge, unless
clinically contraindicated, including, but not limited to:
a. Medication information, including medication name, dosage, instructions for
follow-up, and whether the individual was provided with medication upon
discharge.
(1) The facility may provide the individual with unused, prescribed
medications as part of the discharge process, unless it has been
determined that doing so would pose a risk to the health and safety of
the individual.
b. Detailed information on transitioning care to other providers, including referral
information, when providing referrals.
c. Documentation that the discharge is being made against the advice of the
provider, as applicable.
d. Written notification of discharge with reason for discharge.
e. Written notification of facility and BHA dispute resolution and grievance
procedures.
15.11.7 Treatment Progress Documentation Requirements
A. The individual record must include progress notes, documenting a chronological record of
treatment, date and type of service, session activity, and progress toward individual -specific
treatment goals.
B. The minimum frequency of progress note completion shall be completed at the following intervals:
1. Inpatient/residential: one (1) service note per service, minimum daily or more often when
there is a change in the individual’s functioning.
2. Outpatient: a minimum of one (1) service note per service.
C. Progress notes must include any noted change in physical, behavioral, cognitive, and functional
condition and action taken by personnel to address the individual’s changing needs.
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D. Progress notes must be signed and dated or electronically approved by personnel, practicing
within the scope of their practice, at the time they are written, with at least the first initial, last
name, and degree and/or professional credentials.
E. Treatment progress notes shall include the following:
1. Documentation of all treatment procedures, including, but not limited to: brief physical
restraint, seclusion, medications, and other therapies or interventions.
2. Information regarding any critical incident involving the individual, the circumstances, and
the outcome.
3. Documentation of all transfers, whether permanent or temporary, and reasons for
transfer.
4. Consultations and/or case reviews.
5. Pertinent information from outside facilities or persons or from the individual.
6. Correspondence to and from relevant facilities and persons.
7. Consent forms as appropriate for alternative treatments or voluntary treatment.
8. Use or non-use of psychiatric and medical advance directives.
15.12 Inpatient and Residential Care Requirements for Eating Disorder Treatment and Recovery
A. A facility designated for eating disorder treatment and recovery providing residential, overnight, or
inpatient levels of care shall meet the requirements of this Part 15.12 in addition to the provisions
of Chapter 15. Requirements listed in 15.13 for outpatient levels of care are not applicable to
residential, overnight, or inpatient services and levels of care.
B. Facilities providing inpatient or residential care for eating disorder treatment and recovery shall
have detailed policies and procedures specific to the therapeutic programming provided to the
individual while in the facility’s care.
1. Programming shall be trauma-informed, person-centered, and appropriate for the
individual’s diagnosis and needs.
2. Services provided shall be documented in the individual’s clinical record.
3. Programming shall be facilitated by appropriately trained or credentialed personnel for
the type of service(s) provided.
15.12.1 Service Delivery Requirements
A. The facility shall have policies and procedures specific to the residential/overnight services or
physical location, as applicable, including, but not limited to:
1. Policies and procedures to be followed in the event of serious illness, injury, or death of
an individual during their stay, including, but not limited to:
a. Criteria for when an individual's injury or illness warrants medical treatment or an
in-person medical evaluation.
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b. Requirements for notifying the individual’s emergency contact, including
immediate notification in the case of an emergency room visit or unscheduled
hospitalization.
c. Reporting procedures within the facility.
2. Bed-based or room-based care is allowed only as a last resort and must be documented
in the individual’s clinical record as the reason for such restrictive measures. All lower-
level interventions must be documented as part of the multidisciplinary team decision
making process and reflect meaningful engagement with individuals.
a. This does not apply to eating disorder treatment and recovery designated
services offered within a general hospital setting.
3. Eating disorder facilities that provide overnight/residential services shall maintain enough
food and water on hand to provide all individuals in care with three (3) nutritionally
balanced meals for four (4) days.
4. Procedures for the management of the individual’s personal funds and property,
including, but not limited to:
a. An inventory of all the individual’s personal belongings must be conducted upon
admission, and documented by at least two (2) individuals, one of whom must be
the individual when the individual is capable and willing to document the
inventory. Such inventory must be maintained in the individual record.
b. All inventoried property must be returned to the individual upon discharge, and
such return must be documented by at least two (2) individuals, one of whom
must be the individual when the individual is capable and willing to document the
inventory. Such documentation must be included in the individual record.
5. Infection control procedures to address risks associated with housekeeping, dietary
services, and linen and laundry services.
a. Policies for linen and laundry services must include:
(1) Procedures for preventing contamination between soiled linen and clean
linen through either the use of gloves or hand washing.
(2) Procedures for soiled linen to be stored separately from clean linen, in
separate enclosed areas.
(3) Individuals in care must have access to laundry services for personal
clothing, which may be provided through the use of personal laundry
facilities, a centralized laundry service, or may be contracted for with an
outside provider.
(4) A requirement to maintain a sufficient supply of clean linen, including
sheets and towels.
b. Dietary services must be provided using methods that conform to state or local
food safety standards, including, at a minimum:
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(1) Food must be prepared, handled, and stored in a sanitary manner, so
that it is free from spoilage and/or contamination, and must be safe for
human consumption.
(2) Reusable equipment, dishes, cutlery, and other wares used for the
preparation, serving, or storage of food must be washed in a safe and
sanitary manner, and, in the case of dishwashing machines, in
accordance with the manufacturer’s instructions.
(3) Provide at least three meals daily, at regular times comparable to normal
mealtimes in the community, or in accordance with individual needs,
preferences, and plans of care.
(a) Nourishing meal substitutes and between-meal snacks must be
provided, in accordance with plans of care, to the individual who
want to eat at non-traditional times or outside of scheduled meal
service times.
(b) Meals must include a variety of foods, be nutritionally balanced,
and sufficient in amount to satisfy the appetites of the individual.
(c) Appealing substitutes of similar nutritive value must be available
for the individual who chooses not to eat food that is initially
served or who requests an alternative meal.
(d) Respect and accommodate an individual’s religious or dietary
ethics, unless clinically contraindicated.
(e) Any deviation, and reason for the deviation, from the offered
menu must be documented in the individual’s clinical record.
(4) Offer drinks, including water and other liquids, to individuals in care with
every meal and between meals as determined by the individual’s
nutrition plan.
6. Procedures for required safety checks of all individuals in care should be conducted at
least every thirty (30) minutes and at every shift change to identify and remedy hazards.
a. The facility shall maintain these records for a minimum of two years unless
otherwise required by law.
b. The facility shall have policies and procedures for how and when an individual’s
needs are more restrictive than this requirement occurs, but at a minimum, must
include:
(1) When there is a change in the individual’s functioning or an increase in
danger to self or others, and
(2) When the safety of the individual(s) in care requires a more restrictive
staffing ratio as described in 15.12.3 B.
7. The type of first aid equipment maintained by the facility, including a requirement that
such equipment be maintained in a readily accessible location, at each physical location
providing residential and/or overnight services. First aid equipment must include, but not
be limited to, an automated external defibrillator (AED).
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a. First aid supplies and equipment must be kept unexpired and in a reliable
condition.
8. Smoking policies applicable to individuals in care, including, but not limited to any
prohibitions on smoking, designated areas for smoking, and methods/substances allowed
under any smoking policy, such as tobacco, electronic cigarettes, vaporizers, etc.
9. The facility shall ensure that individuals in care have access to basic hygiene supplies in
a manner consistent with their needs.
10. Emergency policies and procedures shall address:
a. When to evacuate the premises, when to shelter in place, and the procedures for
doing so;
b. A predetermined means of communicating with individuals in care, families,
personnel and other providers;
c. A plan that ensures the availability of, or access to, emergency power for
essential functions and all individual required medical devices or auxiliary aids or
services;
d. Storage and preservation of medications; and
e. In the event relocation of individuals in care becomes necessary, written
agreements with other health facilities and/or community agencies.
11. The facility shall have readily available a roster of current individuals, their room
assignments, and emergency contact information, along with a facility diagram showing
room locations.
12. A facility serving both adults and children must ensure that management of the living
space assignments includes physical barriers and personnel oversight of activities to
ensure safety. This management must include, but is not limited to:
a. Physical barriers, such as doors or walls;
b. Personnel stations that separate living space assignments;
c. Other practical arrangements that support the safe management of the individual
receiving services.
B. Each facility shall maintain reasonable security capabilities to guard against the risk of
unauthorized departures. The least restrictive method to prevent an unauthorized departure shall
be used.
C. Facility rules
1. The facility shall establish written policies, which shall list all possible actions that may be
taken by the facility if any policy is knowingly violated by an individual. Facility policies
may not violate or contravene any rule herein, or in any way discourage or hinder an
individual’s rights.
2. The facility shall prominently post its policies in writing, which shall be available at all
times to individuals in care. Such policies shall address at least the following:
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a. Smoking;
b. Cooking;
c. Visitors;
d. Telephone usage, including frequency and duration of calls;
e. Use of common areas, including the use of television, radio, or other electronic
media;
f. Consumption of alcohol and/or illicit drugs;
g. Dress code; and
h. Pets, which shall not be allowed in the facility; however, in no event shall such
rules prohibit service or guide animals.
D. Physical health assessment by a qualified licensed practitioner:
1. Within twenty-four (24) hours of admission and shall include at a minimum:
a. Baseline vital signs including temperature, resting heart rate, blood pressure,
body mass index (BMI), and physical appearance;
b. Individual’s height and weight;
c. A review of the individual’s overall bodily functioning (i.e., gastrointestinal,
nervous system, cardiovascular, etc.);
d. Complete blood count and metabolic panel, if clinically indicated; and
e. Electrocardiogram, if clinically indicated.
2. Additional physical health assessments are required when:
a. There is a significant change in the individual’s condition;
b. Evidence of possible infection (open sores, etc.);
c. Injury or accident sustained by the individual that might cause a change in the
individual’s condition;
d. Known exposure of the individual to a communicable disease; or
e. Development of any condition that would have initially precluded admission to the
facility.
E. Emergency Medical and Dental Care
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1. The facility shall ensure the availability of emergency medical and dental care to meet the
needs of each individual. The obligation to ensure the availability of emergency medical
services shall not be construed as the obligation to pay for such services; however, the
facility shall secure these services regardless of the source of payment. The facility shall
have and adhere to a written plan for providing emergency medical and dental care to
include at least:
a. The availability of a qualified licensed independent practitioner or emergency
medical facility on a twenty-four (24) hour, seven (7) days a week basis.
b. Emergency medical or dental treatment, when indicated, shall be accessed
immediately upon determination that an emergency exists.
c. Whenever indicated, an individual shall be referred to an appropriate specialist
for either further assessment or treatment. The facility shall be responsible for
securing an appropriate assessment to determine the need for further specialty
consultation. This information shall be contained in the clinical record.
2. If an individual requires inpatient medical care at a hospital, the facility shall be
responsible for coordinating transportation from the facility to the inpatient medical
provider, communicating any psychiatric needs of the individual, and coordinating care
with the medical provider until the individual no longer requires inpatient medical care.
F. Individuals in care may administer oxygen if the individual is able to manage the administration
themselves, and personnel shall assist with the administration as needed for safety, when
prescribed by a physician, and if the facility follows appropriate safety requirements regarding
oxygen herein.
1. Oxygen tanks shall be secured upright at all times to prevent falling over and secured in a
manner to prevent tanks from being dropped or from striking violently against each other.
2. Tank valves shall be closed except when in use.
3. Transferring oxygen from one container to another shall be conducted in a well-ventilated
room with the door shut. Transfer shall be conducted by trained personnel or by the
individual for whom the oxygen is being transferred, if the individual is capable of
performing this task safely. When the transfer is being conducted, no person, except for a
person conducting such transfer, shall be present in the room.
4. Tanks and other oxygen containers shall not be exposed to electrical sparks, cigarettes,
or open flames.
5. Tanks shall not be placed against electrical panels or live electrical cords where the
cylinder can become part of an electric circuit.
6. Tanks shall not be rolled on their side or dragged.
7. Smoking shall be prohibited in rooms where oxygen is used or stored. Rooms in which
oxygen is used shall be posted with a conspicuous “no smoking” sign.
8. Tanks shall not be stored near radiators or other heat sources. If stored outdoors, tanks
shall be protected from weather extremes and damp ground to prevent corrosion.
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G. Whenever transportation of an individual is required, the treating personnel of the facility shall
assess the individual for danger to self and/or others. Whenever clinically and safely appropriate,
the individual may be transported by other means such as an ambulance, a care van, or a private
vehicle.
15.12.2 Building Safety
A. The facility shall ensure the following standards are met regarding the physical operation of the
residential, overnight, or inpatient designated location:
1. The facility shall have common areas adequate to accommodate all individuals in care,
including a designated dining area capable of seating all individuals, and meeting the
following accessibility requirements:
a. All common areas and dining areas must be accessible to individuals in care
using an auxiliary aid without requiring transfer from a wheelchair to a walker or
from a wheelchair to a regular chair.
b. Doors to individual accessible rooms shall be at least thirty-two (32) inches wide.
2. A minimum of two entryways shall be provided for ingress and egress from the building
by any individual using a wheelchair.
B. A facility shall only place an individual in a bedroom with video monitoring due to good cause or
safety/security reasons, which must be noted in the individual’s clinical record. The individual
shall be notified in writing when placed in bedrooms with video monitoring capabilities.
C. Designated facilities shall have policies for assessing when video monitoring in bedrooms is
required, which personnel are allowed access to the video recordings, and under what
circumstances video recordings are maintained longer than thirty (30) days. The policy shall
contain, at a minimum, the following:
1. Video monitoring is prohibited in bathroom facilities.
2. Facilities shall maintain a signed acknowledgement in the individual’s clinical record
when an individual is placed into a room with video monitoring, or when video monitoring
is clinically indicated. The acknowledgement shall be signed by the individual, the
individual’s parent, legal custodian, legal guardian or a legal representative, and
personnel of the facility.
3. Video monitoring shall not be used as a substitute for direct supervision.
4. The use of video monitoring shall ensure individual privacy to the extent allowed by
clinical assessment.
D. The following requirements must be met for bedrooms:
1. No individual may be assigned to any room other than a regularly designated bedroom.
Temporary occupancy of a room not designated as a bedroom is permissible on a limited
basis when the use of the assigned bedroom is contraindicated due to circumstances
related to individual safety or emergent issues. Justification for such placement and the
length of placement shall be documented in the individual record.
2. No more than two (2) individuals in care shall reside in a bedroom.
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3. Each bedroom for individuals in care must have at least 100 square feet for a single
individual, or 120 square feet for two residents. Bathroom areas and closets shall not be
included in the determination of square footage.
4. Each individual shall have separate storage facilities adequate for personal articles, such
as a closet or locker, available inside their bedroom. Shelves may be provided for folded
garments in lieu of hanging garments.
5. Each bedroom must include a comfortable, standard-sized bed with a clean mattress,
mattress protector, and pillow. Rollaway-type beds, cots, folding beds, or bunk beds are
not permitted.
6. The bedroom shall have a safe and sanitary method to store the individual’s towel, such
as a breakaway towel rack.
7. Extension cords and multiple-use electrical sockets shall be prohibited in individual
bedrooms.
8. The bedroom shall include a chair unless contraindicated, in which case, alternate
seating shall be provided in close proximity to the bedroom.
E. The following standards must be met for bathrooms:
1. Each floor with bedrooms must have at least one bathroom that can be accessed without
entering a bedroom.
2. The physical location of the facility’s operations must have at least one full bathroom
accessible to any individual using an auxiliary aid, including properly installed grab bars
at each tub and/or shower, and adjacent to each toilet.
3. Bathtubs and shower floors must have non-skid surfaces.
4. Toilet seats shall be constructed of non-absorbent materials and free of cracks.
5. Individuals in care must have individualized personal care articles and supplies, such as
soap and towels, shall not be shared.
6. Toilet paper must be available at all times in each bathroom.
7. Liquid soap and paper towels must be available at all times in the common bathrooms.
Bathrooms must be equipped with soap dispensers, or the facility shall have a procedure
in place that prevents individuals in care from sharing soap.
8. The facility must ensure there is a minimum of one (1) full bathroom for every six (6)
individuals in care, including a toilet, sink, toilet paper dispenser, mirror, tub and/or
shower, and towel rack.
15.12.3 Inpatient, Residential, or Overnight Personnel
A. Residential, overnight, or inpatient designated providers must meet the requirements listed in Part
15.10 of this Chapter 15 in addition to the requirements listed in this Part 15.12.3.
B. The facility shall employ sufficient personnel to ensure that the provision of services meets the
needs of individuals in care. The facility shall:
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1. Ensure that each shift has a minimum of two (2) personnel whenever one (1) or more
individuals in care are present in the milieu;
2. Inpatient: Maintain individual-to-personnel ratios not exceeding a one to six (1:6) direct
care personnel to individual ratio at all times;
a. Direct care staff includes, but is not limited to, behavioral health technicians,
nursing staff, or other identified milieu staff as per the facility’s policies and
procedures.
b. If the facility is licensed as a hospital with the Colorado Department of Public
Health and Environment (CDPHE), the facility must comply with staffing
requirements pursuant to Section 25-3-128, C.R.S. in lieu of compliance with
Part 15.12 of this Chapter 15.
3. Residential: Maintain individual-to-personnel ratios not exceeding a one to ten (1:10)
direct care personnel to individual ratio at all times;
a. Direct care staff includes, but is not limited to, behavioral health technicians,
nursing staff, or other identified milieu staff as per the facility’s policies and
procedures.
b. Designated facilities shall define staffing patterns and substitute direct care
coverage through the facility's policies and procedures.
4. Each physical location must have appropriate oversight personnel, such as an
administrator and/or clinical director, or personnel delegated those same responsibilities,
available twenty-four (24) hours per day, seven (7) days per week. Appropriate oversight
personnel for all other levels of care must be available during hours of operation.
a. Oversight personnel when the administrator and/or clinical director are not
physically on-site must be in accordance with policies as required at Part 15.10
of this Chapter 15.
C. The facility shall ensure that, at minimum, one of the following qualified personnel is available to
administer medications at all times:
1. Licensed practical nurse, registered nurse, advanced practice registered nurse,
physician, physician’s assistant, pharmacist, or qualified medication administration
person (QMAP).
D. In addition to the training requirements listed in 15.10, personnel providing residential, overnight,
or inpatient services shall also be trained in the following:
1. The recognition and response to common side effects of medications used for behavioral
health disorders, and response to emergency drug reactions;
2. Behavior management and de-escalation techniques, including incidents involving harm
to self or others, and elopement; and,
3. Behavioral health and medical emergency response training, consistent with emergency
services policies .
4. Personnel preparing or serving food shall complete food safety training.
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a. At a minimum, this must include that personnel overseeing dietary services shall
have knowledge of foodborne disease prevention, including, but not limited to,
hygienic practices and food safety techniques pertaining to preparation, food
storage, and dishwashing.
15.13 Outpatient Care Standards for Eating Disorder Treatment and Recovery
15.13.1 General Outpatient Standards
A. A facility designated for eating disorder treatment and recovery providing any outpatient services
shall meet the standards in this Part 15.13, in addition to the service standards of this Chapter 15.
Designated facilities providing outpatient services only are exempt from the provisions of Part
15.12 of this Chapter 15.
B. Outpatient services are generally intended for individuals who are assessed as not appropriate
for more intensive levels of care. Outpatient services may also be a step-down from a higher level
of care or offered when an individual is in early stages of change and declines voluntary
participation in the higher level of care indicated by the assessment.
C. All services provided must be adapted to the individual’s developmental stage, physical, cultural,
and comprehensive needs.
1. Service frequency and intensity must be modified to meet assessment and service plan
objectives. Services may include medical services, individual therapy, group therapy,
medication management, educational/occupational groups, peer professional services,
recreational therapy, and other therapies as deemed appropriate by assessment of the
individual receiving services.
15.13.2 Service Delivery and Setting
A. Outpatient services may be delivered via in-person, audio-visual telehealth, or audio-only
telehealth format in accordance with the following guidelines:
1. If the designated provider uses telehealth methods, it must develop and implement
policies and procedures regarding telehealth services, including:
a. Collection of required signatures;
b. Training for personnel specific to the modality or manner for determining
competence with the modality;
c. Procedure for personnel response if an individual experiences an emergency
while receiving services via telehealth, including collection of information about
the individual’s remote location for each session;
d. Confidentiality protocols designed to protect the individual’s privacy in
accordance with state and federal law; and
e. Specification as to whether policies apply to the facility as a whole, or a physical
location, as appropriate.
2. Services provided via telehealth methods must be documented in the individual’s record,
consistent with documentation requirements for in-person services.
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3. Services may be provided through synchronous audio-visual methods, but must not
include text-only methods such as text message or email. Some services may be
provided through audio-only methods according to state and federal regulations. If audio-
only methods are used, the following must be noted in the individual record:
a. The reason that audio-visual methods were not utilized.
b. The clinical determination and rationale of appropriateness for service delivery
methods.
B. Outpatient treatment services must be provided in accordance with the individual’s service plan
and facilitated by providers acting within their scope of practice.
C. Treatment groups must not exceed fifteen (15) enrolled individuals receiving services.
1. Family members or supportive individuals participating in groups with the enrolled
individual shall not be counted in the total group size.
2. The facility shall create and maintain policies and procedures for ensuring adequate
personnel for supervising larger treatment groups of both enrolled individuals in care and
family members or supportive individuals.
D. For the purposes of this Chapter 15, eating disorder treatment and recovery designated facilities
providing day treatment services shall meet the requirements of partial hospitalization
programming in Part 15.13.3.
15.13.3 Partial Hospitalization Programming
A. These Rules are established to create standards for facilities providing partial hospitalization
program (PHP) eating disorder treatment and recovery services.
B. PHP services are generally intended for individuals who require daily monitoring or management
to treat mental health, eating disorders, and co-occurring disorders, in accordance with the DSM-
5-TR, as incorporated by reference in Part 1.2 of these Rules. These services can be provided in
a structured outpatient setting and include direct access to medical, psychiatric, nutritional
counseling and management, and laboratory services.
1. PHPs require a minimum of 20 hours of treatment contact per week, including a minimum
of three (3) hours per day and a minimum of four (4) calendar days per week.
C. PHP agencies must meet the facility requirements set forth in Part 15.10.1 of this Chapter 15 or
requirements in accordance with facility mandates under other regulatory state and federal
entities for licensure in cases such as a medical facility, school, or other.
D. PHP support systems
1. Facilities providing PHP services must inform individuals receiving treatment how to
access emergency services by telephone twenty-four (24) hours per day, seven (7) days
per week when the program is not in session. At minimum, agencies must provide
emergency services information that includes contact information for services provided by
the behavioral health crisis response system created pursuant to Section 27- 60-103,
C.R.S.
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2. Agencies providing PHP services must have direct affiliation or close coordination
through referral to more and less intensive levels of care. Agencies providing PHP
services must also have a documented consultation and/or referral process through
internal staff or other affiliations for medical, psychiatric, and medication-assisted
treatment needs.
a. Referral(s) will be provided in collaboration with the individual and their choice(s)
for referred services.
15.13.4 Intensive Outpatient Service (IOP) Delivery and Setting
A. IOP services are intended for individuals who require a higher level of intervention than can be
provided in standard outpatient services.
B. All services must be adapted to the individual’s developmental stage and physical and
comprehensive needs.
C. IOP support systems
1. Agencies providing IOP services must have direct affiliation or close coordination through
referral to more and less intensive levels of care. Agencies must also have a documented
consultation and/or referral process through internal staff or other affiliations in place for
medical, psychiatric, and other clinically identified treatment needs.
a. Referral(s) will be provided in collaboration with the individual and their choice(s)
for referred services.
D. Services must be conducted in regularly scheduled sessions that follow a planned format of
treatment services of nine (9) to nineteen (19) contact hours per week for adults and six (6) to
nineteen (19) contact hours per week for children under the age of eighteen (18).
15.13.5 Outpatient Personnel
A. Outpatient services may include recovery support services rendered by peer support
professionals in accordance with Chapter 3 of these Rules.
B. Agencies providing PHP, IOP, or outpatient services must ensure treatment personnel have
supervisor consultation available within twenty-four (24) hours via in-person or by telehealth to
discuss, when warranted, psychiatric or medical concerns of individuals receiving services.
1. Personnel must have supervisor consultation available within one (1) hour via in- person
or telehealth to discuss, when warranted, crisis and/or emergency situations during
program hours.
C. Agencies providing PHP, IOP, or outpatient services must provide training appropriate to the
treatment-type focus and best practice standards.
1. Training must include that treatment personnel understand the signs and symptoms of
mental health, substance use, eating disorders, and co-occurring disorders, and the
basics of psychopharmacology.
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15.14 Rights of Individuals Receiving Services within an Eating Disorder Facility
15.14.1 Individual Rights
A. The facility shall develop, implement, uphold, and enforce policies and procedures regarding
individual rights in accordance with Part 2.7 of these Rules.
B. All individuals in care within an eating disorder treatment and recovery facility shall be provided a
copy of their “Bill of Rights” in written, electronic, and verbal form. Facilities shall uphold and
enforce these rights.
C. All patient rights must be posted (in the predominant languages of the community in which it
operates and explained in a language or modality accessible to the individual) in prominent
places frequented by individuals in care and their family member(s) receiving services, and the
facility shall assist the individual in exercising and upholding the following rights:
1. To request, and have access to, any medical examination, including weigh-ins, without
other patients in the room;
2. To remain clothed during weight checks.
a. If clothing is to be removed, individuals in care have the right to be provided with
alternative clothing. The alternative clothing must cover the individual’s body and
provide sufficient privacy.
3. To not be required to perform physical exercises during weight checks, unless;
a. If the professional providing care has sufficient cause to believe that the
individual would be at risk of harm without requiring a physical exercise, the
professional shall document the concern and need for further investigation in the
individual's clinical record.
b. If the individual is asked to perform any physical exercises, they shall be
provided a space with sufficient privacy that preserves the individual's dignity to
the greatest extent possible.
4. To be provided personal privacy to the greatest extent possible during the course of
treatment. Individuals in care shall not be required to share a stall of a restroom or a
single-occupancy bathroom while in the act of using the restroom:
a. With another individual in care at any time; and
b. With personnel unless medically evaluated and determined to be required.
5. Facilities shall provide gender non-conforming and transgender individuals in care with
the same restroom policies as provided to cisgender individuals in care;
6. Receive care and treatment, in compliance with state statute, that is free from
discrimination on the basis of physical or mental disability, race, ethnicity, socio-economic
status, religion, gender expression, gender identity, sex, sexuality, culture, and/or
languages spoken; and that recognizes an individual's dignity, cultural values and
religious beliefs; as well as provides for personal privacy to the extent possible during the
course of treatment.
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7. The facility shall accommodate the individual’s personal dietary ethics to the greatest
extent possible;
a. Any deviation from the individual’s preferred dietary ethics shall be documented
in the clinical record and shall only be denied based on clinical need as
determined by the interdisciplinary team of the individual;
8. Receive care in a safe setting, provided by a skilled professional, and be treated
humanely. Individuals in care shall have their treatment tailored to their unique needs and
implemented in a trauma-informed and trauma-aware manner. Individuals in care have
the right to be treated fairly, with respect and recognition of their dignity and individuality
by all employees of the facility with whom they come into contact;
a. Only staff qualified by education, experience, training, and/or facility policy and
procedure may be present or facilitate weigh-ins, bathroom time, vital sign
checks, individual therapy, and group therapy.
b. If a staff member performs multiple functions at the facility, the facility must
ensure they preserve and prioritize the therapeutic relationship between the staff
member and the individual in care.
9. To continue to practice their religious or spiritual practices, unless a specific practice
would impact the health or safety of the individual or others in care.
10. To have a minimum amount of physical activity per day, as clinically appropriate.
Individuals in care shall not have their bodily movement restricted as a form of
punishment.
D. Within one (1) business day of making a request, individuals in care have the right to see and
receive the services of a patient representative. The patient representative shall not have direct
clinical or administrative responsibility for care provided. Individuals in care have the right to have
assistance filing a complaint or grievance.
E. If at any time during the course of evaluation, treatment and care, the individual believes their
rights have violated, individuals in care may file a grievance with BHA, the Colorado Department
of Public Health and Environment (CDPHE), or the Office of the Ombudsman for Behavioral
Health Access to Care established pursuant to Section 27-80-303, C.R.S.
15.14.2 Dispute and Grievance Resolution
A. Each facility shall post a clear and unambiguous notice of dispute and grievance procedures for a
violation of an individual’s rights in each physical location and in an area that is open to the public
and on the facility’s website. This posted notice must also be provided in writing and electronically
upon admission to services, and include information regarding the submission of grievances to
BHA as required in Part 15.14.2.B of this Chapter 15.
1. The facility shall establish a uniform procedure for prompt management of disputes
brought by individuals accessing, receiving, or being evaluated for services and their
family members. The facility shall develop policies and procedures for handling disputes.
2. The facility shall provide a fair dispute resolution process that allows options for
submitting both verbal and written disputes. The process must provide the individual with
a response no later than thirty (30) calendar days from submission of the dispute. If the
dispute is received verbally, the representative shall create a written documentation of
the dispute.
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B. As part of the facility’s resolution process, the facility must inform persons who have submitted a
dispute verbally or in writing that they may also submit a grievance to BHA. The facility must
provide information about how to submit a grievance to BHA.
1. The facility shall designate a representative who must be available to assist individuals in
care in resolving disputes.
2. The facility shall educate individuals in care and their representatives about the
mechanisms in place for filing disputes. This education must include an explanation of
the individual's rights; the dispute process and procedures; and the name, contact
information, and responsibilities of the designated representative within the facility.
Appropriate contacts for external appeal must also be provided, which may include, but
are not limited to, the following:
a. Colorado Department of Regulatory Agencies;
b. Colorado Department of Public Health and Environment;
c. Colorado Department of Health Care Policy and Financing; or
d. The governor’s designated protection and advocacy system for individuals with
mental illness.
e. Documentation in the records must include the dated signature of the individual
receiving the information.
3. The facility must post a notice of rights, dispute procedure, and the designated representative’s
name, office location, responsibilities, and telephone number in prominent locations where
persons access, receive or are evaluated for services. The notice shall be translated into
languages commonly used by the populations in the service area.
4. The facility must maintain a record of submitted disputes, separate from the individual records
that include the date, the type of dispute, and the outcome of the investigation. These dispute
records must be provided annually to BHA, upon request.
5. Upon request, the facility must provide an individual and any interested person with contact
information for registering complaints with any other state departments.
15.15 Seclusion, Restraint, and Physical Management
15.15.1 General Provisions
A. The following rules covering seclusion, restraint, and physical management apply to all facilities
that use seclusion, restraint, and/or physical management. If a facility has decided to use
seclusion, restraint, and/or physical management, the facility shall use seclusion, restraint, and/or
physical management only in accordance with the rules in this Part 15.15.
B. These Rules do not supersede any requirements under Sections 26-20-101 through-110, C.R.S.
C. If any provision of this Part 15.15 conflicts with any provision concerning the use of seclusion,
restraint, and/or physical management on an individual with an intellectual or developmental
disability as stated in Article 10.5 of Title 27, C.R.S., Article 10 of Title 25.5, C.R.S. or any rule
adopted pursuant to those articles, the provisions of those articles or rules prevail.
D. A facility may only use seclusion, restraint, and/or physical management:
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1. In cases of emergency, as defined at Section 26-20-102(3), C.R.S., to be a serious,
probable, imminent threat of bodily harm to self or others where there is the present
ability to affect such bodily harm; and,
2. After less restrictive lower-level alternatives have been exhausted, including but not
limited to after all attempts to verbally direct or de-escalate the individual have failed; or
3. After a determination that such alternatives would be inappropriate or ineffective under
the circumstances.
E. A facility that uses seclusion, restraint, and/or physical management pursuant to the provisions of
this Part 15.15 may only use such seclusion, restraint, and/or physical management:
1. For the purpose of preventing the continuation or renewal of an emergency;
2. For the period of time necessary to accomplish its purpose; and
3. In the case of physical restraint, with no more force than is necessary to limit the
individual's freedom of movement.
F. Seclusion, restraint, and/or physical management must never be used:
1. As a punishment or disciplinary sanction;
2. As a means of coercion;
3. As part of an involuntary service plan or behavior modification plan;
4. For convenience;
5. For the purpose of retaliation; or
6. For the purpose of protection, unless:
a. The restraint or seclusion is ordered by a court; or
b. In an emergency, as provided for in this Part above.
G. Physical management for individuals in care under the age of eighteen (18) must always be
considered as restraint and follow the restraint order rules pursuant to Part 15.15.7 of this
Chapter 15.
15.15.2 Policies And Procedures Regarding Seclusion, Restraint, And Physical Management
A. Facilities shall have and shall implement written policies and procedures that describe the
situations in which the use of seclusion, restraint, and/or physical management are considered
appropriate in the facilities and personnel who can order their use. The policies and procedures
must include the requirements in this Part 15.15.2 and Sections 26-20-101 through -110, C.R.S.
these policies and procedures must also include at a minimum:
1. For a facility that does not authorize the use of seclusion, restraint, and/or physical
management of any type, a policy statement noting the prohibition against the use of
seclusion, restraint, and/or physical management and the procedures that personnel will
utilize in lieu of seclusion, restraint, and/or physical management.
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a. When a facility does not utilize physical management, seclusion, and/or restraint
interventions, the policy shall include facility processes and procedures should
personnel use these prohibited interventions.
2. For a facility that utilizes seclusion, restraint, and/or physical management, a policy
statement regarding the review process for the use of seclusion, restraint, and/or physical
management. The review process must include a provision for terminating the seclusion,
restraint, and/or physical management episode when the reviewer does not concur with
the order for continuation.
a. If the reviewer is not an authorized practitioner, then the order must be
discontinued by an authorized practitioner.
3. Personnel shall ensure that no individual endures harm or harassment when secluded
and/or restrained.
4. A policy statement that a facility shall ensure that the care and treatment are skillfully and
humanely administered with full respect for the individual’s dignity
5. Protocols for when the use of restraint, seclusion, and/or physical management is
appropriate, and the restrictions on the use of these techniques, the facility may impose
more, but not fewer, restrictions on the use of these techniques than is required by this
Chapter.
6. Details on the type of physical management, restraint, and seclusion interventions or
models that the personnel are approved to use.
7. Details on how seclusion, restraint, and/or physical management will be altered to include
any necessary accommodations the individual may need, including but not limited to,
changing emergency interventions to not restrain hands and the ability to communicate
for those individuals in care who speak sign language.
15.15.3 Personnel Training
A. The facility shall ensure that all personnel involved in utilizing seclusion, restraint, and/or physical
management are trained in the use of seclusion, restraint, and/or physical management as
described in this Part 15.15.3 in accordance with the training model being utilized by the facility.
B. The facility shall ensure that personnel are trained to explain, where possible, the use of
seclusion, restraint, and/or physical management to the individual who may be secluded,
restrained, or physically managed and to the individual’s designated representative, if
appropriate, upon admission.
C. Training programs must be standardized and evaluated by facility leadership every three (3)
years to ensure incorporation of evidence-based best practices for seclusion, restraint, and/or
physical management.
D. Training must be provided to personnel within the first month of their orientation period and
annually thereafter unless training is needed sooner.
E. Personnel shall obtain certification in cardiopulmonary resuscitation (CPR), including periodic
recertification as needed to maintain certification.
F. Training must include at a minimum, but is not limited to:
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1. The safe use of seclusion, restraint, and/or physical management including content
related to the risks of positional asphyxia, aspiration, traumatization, and recognize and
respond to signs of physical distress of an individual who is secluded, restrained, and/or
physically managed;
2. Address concepts related to prevention and non-physical interventions, including, but not
limited to, de-escalation and mediation;
3. Educate personnel of how their culture, language, biases, values, and perceptions
influence their response and escalation of the individual involved; and
4. Understanding and recognizing underlying behavioral health and physical health
conditions, medications, and their potential effects as well as how age, developmental
level, cultural background, language, history of physical or sexual abuse, and prior
experience with seclusion, restraint, and/or physical management will influence an
individual’s responses to seclusion, restraint, and physical management.
G. Personnel must demonstrate knowledge and application of seclusion, restraint, and physical
management training on an annual basis when working with persons eighteen (18) years of age
and older, and on a semi-annual basis when working with youth seventeen (17) years old and
younger.
15.15.4 Standards of Care Upon Admission
A. At admission, the facility shall inform both the individual and the individual’s parent, legal
custodian, legal guardian or legal representative, as applicable, of the facility’s policy regarding
the use, or prohibition, of seclusion, restraint, and physical management during an emergency
behavioral health episode for individuals in care. This must, as is reasonable under the
circumstances, be communicated, if feasible, in a language and modality accessible to the
individual.
1. If communication barriers exist, they shall be documented in the individual’s clinical
record.
2. The facility shall document all future attempts to communicate the potential for this
intervention while the individual is in the care of the facility.
B. Upon an individual’s admission, personnel shall collaborate with the individual and the individual’s
parent, legal custodian, legal guardian or legal representative, when applicable, to formulate
strategies that may minimize the potential for a behavioral health emergency event that requires
interventions of seclusion, restraint, and/or physical management.
C. A facility electing to utilize seclusion, restraint, and/or physical management shall assess each
individual upon admission regarding:
1. Assault and trauma history;
2. Seclusion, restraint, and/or physical management history;
3. Individual’s risk factors for a behavioral emergency, and individually identified strategies
to avoid seclusion, restraint, and/or physical management; and
4. The facility shall ascertain any applicable behavioral health advance directives.
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D. Assessment of an individual's behavioral health emergency history and prevention plan shall be
maintained in the individual’s clinical record and in a location easily accessible to any personnel
providing direct care to the individual.
15.15.5 Use of Physical Management
A. Physical management for individuals in care under the age of eighteen (18) must always be
considered as restraint and follow the restraint order rules pursuant to Parts 15.15.6, 15.15.7, and
15.15.14 of this Chapter 15.
B. Physical management shall only be used on an emergency basis for a maximum of one (1)
minute.
1. If physical management is used for longer than one (1) minute, the intervention is
restraint, pursuant to Section 26-20-102(6), C.R.S., and personnel must follow the
restraint rules pursuant to Part 15.15.7 of this Chapter 15.
C. To ensure the safety of each individual and personnel, each facility shall designate emergency
physical management techniques to be utilized during emergency situations.
D. The term “physical management” does not include briefly holding an individual in order to comfort
them.
E. The physical management continuum may include:
1. Utilizing transitional measures;
2. Placing one’s hands on an individual to physically guide and/or physically control the
individual;
3. Use of an approved restraint method specified in the facility’s policies and procedures to
maintain the safety of the individual;
4. Placing an individual into an approved prolonged restraint method specified in the
facility’s policies and procedures; or
5. Physical management may be used to move or escort an individual into seclusion.
a. Seclusion, in itself, is not a form of physical management.
F. Physical management must be documented in the clinical record to include the following:
1. Documentation of the behavioral necessity for physical management and any de-
escalation techniques attempted prior to utilizing physical management.
2. Documentation of the approved physical management method utilized.
15.15.6 Orders For Seclusion/Restraint
A. If an order for seclusion/restraint is verbal, the verbal order must be received by a registered
nurse or other trained licensed personnel, such as a licensed practical nurse, while the
emergency safety intervention is being initiated by personnel or immediately after the emergency
safety situation begins.
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1. The registered nurse or other trained licensed professional receiving a verbal order for
the seclusion/restraint must document the verbal order in the clinical record.
2. The physician or other authorized practitioner permitted to order seclusion/restraint must
verify the verbal order in a signed written form in the individual’s record. Signatures must
be entered into the record no more than twenty-four (24) hours after the event.
3. The physician or other authorized practitioner to order seclusion/restraint must be
available to personnel for consultation, at least by telephone, throughout the period of the
emergency safety intervention.
B. Within one (1) hour of the initiation of the original order of seclusion/restraint an authorized
practitioner or a registered nurse, trained in the use of emergency safety interventions and
permitted to assess the physical and psychological well-being of the individual, shall conduct an
in-person assessment of the physical and psychological well-being of the individual
C. When the emergency intervention continues up to one (1) hour, personnel must conduct an in-
person assessment. The assessment may be conducted by a registered nurse or an authorized
practitioner. The assessment shall include the following components at a minimum;
1. The individual’s physical and psychological status;
2. The individual’s behavior and determination if the behaviors require continued
intervention;
3. The appropriateness of the intervention measures; and
4. Any complications resulting from the intervention.
D. Results of the one (1) hour assessment, as described in Part 15.15.6.C, must determine if
continued emergency interventions need to be re-ordered by the authorized practitioner.
1. The new order/extension must not exceed an additional three (3) hours.
2. Assessment results and continuation order, if applicable, must be contained in the clinical
record.
E. Any behavioral health emergency situation that requires intervention past four (4) hours shall
include an in-person assessment and new emergency intervention orders every four (4) hours as
described in Part 15.15.6.C.
15.15.7 Use of Restraint
A. The decision to restrain must be based on a current clinical assessment and behavioral
presentation.
B. Restraint includes chemical restraint, mechanical restraint, and physical restraint.
C. Restraint must not be used solely to prevent unauthorized departure, unless the individual is
being held under the provisions of an emergency mental health hold.
D. Restraint of an individual by a chemical spray is not permissible.
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E. The type of restraint must be appropriate to the type of behavior to be controlled, the physical
condition of the individual, the age of the individual, and the type of effect restraint may have
upon the individual.
F. Lower-level and alternative interventions shall be attempted prior to initiation of restraint unless
the alternative interventions would be ineffective or unsafe to the individual’s self or others
G. The term “restraint” as used in this section, does not include restraints used while the facility is
engaged in transporting an individual from one facility location to another facility location when it
is within the scope of that facility’s powers and authority to conduct such transportation pursuant
to Sections 26-20-101 through -110, C.R.S.
H. No restraint of an individual may place excess pressure on the chest or back of that individual,
cover the individual’s face, or inhibit or impede the individual’s ability to breathe.
15.15.8 Chemical Restraint
A. An order for a chemical restraint, along with the reasons for its issuance, must be recorded in
writing at the time of its issuance.
B. An order for a chemical restraint must be signed at the time of its issuance by such authorized
practitioner, who is present at the time of the emergency.
C. An order for a chemical restraint, if authorized by telephone, must be transcribed and signed at
the time of its issuance by personnel with the authority to accept telephone medication orders
who are present at the time of the emergency.
D. Personnel trained in the administration of medication shall make notations in the record of the
individual as to the effect of the chemical restraint and the individual’s response to the chemical
restraint.
15.15.9 Use of Seclusion
A. Seclusion occurs any time an individual is placed alone in a room and not allowed to leave.
B. The decision to seclude must be based on a current clinical assessment and behavioral
presentation. Seclusion must be used only when other less restrictive methods have failed.
1. Documentation of less restrictive methods and the outcome must be contained in the
clinical record.
C. Seclusion must not be used for punishment, for the convenience of personnel, or as a substitute
for a program of care and treatment.
D. Seclusion rooms must be lighted, clean, safe, and have a window for personnel to observe.
E. Seclusion rooms must be a minimum of 100 square feet, unless the facility is licensed as a
hospital and the seclusion room size is in compliance with applicable CDPHE regulations.
F. Relief periods from seclusion must be offered for reasonable access to toilet facilities.
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15.15.10 Explanation to Individual in Seclusion/Restraint
A. In any situation in which seclusion/restraint is utilized, information must be given to the
secluded/restrained individual, and the individual’s parent, legal custodian, legal guardian or legal
representative when applicable, as soon as possible after they have been secluded or restrained.
The individual must be given a clear explanation of:
1. The reasons for the use of such intervention;
2. The observation procedure, the desired effect, and
3. The circumstances under which the procedure will be terminated.
B. That the explanation has been given to the individual and the individual’s parent, legal custodian,
legal guardian or legal representative, when applicable, must be documented in the clinical
record.
C. As soon as possible, upon termination of seclusion and/or restraint, personnel shall debrief with
the individual and assess for any traumatic stress that may have been triggered as a result of
seclusion/restraint.
15.15.11 Observation and Care of Individuals in Seclusion and/or Restraint
A. An individual who is in seclusion/restraint must be observed in person by trained facility
personnel. Observation for an individual in restraint must not be more than ten (10) feet physical
distance from the individual. Any individual placed in seclusion must be observed through direct
observation and not solely through the use of video surveillance.
1. Such observation, along with the behavior of the individual, must be documented every
fifteen (15) minutes.
B. Unless contraindicated by the individual's condition, such observation must include consistent
efforts to interact personally with the individual throughout the episode.
1. All contraindications shall be documented in the clinical record.
C. Ongoing provisions must be made for nursing care, hygiene, diet, and motion of any restrained
limbs throughout the episode.
D. Facility personnel must maintain a continuous line-of-sight throughout the episode with the
individual held in mechanical restraints.
E. For individuals in care held in mechanical restraints, facility personnel must observe the individual
at least every fifteen (15) minutes to ensure that:
1. The individual is properly positioned;
2. The individual’s blood circulation is not restricted;
3. The individual’s airway is not obstructed; and
4. The individual’s other physical needs are met, pursuant to this Part 15.15.11 C.
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F. For individuals in care held in mechanical restraints, the facility shall offer relief periods of at least
ten (10) minutes as often as every two (2) hours, so long as relief from the mechanical restraint is
determined by personnel to be safe pursuant to this Part 15.15.11.
G. Personnel must document relief periods both offered and granted.
H. The individual must have access to food at least every four (4) hours.
I. The individual must have access to fluids and toileting upon request or during offered relief
periods, but must at minimum be offered every two (2) hours.
1. During such relief periods, personnel shall ensure proper positioning of the individual and
provide movement of limbs, as necessary.
J. Personnel must provide assistance for the use of necessary toileting methods.
1. Appropriate toileting does not include the use of adult diapers, bedpans, or other mobile
toileting equipment if not typically used by the individual when not restrained or secluded.
2. If the individual typically uses adult diapers, they are to be changed immediately if soiled.
K. Personnel shall maintain the individual’s dignity and safety during relief periods.
L. Cameras and other electronic monitoring devices must not replace face-to-face observations.
M. To the extent that the duties specified in Sections 26-20-101 through -110, C.R.S. are more
protective of individual rights or are in conflict with the provisions in this Part 15.15, the provisions
of Sections 26-20-101 through -110, C.R.S. shall apply.
15.15.12 Continued Use of Seclusion and/or Restraint
A. Personnel must document efforts to assure that the use of seclusion/restraint are as brief as
possible.
B. Seclusion and/or any type of restraint must not be ordered on an “as needed” basis.
C. Continued seclusion/restraint in excess of twenty-four (24) hours shall require an administrative
review.
1. The administrative reviewer shall be a different authorized practitioner with the authority
and knowledge necessary to review clinical information and reach a determination that
the extension of a seclusion and/or restraint episode beyond twenty-four (24) hours is
clinically necessary.
2. If the administrative reviewer does not concur with the order for continuation of
seclusion/restraint, the order must be discontinued, and the authorized practitioner in
charge of treatment shall be notified of such discontinuation.
D. An administrative review must be initiated at the conclusion of each twenty-four (24) hour period
of continuous use of seclusion/restraint.
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15.15.13 Documentation Requirements
A. Each facility must ensure that an appropriate notation of the use of seclusion, restraint and/or
physical management is documented in the record of the individual who was secluded,
restrained, and/or physically managed and must be completed before the end of the shift of the
personnel involved in the seclusion, restraint and/or physical management episode(s). Each
facility shall document the following in the individual’s record:
1. Specifics of the episode including identified triggers, precipitating events, the individual's
specific behavior(s), and the nature of the danger;
2. Lower-level interventions utilized, or reasoning why lower-level interventions would have
been ineffective or inappropriate;
a. A description of specific non-physical and least restrictive interventions that were
attempted prior to the intervention and the individual’s response;
3. Type of restraint, if utilized;
4. Specific date and times of initiation and discontinuation of seclusion, restraint, and/or
physical management and total length of time individual is secluded, restrained, and/or
physically managed;
5. Identification of personnel involved in the initiation and application of the seclusion,
restraint, and/or physical management;
6. Notification to an authorized practitioner within one (1) hour of the seclusion/restraint
intervention;
7. Care provided while the individual was secluded, restrained, and/or physically managed,
including:
a. Observations conducted;
b. Assessments of position, respiration, circulation, and range of motion;
c. Documentation of ongoing 15-minute observation and care checks, as subject to
applicable rules, along with relief periods both offered and granted for food, fluid,
and/or toileting;
d. Interventions provided to promote comfort and safety as well as expedite release;
e. The individual’s response to these interventions; and
f. The effect of the restraint or seclusion on the individual;
8. Documentation that the individual, and the individual’s parent, legal custodian, legal
guardian or legal representative if applicable, was given a clear explanation of the
reasons for use of such intervention, the observation procedure, the desired effect, and
the circumstances under which the intervention will be terminated including criteria for
release and individual understanding of that criteria; and,
9. Documentation that personnel debriefed the incident with the individual and assessed for
trauma, processed the traumatic event, and identified triggers.
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B. Any administrative reviewer shall document the clinical justification for the continued use of
seclusion/restraint in the individual's clinical record. The justification must include:
1. Documentation that the authorized practitioner ordering the continuous use of
seclusion/restraint in excess of four (4) hours has conducted a face-to-face evaluation of
the individual within the previous four (4) hours;
2. Documentation of the ongoing behaviors or findings that warrant the continued use of
seclusion/restraint and other assessment information as appropriate;
3. Documentation of a plan for ongoing efforts to actively address the behaviors that
resulted in the use of seclusion/restraint;
4. A determination of the clinical appropriateness of the continuation of seclusion/restraint;
and
5. A summary of the information considered by the reviewer and the result of the
administrative review, with the date, time and signature of the person completing the
review.
C. Information regarding the use of seclusion/restraint must be readily accessible to authorized
persons for review. The facility shall have the ability to gather data as follows:
1. Each seclusion/restraint episode, including date and time the episode started and ended,
specific to each individual over the period of one complete calendar year from January 1
through December 31.
15.15.14 Additional Procedures and Requirements for Seclusion/Restraint of a Youth
A. Procedures for youth must include the following in addition to the requirements found in this Part
15.15, unless otherwise required in this Part 15.15.14.
B. This Part 15.15.14 does not apply to adult individuals in care, ages 18 (eighteen) and older,
receiving services in an adult facility.
C. An emergency safety intervention must be performed in a manner that is safe, proportionate, and
appropriate to the severity of the behavior, and the youth’s chronological and developmental age;
size; gender; physical, medical, and psychiatric condition; and personal history (including any
history of physical or sexual abuse).
D. Orders for seclusion/restraint must be made by an authorized practitioner in the facility within the
scope of practice to order seclusion/restraint, trained in the use of emergency safety
interventions, and in accordance with 42 C.F.R. Part 441, which is incorporated by reference in
Part 1.2 of these Rules.
1. This requires that inpatient psychiatric services for individuals in care under age twenty -
one (21) be provided under the direction of a physician.
E. If the individual’s treatment team assigned physician or authorized practitioner is available, only
they can order seclusion/restraint. If they are not available, then another authorized practitioner
on the treatment team may make the order.
F. A physician or other authorized practitioner must order the least restrictive emergency safety
intervention that is most likely to be effective in resolving the emergency safety situation based on
consultation with personnel.
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G. If the order for seclusion/restraint is verbal, the order must be received by a registered nurse or
other trained licensed personnel, such as a licensed practical nurse, while the emergency safety
intervention is being initiated by personnel or immediately after the emergency safety situation
begins.
1. The registered nurse or other trained licensed professional receiving a verbal order for
the emergency intervention must document the verbal order in the clinical record.
2. The physician or other authorized practitioner permitted to order restraint or seclusion
must verify the verbal order in a signed written form in the youth’s record. Signatures
must be entered into the record no more than twenty-four (24) hours after the event.
3. The physician or other authorized practitioner to order restraint or seclusion must be
available to personnel for consultation, at least by telephone, throughout the period of the
emergency safety intervention.
H. Each order for seclusion/restraint must be limited to no longer than the duration of the emergency
safety situation.
I. If the total order time exceeds the following durations, the facility must evaluate the individual to
determine whether they should be moved to a higher level of care, unless the facility is a hospital:
1. Four (4) hours for persons ages eighteen (18) to twenty-one (21);
2. Two (2) hours for persons ages nine (9) to seventeen (17); or
3. One (1) hour for persons under the age of nine (9).
J. Within one (1) hour of the initiation of the order of the emergency safety intervention a registered
nurse or authorized practitioner trained in the use of emergency safety interventions and
permitted to assess the physical and psychological well-being of the youth, must conduct an in-
person assessment of the physical and psychological well-being of the individual including but not
limited to:
1. The youth’s physical and psychological status;
2. The youth’s behavior;
3. The appropriateness of the intervention measures; and
4. Any complications resulting from the intervention.
K. Results of the one (1) hour assessment must be documented in the individual’s record.
L. Notification of parent(s) and/or legal guardian(s), when applicable:
1. The facility must notify the parent(s) and/or legal guardian(s) of the individual who has
been in seclusion or restraint as soon as possible after the initiation of each emergency
safety intervention.
2. The facility shall document in the individual’s record that the parent(s) or legal guardian(s)
have been notified of the emergency safety intervention, including date and time of the
notification and the name of personnel providing the notification.
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3. If notification to the parent, legal guardian, or legal custodian is contraindicated, this shall
be documented in the youth’s clinical record.
15.16 Use of Feeding Tubes for Eating Disorder Treatment and Recovery
15.16.1 Informed Consent for Feeding Tubes
A. Use of a feeding tube for purposes of eating disorder treatment requires obtaining signed written
informed consent prior to initiation of such procedure unless the facility is initiating involuntary
placement of the feeding tube. If the facility is involuntarily placing a feeding tube, the facility must
provide the individual with the written advisement of Rule 15.16.1 C of this Chapter 15 to allow
the individual an opportunity to give informed consent. Informed consent is required when:
1. A feeding tube is initially placed;
2. When a facility wants to utilize and use an existing tube that was not placed by the
facility; or
3. When a facility initiates an emergency feeding tube in alignment with Part 15.16.3 of this
Chapter 15.
B. For voluntary placement of a feeding tube, written informed consent shall be obtained and
documented in the individual’s clinical record, reflecting the agreement by both the individual and
the treatment provider or facility.
1. When the individual receiving the feeding tube ages fourteen (14) and younger, the
parent/guardian must provide written informed consent for the feeding tube. The
individual must be provided with the information and opportunity to ask questions
regarding the process.
2. When the individual receiving the feeding tube, age fifteen (15) years and older, both the
individual and the parent or legal guardian, as applicable, must provide written informed
consent for the use of the feeding tube. If the individual does not consent, the facility
must follow the procedures outlined in Sections 27-65-104(6) and 27-65-113, C.R.S.
a. A facility may not involuntarily place or utilize a feeding tube unless designated
under Section 65 Title 27, C.R.S. and Chapter 11 of these Rules. A facility
involuntarily placing or continuing the use of a feeding tube must follow all
requirements listed in Chapter 11 of these Rules.
C. Informed consent for a feeding tube procedure shall contain and document the following:
1. The reason for such treatment;
2. The nature of the procedures to be used in such treatment, including their probable
frequency and duration;
3. The probable degree and duration of improvement or remission of symptoms expected
with or without such treatment;
4. The nature, degree, duration, and probability of the side effects and significant risks of
such treatment commonly known by the medical profession;
5. The reasonable alternative treatments, if any, and why the authorized practitioner is
recommending the specific treatment;
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6. That the individual has the right to refuse or accept the proposed treatment and has the
right to revoke their consent for any reason at any time, either orally or in writing; and
7. An offer to answer any inquiries concerning the recommended feeding tube placement.
D. For voluntary feeding tubes, if written informed consent is not obtained, then the individual's
consent for the procedure is revoked.
15.16.2 Personnel Training Requirements
A. Feeding tubes shall only be placed by personnel of the facility who possess the knowledge and
skill of placement through training and/or education. Personnel shall only place feeding tubes
when their scope of practice allows.
B. In addition to the training requirements in Part 15.10 of this Chapter 15, personnel placing or
utilizing feeding tubes must have annual competency training.
C. The facility shall maintain policies and procedures regarding which personnel can place or utilize
the feeding tube procedures, processes, and training based on their education and credentials.
15.16.3 Emergency Feeding Tube Requirements
A. Emergency feeding tubes may be administered in an emergency situation as determined by the
facility’s policies and procedures. Policies shall include, at a minimum, the following:
1. Consultation by two licensed physicians, with expertise in treating eating disorders, prior
to placement and use of the emergency feeding tube;
2. Medical condition(s) that would constitute the need for emergency feeding;
3. Evaluation of an individual’s decision to refuse nutrition; and
4. Documentation of insufficient time to obtain a court order for an involuntary feeding tube.
B. Emergency feeding tubes shall only be utilized by designated facilities that also hold a valid 27- 65
Designation from BHA.
C. Emergency feeding tubes shall only be utilized by an eating disorder treatment and recovery
facility within a general hospital setting, where emergency medical services are available onsite.
D. Reasonable attempts to obtain voluntary acceptance of a feeding tube shall be made prior to the
placement or use of an emergency feeding tube. All attempts shall be documented in the
individual’s record.
E. Continuation of an emergency:
1. If the emergency has abated because of the use of the feeding tube and the physicians
are of the opinion that the feeding tube is necessary to keep the emergency in abeyance
beyond seventy-two (72) hours, then within that seventy-two (72) hours, the following
steps shall be taken:
a. The facility shall send a written request for a court hearing for an order to
administer the feeding tube involuntarily; and
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b. An examination of the individual, a review of the clinical record, including an
assessment as to whether the emergency condition continues to exist, and
whether or not the individual can voluntarily receive nutrition.
2. In no case shall an individual receive an emergency feeding tube involuntarily for a period
exceeding ten (10) business days without an order from a court of competent jurisdiction,
including continuation orders from the court.
3. The individual shall be notified of the right to contact their attorney and/or the court of
competent jurisdiction at the time the written request for court-ordered feeding tube is
made. This notification shall be documented in the clinical record. If an individual chooses
to exercise this right, the eating disorder treatment and recovery facility shall aid the
individual, if necessary, in accomplishing the foregoing.
F. The specific facts outlining conditions supporting the finding of the emergency condition shall be
detailed in the clinical record. Every twenty-four (24) hours thereafter until such time a final court
order is issued, the emergency is resolved, or the individual accepts a feeding tube or other
appropriate nutrition voluntarily, the facility shall document the behaviors that substantiated the
need to continue the emergency feeding tube, and the physician shall continue the order.
G. During the course of the emergency feeding tube, the individual shall be offered the nutrition on a
voluntary basis each time the nutrition is given. If the individual voluntarily consents to take the
nutrition, and the attending physician determines that the individual will likely continue to accept
the nutrition on a voluntary basis and no longer requires an involuntary feeding tube, this shall be
documented in the record and the involuntary procedures shall be terminated.
H. If the individual again refuses to voluntarily accept nutrition and their clinical condition returns to
an emergency situation, pursuant to Part 15.16.3 of this Chapter 15, the emergency feeding tube
procedures may be re-instituted.
15.16.4 Involuntary Feeding Tube Requirements
A. Any eating disorder treatment and recovery facility utilizing involuntary feeding tubes and/or
restraint for feeding tubes shall be a 27-65 designated facility and meet the requirements of the
designation as described in Chapter 11.
B. In non-emergency situations in which an individual is detained pursuant to Sections 27- 65-106, -
108.5, -109, -110, or –111, C.R.S. would benefit from the placement and utilization of a feeding
tube, but the individual does not consent, the facility shall petition the court to obtain permission
to administer such procedure. The following conditions must be documented in the petition:
1. The individual is unable to effectively participate in the treatment decision;
a. The individual is unable to effectively participate in treatment decision making or
unable to consent due to their mental illness, as determined by an evaluation of
capacity. This evaluation shall be documented in the clinical record.
2. Treatment by an involuntary feeding tube is necessary to prevent significant and likely
long-term deterioration in the individual’s mental and physical condition;
3. A less intrusive and appropriate treatment alternative is not available or inappropriate;
and
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4. The individual’s need for treatment by an involuntary feeding tube is sufficiently
compelling to override any bona fide and legitimate interest of the individual refusing
treatment.
C. The petition shall specify the type of feeding tube is being recommended as potentially beneficial
to the individual.
D. Feeding tubes shall not be placed and/or utilized without the individual’s consent or the consent
of the individual’s parent/legal guardian, except under emergency conditions under Part 15.16.3
of this Chapter 15 or pursuant to an order from a court of jurisdiction.
1. Individuals subject to involuntary feeding tubes shall be provided the same information as
described Part 15.16.1, ability to ask questions, and receive answers.
15.16.5 Use of Restraint During Feeding Tube Placement and Utilization
A. Use of restraint for feeding tube intervention shall be used as a last resort, when all lower -level
interventions have been exhausted, and shall not be used as a punitive or coercive response to
the individual.
1. Multidisciplinary team decision-making to utilize physical or mechanical restraints for
feeding tube placement shall be made on an individual basis. Decision-making shall be
documented within the individual’s clinical record.
B. Eating disorder treatment and recovery designated facilities utilizing restraint for the placement
and intervention of a feeding tube shall develop and implement policies and procedures in
accordance with Parts 15.15 and 15.16 and the following minimum requirements:
1. Details on the type of physical management, restraint, and/or model the personnel are
approved to use.
2. The multidisciplinary team shall document the decision-making process, including a
comprehensive physical and mental health risk assessment prior to implementation of
restraint;
3. Restraint may only be utilized to ensure the physical safety of the individual and/or
personnel; and
4. How the restraint will be removed and in what timeframe.
15.16.6 Documentation Requirements
A. Any physical management, physical restraint, and/or mechanical restraint required for feeding
tube placement or use must be documented as described in Part 15.15.13 of this Chapter 15.
B. Any facility utilizing physical management, physical restraint, and/or mechanical restraint for
feeding tube placement or use shall have policies and procedures that comply with the
requirements of Part 15.15 of this Chapter 15.
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15.17 Psychiatric Medications
15.17.1 Informed Consent
A. In all instances where prescription medications are to be ordered as a part of a treatment
program, the following information in these Parts 15.17 shall be provided, consistent with federal
and state law, to the individual and legal guardian(s), if applicable, and communicated in both
written and verbal formats.
1. For individuals in care, ages fifteen (15) up to age eighteen (18), the information outlined
in 15.17.1 C of this Chapter 15 shall also be provided to the individual’s parent(s) or legal
guardian(s).
2. When an individual has designated another to act concerning medication issues,
pursuant to a medical durable power of attorney, advanced directive, or proxy, the
information shall be provided to that person also.
B. The facility shall have policies and procedures for documenting in the clinical record that the
required information was given to the individual, parent, or guardian and consent obtained before
prescribing and the initial administration of medication(s).
C. The information required as part of the informed consent shall include, at a minimum, the
following:
1. The name(s) of the medication being prescribed;
2. The typical uses of the medication(s) to be prescribed;
3. The reasons for ordering the medication(s) for this individual;
4. A description of the benefits expected;
5. The common side effects and common discomforts, if any;
6. The major risks, if any;
7. The probable consequences of not taking the medication(s);
8. Any significant harmful drug or alcohol interactions, or food interactions;
9. Appropriate treatment alternatives, if any;
10. That the individual may withdraw agreement to take the medication at any time; and
11. Ensure that medication will not interfere or negatively interact with any of the individual’s
other prescribed medication(s).
D. The provider with prescriptive authority or their designee shall offer to answer inquiries regarding
the medication(s) upon prescribing or any other time upon request.
E. No individual shall be threatened with or subjected to adverse consequences by facility personnel
solely because of a refusal to accept psychiatric medication voluntarily.
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15.17.2 Prescribing, Handling, and Administration of Psychiatric Medication(s)
A. All psychiatric medication(s) may only be administered on the written order of a professional
authorized by statute to order such medications. Verbal medication orders may be given
according to facility policies.
B. The facility shall have written policies and procedures regarding Part 15.17 of this Chapter 15 for
informed consent, and the following:
1. Documentation of the administration of medication, medication variances/errors, and
adverse medication reactions related to medication administration;
2. Notification to professional staff authorized by statute to order such medications in case
of medication errors and/or medication reactions/events;
3. Discontinuance of medication;
4. Disposal of medications;
5. Acceptance of verbal, fax, or electronically transmitted medication orders; and
6. Medication shortages and substitutions.
C. Facilities shall ensure all clinical staff are aware of and have access to the medication formulary,
when applicable and appropriate.
D. Facilities shall ensure their providers have access to the medications on the medication formulary
when prescribing medications to treat behavioral health disorders.
E. Facilities shall document in the individual’s clinical and/or medication administration record all
prescription medications administered to the individual by the facility, including:
1. The name and dosage of medication;
2. The reason for ordering the medication;
3. The time, date and dosage when medication(s) is administered;
4. The name and credentials of the person who administered the medication; and
5. The name of the prescribing physician or advanced practice registered nurse to order
such medication.
F. Medication Administration
1. The facility must ensure that medications are administered only by licensed or certified
personnel allowed to administer medications under their own scopes of practice, or
unlicensed personnel who are qualified medication administration persons (QMAPs)
acting within their own scope of practice.
2. When using QMAPs to administer medication, the facility shall ensure compliance with 6
CCR 1011-1 Chapter 24, as incorporated by reference in Part 2.15.B of these Rules.
3. Facilities shall follow psychiatric medication standards as outlined in Part 15.17 of this
Chapter 15 and the following:
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a. Only a licensed registered nurse may accept telephone or verbal orders for
medication from a physician or other authorized practitioner. All telephone orders
shall be evidenced by a written and signed order and documented in the
individual’s record and the facility’s medication administration record.
b. The facility shall be responsible for complying with the prescriber’s or advanced
practice registered nurse's orders associated with the administration of
medication or treatment. The facility shall implement a system that obtains
clarification from the physician, as necessary, and documents that the physician:
(1) Has been asked whether refusal of the medication or treatment should
result in physician notification.
(2) Has been notified, where such notification is appropriate.
(3) Has provided documentation that such notification shall be made in the
individual’s clinical record.
(4) Coordinates with external providers or accepts responsibility to perform
the care using facility personnel.
(5) Trains personnel regarding the parameters of the ordered care as
appropriate.
(6) Documents the delivery of the care, including refusal by the individual, of
the medication or treatment.
15.17.3 Medication Storage, Disposition, and Disposal
A. All personal medication must be surrendered to the facility to be logged in and stored by the
facility. Individuals in care shall not be allowed to self-administer medication in the facility, when
the facility is providing residential or inpatient level(s) of care.
B. Personal medication shall be returned to the individual or individual’s parent, legal custodian,
legal guardian or legal representative, upon discharge or death.
1. The return of medication to the individual may be withheld when a physician or other
authorized medical practitioner has determined that the individual lacks the decisional
capacity to possess or administer such medication safely.
2. If the medication is withheld, the decision to withhold the medication shall be documented
in the individual’s clinical record.
C. Medications shall be labeled with the individual’s full name, pursuant to Article 280 of Title 12,
C.R.S.
D. Any medication container that has a detached, excessively soiled, or damaged label shall be
returned to the issuing pharmacy for re-labeling or disposed of appropriately.
E. All medication shall be stored in a manner that ensures the safety of all individuals in care.
F. Medication shall be stored in a central location, including refrigerators, and shall be kept under
lock and shall be stored in separate or compartmentalized packages, containers, or shelves for
each individual in order to prevent intermingling of medication.
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G. Individuals in care shall not have access to medication that is kept in a secure and central
location.
H. Medications that require refrigeration shall be stored separately in locked containers in the
refrigerator. If medication is stored in a refrigerator dedicated to that purpose, and the refrigerator
is in a locked room, then the medications do not need to be stored in locked containers.
I. Prescription and over the counter medication shall not be kept in stock or bulk quantities unless
such medication is administered by a licensed medical practitioner.
J. Medication disposal procedures include:
1. The return of medication shall be documented by the facility.
2. Medication that has a specific expiration date shall not be administered after that date
and shall be disposed of appropriately.
15.18 Continuity of Care and Transfer of Care
15.18.1 Continuity of Care
A. Each facility shall adopt and implement a written policy for continuity of care. The policy shall
include at a minimum the following:
1. Access to all necessary care and services within the facility, and coordination with any
other current health care providers or other systems of care or support as appropriate;
2. Coordination of care with the individual's previous mental health care providers or
medical providers as appropriate, including retrieval of psychiatric and medical records;
3. Coordination of the individual's care with family members, guardians, and other
interested parties as appropriate and in a manner that reflects the individual's culture;
and/or
4. The facility shall facilitate access to proper medical care and shall be responsible for
coordinating mental health treatment with medical treatment provided to the individual.
15.18.2 Transfer of Care: Non-Emergent
A. The individual shall only be transferred to another eating disorder treatment and recovery facility
when adequate arrangements for care by the receiving facility have been made and documented
in the clinical record. Transfer coordination shall include at least one discharge planning
conference, face-to-face or by telephone, with participants from both facilities and the individual
and their guardian, whenever possible.
B. At least twenty-four (24) hours advance notice of transfer shall be given to the individual, unless
knowingly waived in writing by the individual and guardian, if applicable and as appropriate,
except in cases of a medical emergency.
C. The transferring facility shall ask the individual to indicate two (2) persons to whom notification of
transfer should be given and shall notify such persons within twenty-four (24) hours of notification
to the individual. Such notification shall be made by the transferring facility with the appropriate
written authorization. Actions taken under Part 15.18 of this Chapter 15, shall be documented in
the clinical record.
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15.18.3 Care Coordination
A. Eating disorder treatment and recovery designated facilities shall work with the individual to
identify the individual’s service and support needs and preferences and shall carry out care
coordination as defined in Part 1.1 of these Rules to facilitate access to those services and
supports.
B. Care coordination must, to the extent possible, be carried out in accordance with the individual's
expressed preferences and with involvement of the individual's family member(s), parent, legal
custodian, legal representative, advocate, caregiver, and other supports identified by the
individual.
C. Care coordination activities may include, as appropriate for the needs and preferences of the
individual:
1. Development of person and family-centered service plans that:
a. Promote integrated whole person care across the spectrum of health services.
b. Address each individual’s priorities, goals, and the barriers they face.
c. Address access to acute and chronic physical and behavioral health care, peer
support networks, social services including income supports, health insurance,
housing, educational systems, and employment opportunities as necessary to
facilitate wellness and recovery of the whole person in alignment with an
individual’s assessed needs and expressed goals.
2. Facilitating access to needed resources and services to carry out the service plan. This
may include, but is not limited to:
a. Conducting application assistance, referrals, and warm hand-offs to access
resources and care;
b. Providing accessible, culturally and linguistically appropriate resources and
information, including access to resource directories such as OWNPATH;
c. Coordinating with partners to provide specialized services, risk stratification,
discharge planning, transition planning, prior authorization, insurance appeal,
and medication reconciliation;
d. Identifying the information, social service, and health care systems that an
individual will need to access in order to navigate systems, manage their care,
and achieve whole person health;
e. Equipping the individual with information through means that are accessible and
appropriate for the individual based on their needs and preferences and as
required by federal and state statute;
f. Collaborating with other systems and entities providing care coordination
services to the individual;
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(1) If care coordination activities necessary to meet the individual’s needs
and fulfill the service plan are being carried out by an alternate entity, the
behavioral health safety net provider shall document the responsibilities
of each entity within the record and update the record in response to
changes in the individual's needs and/or preferences, and the alternate
entity’s involvement.
g. Providing outreach, planning, problem-solving, advocacy, education, and self-
management support;
3. Deliberate and coordinated planning to prevent disengagement from services, identifying
and mitigating risks for individuals in care, including identifying and implementing
prevention strategies to proactively mitigate risk, and connecting the individual to
supports to promote ongoing maintenance and prevention.
a. Risks may include, but are not limited to, risk of grave disability, risk of danger to
self or others, risk of institutionalization, risk of incarceration, risk of overdose,
risk of housing and income instability including loss of benefits, and risk for out of
home placement for a youth.
b. Risk assessment must involve the individual and their service providers, be done
on an ongoing basis, and be addressed within the service plan.
c. When a risk for disengagement is identified, the service plan must address
prevention of and response to an individual disengaging from services including
missing appointments.
4. Monitoring an individual’s progress, engagement, and satisfaction with treatment and
recovery in alignment with outcomes identified by the individual.
5. If the facility does not provide a treatment approach or support service necessary to meet
the individual’s treatment needs, the facility must ensure that care coordination occurs.
6. All care coordination efforts and implementation must be documented in the individual’s
clinical record.
15.19 Data Reporting for Eating Disorder Treatment and Recovery Services
A. Each facility designated for eating disorder treatment and recovery services shall file an annual
report with BHA. This report shall be submitted in the format and timeframe specified by BHA.
B. For each facility, the annual report shall include:
1. Facility name;
2. County, and address of the facility; and
3. A list of any other licenses approved by BHA and held by the facility.
C. The facility shall maintain confidentiality over the data sets. The reports generated from these
data sets are also confidential. BHA may release aggregated information contained in the reports
so long as the total number of individuals in care in any aggregate group is greater than thirty
(30). If the total number of such a data group is less than or equal to thirty (30), BHA may release
this information by redacting such a number.
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D. Facilities must submit their annual data report to BHA by July 1 of each year for the most recent,
complete calendar year covering January 1 through December 31. The report must meet the
requirements of this Part 15.19 of this Chapter 15 and on the BHA-created form available on the
BHA website. All submitted data shall include non-identifying information and whole numbers.
1. Demographic summary of individuals served:
a. Age;
b. Sex;
c. Gender identity; and
d. Race and ethnicity.
2. Total number of individuals served, at each level of care, as applicable:
a. Inpatient;
b. Residential;
c. Partial hospitalization;
(1) Virtual;
(2) In-person; or
(3) Hybrid.
d. Intensive outpatient; and
(1) Virtual;
(2) In-person; or
(3) Hybrid.
e. Outpatient.
(1) Virtual;
(2) In-person; or
(3) Hybrid.
3. Total number of outcomes per level of care:
a. Programming completed successfully;
b. Individual discharged against medical or clinical advice; and/or
c. Individual was administratively discharged prior to program completion. Reason
for individual’s administrative discharge:
(1) Individual eloped from facility;
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(2) Individual was transferred to higher level of care or more appropriate
treatment setting (i.e. substance use services, detox, involuntary mental
health care, etc.);
(3) Individual was non-compliant with treatment or services;
(4) Individual no longer had funding;
(5) Medical emergency;
(6) Death of the individual;
(7) A legal guardian or legal custodian removed the individual from
treatment.
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21.000 BEHAVIORAL HEALTH
21.100 DEFINITIONS
“42 C.F.R. Part 2” means the federal regulations issued by the Substance Abuse & Mental Health
Services Administration of the U.S. Department of Health & Human Services found at 42 C.F.R. Part 2
(Feb. 2018), which are hereby incorporated by reference. No later editions or amendments are
incorporated. These regulations are available at no cost from the U.S. Department of Health & Human
Services, Substance Abuse & Mental Health Services Administration, Office of Communications, 5600
Fishers Lane, Rockville, MD 20857 or at https://www.ecfr.gov/. These regulations are also available for
public inspection and copying at the Colorado Department of Human Services, Office of Behavioral
Health, 3824 West Princeton Circle, Denver, Colorado 80236, during regular business hours.
“Acute Treatment Unit” (ATU) means a designated facility or a distinct part of a facility for short-term
psychiatric care, which may include substance use disorder treatment. An ATU provides a twenty-four
(24) hour, therapeutically planned and professionally staffed environment for individuals who do not
require inpatient hospitalization but need more intense and individualized services, such as crisis
management and stabilization services, than are available on an outpatient basis, as defined in 27-65-
102(1), C.R.S.
“A ggrieved” means having suffered actual loss or injury or being exposed to potential loss or injury to
legitimate interests as defined in 24-4-102 (3.5), C.R.S.
“Behavioral Health” for the purposes of these rules, behavioral health includes substance use and mental
health. “Department” is the Colorado Department of Human Services.
“Community Mental Health Clinic” means a health institution planned, organized, operated, and
maintained to provide basic community services for the prevention, diagnosis, and treatment of emotional
or mental disorders, such services being rendered primarily on an outpatient and consultative basis.
"Counselor-in-training" means an individual currently in the process of obtaining a professional credential
pursuant to Part 8 of Article 245 of Title 12, C.R.S. "Counselor-in-training" does not include a psychologist
candidate; a clinical social worker candidate; a marriage and family therapist candidate; a licensed
professional counselor candidate; or an addiction counselor candidate.
“Designated Facility” means an agency has applied for and been approved by the department under
these rules to provide mental health services.
“Designated Managed Service Organization” means an organization approved and authorized by the
Department to manage oversight, quality assurance, and contract compliance of substance use disorder
treatment providers within one or more of the seven established geographic sub-state planning areas.
“D isaster ” means the occurrence or imminent threat of widespread or severe damage, injury, or loss of life
or property resulting from any natural cause or cause of human origin, including but not limited to fire,
flood, earthquake, wind, storm, wave action, hazardous substance incident, oil spill or other water
contamination requiring emergency action to avert danger or damage, volcanic activity, epidemic, air
pollution, blight, drought, infestation, explosion, civil disturbance, hostile military or paramilitary action, or
a condition of riot, insurrection, or invasion existing in the state or in any county, city, town, or district in
the state as defined in Section 24-33.5-703(3), C.R.S..
“Emergency” means an unexpected event that places life or property in danger and requires an
immediate response through the use of state and community resources and procedures Section 24-33.5-
703(3.5), C.R.S.
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“HIPAA” means the Health Insurance Portability and Accountability Act of 1996, pub. l. no. 104-191, 110
stat. 1936 (1996), codified at 42 U.S.C. § 300GG (2012) and 29 U.S.C. § 1181 et seq. (2012) and 42
U.S.C. § 1320D et seq. (2012) and the federal regulations issued by the U.S. Department of Health &
Human Services found at 45 C.F.R. Part 160 (2017); 45 C.F.R. Part 162 (2017); and, 45 C.F.R. Part 164
(2017), which are hereby incorporated by reference. No later editions or amendments are incorporated.
These statutes are available for public inspection and copying from the Tenth Circuit Court of Appeals
Library, Room 430 Byron Rogers Courthouse, 1929 Stout Street, Denver, Colorado 80294, from the
hours of 8 A.M. TO 4:30 P.M. or at http://uscode.house.gov/. These statutes are also available for public
inspection and copying at the Colorado Department of Human Services, Office of Behavioral Health, 3824
West Princeton Circle, Denver, Colorado 80236, during regular business hours. These regulations are
available at no cost from the U.S. Department of Health & Human Services, Office of Civil Rights, 200
Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 or at
https://www.ecfr.gov/. These regulations are also available for p ublic inspection and copying at the
Colorado Department of Human Services, Office of Behavioral Health, 3824 West Princeton Circle,
Denver, Colorado 80236 during regular business hours.
“I ndividual ” means a person seeking or receiving services.
“Inpatient” refers to inpatient hospitalization as well as twenty-four (24) hour residential levels of care.
“Inspection” means a process of review to ensure licensed or designated entities are operating in
substantial conformity with applicable licensing and/or designation rules. Inspections may be conducted
remotely for licensure or designation renewals if the entity has received an on-site visit within three (3)
years or for entities providing telehealth-only services.
“Legal Guardian” is an individual appointed by the court, or by will, to make decisions concerning an
incapacitated individual's or minor's care, health, and welfare.
“Legal Representative” means one of the following:
A. The legal guardian of the individual, where proof is offered that such guardian has been duly
appointed by a court of law, acting within the scope of such guardianship;
B. An individual named as the agent in a Power of Attorney (POA) that authorizes the individual to
act on the individual's behalf, as enumerated in the POA;
C. An individual selected as a proxy decision-maker pursuant to Section 15-18.5-101, et seq.,
C.R.S., to make medical treatment decisions. For the purposes of these rules, the proxy decision-
maker serves as the individual's legal representative for the purposes of medical treatment
decisions only; or,
D. A c onservator, where proof is offered that such conservator has been duly appointed by a court of
law, acting with the scope of such conservatorship.
“Licensed Agency” means an agency approved and licensed under these rules by the Department to
provide substance use disorder treatment.
“Medication formulary” means the Required Formulary Psychotropic Medications: 2018, which is hereby
incorporated by reference. No later editions or amendments are incorporated. The medication formulary
is available at no cost from the Colorado Department of Human Services at
https://www.colorado.gov/pacific/cdhs/behavioral-health-laws-rules. The medication formulary is also
available for public inspection and copying at the Colorado Department of Human Services, Office of
Behavioral Health, 3824 West Princeton Circle, Denver, CO 80236, during regular business hours.
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The medication formulary is a list of minimum medications, established pursuant to 27-70-103, C.R.S.,
that may be used by service providers to increase the likelihood that a broad spectrum of effective
medications are available to individuals to treat behavioral health disorders, regardless of the setting or
service provider. The medication formulary may not contain a complete list of medications, and providers
may prescribe and/or carry any additional medications they deem necessary.
“Office” is the Office of Behavioral Health within the Colorado Department of Human Services.
“Plan of Action” is a description of how an agency plans to bring into compliance any standards identified
as out of compliance within a specified time period.
“Placement facility” means a public or private facility that has a written agreement with a designated
facility to provide care and treatment to any individual undergoing mental health evaluation or treatment
by the designated facility. A placement facility may be a general hospital, nursing care facility, or licensed
residential child care facility.
“RCCF” means a residential child care facility licensed pursuant to 12 CCR 2509-8, Section 7.705, et
seq., by the Colorado Department of Human Services, Division of Child Welfare.
“S hort -Term” psychiatric care means the average lengths of services are from three (3) to seven (7) days.
“The ASAM Criteria” means the publication from the American Society of Addiction Medicine, Mee-Lee,
D., Shulman, G.D., Fishman, M.J., Gastfriend, D.R., Miller, M.M., EDS. The ASAM Criteria: Treatment
Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd ed. Carson City, NV: The
Change Companies®; 2013, which is hereby incorporated by reference. No later editions or amendments
are incorporated. Mee-Lee, D., Shulman, G.D., Fishman, M.J., Gastfriend, D.R., Miller, M.M., EDS. The
ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd
ed. Carson City, NV: The Change Companies®; 2013, is available for a reasonable charge at
http://www.asam.org/resources/the-asam-criteria. Mee-Lee, D., Shulman, G.D., Fishman, M.J.,
Gastfriend, D.R., Miller, M.M., EDS. The ASAM Criteria: Treatment Criteria for Addictive, Substance
Related, and Co-Occurring Conditions, 3rd ed. Carson City, NV: The Change Companies®; 2013, is also
available for public inspection at the Colorado Department of Human Services, Office of Behavioral
Health, 3824 West Princeton Circle, Denver, Colorado 80236, during regular business hours.
21.105 RIGHT TO APPEAL [Eff. 5/1/16]
Any licensee or designee adversely affected or aggrieved by these rules or by the Department’s decisions
in regard to implementation of these rules, has the right to appeal to the Colorado Department of
Personnel and Administration, Office of Administrative Courts, and may subsequently seek judicial review
of the Department’s action in accordance with Section 24-4-101, et seq., C.R.S.
A. T he following actions may be submitted to an Administrative Law Judge for an evidentiary
hearing: denial of a license or designation, provisional license, probationary license, revocation,
denial of a waiver, limitation of a license, denial of a modification.
B. After written notification from the Department of intended action, the licensee or designee has
twenty one (21) calendar days to submit a written appeal. The appeal must be received by the
Division of Behavioral Health within twenty one (21) days from the date the written notification of
action letter was sent by the Department.
C. In all cases except waiver denials, the Department will file a notice of charges with the Office of
Administrative Courts to begin the administrative process. In waiver denials, the Appellant’s
request for appeal shall be forwarded to the Office of Administrative Courts. Once the appellant’s
request is forwarded to the Office of Administrative Courts, the Department may file a notice of
charges.
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D. An answer to the notice of charges shall be due twenty one (21) calendar days after the date of
mailing of the notice of charges.
E. The Office of Administrative Courts shall send out a procedural order directing the course of the
proceedings and setting the matter for hearing.
F. Subsequent to an evidentiary hearing at the Office of the Administrative Courts and the issuance
of a final agency decision, a party may seek to appeal the final agency decision through judicial
review in accordance with Section 24-4-106, C.R.S.
21.110 GOVERNANCE [Eff. 11/1/13]
A. Licensed and or designated entities by the Department shall be recognized by and allowed to do
business in Colorado.
B. Governance shall provide for and maintain at minimum:
1. Compliance with these rules and applicable federal and state regulations;
2. Agency operating policies and procedures based on these rules, Department policies and
procedures, and applicable state and federal regulations;
3. Organizational structures that clearly delineate staff positions, and lines of authority, and
supervision;
4. Adequate financial resources to maintain agency personnel, physical facilities, and
operations;
5. Physical facilities that meet all current and applicable local and state health, safety,
building, plumbing and fire codes and zoning ordinances;
6. P roperty liability insurance;
7. Professional liability (malpractice) insurance;
8. Accurate, up-to-date individual attendance and payment records; and,
9. A written emergency plan and procedures that address provisions for dealing with
medical or natural emergencies. Maps of emergency exits shall be conspicuously posted
in each site.
21.120 BEHAVIORAL HEALTH LICENSURE AND DESIGNATION
21.120.1 General Provisions
A. Any agency licensed and/or designated by the Department shall comply with Sections 21.100
through 21.190 and all rules applicable to the specific behavioral health services for which it is
licensed or designated.
B. The Department will review compliance, at a minimum:
1. Licensed agencies once every two (2) years;
2. Facilities designated to provide mental health services per Title 27, Article 65, C.R.S.,
annually and all other designated agencies at least once every two (2) years; and,
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3. When there is reasonable cause to question the agency’s fitness to conduct or maintain a
license or designation.
C. Compliance review of sub-contractors and affiliate agencies shall be at the discretion of the
Department. Review will be limited to those services that are provided pursuant to contract or
affiliation agreement with the licensed or designated agency.
D. Based on compliance issues identified through application review and inspection, the agency may
be issued a provisional or probationary license or designation.
E. Applicants that are in full compliance shall be granted a Department license to provide substance
use disorder services and/or designated to provide mental health services for up to two (2)
consecutive years from the date granted.
F. Licenses and designations shall be displayed in a prominent, publicly accessible place within
each agency and or site.
G. Current licenses and designations shall remain in effect during the approval process when
completed license and designation applications are received by the Department sixty (60)
calendar days prior to the existing license or designation expiration date.
H. An agency whose license or designation is not current shall not indicate in any form or manner
that it is licensed or designated and shall not provide behavioral health services requiring a
license or designation.
I. An y agency site that has not provided behavioral health services specific to its license or
designation status for two (2) years shall be reviewed for termination of licensure or designation.
J. Applicants may appeal licensing decisions in accordance with the state Administrative Procedure
Act, as found in Section 24-4-101, et seq., C.R.S.
21.120.2 LICENSING PROCEDURES FOR AGENCIES PROVIDING SUBSTANCE USE
DISORDER SERVICES
21.120.21 Criteria [Eff. 11/1/13]
A. Providers shall obtain a license if:
1. Required by statute to be licensed by the Department;
2. They receive public funds to provide substance use disorder treatment or substance use
disorder education;
3. They provide such treatment to individual populations whose referral sources require
them to be treated in agencies licensed by the Department; or,
4. They are acquiring existing agencies or sites licensed by the Department.
B. Licenses for treatment and education services and levels of care are required for each physical
site.
C. A license is not transferable from one licensed agency to another, from one treatment site to
another, or from a licensed agency to an unlicensed organization or individual.
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D. Hours of education and treatment provided by agencies whose license is not currently in effect
may not count toward fulfilling individual obligations to courts; probation; parole; Colorado
Department of Revenue, Motor Vehicle Division; and, other referral sources.
E. Agencies funded by the Department or a by a designated Managed Service Organization shall be
licensed to treat individuals involuntarily committed to treatment in accordance with Section
21.270.
21.120.22 Initial Licenses
A. Applicants for an initial license to provide substance use disorder services shall submit a
completed application with required documentation and fees.
B. An agency may be approved for licensure, granted provisional approval, or have its application
denied. The applicant shall be advised of the decision in writing within sixty (60) business days of
the initial inspection.
C. An applicant not in compliance may have its license application returned by certified mail with
written summaries of deficiencies and notification that the license application is denied. If an
applicant disagrees with the decision, s/he may appeal (see Section 21.105); or upon remedying
the noted deficiencies, may re-apply for an initial license in accordance with Section 21.120.2 of
these rules. Application fees may not be refunded.
21.120.23 P rovisional Licenses
A. A provisional license may be granted for a period not to exceed ninety (90) calendar days if after
initial inspection and review:
1. The provider is in substantial compliance with these rules and regulations and is
temporarily unable to conform to all the minimum standards required under these rules.
No provisional license shall be issued to a provider if the operations may adversely affect
individual health, safety, or welfare;
2. Compliance will be achieved within a reasonable period of time;
3. The provider has a reasonable written plan or schedule for achieving compliance; and,
4. The provider shall provide proof that attempts are being made to conform and comply
with applicable rules.
B. A second provisional license for a period not to exceed ninety (90) calendar days may be granted
if 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. During the term of the provisional license, reviews and inspections may be conducted to
determine if the applicant is in compliance and meets the requirements for a license.
D. Initial applicants who have completed all provisions and are found to be in compliance prior to the
expiration of the provisional license shall be granted a license for up to two (2) consecutive years
from the date the original provisional license was issued.
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E. If the applicant does not come into compliance during the provisional licensing period, the
application for a two (2) year license shall be denied. A denied application shall be returned by
certified mail with written summaries of deficiencies and notification that the provisional license is
no longer in effect as of ten (10) days from the date the letter was mailed. Original application
fees shall not be refunded. If an applicant disagrees with the decision, s/he may appeal (see
Section 21.105); or upon remedying the noted deficiencies, may re-apply for an initial license in
accordance with Section 21.120.2 of these rules.
21.120.24 License Renewal
A. An agency seeking renewal shall provide the Department with a completed license application
and the applicable fee at least sixty (60) calendar days prior to the expiration of the existing
license.
B. License renewal applications received by the Department after the current license expiration date
shall be returned by certified mail with written notification that the license is no longer in effect.
Applicants may reapply for an initial license in accordance with Section 21.120.2 of these rules.
C. License renewal applications that are received by the Department fewer than sixty (60) calendar
days prior to the expiration of their existing license may fail to receive their new license prior to
the expiration of their old license. An agency that submits its renewal application fewer than sixty
(60) days prior to the expiration of the current license and does not receive a new license prior to
that date may reapply for an initial license in accordance with Section 21.120.2 of these rules.
D. F ailure of a licensee to accurately answer or report any of the information requested by the
Department shall be considered good cause to deny the license renewal application.
E. The agency licensee shall be notified in writing of non-compliance areas and the need for a plan
of action as outlined in Section 21.120.6. A probationary license may be granted.
F. An agency in compliance with the applicable Department rules and state and federal regulations
shall be granted a license renewal effective as of the expiration dates of the current license.
21.120.25 Probationary License [Eff. 11/1/13]
A. At the Department’s discretion, a probationary license may be granted to an agency out of
compliance with applicable Department, state or federal regulations prior to issuance of a renewal
license or during a current license term. The agency will be notified in writing of non-compliance
areas and the need for a plan of action (see Section 21.120.6).
B. A probationary license will replace the current license for a period not to exceed ninety (90)
calendar days.
C. Administrative and treatment activities may be limited by a probationary license while the agency
addresses corrective actions.
D. A pr obationary license may be re-issued for a period not to exceed ninety (90) calendar days if
substantial progress continues to be made and it is likely that compliance can be achieved by the
date of expiration of the second probationary license.
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E. If the licensee fails to comply with or complete a plan of action in the time or manner specified, or
is unwilling to consent to the probationary license, the modification to a probationary license shall
be treated as a revocation of the licensee and s/he shall be notified by certified mail that the
probationary license is no longer in effect as of ten (10) days from the date the letter was mailed.
If an applicant disagrees with the decision, s/he may appeal (see Section 21.105); or upon
remedying the noted deficiencies, may re-apply for an initial license in accordance with Section
21.120.2 of these rules.
21.120.26 License Modifications
A. An agency shall submit a license modification application and written documentation
demonstrating compliance with all applicable Department rules, policies and procedures, a
minimum of thirty (30) calendar days prior, in the following circumstances:
1. Adding, selling, moving or closing agencies, sites, services, or levels of care;
2. Changing the agency name;
3. Changing agency governance.
B. Failure to submit license modification applications and required documentation within thirty (30)
calendar days may result in the agency, specific sites, and or levels of care not being licensed.
C. A pplication fees for a license modification are not required.
D. Emergency license modification request
1. An agency may submit a request to the department for an emergency or disaster
modification to their license during the timeframe services are disrupted due to a
statewide emergency or disaster.
2. An agency shall provide the department information including but not limited to:
a. An explanation for the need for an emergency or disaster license modification;
and,
b. An explanation or demonstration of compliance with all applicable department
rules, policies and procedures.
3. At the department’s discretion, an emergency or disaster license modification may be
granted to an agency without an on-site inspection by the department.
4. Upon receiving confirmation of an emergency or disaster license modification, an agency
may provide services immediately and continue to operate under the modified license for
up to sixty (60) days after the disaster or emergency has ceased.
5. To continue to operate beyond sixty (60) days after the emergency or disaster has
ceased, an agency shall submit a permanent license modification pursuant to
21.120.26.a.
21.120.27 Limited License [Eff. 11/1/13]
A. At the Department’s discretion, a limited license may be issued to an agency to prevent or
address a perceived conflict of interest and/or a dual relationship within the agency that may
negatively impact persons receiving services.
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The following include, but are not limited to, circumstances where there may be a perceived
conflict of interest and/or a dual relationship exists within an agency:
1. The sharing of information across systems that could negatively impact the individual; or,
2. A financial interest of the agency that may have negative treatment and/or referral
implications pertaining to the individual; or,
3. The combining of professional roles within the agency that is incompatible to the best
interests of the individual(s) receiving treatment.
B. Limitation of the license may include, but is not limited to:
1. Limiting the specific clientele an agency may serve;
2. Limiting the specific location(s) where an agency may or may not offer services; or,
3. Limiting the specific level of care that may be provided pursuant to the license.
C. If an applicant is unwilling to consent to the limitation on the license, the limitation shall be treated
as a denial and s/he may appeal (see Section 21.105); or upon remedying the noted perceived
conflict of interest and/or a dual relationship, may re-apply for an initial license in accordance with
Section 21.120.2 of these rules.
21.120.3 FACILITIES DESIGNATED TO PROVIDE MENTAL HEALTH SERVICES [Eff. 11/1/16]
Facilities des ignated to provide mental health services may be:
A. A general or psychiatric hospital licensed or certified by the Colorado Department of Public Health
and Environment;
B. A community mental health center Licensed by the Colorado Department of Public Health and
Environment or a community mental health clinic;
C. An acute treatment unit licensed by the Colorado Department of Public Health and Environment;
D. A crisis stabilization unit, licensed as an acute treatment unit or as a community clinic by the
Colorado Department of Public Health and Environment; or,
E. A residential child care facility licensed by the Colorado Department of Human Services, Division
of Child Welfare.
Applicant facilities shall identify any parent organization ultimately responsible for their operation.
21.120.31 Application of Rules [Eff. 11/1/16]
A. Designated facilities that are hospitals, acute treatment units, or crisis stabilization units shall
comply with all applicable rules including provisions contained in Section 21.280.
B. Designated facilities that are community mental health centers pursuant to Section 27-66-101,
C.R.S., shall comply with Sections 21.130 through 21.200.15, where applicable, and Section
21.280. Treatment provisions, as contained in Sections 21.280.3 through 21. 280.9 shall apply to
only those individual being treated involuntarily pursuant to Title 27, Article 65, C.R.S.
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C. Designated facilities that are community mental health clinics shall comply with Sections 21.130
through 21.200.15 and Sections 21.280.21 through 21.280.22.
D. Designated facilities that are residential child care facilities (RCCF) shall follow Section 21.120.3
through 21.120.44 and 21.200 through 21.200.15, where applicable. RCCFs designated to
provide mental health services pursuant to Title 27, Article 65, C.R.S. shall follow Sections
21.200, where applicable, and Section 21.280.
E. Designated managed service organizations (DMSO) shall only comply with 21.120.5 and
21.120.8.
21.120.32 Mental Health Services Pursuant to Title 27, Article 65, C.R.S., Care and Treatment
of Persons with Mental Illness Designations [Eff. 5/1/16]
A. A facility meeting the criteria in Section 21.120.3, excluding community mental health clinics, may
apply to the Department to become designated to provide any or all of the following services:
1. Seventy-two (72) hour treatment and evaluation;
2. Short-term treatment; or,
3. Long-term treatment.
B. Facilities designated for seventy-two (72) hour treatment and evaluation, short-term, or long-term
treatment shall have a person who is licensed in Colorado to practice medicine or a certified
Colorado psychologist, either employed or under contract, who is responsible for the evaluation
and treatment of each individual. Hospital staff privileges shall be an acceptable form of
contractual arrangement. The professional person licensed in Colorado to practice medicine or a
certified Colorado psychologist may delegate part of his/her duties, except as limited by licensing
statutes or these rules, but s/he shall remain responsible at all times for the mental health
treatment administered.
21.120.33 S eventy-Two (72) Hour Treatment and Evaluation Facilities [Eff. 5/1/16]
A. Facilities that are designated as seventy-two (72) hour treatment and evaluation facilities may
detain on an involuntary basis persons placed on a seventy-two (72) hour hold for the purpose of
evaluation and treatment.
B. ExcIusion of Saturdays, Sundays, and Holidays
Evaluation shall be completed as soon as possible after admission. The designated treatment
and evaluation facility may detain a person for seventy-two (72) hour evaluation and treatment for
a period not to exceed seventy-two (72) hours, excluding Saturdays, Sundays and holidays if
evaluation and treatment services are not available on those days. For the purposes of these
rules, evaluation and treatment services are not deemed to be available merely because a
professional person licensed in Colorado to practice medicine or a certified Colorado psychologist
is on call during weekends and holidays.
21.120.34 Short-Term and Long-Term Treatment Facilities [Eff. 5/1/16]
A. Facilities that are designated as short-term treatment facilities may involuntarily detain individuals
for short-term (a period of not more than three months) or extended short-term care and
treatment (a period of not more than an additional three months).
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B. Facilities that are designated as long-term treatment facilities may involuntarily detain individual
for long-term care and treatment (a period not to exceed six months) or extended long-term
treatment (a period of not more than additional six months).
C. Every person receiving treatment for a mental health disorder by a designated short-term or long-
term facility shall upon admission be placed under the care of a person who is licensed in
Colorado to practice medicine or a certified Colorado psychologist and employed by or under
contract with the designated facility.
21.120.35 Mental Health Centers and Community Mental Health Clinics [Eff. 5/1/16]
A. Mental health centers and community mental health clinics shall use membership on the
governing board or equivalent for soliciting input regarding issues which impact persons receiving
care. Input shall be solicited from adults, children and adolescents receiving services, and their
parents or guardians. The input shall be taken into consideration by management or the
governing board during decision-making processes.
B. Emergency/crisis services and evaluation under Sections 27-65-105 and 106, C.R.S., shall be
provided twenty-four (24) hours per day including Saturdays, Sundays and holidays. Initial
responses to emergencies shall occur either by telephone within fifteen (15) minutes of the call,
within one (1) hour of contact in urban and suburban areas, or within two (2) hours of contact in
rural and frontier areas.
21.120.36 Med ication Consistency in Designated Facilities
A. Designated facilities shall ensure all clinical staff are aware of and have access to the medication
formulary.
B. Designated facilities shall ensure their providers have access to the medications on the
medication formulary when prescribing medications to treat behavioral health disorders.
21.120.4 DESIGNATION PROCEDURE
A. Facilities applying for designation shall submit an application to the Department on a state
approved form.
B. Facilities providing twenty-four (24) hour inpatient or acute crisis care, must apply for a separate
designation based on the unique physical address of each site.
C. Except in emergency circumstances affecting the facility's ability to provide evaluation and
treatment services, a facility seeking to exclude Saturdays, Sundays and holidays from the
seventy-two (72) hour limitation on detaining persons for evaluation and treatment must supply in
its application for designation or re-designation documentation to establish that it does not have
evaluation services available on these days due to the limited availability of a professional person
licensed in Colorado to practice medicine or a certified Colorado psychologist.
D. Receipt of the application shall be acknowledged in writing and state what additional information
or documents, if any, are required for review prior to an inspection.
E. F or initial designation applications, the applicant shall be advised in writing within sixty (60)
calendar days of initial inspection of the decision of the Department. The facility may be approved
for designation, granted provisional approval, or the application may be denied.
F. A facility that is found to be in compliance with these rules shall be approved as a facility
designated to provide mental health services effective for up to a two (2) year period.
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G. Designations shall be automatically revoked or deemed lapsed for any facility whose license to
operate as a health care or residential child care facility has been withdrawn, revoked or allowed
to lapse.
H. If the application for designation is denied, the reason(s) for denial shall be provided in a certified
letter. If an applicant disagrees with the decision, s/he may appeal (see Section 21.105); or upon
remedying the noted deficiencies, may re-apply for designation in accordance with Sections
21.120.3 and 21.120.4 of these rules.
21.120.41 Provisional Designation [Eff. 11/1/13]
A. Provisional approval may be granted for a period not to exceed ninety (90) calendar days if, after
initial inspection and review of a facility:
1. The facility is in substantial compliance with these rules, and is temporarily unable to
conform to all the minimum standards required under these rules. No provisional
designation shall be issued to a facility if the operation of the facility may adversely affect
individual health, safety, or welfare;
2. Compliance will be achieved within a reasonable period of time; and,
3. The facility has a reasonable plan or schedule in writing for achieving compliance.
B. The facility shall provide proof that attempts are being made to conform and comply with
applicable rules.
C. A s econd provisional approval for a period not to exceed ninety (90) calendar days may be
granted under the same criteria if necessary to achieve compliance.
D. If the facility is not able to come into compliance within one hundred and eighty (180) calendar
days from date initial provisional license granted, the application may be denied.
21.120.42 Re-Designation
A. A facility seeking designation renewal shall provide the department with a completed designation
application at least sixty (60) calendar days prior to the expiration of the existing designation.
B. Designation renewal applications received by the Department after the current designation
expiration date shall be returned by certified mail with written notification that the designation is
no longer in effect. Applicants may reapply for an initial designation in accordance with Section
21.120.4 of these rules.
C. Designation renewal applications that are received by the Department fewer than sixty (60)
calendar days prior to the expiration of their existing designation may fail to receive their new
designation prior to the expiration of their old designation. An agency that submits its renewal
application fewer than sixty (60) days prior to the expiration of the current designation and does
not receive a new designation prior to that date may reapply for an initial designation in
accordance with section 21.120.2 of these rules.
D. F ailure of a designee to accurately answer or report any of the information requested by the
Department shall be considered good cause to deny the designation renewal application.
E. Facilities designated to provide care and treatment to persons with mental health disorders
pursuant to Section 27-65-101, et seq., C.R.S., shall receive an annual review for compliance. All
other designated facilities shall be reviewed on-site at least every two (2) years.
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F. Facilities shall be notified in writing of non-compliance areas and the need for a plan of action as
outlined in Section 21.120.6. A probationary designation may be granted.
G. A facility in compliance with applicable Department rules and state and federal regulations shall
be granted designation effective as of the expiration date for a period not to exceed two (2) years.
21.120.43 Probationary Designation [Eff. 11/1/13]
A. A probationary designation may be granted to a licensee out of compliance with applicable
Department or state and federal regulations prior to issuance of a renewal designation or during a
current designation period. The facility will be notified in writing of non-compliance areas and the
need for a plan of action (see Section 21.120.6).
B. A probationary designation will replace the current designation for a period not to exceed ninety
(90) calendar days.
C. Administrative and treatment activities may be limited by a probationary designation while the
facility addresses corrective actions.
D. A probationary designation may be re-issued for a period not to exceed ninety (90) calendar days
if substantial progress continues to be made and it is likely that compliance can be achieved by
the date of expiration of the second probationary license.
E. If the facility fails to comply with or complete a plan of action in the time or manner specified, or is
unwilling to consent to the probationary designation, the modification to a probationary
designation shall be treated as a revocation of the designation and the facility shall be notified by
certified mail of the deficiencies, reason for action, and that the probationary designation is no
longer in effect as of ten (10) days from the date the letter was mailed. If the facility disagrees
with the decision, it may appeal (see Section 21.105); or upon remedying the noted deficiencies,
may re-apply for a designation in accordance with Sections 21.120.3 and 21.120.4 of these rules.
21.120.44 Change in Designation [Eff. 11/1/13]
If a facility makes a change in its designation status or decides to drop its designation, it shall notify the
Department in writing not later than thirty (30) calendar days prior to the desired effective date. The facility
shall submit a written plan for the transfer of care for the individuals with mental health disorders if the
facility will no longer treat those individuals. This plan shall be submitted no later than ten (10) business
days prior to the effective date.
21.120.5 DE SIGNATED MANAGED SERVICE ORGANIZATION (DMSO) [Eff. 11/1/13]
A. The Office of Behavioral Health, within the Department, has the authority pursuant to Section 27-
80-107, C.R.S., to designate a Managed Service Organization (MSO) responsible for service
delivery to eligible persons, as described in the annual federal Substance Abuse Prevention and
Treatment Block Grant application, residing in each of the seven (7) defined geographic regions.
B. Once designated, each managed service organization shall be reviewed annually for compliance
pursuant to Section 27-80-107, C.R.S., and Department rules and contract.
C. MSO’s shall follow all applicable Department rules.
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21.120.51 Role of Designated Managed Service Organizations (DMSO) [Eff. 11/1/13]
A. Each DMSO will oversee the expenditure of Department funds in providing effective population-
specific substance use disorder treatment and related services to the priority populations
identified in each applicable contract.
B. Each DMSO will develop and monitor a network of licensed providers of substance use disorder
services to deliver a full continuum of care as defined in the Department contract within the
designated geographic regions of the state.
C. Each DMSO will ensure the delivery of population-specific services to priority populations as
defined in the Department contract, to include individuals and families in need of substance use
disorder treatment and related services.
21.120.52 Reporting Requirements [Eff. 11/1/13]
A. Each DMSO must maintain a fiscal reporting system that complies with state and federal
requirements.
B. Each DMSO must maintain an individual-services reporting system that complies with state and
federal requirements.
21.120.53 Service Provision [Eff. 11/1/13]
When a DMSO provides substance use disorder treatment or a related service to any individual, it must
be licensed by the Department and demonstrate compliance with all applicable rules.
21.120.54 Monitoring and Quality Improvement [Eff. 11/1/13]
A. Ea ch DMSO must demonstrate ethical, legal, and solvent fiscal practices, and must maintain a
system for periodic review of its contracts, billing and coding procedures, billing records,
contractual requirements, and legal requirements.
B. Each DMSO must maintain a system for periodic review of its contractors to identify any
intentional or unintentional wrongdoing and to ensure that they are exercising ethical, legal, and
solvent fiscal practices.
21.120.55 Revocation [Eff. 11/1/13]
A. Designation shall be revoked for reasons including but not limited to those in Section 21.120.8.
B. Prior to starting a revocation process, the DMSO shall be notified of the facts or conduct that may
warrant such action. A plan of action may be required (see Section 21.120.6).
C. Where there are grounds to find that the DMSO has engaged in deliberate and willful violation or
that the public health, safety, or welfare requires emergency action, the Department may
summarily suspend the designation pending proceedings for suspension or revocation.
D. Written notification of action to revoke a designation shall be sent to the DMSO. Except in cases
of deliberate and willful violation or of substantial danger to the public health and safety, such
notice shall be sent at least ten (10) working days before the date such action goes into effect,
and shall include reasons for the action and rights to the appeal process specified in the State
Administrative Procedure Act, pursuant to Sections 24-4-105 through 107, C.R.S.
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21.120.6 LICENSE AND DESIGNATION REVIEW PROCESS AND PLANS OF ACTION [Eff.
11/1/13]
A. If after review or pursuant to a complaint, that a licensed or designated agency, contractor, or
affiliate is not in compliance with these rules, the organization shall be notified in writing, within
thirty (30) business days, of the specific items found to have been out of compliance.
B. If the agency does not agree with any or all of the findings regarding non-compliance, the agency
has ten (10) business days from the receipt of non-compliance notice to dispute the findings by
submitting evidence to the Department.
The agency shall receive a written response within thirty (30) business days of the review of
submitted evidence.
If the submitted information is sufficient, the agency shall be determined in compliance with these
rules.
If the agency continues to be found out of compliance with these rules, the agency shall have
thirty (30) business days from the date of receipt of the review findings to submit a plan of action.
The plan shall include anticipated dates for achieving full compliance.
C. If the agency does not dispute the findings, it shall have thirty (30) business days from the receipt
of the notice of non-compliance to submit a written plan of action addressing the compliance
issues. The plan shall include anticipated dates for achieving full compliance within ninety (90)
business days of the submitted plan.
D. A fter reviewing the agency’s plan of action, the Department may take action as follows:
1. Approve the proposed plan and schedule for achieving full compliance; or,
2. Approve a modified plan and schedule for achieving full compliance; or,
3. Initiate action to revoke, suspend, make probationary, limit, or modify the license or
designation of the agency as provided in Section 24-4-104, C.R.S.; and,
4. In cases where a plan of action has been approved, the agency shall remain licensed or
designated subject to the achievement of the plan of action.
21.120.7 WAIVERS [Eff. 11/1/13]
Every licensed and designated agency shall comply in all respects with applicable rules. Upon application
to the Department, a waiver of the specific requirements of these rules may be granted in accordance
with this section, unless the requirements are otherwise required by state or federal law, and individual
rights shall not be waived.
A. Time Period
A waiver of a specific rule may be granted to a licensed or designated agency, or an agency
seeking initial application, for a period not to exceed the two year licensing or designation period.
The waiver may be renewed at the time of re-licensing or designation.
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B. Compliance with all Other Regulations
Agencies applying for or granted a waiver shall be in compliance with local, state and federal
regulations, shall not have outstanding findings with regulatory authorities, and be in good
standing with meeting any and all contractual requirements related to providing behavioral health
services.
C. Grounds for a Waiver
A waiver may be granted upon a finding that:
1. The waiver would not adversely affect the health, safety and welfare of the individuals;
and/or,
2. Either it would improve care or application of the particular rule would create a
demonstrated financial hardship on the organization seeking the waiver.
D. Burden of Proof
The agency seeking the waiver has the burden of proof. Consideration shall be given as to
whether the intent of the specific rule has been met.
E. Placement Facilities
When a designated agency provides mental health services through a placement facility and a
waiver is sought for such services, the designated agency and not the placement facility shall
request the waiver.
F. Requests for Waivers
Requests for waivers shall be submitted to the Department on the state prescribed form. The
request shall include:
1. A de tailed description of the behavioral health services provided by the agency;
2. The rule section proposed to be waived and the waiver’s effect on the health, safety and
welfare of the individuals served;
3. The expected improvement in the care of individuals;
4. If there would be undue financial hardship on the agency, and to what degree; and,
5. Signature of the Board President, Director of the agency, or designee.
G. Decision Process
Unless additional time is required to make inspections or obtain additional information from the
agency, the agency shall be notified in writing of the decision within thirty (30) calendar days
following the date of receipt of the completed waiver application.
H. Appeal Rights
An agency may appeal the decision of the Department regarding a waiver application as provided
by the Colorado Administrative Procedure Act, Sections 24-4-104 and 24-4-105, C.R.S.
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21.120.8 LICENSE AND DESIGNATION REVOCATION, DENIAL, SUSPENSION, LIMITATION
OR MODIFICATION [Eff. 11/1/13]
A. At the Department’s discretion, a license or designation may be revoked, denied, suspended,
modified or have limited licenses or designation. Written notification of the basis for action shall
be sent by certified mail to the last known address of the agency, and is effective ten (10) days
from the date the letter was mailed. If the affected agency disagrees with the decision, it may
appeal per Section 21.105.
B. A license or designation may be summarily suspended pending proceedings for suspension or
revocation in cases of deliberate or willful violation of applicable statutes and regulations or where
the public health, safety, or welfare requires emergency action.
C. A license or designation may be revoked, denied, suspended, modified, or limited for reasons
including, but not limited to, the following:
1. Non-compliance with these rules, applicable federal and state laws and regulations, or
contracting requirements.
2. Negligence resulting in risk to individuals, staff, public health or safety;
3. Knowingly using or disseminating misleading, deceptive, or false information about other
agencies including, but not limited to, advertising;
4. Exercising undue influence on or otherwise exploiting individuals to obtain or sell
services, goods, property, or drugs for financial or personal gain;
5. A ccepting commissions, rebates, or other forms of remuneration for referring persons to
or by the licensed or designated agency;
6. Evidence of agency fraud or misrepresentation;
7. Failure to provide persons with information required by these rules and applicable state
and federal statutes, rules, and regulations;
8. Failure to submit required data in an accurate and timely manner to the Department or its
authorized representatives;
9. Withholding access to clinical, staff, or fiscal records, or administrative information when
requested by the Department;
10. Sale, use or distribution of alcohol or illicit drugs, or unauthorized sale or distribution of
prescription or over-the-counter drugs on treatment premises or during treatment
activities off premises;
11. Knowingly using, and/or disseminating false information about these rules, Department
rules and state or federal regulations, or other information essential to interpreting or
managing an individual’s status, case management or interagency coordination.
12. Commits a fraudulent insurance act as defined in Section 10-1-128, C.R.S.
13. Failure to comply with a written plan of action.
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21.130 DATA REQUIREMENTS [Eff. 11/1/13]
Licensed and designated organizations shall provide accurate and timely submission of required data to
the Department identified data collection systems or its authorized representatives and retain a copy in
treatment record.
21.140 CRITICAL INCIDENT REPORTING
A critical incident is any significant event or condition that must be reported within twenty-four (24) hours
to the Department that is of public concern and/or has jeopardized the health, safety and/or welfare of
individuals or staff.
A. The Department may conduct scheduled or unscheduled site reviews for specific monitoring
purposes and investigation of critical incidents reports in accordance with:
1. CDHS policies and procedures;
2. Regulations that protect the confidentiality and individual rights in accordance with
Sections 27-65-101, et seq., C.R.S.; HIPAA; AND, 42 C.F.R. Part 2.
3. Controlled substance licensing, Title 27, Article 82, C.R.S.; Section 27-80-212, C.R.S.,
and Section 18-18-503, C.R.S.
B. The Department shall have access to relevant documentation required to determine compliance
with these rules.
C. The agency shall:
1. Establish written policies and procedures for reporting and reviewing all critical incidents
occurring at the facility;
2. Submit Critical Incidents reports to the Department according to state prescribed forms.
This is not in lieu of other reporting mandated by state statute or federal guidelines;
3. Mak e available a report with the investigation findings for review by the Department, upon
request; and,
4. Maintain critical incidents reports for a minimum of three years following the incident.
D. Nothing in this section shall be construed to limit or modify any statutory or common law right,
privilege, confidentiality or immunity.
21.150 QUALITY IMPROVEMENT [Eff. 11/1/13]
A. The agencies and programs that the Department contracts with, licenses, or designates, shall
have a quality improvement program designed to monitor, evaluate, and initiate activities to
improve the quality and effectiveness of administrative and behavioral health services.
B. The agency shall adopt and implement a written quality improvement plan that includes, at a
minimum the following processes:
1. Clinical quality measurement of performance.
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2. Determine the appropriateness and effectiveness of treatment through a clinical review of
a representative sample of open and closed records at a minimum of every six (6)
months.
3. Identify and respond to trends concerning significant events, risks, emergency
procedures, critical incidents as defined in Section 21.140, and grievances as defined in
Section 21.180.
4. Incorporate documented quality improvement findings into clinical and organizational
planning, decision making, and to develop staff and individual educational programs.
5. Evaluate annually and update the quality improvement plan as necessary. A copy of the
annual findings and report shall be available for review.
21.160 PERSONNEL
21.160.1 GENERAL PROVISIONS
A. The organization shall have written personnel policies and procedures that include:
1. Personnel (including contracted staff, interns, and volunteers) shall have access to and
be knowledgeable about the organization’s policies, procedures, and state and federal
laws and regulations relevant to their respective duties.
2. Personnel are assigned duties that are commensurate with documented education,
training, work experience, and professional licenses and certifications. Licensed or
certified staff shall perform duties in accordance with applicable statutes, rules and
regulations.
3. Training
a. The organization shall document the evaluation of applicable previous related
experience for volunteers and for staff, and ensure that these personnel have all
of the training, including on-the-job training, required in this section.
b. Al l staff shall be given on-the-job training or have related experience in the job
assigned to them. They shall be supervised until they have completed on-the-job
training appropriate to their duties and responsibilities, or have had previous
related experience evaluated.
c. The organization shall maintain records documenting completion of all required
training, or review of evaluation of previous related experience.
d. Volunteers having direct individual contact shall receive training appropriate to
their duties and responsibilities.
e. Personnel shall receive the following training when first hired and on a periodic
basis:
1) Training specific to the particular needs of the populations served;
2) Orientation of the physical plant;
3) Emergency preparedness;
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4) Individual rights of the population served;
5) Confidentiality (individual privacy and records privacy and security); and,
6) Training on needs identified through the quality improvement program.
4. Personnel (including contracted staff, interns, and volunteers) shall not engage in
prohibited activities outlined in Section 12-245-224, C.R.S.
B. Documentation of training, including topics and attendance, shall be maintained in personnel files
or organization training log.
C. Personnel files for each staff shall be maintained by the organization.
1. Files of current staff shall be available onsite for review by the Department.
2. Files shall include documentation of:
a. Job description that shall detail minimum qualifications, core competencies,
duties, and supervisory structure;
b. Education and work experience; and
c. Background investigations as described in Section 21.160.2.
21.160.2 BACKGROUND CHECKS AND EMPLOYEE VERIFICATION
A. Pre-employment background investigations:
1. Shall be required for all staff, interns and volunteers who have direct contact with
individuals receiving services.
2. Take place at submission of an initial Office of Behavioral Health license or designation
application or take place at pre-employment.
3. Consist of at least a criminal background check performed by the Colorado Bureau of
Investigation.
B. Pr e -employment inquiries:
1. The agency shall verify license, certification, and a check of disciplinary action through
the Colorado Department of Regulatory Agencies; and,
2. Complete a reference check.
C. Organizations shall maintain evidence of background investigations and employee verification in
personnel files.
D. The organization shall have written criteria for evaluating which convictions or complaints make
an applicant unacceptable for hire or a staff unacceptable for retention.
E. The organization shall incur the costs of obtaining a criminal history and background check of
potential employees.
F. The organization shall develop and implement written criteria for:
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1. Routine monitoring of employee credentials and disciplinary actions; and,
2. Reporting requirements of investigations, indictments, or convictions that may affect
employee’s ability to carry out his/her duties or functions of job.
21.170 RECORDS CARE AND RETENTION
21.170.1 GENERAL PROVISIONS
A. Agencies shall assure that all paper and electronic records are maintained to prevent
unauthorized access in accordance with 42 C.F.R. Part 2 and HIPAA.
B. For outpatient agencies:
1. Individual records for adults shall be retained for seven (7) years from date of discharge
from agency.
2. For individuals who are under eighteen (18) years of age when admitted to the agency,
records shall be retained until the individual is twenty five (25) years of age.
C. For inpatient agencies:
1. Individual records for adults shall be retained for ten (10) years from date of discharge
from agency.
2. For individuals who are under eighteen (18) years of age when admitted to the agency,
records shall be retained until the individual is twenty eighty (28) years of age.
D. All records are to be disposed in accordance with State and Federal confidentiality statutes and
regulations.
E. Disposal services commissioned by an agency to dispose of individual records shall sign
Qualified Service Organization Agreements or Business Associate Agreements.
F. S taff having access to individual records shall be knowledgeable of state and federal statutes,
policies, and procedures which protect individual identity and service information from
unauthorized access and disclosure.
G. Agencies shall develop policies and procedures that protect individual identity and treatment
information when transporting electronic and written records.
H. Agencies shall establish guidelines for reporting breach or potential loss of individual identity and
service information in accordance with state and federal confidentiality statutes and regulations.
I. Records shall be accessible to agency staff and the Department.
J. Agencies that are closing or acquired by another agency shall protect individual identity per state
and federal regulations.
21.170.2 CONFIDENTIALITY [Eff. 11/1/13]
A. The confidentiality of the individual record, including all medical, mental health, substance use,
psychological and demographic information shall be protected at all times, in accordance with all
applicable state and federal laws and regulations.
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B. The information in this section shall not be construed to limit the access of duly authorized
representatives of the Department to confidential material for purposes of assuring compliance
with these rules. Such duly authorized representatives of the Department are obligated to protect
the confidentiality of any individual information reviewed.
21.170.3 RELEASE OF INFORMATION
A. An agency that is licensed or designated by the Department must comply with release of
information regulations Pursuant to 42 C.F.R. Part 2 and HIPAA.
B. The signed release of information shall state, at a minimum:
1. Persons who shall receive the information;
2. For what purpose;
3. The information to be released;
4. That it may be revoked by the individual, parent, or legal guardian at any time;
5. That the release of information shall be time limited up to two (2) years.
C. Records shall be released to the staff of the governor’s designated Protection and Advocacy
System for Individuals with Mental Illness, per Section 27-65-121(1)(i), C.R.S., under the
following guidelines for all records of:
1. Any individual who is an individual of the system or the legal guardian, conservator, or
other legal representative of such individual has authorized the system to have access;
2. An y individual with a mental health disorder, who has a legal guardian, conservator, or
other legal representative, with respect to whom a complaint has been received by the
system or with respect to whom there is probable cause to believe the health or safety of
the individual is in serious and immediate jeopardy, whenever:
a. Such representative has been contacted by such system upon receipt of the
name and address of such representative;
b. Such system has offered assistance to such representative to resolve the
situation;
c. Such representative has failed or refused to act on behalf of the individual.
D. Whenever a family member or other party requesting information, not including the agency,
requests that information revealed to treating personnel remain confidential, such information
shall not be released unless otherwise provided by law or court order.
1. Whenever confidential information provided by a family member or other party providing
information is ordered released, attempts shall be made to notify the family member or
informant of the release of information by the individual who has obtained the court order.
2. The fact that confidential information is being withheld may be disclosed to individuals
requesting the information, but if the individual's attorney has requested the information,
the fact that confidential information is being withheld shall be disclosed.
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21.170.4 CONSENTS
A. A written agreement shall be executed between the agency and the individual or the individual’s
legal representative at the time of admission. The parties may amend the agreement provided
such amendment is evidenced by the written consent of both parties. No agreement shall be
construed to relieve the organization of any requirement or obligation imposed by law or
regulation.
B. Individual consents shall include consent to treatment.
C. Services shall involve families and significant others with written individual consent, unless
clinically contraindicated.
D. For minor's consent, please review Care of Children, Youth, and Families in Section 21.200.13.
E. For opioid medication assisted treatment consent, see Section 21.320.
F. If the Governor or local government declares an emergency or disaster an agency may obtain
documented oral agreements or consents in place of written agreements or consents.
Documented oral agreements and consents shall only be used as necessary because of
circumstances related to the emergency or disaster. Agencies shall send a hard copy or
electronic copy of the documented agreement or consent to the individual within two (2) business
days of the oral agreement or consent.
21.180 GRIEVANCE [Eff. 11/1/13]
A. The agency shall establish a uniform procedure for prompt management of grievances brought by
individuals accessing, receiving or being evaluated for services and their family members. The
organization shall develop policies and procedures for handling grievances. A grievance shall
mean any expression of dissatisfaction about any matter related to provided services, and shall
be accepted verbally or in writing.
B. T he agency shall provide a fair and accessible grievance resolution process, which shall provide
the individual with a resolution no later than fifteen (15) business days from submission of the
grievance. If the grievance is received verbally the representative shall create a written
documentation of the grievance.
C. The agency shall designate a representative, who shall be available to assist individuals in
resolving grievances, and who shall have no involvement in the clinical or regular care of the
individual.
D. The agency shall educate service recipients and their representatives about the mechanisms in
place for filing grievances. This education shall include rights, and internal grievance process and
procedures, and the name, contact information, and responsibilities of the designated
representative within the agency. Appropriate contacts for external appeal shall also be provided,
which may include, but are not limited to, the following: the Colorado Department of Regulatory
Agencies, the Colorado Department of Public Health and Environment, the Colorado Department
of Health Care Policy and Financing, or the governor’s designated Protection and Advocacy
System for Individuals with Mental Illness. Documentation in the records shall include dated
signature of the individual receiving the information.
E. A notice of rights, grievance procedure, the representative’s name, office location,
responsibilities, and telephone number shall be posted within the agency in prominent locations
where persons access, receive or are evaluated for services.
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F. The agency shall maintain a record of submitted grievances, separate from the individual records
that include the date, the type of grievance, and the outcome of investigation. Data shall be
reported annually to the Department.
21.190 DOCUMENTATION IN INDIVIDUAL RECORDS
21.190.1 DEFINITIONS [Eff. 5/1/16]
“Admission Summary” is a brief review of assessments and other relevant intake data, including
screenings, which summarizes the current status and provides a basis for individualized service planning.
“Assessment” is a formal and continuous process of collecting and evaluating information about an
individual for service planning, treatment and referral. This information establishes justification for
services.
“Best Practices” are interventions, techniques, and treatment approaches that have some quantitative
data showing positive treatment outcomes over a period of time, but may not have enough research or
replication to be considered an evidence-based approach.
“Case Management” means activities that are intended to help individuals gain access to behavioral
health and supportive services (including social, educational, and medical) that are coordinated and
appropriate to the changing needs and stated desires of the individual over time. Activities include, but
are not limited to: service planning, referral, monitoring, follow-up, advocacy, and crisis management.
“C hief Complaint/Presenting Problem” means the reason/concern/motivation that prompts the client to
seek services or that their referral source identifies as the issue, which requires intervention, usually in
the person’s own words. It also includes onset, duration, other symptoms noted, progression of the
problem, solutions attempted at alleviating the problem, how the person’s life has been impacted, and
how the person views responsibility for the problem. It can be information from a referral, family or other
professional.
“Culture” means the shared patterns of behaviors and interactions, cognitive constructs, and affective
understanding learned through a process of socialization. These shared patterns identify the members of
a culture group while also distinguishing those of another group. People within a culture usually interpret
the meaning of symbols, artifacts, and behaviors in the same or similar ways. Culture includes, but is not
limited to: race, ethnicity, religion, spirituality, gender, sexual orientation, language and disabilities.
“Cultural Assessment” means identifying and understanding aspects of an individual's culture and
linguistic needs in order to incorporate the information into service planning and service delivery. It is
necessary to incorporate cultural considerations into service delivery in order to best understand and
address ways in which culture influences an individual's behavioral health issues.
“D ischarge” means the termination of treatment obligations and service between the individual and the
agency.
“Evidence-Based” practices, principles, and programming are interventions, techniques, and treatment
methods that have been tested using scientific methodology and proven to be effective in improving
outcomes for a specific population.
“Screening” is a brief process used to determine the identification of current behavioral health or health
needs and is typically documented through the use of a standardized instrument. Screening is used to
determine the need for further assessment, referral, or immediate intervention services.
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21.190.2 CONTENT OF RECORDS [Eff. 5/1/16]
A. A confidential record shall be maintained for each individual. Records shall be dated and legibly
recorded in ink or in electronic format.
B. Documents shall include, where applicable:
1. Consent to treatment;
2. Consent to release confidential information;
3. Assessments and screenings;
4. Admission summary;
5. Service plan;
6. Re-assessment(s);
7. Progress notes;
8. Medication administration or monitoring record;
9. Physician's orders;
10. Documentation of on-going services provided by external services providers;
11. Advance directives;
12. Acknowledgements and disclosures;
13. Legal and court paperwork; and,
14. Discharge summaries.
C. See specific program areas for additional content of record requirements.
21.190.3 ASSESSMENT [Eff. 5/1/16]
A. A comprehensive best practices assessment shall be completed as soon as is reasonable upon
admission and no later than seven (7) business days of admission into services with the noted
exceptions:
1. Acute Treatment Unit: within twenty-four (24) hours of admission.
2. Withdrawal Management units, inpatient hospitalization: within seventy-two (72) hours of
admission.
B. Assessment shall continue throughout the course of treatment and shall be reviewed and
updated when there is a change in the person's level of care or functioning, or, must occur at
minimum, every six months.
C. Al l methods and procedures used to assess and evaluate an individual shall be developmentally
and age appropriate, culturally responsive, and conducted in the individual's preferred language
and/or mode of communication.
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D. The assessment shall be documented in the individual record and, at minimum, include the
following where information is available and applicable:
1. Identification and demographic data;
2. Chief complaint/presenting problem;
3. Mental health history;
4. Substance use;
5. Physical and dental health status;
6. A diagnosis with sufficient supporting criteria and any subsequent changes in diagnosis;
7. A mental status examination for each individual who is given a diagnosis;
8. History of involuntary treatment;
9. Advance directives.
10. Capacity for self-sufficiency and daily functioning;
11. Cultural factors that may impact treatment, including age, ethnicity,
linguistic/communication needs, gender, sexual orientation, relational roles, spiritual
beliefs, socio-economic status, personal values, level of acculturation and/or assimilation,
and coping skills;
12. Education, vocational training, and military service;
13. Family and social relationships;
14. Trauma;
15. Physical/sexual abuse or perpetration and current risk;
16. Legal issues;
17. Issues specific to older adults such as hearing loss, vision loss, strength; mobility and
other aging issues;
18. Issues specific to children/adolescents such as growth and development, daily activities,
legal guardians and need for family involvement and engagement in the child's treatment;
19. S trengths, abilities, skills, and interests; and,
20. Barriers to treatment.
E. See specific program areas for additional assessment requirements.
21.190.4 SERVICE PLANNING AND REVIEWS
21.190.41 Service Planning Requirements [Eff. 5/1/16]
A. An individualized, integrated, comprehensive, written service plan will be:
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1. Collaboratively developed between the individual and service provider or treatment team;
2. Goal focused;
3. Written in a manner that fosters an individual's highest possible level of independent
functioning; and,
4. Ongoing throughout treatment.
B. Service planning shall be developed with the individual following an identified assessment(s) and
shall apply intervention, treatment, recovery oriented services and continuing care strategies to
the degree indicated by the findings of the assessment(s).
C. An initial service plan shall be formulated to address the immediate needs of the individual within
twenty-four (24) hours of assessment.
D. The service plan shall be developed, by a multidisciplinary team when applicable, as soon as is
reasonable after admission and no later than:
1. Acute Treatment Units (ATU): twenty-four (24) hours of admission;
2. Withdrawal Management: seventy-two (72) hours of admission;
3. Inpatient Hospitalization: seventy-two (72) hours of admission;
4. Residential Treatment Facility: ten (10) business days after assessment;
5. Partial Hospitalization: seven (7) business days after assessment; or,
6. Outpatient: fourteen (14) business days after assessment.
E. In addition, services plans shall:
1. Specify goals based on the assessment;
2. Be s trength-based, gender appropriate, and individually directed;
3. Reflect findings of a cultural assessment, to include, but not limited to: gender, sexual
orientation, socio-economic status, ethnicity, personal values, level of acculturation
and/or assimilation, spirituality, linguistics, age, family systems, interpretation of trauma
and coping skills;
4. Contain specific, measurable, attainable objectives that relate to the goals and have
realistic expected date(s) of achievement;
5. Goals and objectives written in a manner understandable to the individual;
6. Identify the type, frequency and duration of services;
7. Be developmentally and/or age appropriate; and,
8. Include involvement of other identified family and supportive individuals, when
appropriate.
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F. All parties (the individual, legal guardian, multidisciplinary team members) who participate in the
development of the plan shall sign the plan. The record shall contain documentation whenever a
plan is not signed by the individual or participating parties.
G. There shall be documentation that the individual was offered a copy of the plan.
21.190.42 Service Plan Revisions and Reviews [Eff. 5/1/16]
A. Unless otherwise indicated, reviews and any service plan revisions shall be completed and
documented when there is a change in the individuals' level of functioning or service needs and
no later than:
1. Acute Treatment Units (ATU) and Withdrawal Management: three (3) calendar days;
2. Inpatient Hospitalization: every seven (7) calendar days for four (4) weeks; after four (4)
weeks: monthly; and, after six (6) months: quarterly;
3. Residential Treatment Facility: monthly for six (6) months and quarterly after six (6)
months;
4. Partial Hospitalization: every fourteen (14) calendar days;
5. Opioid Medication Assisted Treatment: every three (3) months; or,
6. Outpatient: every six (6) months, unless individuals receive medication/psychiatric
services only as described in Section 21.190.7.
B. The service plan review shall include documentation of:
1. P rogress made in relation to planned treatment outcomes;
2. Any changes in the individual's treatment focus; and,
3. Adjustments to the plan concerning individual lengths of stay as indicated by on-going
assessments.
C. Reviews shall be conducted collaboratively by clinician and individual.
D. The record shall contain documentation whenever the individual or participating parties do not
sign a revised plan.
E. There shall be documentation that the individual was offered a copy of the plan.
21.190.5 TREATMENT PROGRESS DOCUMENTATION REQUIREMENTS [Eff. 5/1/16]
A. Progress notes are a written chronological record of an individual's progress in relation to planned
outcomes of services.
B. Progress notes shall contain the following information unless otherwise noted in specific service
population sections of these rules:
1. Ongoing progress including dates and types of service, adhering to program-specific
frequency requirements;
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2. A summary of the activity for the session and progress toward specific treatment goals to
be completed with minimum frequency of:
a. One (1) note per session for outpatient and intensive outpatient,
b. Daily for inpatient and intensive residential services,
c. Weekly for partial hospitalization and all other levels of residential treatment;
3. The individual's response to treatment approaches and information about progress
toward achieving service plan goals and objectives;
4. Changes in the service plan with reasons for such changes;
5. Information regarding support and ancillary services recommended and provided;
6. Any significant change in physical, behavioral, cognitive and functional condition and
action taken by staff to address the individual's changing needs; and,
7. Case management notes reflecting the content of each contact, including ancillary and
collateral contacts.
C. Treatment notes shall not include protected health information pertaining to other individuals
receiving services.
D. Treatment entries shall be signed and dated by the author at the time they are written, with at
least first initial, last name, degree and or professional credentials. Telephone orders shall be
written at the time they are given and authenticated at a later time.
21.190.6 DI SCHARGE PLANNING AND SUMMARIES
21.190.61 Discharge Planning Requirements [Eff. 5/1/16]
A. Discharge planning begins at the time of admission, is updated during the course of services, and
engages the individual and support systems s/he identifies in the planning process.
B. Discharge policies and procedures shall include criteria outlining the requirements for an
individual's discharge from treatment.
C. Discharge plans shall be concise, complete, and comprehensive to facilitate transition to the next
level of care when applicable.
D. Persons receiving services on a voluntary basis shall be discharged from treatment immediately
at their request unless emergency commitments or emergency mental health holds are in effect.
E. Documentation of discharge information provided to the individual, where applicable, shall
include:
1. Medications at discharge including, dosages and instructions for follow-up;
2. Legal status and any other legal restrictions placed upon the individual;
3. Referrals with details; and,
4. Information if the discharge is being made against advice of provider.
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21.190.62 Discharge Summary [Eff. 5/1/16]
Discharge summaries shall be completed as soon as possible, no later than thirty (30) calendar days after
discharge. The agency's policy and procedures shall determine the minimum timeframe for completion.
Records shall contain a written discharge summary to include, but not limited to, the following information,
where applicable:
A. Reason for admission;
B. Reason for discharge;
C. Primary and significant issues identified during course of services;
D. Diagnoses;
E. Summary of services, progress made, and outstanding concerns;
F. Coordination of care with other service providers;
G. Advance directives developed or initiated during course of services.
H. Summary of medications prescribed during treatment, including the individual's responses to
medications;
I. Medications recommended and prescribed at discharge;
J. Summary of legal status throughout the course of services and at time of discharge;
K. Documentation of referrals and recommendations for follow up care;
L. Documentation of the individual's and/or family's response and attitude regarding discharge; and,
M. Information regarding the death of the individual.
21.190.7 MEDICATION/PSYCHIATRIC SERVICES ONLY AT MENTAL HEALTH CENTERS
AND CLINICS [Eff. 11/1/13]
A. A person qualifies to be classified as receiving medication/psychiatric services only when the
agency provides a maximum of three (3) services, in addition to services related to medications,
within a six (6) month period of time.
B. At l east annually, a licensed behavioral health professional shall complete and document in the
clinical record:
1. Clinical rationale supporting a medication/psychiatric services only status;
2. An updated assessment;
3. An updated service plan; and,
4. A Colorado Client Assessment Record (CCAR).
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21.200 CARE AND TREATMENT OF CHILDREN, YOUTH AND FAMILIES
21.200.1 BEHAVIORAL HEALTH SERVICES FOR CHILDREN AND YOUTH
21.200.11 Definitions
A. “ Psychotherapy” or “psychotherapy services” as defined in Section 12-245-202(14), C.R.S.,
means the treatment, diagnosis, testing, assessment, or counseling in a professional relationship
to assist individuals or groups to alleviate behavioral and mental health disorders, understand
unconscious or conscious motivation, resolve emotional, relationship, or attitudinal conflicts, or
modify behaviors that interfere with effective emotional, social, or intellectual functioning.
Psychotherapy follows a planned procedure of intervention that takes place on a regular basis,
over a period of time, or in the cases of testing, assessment, and brief psychotherapy,
psychotherapy can be a single intervention.
B. “ Youth” in this section means, under the age of twenty-one (21), unless otherwise noted.
21.200.12 General Provisions
A. In addition to these rules, programs providing behavioral health services to children and
adolescents must follow provisions made in Sections 21.110 through 21.190.
B. Residential child care facilities licensed by the Colorado Department of Human Services, Division
of Child Welfare, shall follow Sections 21.120 and 21.200, where applicable.
21.200.13 Rights of Children and Adolescents
These pr ovisions shall not apply to any youth admitted to a facility designated under Title 27, Article 65,
C.R.S., Care and Treatment of Persons with Mental Illness, for behavioral health purposes pursuant to
the Children’s Code, Title 19, C.R.S., when there have been judicial proceedings authorizing the
placement of the youth into a facility.
A. In addition to the individual rights in Section 21.280.26 for adults, youth who are fifteen (15) years
of age or older, with or without the consent of a parent or legal guardian, have the right to:
1. Consent to receive behavioral health services from an agency or a professional person;
2. Consent to voluntary hospitalization;
3. Object to hospitalization and to have that objection reviewed by the court under the
provision of Section 27-65-103, C.R.S.; and
4. Consent to release of information.
B. Parents or legal guardians shall be contacted without the youth’s written or verbal consent if:
1. The individual presents as a danger to self or others; or,
2. Essential medical information is necessary for parents or legal guardians to make
informed medical decisions on behalf of youth.
C. Behavioral health facilities must obtain parental or legal guardian consent for youth under fifteen
(15) years of age, with the following exception:
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1. Section 12-245-203.5(2), C.R.S. allows psychotherapy services, as defined in Section
12-245-202(14)(a), C.R.S., to be provided to a youth who is twelve (12) years of age or
older, with or without the consent of the youth’s parent or legal guardian if the youth is
knowingly and voluntarily seeking such services and the provision of psychotherapy
services is clinically indicated and necessary to the youth’s well-being. The following
mental health professionals are the only professionals allowed to provide outpatient
psychotherapy services in an outpatient setting, to a youth who is twelve (12) years of
age or older, with or without the consent of the youth’s parent or legal guardian:
a. A professional person as defined in Section 27-65-102(17), C.R.S., which means
a person licensed to practice medicine in this state, a psychologist certified to
practice in this state, or a person licensed and in good standing to practice
medicine in another state or a psychologist certified to practice and in good
standing in another state who is providing medical or clinical services at a
treatment facility in this state that is operated by the armed forces of the united
states, the united states public health service, or the united states department of
veterans affairs;
b. A m ental health professional licensed pursuant to Article 245, of Title 12, C.R.S.,
which in accordance with Section 12-245-203.5, C.R.S., includes:
1) A psychologist licensed pursuant to Part 3 of Article 245, of Title 12,
C.R.S. or a psychologist candidate pursuant to Part 3 of Article 245, of
Title 12,C.R.S.;
2) A social worker licensed pursuant to Part 4 of Article 245, of Title 12,
C.R.S.;
3) A marriage and family therapist licensed pursuant Part 5 of Article 245,
of Title 12, C.R.S.;
4) A professional counselor licensed pursuant to Part 6 of Article 245, of
Title 12, C.R.S. or a licensed professional counselor candidate pursuant
to Part 6 of Article 245, of Title 12, C.R.S.;
5) An addiction counselor licensed pursuant to Part 8 of Article 245, of Title
12, C.R.S.; or
c. A school social worker licensed by the Department of Education.
D. Youth who are under the age of fifteen (15) have the right to object to hospitalization and to have
a guardian ad litem appointed pursuant to Section 27-65-103, C.R.S.
E. Appropriate educational programs shall be available for all school age youth who are residents of
the designated facility in excess of fourteen (14) calendar days. These educational programs may
be provided by either the local school district or by the designated facility. If provided by the
designated facility, the educational program shall be approved by the Colorado Department of
Education.
21.200.14 A ssessment of Children and Adolescents [Eff. 5/1/16]
Agencies shall follow Section 21.190.3 and the following:
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A. Assessments must include an evaluation of the family's, or other supportive adult's, social and
environmental challenges and strengths that may pertain to the youth's treatment. If family or
other supportive adults support needs are identified, this shall be addressed in the service plan.
B. The assessment must explore how the identified family members, supportive individuals or
significant others will be involved in behavioral health services. In the event that any individual's
involvement is contraindicated, the clinical rationale must be documented.
C. An assessment shall address any needs of a youth at least seventeen (17) years of age who is
expected to require behavioral health services and supports beyond the age of eighteen (18).
21.200.15 Service Planning for Children and Adolescents [Eff. 5/1/16]
Agencies shall follow Section 21.190.4, service planning and reviews, and the following:
A. The service plan shall be developed in collaboration with the youth's parent or legal guardian and
be signed by both. In the event that involvement of the parent or legal guardian is contraindicated,
the rationale shall be documented.
B. A copy of the service plan shall be provided to the individual and parent or legal guardian, unless
contraindicated.
C. T he service plan shall include goals and objectives that address family support needs as
identified in the assessment.
21.200.2 LICENSED SUBSTANCE USE DISORDER AGENCIES TREATING YOUTH [Eff.
5/1/16]
A. Agencies providing substance use disorder treatment services to youth shall be licensed by the
Department to treat youth and comply with Section 21.210.
B. Agencies shall implement evidence-based screening, assessment instruments, and curricula,
designed and developed for youth.
C. Agencies shall provide recovery-oriented services appropriate for youth, when indicated.
D. Youth shall be informed that non-compliance with treatment programs to which they are
sentenced shall be reported by the agency to referring courts and/or their agents.
21.200.3 Minor in Possession: Education and Treatment [Eff. 5/1/16]
For the purposes of this section “Minor in Possession” (MIP) is the legal terminology used for an offense
that is issued to individuals age twenty (20) and younger for underage drinking or possession. MIP may
result in a revocation of a driver's license, a substance use disorder assessment, and/or alcohol
education and treatment classes per Section 18-13-122, C.R.S.
21.200.31 General Provisions [Eff. 5/1/16]
A. Agencies providing MIP services shall comply with Section 21.200.2.
B. A gencies shall not place a youth with a MIP citation in DUI/DWAI education or therapy groups
unless the youth also has a DUI/DWAI offense.
C. All agency education and treatment staff shall have documented training, supervision and
experience in adolescent development and prevention, intervention and treatment approaches.
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D. When possible, minors sixteen (16) years of age and under should be treated in separate groups
than those that are provided to individuals seventeen (17) to twenty (20) years old.
E. Agencies shall conduct ongoing assessment of progress in education and/or treatment level of
care to determine if youth are in the appropriate service level.
21.200.32 Minor in Possession: First Offense Education and Intervention [Eff. 5/1/16]
A. MIP education is for youth who have received their first MIP citation and shall be conducted in an
outpatient setting.
B. MIP education shall be at least eight (8) hours, completed over no less than a two (2) day period
with no more than four (4) hours of education per day.
C. E ducation topics shall include:
1. Current legal consequences for additional MIP citations;
2. Resources or referrals for treatment level services, when indicated;
3. Developmental impact of early onset substance use and subsequent impact on
developing brain;
4. Physiological effect of alcohol and other drug use;
5. Refusal skills; and,
6. Avoidance of high risk situations.
D. For youth seventeen (17) years old and younger, agencies shall include and document a
minimum of two (2) hours of parental involvement, unless contraindicated.
21.200.33 M inor in Possession: Second and Subsequent Offense Treatment [Eff. 5/1/16]
A. Second Minor in Possession Offense
1. Second offense MIP therapy shall be conducted in an outpatient setting, shall be a
minimum of twelve (12) hours in duration over eight (8) weeks, and shall not exceed
ninety (90) minute sessions, excluding breaks and administrative procedures.
2. Agencies shall complete an individualized service plan, with each youth in accordance
with Sections 21.190.4 and 21.200.15 of these rules.
3. For youth seventeen (17) years old and younger, agencies shall include and document a
minimum of four (4) hours of parental involvement, unless contraindicated.
B. Third and Subsequent Minor in Possession Offenses
1. A third MIP results in a Class 2 misdemeanor. Youth shall complete a minimum of twenty
(20) hours of substance use disorder treatment over a minimum thirteen (13) week
period, as determined by the assessment. Groups shall not exceed ninety (90) minutes in
duration.
2. Multiple levels of care shall be offered to meet the needs of the individual and family
members, when appropriate.
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3. Agencies shall include and document parental involvement, unless contraindicated,
throughout the length of treatment.
21.200.4 [THIS SECTION HAS BEEN MOVED TO 2 CCR 502-6] <Chapter 4>
21.200.41 [THIS SECTION HAS BEEN MOVED TO 2 CCR 502-6] <Part 4.1>
21.200.42 [THIS SECTION HAS BEEN MOVED TO 2 CCR 502-6] <Part 4.2>
21.200.43 [THIS SECTION HAS BEEN MOVED TO 2 CCR 502-6] <Part 4.3>
21.200.44 [THIS SECTION HAS BEEN MOVED TO 2 CCR 502-6] <Part 4.4>
21.200.45 [THIS SECTION HAS BEEN MOVED TO 2 CCR 502-6] <Part 4.5>
21.200.47 [THIS SECTION HAS BEEN MOVED TO 2 CCR 502-6] <Part 4.7>
21.200.48 [THIS SECTION HAS BEEN MOVED TO 2 CCR 502-6] <Part 4.8>
21.200.481 [THIS SECTION HAS BEEN MOVED TO 2 CCR 502-6] <Part 4.8.1>
21.200.482 [THIS SECTION HAS BEEN MOVED TO 2 CCR 502-6] <Part 4.8.2>
21.200.5 FAMILY ADVOCACY MENTAL HEALTH JUVENILE JUSTICE PROGRAMS [Eff.
5/1/16]
These rules and standards implement the Integrated System of Care Family Advocacy Programs for
Mental Health Juvenile Justice Populations defined in Section 27-69-101, et seq., C.R.S. The rules and
standards do not apply to other forms of family advocacy provided by persons or organizations, nor do
they place any requirements or assume authority over such persons or organizations. Families of youth
with mental health and co-occurring disorders who are in, or at-risk of becoming involved with, the
juvenile justice system, may choose any form of advocacy and support that best meets their needs and
are not limited to utilizing entities approved under these rules and standards.
In order to be eligible for state funding for a family advocacy program as described in Section 27-69-101,
et seq., C.R.S., and these rules, an entity must be approved by the Department according to the rules
described herein. Such funding is contingent on available appropriations.
21.200.51 D efinitions [Eff. 5/1/16]
“At-risk of involvement with the juvenile justice system” means a youth who has come into contact with
law enforcement due to a suspected offense or otherwise exhibits behaviors that will likely result in
juvenile justice involvement.
“Family advocacy organization” means an entity governed by individuals who have parented, are
parenting, or have legal responsibility for a child or youth with a mental health or co-occurring disorder.
“Family member” means individual who has parented, is parenting, or has legal responsibility for a youth
with a mental health or co-occurring disorder.
“Involved in the juvenile justice system” means a youth who has committed a delinquent act as defined at
Section 19-1-103(36), C.R.S.
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“Partnership” means a relationship between a family advocacy organization and another entity whereby
the family advocacy organization works directly with another entity for oversight and management of the
family advocate or family systems navigator and family advocacy demonstration program, and the family
advocacy organization employs, supervises, mentors, and provides training to the family advocate or
family systems navigator.
“System of care” means a spectrum of effective, community-based services and supports for children and
youth with or at risk for mental health or other challenges and their families, that is organized into a
coordinated network, builds meaningful partnerships with families and youth, and addresses their cultural
and linguistic needs, in order to help them to function better at home, in school, in the community, and
throughout life.
“Technical assistance and coordination” means linking with resources for the purpose of developing or
strengthening a family advocacy program.
“Transition services” include, but are not limited to, assisting a youth and family in accessing services and
supports necessary for the youth to become a successful adult; developing life skills necessary to
function in the community; returning to home, community, or school from an out-of-home placement.
“Y outh” for the purposes of this section means an individual whose age falls within the jurisdiction of the
juvenile justice system and is older than ten (10) years of age and under eighteen (18) years of age (see
Section 19-1-103 (18) for definition of “child”). A young person receiving family advocacy services may
continue to do so up to twenty one (21) years of age if enrolled in the program between the ages of ten
(10) and eighteen (18).
21.200.52 Intent to Become a Family Advocacy Program [Eff. 5/1/16]
A. A partnership will indicate its intent to become a family advocacy program by completing the
family advocacy program application and submitting it to the Department.
B. The partnership will follow all requirements of Section 27-69-101 through 27-69-105, C.R.S. and
these corresponding rules.
C. The Department will acknowledge in writing receipt of the letter of application and state which
documents, if any, are required to be forwarded to the Department for review.
D. A partnership may request the Department to facilitate technical assistance and coordination, as
described in Section 21.200.53, needed to complete its application.
21.200.53 Program Standards
A. F amily advocacy programs will consist of a partnership between a family advocacy organization
providing family advocacy and the system of care, whereby the family advocacy organization
works with other entities to enable youth and families to access necessary services and supports.
The family advocacy organization employs or otherwise utilizes, supervises, mentors, and
provides training to the family advocate or family systems navigator. A community agency may
employ or otherwise utilize, supervise, mentor, and provide training to the family advocate or
family systems navigator if there is a written agreement with a family advocacy organization
describing how this will occur.
B. The purpose of a family advocacy program is to provide support to families of youth with mental
health and co-occurring disorders who are in, or at-risk of becoming involved with, the juvenile
justice system.
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C. The support provided to families and youth will include early intervention, navigation, crisis
response, integrated planning, transition services, and diversion. These supports will be provided
in collaboration with community agencies with specific expertise in the area.
D. Family support will be provided by a family advocate or a family systems navigator as outlined in
Section 27-69-102(5) and (5.5), C.R.S. The requirements for these roles are as follows:
1. Family advocate:
a. Training in assisting families in accessing and receiving services and supports,
and the system of care philosophy;
b. Experience as a family member of a child or adolescent with a mental health or
co-occurring disorder; and,
c. Experience in working with multiple youth-serving agencies and providers.
2. Family systems navigator:
a. Training in assisting families in accessing and receiving services and supports,
and the system of care philosophy;
b. Skills, experience, and knowledge to work with children and youth with mental
health or co-occurring disorders; and,
c. Worked with multiple youth-serving agencies and providers.
E. A family advocacy program will coordinate its efforts with key service providers to ensure that
support provided by family advocates and family systems navigators is integrated with services
provided by community agencies. Where applicable, this coordination will include the local
Interagency Oversight Group of the Collaborative Management Program, described in Section
24-1.9-102, C.R.S. and local juvenile services planning committee described in Section 19-2-211,
C.R.S.
F. A f amily advocate or family systems navigator will receive training commensurate with their duties
and responsibilities. The training will include content on behavioral and co-occurring conditions,
working with youth-serving systems, ethics, confidentiality and HIPAA, system of care, working
with families, meeting facilitation, prevention and intervention, and documentation and service
planning.
G. A family advocacy program will provide education to the relevant agencies in the system of care,
describing the roles and responsibilities of family advocates and family systems navigators, and
the ways in which these positions can benefit youth, families, and agency staff members.
H. A family advocacy program will ensure that adequate resources are available for program
operations and evaluation as described in Section 21.200.54.
I. Family advocates or family systems navigators will receive supervision commensurate with the
needs of the youth and families. Family advocates or family systems navigators working in
community agencies will receive supervision consistent with the policies and procedures of the
host agency.
J. Any person providing supervision to a family advocate or family systems navigator will have
demonstrable knowledge about Section 27-69-101, et seq., C.R.S., these rules, and the role and
function of a family advocacy program.
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K. Family advocacy programs will have policies and procedures concerning the work of family
advocates and family systems navigators that address:
1. Experience and hiring requirements, including a name search through the Colorado
Bureau of Investigation;
2. The program's standards of practice and code of ethics;
3. Training related to providing support to families of youth with a mental health or co-
occurring condition;
4. A description of each aspect of the program, including related staff roles and
responsibilities;
5. The handling of grievances and complaints;
6. Confidentiality, HIPAA, and 42 C.F.R. Part 2; and,
7. Methods for recording information concerning each family receiving support including
demographics, assessment results, needs and strengths, goals and objectives, support
provided, and other information as needed.
L. The services and supports provided by a family advocacy program will include, but not be limited
to, those outlined in Section 27-69-104(3), C.R.S., and the following:
1. An assessment of the needs and strengths of the youth and family;
2. Assisting families with significant transitions in the youth's life;
3. Coordination with the local community mental health center and other behavioral health
service, and;
4. C ulturally and linguistically appropriate and responsive services including bilingual family
advocates and/or family systems navigators, and/or access to translation services for
families when necessary.
21.200.54 Data Reporting [Eff. 5/1/16]
A. Family advocacy programs will collect and report data to the Department. This is necessary for
the program and the Department to determine its effectiveness and what, if any, changes are
necessary to improve outcomes for youth and families. The results of any data analysis
conducted by the Department will be shared with the respective family advocacy program.
B. The data collected and reported to the Department shall include the following:
1. Types of services and support the youth and families received prior to and during
involvement in the family advocacy program;
2. Outcomes of services and supports provided during the youth and family's involvement in
the family advocacy program;
3. Indicators of the youth and family's satisfaction with support provided by the family
advocate or family systems navigator;
4. Indicators of the effectiveness of the family advocate or family systems navigator;
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5. Indicators of change in the system of care, e.g., interagency agreements, service access
and utilization, leadership development among youth and families; and shared resources;
6. Costs of services provided; and,
7. Types of transition services provided.
C. Data will be submitted to the Department in an established and standardized format.
21.200.55 Technical Assistance and Coordination [Eff. 5/1/16]
A. The Department will facilitate the provision of technical assistance and coordination for the
purpose of developing or strengthening a family advocacy program.
B. Technical assistance may include linking with written materials, family organizations, and phone
consultation.
C. Technical assistance provided by organizations other than the Department may require a fee paid
to that organization.
D. Interested entities will request technical assistance by contacting the Department verbally or in
writing.
21.210 AGENCIES LICENSED TO PROVIDE SUBSTANCE USE DISORDER SERVICES
In addition to the rules provided in Sections 21.000 through 21.190, all agencies licensed to provide
substance use disorder services shall comply with the following rule Sections 21.210.1 through
21.210.924.
21.210.1 Agency Staff Qualification and Training
A. Agencies shall ensure treatment staff are appropriately trained and properly credentialed to
provide substance use disorder services in Colorado and are in good standing with their
credentialing body.
B. A gencies shall ensure treatment staff providing independent treatment services in substance use
disorder programs within each licensed site are credentialed in accordance with applicable state
laws and regulations and are providing treatment services allowed within their scope of practice.
Treatment staff is defined in 21.210.1.E. For clinically managed residential withdrawal
management staffing requirements, see 21.210.914.
C. Counselor-in-training staff or certified addiction technician shall not independently counsel, sign
clinical documentation or carry out other duties relegated solely to the treatment staff identified in
21.210.1.E. Counselor-in-training staff and certified addiction technicians shall not comprise more
than twenty-five percent (25%) of total staff.
1. Counselor-in-training staff must have all clinical documentation reviewed and co-signed
by their agency clinical supervisor able to supervise pursuant to their scope of practice.
2. Certified addiction technicians may independently provide services within the statutorily
defined scope of practice pursuant to Section 12-245-805(3)(a), C.R.S.
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D. Unless otherwise noted, all agencies shall have a designated clinical administrator who shall
authorize and oversee the clinical practice and supervise the treatment staff defined in
21.210.1.E. The clinical administrator shall be in good standing with his or her credentialing body
and properly licensed as a physician or as one of the following mental health professionals:
1. Licensed psychologist;
2. Licensed clinical social worker;
3. Licensed marriage and family therapist;
4. Licensed professional counselor; or
5. Licensed addiction counselor.
E. Treatment staff, for the purpose of this Section 21.210, unless otherwise noted, means the
following behavioral health professionals trained in substance use disorder identification and
treatment and acting within his or her scope of practice:
1. Licensed physician;
2. Licensed advanced practice nurse included in the advanced practice registry with a
population focus in mental health, behavioral health or psychiatry;
3. Licensed psychologist;
4. Licensed clinical social worker;
5. Licensed marriage and family therapist;
6. Licensed professional counselor;
7. Licensed addiction counselor;
8. Certified addiction specialist; or
9. Candidate status staff receiving supervision to become a licensed or certified mental
health professional pursuant to Article 245 of Title 12, C.R.S. Candidate level staff shall
not make up more than fifty percent (50%) of an agency’s treatment staff.
F. Al l agencies shall provide and document initial training in methods of preventing and controlling
infectious diseases and in universal precautions providing protection from possible infection when
handling blood and other body fluids. Annual refresher training, including updates, shall be
provided and documented.
G. Staff collecting samples for drug or alcohol testing shall be knowledgeable of collection, handling,
recording and storing procedures assuring sample viability for evidentiary and therapeutic
purposes.
H. Agencies administering and/or monitoring individual medications shall maintain at least one staff
person per shift who is currently qualified by certification and/or training to perform those
functions in accordance with applicable Department rules and state and federal regulations.
I. Agencies shall document that at least one residential treatment staff person per shift is currently
certified in cardiopulmonary resuscitation and basic First Aid.
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21.210.2 CONTENT OF RECORDS
In addition to 21.190.2, agencies licensed to provide substance use disorder services shall maintain
individual records to include:
A. Individual acknowledgments of:
1. 42 C.F.R. PART 2;
2. HIPAA;
3. Individual rights;
4. Mandatory disclosure statement;
5. Chargeable fees and collection procedures; and,
6. Awareness of agency emergency procedures.
B. The out-of state offender questionnaire shall be completed and in all clinical records.
C. Personal belongings inventories, when applicable.
D. Court documents, when applicable.
E. Records of required communication with referral sources such as court, probation, child welfare,
and parole, when applicable.
F. Drug and alcohol testing and monitoring results, when applicable.
21.210.3 COUNSELOR AND INDIVIDUALS RECEIVING SERVICES’ SIGNATURES [Eff.
11/1/13]
A. Counselor signatures shall be required on the following treatment documents:
1. Screenings;
2. Assessments;
3. Admission summaries;
4. Service plans;
5. Service plan reviews;
6. Treatment notes;
7. Discharge summaries.
B. Credentialed counselors who counsel independently shall sign treatment documents with at least
first initial, last name, and Colorado addiction counselor credential, other professional credential,
or academic degree.
C. C ounselors not credentialed may sign treatment documents if countersigned by supervising
credentialed counselors.
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D. Signature stamps shall be permissible in lieu of written signatures if initialed by the counselors
whose signatures they represent. Electronic signatures shall be permissible for computerized
individual records.
E. Agencies shall require persons receiving services, or guardians, to sign service plans, service
plan reviews, and revisions, consents, acknowledgments, and other documents needing
individual authorization.
21.210.4 PROVISION OF SERVICES
21.210.41 Admission Criteria [Eff. 11/1/13]
A. The following shall not be the sole reason for treatment ineligibility:
1. Relapse;
2. Leaving previous treatment against advice;
3. Pregnancy;
4. Intravenous drug use; or,
5. Involuntary commitment.
B. Restrictions, priorities, or special admission criteria shall be applied equally to all prospective
persons seeking services.
21.210.42 Screening [Eff. 5/1/16]
A. Agencies shall screen all female individuals of child bearing age seeking or being referred to
substance use disorder treatment for pregnancy.
B. At admission individuals shall be screened for past and present risk factors associated with
substance use disorders that are associated with:
1. Pregnancy complications, including risks to the health of the pregnant woman and fetus;
2. Acquiring and transmitting Human Immunodeficiency Virus/Acquired Immune Deficiency
Syndrome (HIV/AIDS), Tuberculosis (TB), Hepatitis A, B, or C, and other infectious
diseases; and,
3. If clinically indicated by the presence of continuing risk factors, screening shall be
conducted at a minimum on a quarterly basis.
C. Individuals shall be apprised of risk factors associated with acquiring and transmitting HIV/AIDS,
TB, Hepatitis A, B, C, and other infectious diseases. Appropriate testing and pre and post-test
counseling shall be offered on-site or through referral.
D. Criminal justice system referrals for substance use related offenses, such as DUI/DWAI, BUI,
FUI, and/or controlled substance violations, may be exempt from further substance use disorder
screening if previously assessed, or evaluated. Supporting documentation from the referring
agency shall be present in the individual record.
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E. Adults shall be screened for past and present criminal charges in any state. Persons with out-of-
state charges must be registered by the licensed agency with the interstate compact office in
accordance with Title 17, Article 27.1, Section 101, et seq., C.R.S.
21.210.43 LEVEL OF CARE GENERAL PROVISIONS
A. In addition to meeting the requirements established in 21.190, Agencies shall:
1. Use the ASAM Criteria as a guide for assessing and placing individuals in the appropriate
level of care;
2. Include information gathered on all six (6) dimensions outlined in The ASAM Criteria in
assessments; and
3. Utilize the decisional flow process as outlined in The ASAM Criteria to determine level of
care.
B. Agencies shall specify the specific level(s) of care services the agency plans to provide, including
the population(s) the agency plans to serve.
C. Each level of care shall offer a range of treatment approaches and support services based on the
assessment of the individual’s treatment needs. Treatment services may include, but are not
limited to:
1. Assessment;
2. Group and individual counseling;
3. Motivational enhancement;
4. Family therapy;
5. Educational groups;
6. O ccupational and recreational therapy;
7. Addiction pharmacology;
8. Medication management;
9. Peer, social and recovery support;
10. Case management or service coordination; and
11. Support for development of life skills.
D. In addition to meeting the staff qualification and training requirements established in 21.210,
agencies shall document that staff are appropriately credentialed and qualified to provide
treatment services in the levels of care described in this section and to the individual populations
they serve.
E. Agencies shall apply sliding fee scales equally to all prospective persons seeking services.
F. Agencies shall be responsible for monitoring and routinely reporting to referring courts and the
criminal justice system the individual’s progress within treatment, including any ancillary services.
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G. In addition to meeting the requirements established in 21.200, agencies shall ensure all staff
working with youth under the age of twenty-one (21) at each level of care are trained and
knowledgeable of youth development and engaging youth in care.
H. agencies shall obtain a Controlled Substance License from the Office of Behavioral Health if the
program plans to dispense, compound, or administer a controlled substance in order to treat a
substance use disorder or to treat the withdrawal symptoms of a substance use disorder.
I. Agencies shall continue individuals on their medication-assisted treatment regimen and will only
detox individuals from medications treating opioid use disorders at the individual’s request or if it
is deemed medically necessary.
J. Agencies shall inform individuals receiving services about access to medication-assisted
treatment. Upon the individual’s consent, agencies shall provide medication-assisted treatment
directly, if the agency or provider is appropriately licensed to do so. If an agency or provider is not
licensed to provide medication-assisted treatment and an individual receiving services requests
medication-assisted treatment, an agency shall refer the individual to an agency that provides
medication-assisted treatment.
21.210.5 LEVELS OF CARE Specific Requirements
Each le vel of care is based on a specific level of care outlined in The ASAM Criteria.
21.210.6 OUTPATIENT SUBSTANCE USE DISORDER SERVICES (Level 1)
A. Level 1 services shall generally be intended for individuals who are assessed as not appropriate
for more intensive levels of care. Level 1 may also be a step-down from a higher level of care or
offered when an individual is in early stages of change and not willing to participate in the higher
level of care indicated by the assessment.
B. Level 1 services are appropriate for individuals with co-occurring mental health and substance-
related disorders if the mental health disorders are of moderate severity, or are of high severity
but have been stabilized.
21.210.61 Level 1 Service Provisions
A. Level 1 services shall be conducted in regularly scheduled sessions of less than nine (9)
treatment contact hours per week for adults, and less than six (6) treatment contact hours per
week for youth under the age of eighteen (18).
B. Level 1 treatment services shall be provided by treatment staff defined in section 21.210.1.E.
C. Agencies providing Level 1 services shall inform individuals receiving services how to access
emergency services by telephone twenty-four (24) hours per day, seven (7) days per week. At
minimum, emergency services information shall include contact information for services provided
by the Behavioral Health Crisis Response System created pursuant to § 27-60-103, C.R.S.
D. A gencies providing Level 1 services shall have direct affiliation or close coordination through
referral to more intensive levels of care.
E. Agencies providing Level 1 services shall ensure treatment staff has staff-to-staff consultation
available within twenty-four (24) hours by telephone to discuss when warranted, at minimum,
psychiatric or medical concerns of individuals receiving services.
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21.210.7 INTENSIVE OUTPATIENT/PARTIAL HOSPITALIZATION SUBSTANCE USE
DISORDER SERVICES (Level 2)
21.210.71 INTENSIVE OUTPATIENT SUBSTANCE USE DISORDER SERVICES (Level 2.1)
A. Level 2.1 services shall generally be intended for individuals who require a more structured
substance use disorder outpatient treatment experience than can be received in Level 1
outpatient treatment.
B. Level 2.1 services are appropriate for individuals with co-occurring mental health and substance-
related disorders if the disorders are of moderate severity, or are of higher severity but have been
stabilized.
21.210.711 Level 2.1 Service Provisions
A. Level 2.1 services shall be conducted in regularly scheduled sessions that follow a planned
format of treatment services of nine (9) to nineteen (19) contact hours per week for adults and six
(6) to nineteen (19) contact hours per week for youth under the age of eighteen (18).
B. Level 2.1 treatment services shall be provided by treatment staff defined in section 21.210.1.E.
C. Agencies providing Level 2.1 services shall inform individuals receiving services how to access
emergency services by telephone twenty-four (24) hours per day, seven (7) days per week. At
minimum, emergency services information shall include contact information for services provided
by the behavioral health crisis response system created pursuant to § 27-60-103, C.R.S.
D. A gencies providing Level 2.1 services shall have direct affiliation or close coordination through
referral to more and less intensive levels of care.
E. Agencies providing Level 2.1 services shall ensure treatment staff has staff-to-staff consultation
available within twenty-four (24) hours by telephone and within seventy-two (72) hours in person
to discuss when warranted, at minimum, psychiatric or medical concerns of individuals receiving
services.
2.210.72 PARTIAL HOSPITALIZATION SUBSTANCE USE DISORDER SERVICES (Level 2.5)
A. Level 2.5 services shall generally be intended for individuals who require daily monitoring or
management to treat substance use disorders that can be provided in a structured outpatient
setting. Services include direct access to medical, psychiatric, and laboratory services. Level 2.5
service sites for school aged youth shall include access to educational services and coordination
with a school system, as appropriate.
B. Level 2.5 services are appropriate for individuals with co-occurring mental health and substance-
related disorders if the disorders are of moderate severity, or are of higher severity but have been
stabilized. Staff of Level 2.5 services shall understand the signs and symptoms of mental health
disorders and the uses of psychotropic medications and their interactions with substance use
disorders.
21.210.721 L evel 2.5 Service Provisions
A. Level 2.5 services shall be conducted with a minimum frequency of twenty (20) regularly
scheduled treatment contact hours per week.
B. Level 2.5 treatment services shall be provided by treatment staff defined in section 21.210.1.E.
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C. Agencies providing Level 2.5 services shall inform individuals receiving services how to access
emergency services by telephone twenty-four (24) hours per day, seven (7) days per week when
the program is not in session. At minimum, agencies shall provide emergency services
information that includes contact information for services provided by the behavioral health crisis
response system created pursuant to § 27-60-103, C.R.S.
D. Agencies providing Level 2.5 services shall have direct affiliation or close coordination through
referral to more and less intensive levels of care.
E. Agencies providing Level 2.5 services shall ensure treatment staff has staff-to-staff consultation
available within eight (8) hours by telephone and within forty-eight (48) hours in person to discuss
when warranted, at minimum, psychiatric or medical concerns of individuals receiving services.
21.210.8 RESIDENTIAL/INPATIENT SUBSTANCE USE DISORDER SERVICES (Level 3)
Agencies providing residential/inpatient substance use disorder services (Level 3) shall construct and
maintain sound and sight barriers between male and female individuals and between adult and youth
under the age of eighteen (18) in bathrooms and sleeping quarters.
21.210.81 CLINICALLY MANAGED LOW-INTENSITY RESIDENTIAL SUBSTANCE USE
DISORDER SERVICES (Level 3.1)
A. Level 3.1 services shall generally be intended for whose history of chronic substance use
disorders, lack of supportive living situations, unemployment, levels of social or psychological
dysfunction and/or lack of housing necessitates twenty-four (24) hour structure and support. Level
3.1 services are generally provided in settings such as a halfway house, group home or other
supportive living environment providing twenty-four (24) hour staff and close integration with
treatment services.
B. Lev el 3.1 services shall have staff who are able to identify the signs and symptoms of acute
psychiatric conditions and understand the signs and symptoms of mental health disorders, the
uses of psychotropic medication and their interaction with substance use disorders.
C. Level 3.1 services shall have the capacity to arrange for psychiatric or addiction medications.
21.210.811 Level 3.1 Service Provisions and Staffing
A. Level 3.1 services shall be regularly scheduled and include a minimum of five (5) hours of
planned treatment services per week.
B. Agencies providing Level 3.1 services shall maintain individual to staff ratio not exceeding twenty
to one (20:1) during nighttime hours, per agency site.
C. Agencies providing Level 3.1 services shall provide twenty-four (24) hour per day, seven (7) days
per week on-site staff. Twenty-four (24) hour on-site staff shall be trained and knowledgeable of
substance use disorders and the treatment of substance use disorders and in addition to
treatment staff defined in 21.210.1.E may include:
1. Peer support specialists as defined in Section 21.400.1; or
2. Addiction technicians certified pursuant to Part 8 of Article 245 of Title 12, C.R.S. or staff
in the process of obtaining addiction counselor certification.
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D. Agencies providing Level 3.1 services shall have at least one (1) treatment staff, as defined in
21.210.1.E, trained and knowledgeable of substance use disorders, the treatment of substance
use disorders and able to monitor and identify psychiatric conditions available by telephone
twenty-four (24) hours per day, seven (7) days per week and available to be on-site within thirty
(30) minutes.
E. Agencies providing Level 3.1 services shall have direct affiliation or close coordination through
referral to more and less intensive levels of care.
F. Agencies providing Level 3.1 services shall ensure staff have telephone or in-person consultation
with a physician and emergency services available twenty-four (24) hours per day, seven (7) days
per week.
21.210.82 CLINICALLY MANAGED POPULATION-SPECIFIC HIGH-INTENSITY RESIDENTIAL
SUBSTANCE USE DISORDER SERVICES (Level 3.3)
A. Level 3.3 services are a structured recovery environment in combination with high-intensity
clinical services to support recovery from substance-related disorders.
B. Level 3.3 is appropriate for individuals who are unable to benefit from outpatient services or
services in general settings because of cognitive impairments that result in functional limitations.
Treatment is focused on preventing relapse, continued problems and/or continued use, and
promoting the eventual reintegration of the individual into the community. Therapeutic
rehabilitation facilities or traumatic brain injury programs are examples of this level of care.
21.210.821 L evel 3.3 Service Provisions and Staffing
A. Agencies providing Level 3.3 services shall deliver treatment services in a manner that is
matched to the individual’s functioning and may be provided in a deliberately repetitive fashion to
address the special cognitive needs of individuals for whom this level of care is considered a
medical necessity.
B. Agencies shall provide daily scheduled Level 3.3 services and include a minimum of nine (9)
hours of planned treatment services per week.
C. Agencies providing Level 3.3 services shall maintain individual to staff ratios not exceeding
twenty to one (20:1) during nighttime hours, per agency site. Staff shall include:
1. At least one (1) treatment staff, as defined in 21.210.1.E, trained and knowledgeable of
substance use disorders, the treatment of substance use disorders and able to monitor
and identify psychiatric conditions available by telephone twenty-four (24) hours per day,
seven (7) days per week and available to be on-site within thirty (30) minutes;
2. Addiction technicians certified pursuant to Part 8 of Article 245 of Title 12, C.R.S.;
3. A physician, physician assistant or nurse practitioner available by telephone or in-person
twenty-four (24) hours per day, seven (7) days per week to provide medical evaluation
and consultation; and
4. P eer support specialists as defined in Section 21.400.1.
D. Agencies providing Level 3.3 services shall have direct affiliation or close coordination through
referral to more and less intensive levels of care.
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21.210.83 CLINICALLY MANAGED HIGH-INTENSITY RESIDENTIAL SUBSTANCE USE
DISORDER SERVICES (Level 3.5)
A. Level 3.5 services provide a safe and stable living environment with treatment focused on
promoting skills needed to avoid relapse or continued use. Level 3.5 is appropriate for individuals
with multiple limitations including criminal activity, psychological problems, and/or impaired social
and/or vocational functioning.
B. Treatment is directed toward reducing relapse risk, enhancing prosocial behaviors and
reintegration into the community. A variable length therapeutic community or residential treatment
center are examples of this level of care.
21.210.831 Level 3.5 Service Provisions and Staffing
A. Agencies shall provide daily Level 3.5 services and include a minimum of ten (10) hours of
planned treatment services per week.
B. Agencies providing Level 3.5 services shall maintain individual to staff ratios not exceeding
twenty to one (20:1) during nighttime hours, per agency site, and each shift shall have a minimum
of two (2) staff members, whenever one (1) or more individuals are present. Staff shall include:
1. At least one (1) treatment staff, as defined in 21.210.1.E, trained and knowledgeable of
substance use disorders, the treatment of substance use disorders and able to monitor
and identify psychiatric conditions available twenty-four (24) hours per day, seven (7)
days per week;
2. A ddiction technicians certified pursuant to Part 8 of Article 245 of Title 12, C.R.S. or staff
in the process of obtaining addiction counselor certification;
3. a physician, physician assistant or advanced practice nurse available to provide medical
evaluation and consultation and assess and treat co-occurring biomedical disorders, as
well as prescribe and monitor the administration of medications; and
4. Peer support specialists as defined in Section 21.400.1.
C. Agencies providing Level 3.5 services shall have direct affiliation or close coordination through
referral to more and less intense levels of care.
21.210.84 MEDICALLY MONITORED INTENSIVE INPATIENT SUBSTANCE USE DISORDER
SERVICES (Level 3.7)
A. Level 3.7 services provide a planned and structured regimen of twenty-four (24) hour evaluation,
observation, medical monitoring and addiction treatment.
B. Level 3.7 services are appropriate for individuals whose medical, emotional, behavioral or
cognitive problems are so severe that they require twenty-four (24) hour medical monitoring but
do not need the full resources of an acute care general hospital or medically managed inpatient
treatment program (Level 4). Treatment is designed for individuals who have functional limitations
in the areas of intoxication/withdrawal potential; biomedical conditions; or emotional, behavioral or
cognitive conditions.
21.210.841 L evel 3.7 Service Provisions and Staffing
A. Level 3.7 services shall be scheduled daily and include a minimum of twenty (20) hours of
planned treatment services per week.
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B. Agencies providing Level 3.7 services shall maintain individual to staff ratios not exceeding
twenty to one (20:1) during nighttime hours per agency site, and each shift shall have a minimum
of two (2) staff members, whenever one (1) or more individuals are present.
C. Level 3.7 services shall be staffed with a team that includes physicians, nurses and mental health
professionals licensed or certified pursuant to Article 245 of Title 12, C.R.S. that provide twenty-
four (24) hour professionally directed evaluation, care and treatment services including
administration of prescribed medications, withdrawal management and integrated treatment of
co-occurring medical, emotional, behavioral or cognitive conditions.
D. A licensed physician shall oversee treatment and assure quality of care in Level 3.7 services. A
physician, physician assistant or nurse practitioner shall perform physical examinations for all
individuals admitted. Examinations shall occur within twenty-four (24) hours of admission and
thereafter as necessary.
E. A registered nurse shall conduct an alcohol or other drug-focused nursing assessment at the time
of admission.
F. A licensed nurse is responsible for monitoring the individual’s progress and/or medication
administration twenty-four (24) hours per day, seven (7) days per week.
G. Additional medical specialty consultation, psychological, laboratory and toxicology services are
available on-site through consultation or referral. Psychiatric services are available on-site
through consultation or referral within eight (8) hours by telephone or twenty-four (24) hours in
person.
21.210.9 W ITHDRAWAL MANAGEMENT SERVICES
21.210.91 CLINICALLY MANAGED RESIDENTIAL WITHDRAWAL MANAGEMENT (LEVEL 3.2-
WM)
A. Level 3.2-WM programs shall provide twenty-four (24) hour supervised withdrawal from alcohol
and/or other drugs in a residential setting.
B. Level 3.2-WM programs shall provide collaboration and coordination with emergency mental
health services as needed.
C. Level 3.2-WM programs shall obtain a Controlled Substance License from the Office of
Behavioral Health if the program plans to dispense, compound, or administer a controlled
substance in order to treat a substance use disorder or to treat the withdrawal symptoms of a
substance use disorder.
D. Level 3.2-WM programs shall develop and implement policies and procedures in accordance with
federal and state regulations, department rules, and in consultation with medical professionals
qualified in substance use disorders. Policies and procedures must address but are not limited to:
1. Handling individuals who are assessed as being a current threat to themselves or others
and shall include appropriate uses of law enforcement and monitor any use of individual
restraint and/or seclusion;
2. Communication with intoxicated individuals leaving treatment against staff
recommendations, including the use of emergency commitments; and
3. Circumstances under which individuals shall be discharged, other than completing
withdrawal management or leaving against staff recommendations.
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21.210.911 Level 3.2-WM Admission and Monitoring
A. Individuals admitted to level 3.2-WM services shall be intoxicated, under the influence, or in any
stage of withdrawal from alcohol and/or other drugs.
B. Level 3.2-WM admission procedures shall include at a minimum:
1. Degree of alcohol and other drug intoxication as evidenced by breathalyzer, urinalysis,
self-report, observation or other evidence-based or best practices;
2. Initial vital signs;
3. Need for emergency medical and/or psychiatric services;
4. Inventorying and securing personal belongings;
5. Substance use disorder history and the degree to which the use of substance affects
personal and social functioning, as soon as clinically feasible following admission;
6. Pregnancy screening; and
7. Administration of a validated clinical withdrawal assessment tool.
C. Withdrawal management monitoring of individuals shall include:
1. Routine monitoring of physical and mental status including observation of individual;
2. Vital signs taken at least every two (2) hours until they remain at the person's baseline for
at least four (4) hours, and then taken every eight (8) hours thereafter until discharge;
and
3. Documentation per shift to include all individual monitoring activities.
21.210.912 L evel 3.2-WM Service Planning
A. level 3.2-WM programs shall develop and implement service plans in accordance with Section
21.190.4 and address safe withdrawal, motivational counseling, and referral for treatment.
B. Level 3.2-WM programs shall provide additional service planning for managing individuals with
medical conditions, suicidal ideation, pregnancy, psychiatric conditions, and other conditions
which place individuals at additional risk during withdrawal management.
C. Level 3.2-WM programs shall provide assessments of individual readiness for treatment and
interventions based on the service plan and the assessments and interventions shall be
documented in the individual’s record.
21.210.913 Level 3.2-WM Discharge
A. Level 3.2-WM programs shall provide discharge information to individuals and document in the
individual’s records the requirements established in Section 21.190.6, and:
1. Effects of alcohol and other drugs;
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2. Risk factors associated with alcohol and other drug abuse for acquiring and transmitting
HIV/AIDS (Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome),
Tuberculosis (TB), and other infectious diseases, and for pregnancy;
3. Availability of testing and pre/post-test counseling for HIV/AIDS, TB, Hepatitis C and
other infectious diseases, and pregnancy; and
4. Availability of alcohol and other drug abuse treatment services.
21.210.914 Level 3.2-WM Staff Requirements
A. At least fifty percent (50%) of withdrawal management staff including on-call staff shall consist of
treatment staff as defined in 21.210.1.E, certified addiction technicians or staff in the process of
obtaining addiction counselor certification. Plans for addiction counselor certification shall be
available for review. Full-time staff shall obtain at least an addiction technician certification within
eighteen (18) months of employment.
B. Uncertified staff or staff without a plan for addiction counselor certification shall not comprise
more than fifty percent (50%) of total withdrawal management staff.
C. Level 3.2-WM programs’ individual to staff ratios shall not exceed ten to one (10:1); and
1. Procedures for responding to periods of high census and/or emergency situations shall
be conspicuously posted; and
2. Each shift shall have a minimum of two (2) staff members, whenever one (1) or more
individuals are present.
D. T he staff person overseeing day-to-day operations shall be:
1. Certified as an addiction specialist or licensed as an addiction counselor pursuant to Part
8 of Article 245 of Title 12, C.R.S.;
2. A physician licensed pursuant to Article 240 of Title 12, C.R.S.;
3. A psychologist licensed pursuant to Part 3 of Article 245 of Title 12, C.R.S.;
4. An advanced practice nurse licensed pursuant to Section 12-255-111, C.R.S.; or
5. A licensed clinical social worker, licensed marriage and family therapist, or licensed
professional counselor licensed under Part 4, 5, or 6 of Article 245 of Title 12, C.R.S.
E. Level 3.2-WM programs shall provide twenty-four (24) hour per day, seven (7) days per week on-
site staff. Twenty-four (24) hour on-site staff shall be trained and knowledgeable of substance use
disorders and the treatment of substance use disorders and in addition to treatment staff as
defined in 21.210.1.E, twenty-four (24) hour staff may include:
1. Peer support specialists as defined in 21.400.1; or
2. Addiction technicians certified pursuant to Part 8 of Article 245 of Title 12, C.R.S. or staff
in the process of obtaining addiction counselor certification.
F. P rograms shall maintain documentation that all direct care staff have training in and evaluated
knowledge of the following before providing independent services:
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1. Withdrawal management;
2. Infectious diseases (AIDS/HIV, Hepatitis C, TB), including universal precautions against
becoming infected;
3. Administering cardiopulmonary resuscitation (CPR) and first aid;
4. Monitoring vital signs;
5. Conducting assessment and triage, including identifying suicidal ideation;
6. Emergency procedures and their implementation;
7. Collecting urine and breath samples;
8. Cultural factors that impact withdrawal management;
9. Ethics and confidentiality;
10. Individual records systems;
11. De-escalating potentially dangerous situations; and
12. Basic counseling and motivational interviewing skills.
21.210.92 MEDICALLY MONITORED INPATIENT WITHDRAWAL MANAGEMENT (LEVEL 3.7-
WM)
Level 3.7-WM services shall be provided by licensed medical staff qualified to supervise withdrawal from
alcohol and other drugs through use of medication and/or medical procedures in residential settings
which possess Controlled Substances Licenses in compliance with Part 2 of Article 80 of Title 27, C.R.S.
21.210.921 Level 3.7-WM Admission and Evaluation
A. Level 3.7-WM programs shall develop and implement specific admission criteria detail for which
drugs, including alcohol, medical withdrawal management is provided.
B. In addition to the consent requirements established in 21.170.4, level 3.7-WM programs shall
provide informed consent to medical withdrawal management that include:
1. Med ications to be used; and
2. Need to consult with primary care physicians.
C. Level 3.7-WM programs shall provide medical evaluations by physicians licensed pursuant to
Article 240 of Title 12, C.R.S. or authorized health-care professionals under the supervision of
authorized physicians. The medical evaluations shall consist of, at minimum:
1. Medical histories including detailed chronologies of substance use disorders;
2. Identification of current physical addiction including drug types;
3. Physical examinations to determine appropriateness for outpatient or inpatient medical
withdrawal management; and
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4. Appropriate laboratory tests including pregnancy tests, and other evaluations as
indicated.
D. Level 3.7-WM service protocols for usual and customary withdrawal management from each drug
delineated in the admission criteria shall be developed in consultation with licensed physicians
and other allied health-care professionals and shall be implemented in the form of individualized
withdrawal management plans under direct supervision of program medical directors. Protocols
shall include:
1. Types of intoxication;
2. Tolerance levels for the individual's drug of choice;
3. Degrees of withdrawal;
4. Possible withdrawal and/or intoxication complications;
5. Other conditions affecting medical withdrawal management procedures;
6. Types of medications used;
7. Recommended dosage levels;
8. Frequency of visits (outpatient settings);
9. Procedures to follow in the event of withdrawal management complications;
10. Daily assessments including expected improvements as well as potential problems; and
11. Expected duration of withdrawal management.
E. Medical withdrawal management programs using any controlled substances are required to have
Controlled Substance Licenses issued by the Department. Buprenorphine is the only medication
that can be used for opioid dependent individuals unless the medical withdrawal management
program is licensed as an opioid treatment program and it has been verified through the program
and coordinated with the Federal Center for Substance Abuse Treatment.
F. A uthorized physicians may prescribe buprenorphine under his/her own Drug Enforcement
Administration (DEA) registration number for individuals admitted to the hospital for inpatient
withdrawal management or addiction treatment.
G. Withdrawal management programs must continue patients on their medication-assisted treatment
regimen when available and will only detox individuals from medications treating opioid use
disorders at the patient’s request or if it is deemed medically necessary.
21.210.922 Level 3.7-WM Clinical Staff
A. Level 3.7-WM programs shall provide, at minimum, the following clinical staff:
1. One medical director;
2. One registered nurse or licensed practical nurse (R.N. or L.P.N.) with at least one year of
withdrawal management experience; and
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3. Treatment staff as defined in 2.210.1.E, staffed at a rate that meets the needs of the
individuals receiving level 3.7-WM services.
B. Level 3.7-WM program medical directors' responsibilities shall include, at minimum:
1. Quarterly reviews and revisions of drug withdrawal management categories and
protocols;
2. Reviews of individual withdrawal management plans;
3. Reviews of individual prescriptions that deviate from standard withdrawal management
protocols;
4. Five (5) hours of monthly supervision of and consultation with staff providing withdrawal
management services;
5. Direct supervision of individual withdrawal management cases that deviate from standard
protocols and/or experience complications; and
6. Develop and implement back-up systems for physician coverage when medical directors
are unavailable and/or for emergencies.
C. level 3.7-WM programs shall ensure twenty-four (24) hour access to clinical staff by telephone
and accommodation for unscheduled visits for crises or problem situations.
21.210.923 Level 3.7-WM Treatment Services
A. Level 3.7-WM programs shall provide the following treatment services in addition to medication
dosing contacts:
1. Motivational counseling and support;
2. Continuous evaluation and behavioral health intervention; and
3. Development and monitoring of a service plan per Section 21.190.4.
B. Lev el 3.7-WM programs shall ensure a minimum of one (1) daily clinical supportive services
contact, which shall be documented in individual records.
21.210.924 Level 3.7-Wm Dispensing and Administration Procedures
A. Level 3.7-WM programs shall develop and implement policies and procedures for dispensing
medications per standard withdrawal management protocols that are in accordance with
applicable state and federal statutes and for the following:
1. Individual prescriptions filled and dispensed by a registered pharmacist at a designated
pharmacy location; and
2. Individual prescriptions from medical directors that are filled from stock quantities.
B. Level 3.7-WM programs shall develop and implement policies and procedures in accordance with
applicable federal and state statutes for storing and accounting for all drugs including controlled
substances.
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21.220 GENDER-RESPONSIVE WOMEN'S TREATMENT IN SUBSTANCE USE DISORDER
PROGRAMS [Eff. 11/1/13]
In addition to Section 21.210, agencies licensed to provide Gender-Responsive Women’s Treatment shall
be in compliance with Subsections 21.220.1 through 21.220.4.
21.220.1 GENERAL PROVISIONS [Eff. 11/1/13]
A. Treatment staff shall have documented training, supervision and experience in women-specific
issues and services.
B. Treatment for substance use disorders shall be provided to the family as a whole, unless clinically
contraindicated. Clinical contraindications to this provision must be documented in the individual
record.
C. Agencies shall offer any pregnant woman admission to treatment within forty-eight (48) hours and
shall demonstrate compliance with Section 21.220.4, D, Services to Pregnant Women.
D. Agencies providing gender specific women’s treatment shall include the following components:
1. Emotional and physical safety of individuals take precedence over all other
considerations in the delivery of services;
2. Services designed to increase women’s access to care, and engagement and retention of
individuals (such as comprehensive case management, transportation, child care);
3. Women-only therapeutic environments;
4. Women-specific service needs and topic areas;
5. Program services shall directly address trauma issues currently manifesting in the
individual’s life either through direct service provision or by referral; and,
6. M ultiple modalities that meet the specific needs of women (group and individual therapy,
case management and opportunities for women to be in treatment with their children
where possible).
E. Agency policy and procedures shall include the mandatory reporting of suspected child abuse,
neglect and/or child safety issues, which shall include definitions of abuse and neglect under the
Colorado Children’s Code (Section 19-1-103, C.R.S.), and which are consistent with the reporting
of child abuse allowed under federal law.
F. Agency policy and procedures shall include the criteria for interventions offered and expected
outcomes of services delivered.
21.220.2 SCREENING [Eff. 11/1/13]
In addition to the Section 21.190.3, screening shall include all of the following unless clinically
contraindicated:
A. Screening and documentation of individual’s need for prenatal care (where applicable), primary
medical care and family planning services;
B. Screening for child safety issues utilizing an evidence-based or best practices approved
instrument.
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21.220.3 TREATMENT [Eff. 11/1/13]
A. Service plans shall be established in accordance with Section 21.190.4 of these rules, and shall
address each of the need areas identified in Section 21.220.3.
B. When not clinically contraindicated the following topic areas shall be addressed in treatment or by
referral when applicable:
1. Reductions or elimination of substance use;
2. Individual safety issues
3. Child safety issues;
4. Trauma issues;
5. Parenting issues;
6. Ways in which substance use disorders impact and are impacted by family and
relationships;
7. Medical and primary health issues;
8. Mental health issues;
9. Nutrition.
21.220.4 SERVICES TO PREGNANT WOMEN [Eff. 11/1/13]
A. Pregnant women shall be given priority admission to treatment for substance use disorders.
B. Programs shall develop policies and procedures for service delivery to pregnant women, which
shall include circumstances under which pregnant women may be discharged from treatment.
1. Pregnant women may not be discharged from treatment solely for failure to maintain
abstinence from substance use.
2. Every effort shall be made to retain pregnant women in treatment for the duration of their
pregnancies in order to maintain an optimal period of abstinence from substance use.
C. Ev ery attempt shall be made to admit pregnant women to treatment within forty-eight (48) hours
of first contact between the woman and the admitting program.
D. If a pregnant woman is not admitted to treatment within forty-eight (48) hours of first contact, the
denial shall be clearly documented, the women's treatment coordinator for OBH shall be
informed, and interim services shall be provided consisting of the following at minimum:
1. Referral for pre-natal care;
2. Information on the effects of alcohol and drug use on the fetus;
3. Daily phone contact with the individual; and,
4. Education regarding the transmission and prevention of communicable diseases such as
HIV, hepatitis.
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E. Pregnant women shall be linked to prenatal care immediately and barriers to accessing prenatal
care shall be addressed, including transportation to prenatal care.
F. When a woman refuses to seek prenatal care or fails attempts to link her to care, this shall be
documented in her record, and there shall be continuing efforts to link her to prenatal care until
this is accomplished.
21.230 SUBSTANCE USE DISORDER EDUCATION AND TREATMENT FOR PERSONS INVOLVED
IN THE CRIMINAL JUSTICE SYSTEM
21.230.1 GENERAL PROVISIONS
A. Education, treatment, and ancillary services shall be provided to individuals convicted of
misdemeanors and felonies who are assessed as needing substance use disorder treatment, as
provided by Title 16, Article 11.5, Part 1, and C.R.S. and in accordance with current standardized
assessment and placement protocol.
B. All agencies admitting out of state offenders must identify and notify the Interstate compact unit
for Adult Offender Supervision per Section 17-27.1-101, C.R.S.
C. Services shall be based on the results of current screening and assessments.
D. Agencies shall place individuals involved in the criminal justice system according to the
standardized offender assessment provided by the referring criminal justice agency.
E. Education, treatment and ancillary services as indicated by assessment and included in the
service plan shall be provided for by the agency or through referrals.
F. A gencies shall have a written memorandum of understanding with ancillary providers to make
available agreed upon services and require specific data and exchange of information related to
the individualized services.
G. Education and treatment shall be a minimum of nine (9) months or as required by the referring
criminal justice agency.
H. Frequency and intensity of education and treatment services shall be based on assessments and
at minimum one two hour session per week.
I. The following content/topics shall be presented during offender treatment:
1. Physiological and psychological effects of alcohol, marijuana and/or marijuana/THC
infused products, stimulants, and other drugs;
2. Signs and symptoms of substance use disorders;
3. Stress management and substance use disorders;
4. Anger management and substance use disorders;
5. Behavioral triggers leading to substance use disorders;
6. Drugs in the work place; and,
7. Legal issues and substance use disorders.
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J. Agencies shall implement treatment curricula that are written in manual format and are evidence-
based or best practices. All agency clinical staff working with the individuals involved in the
criminal justice system population must be trained on and follow the specific curricula as written.
K. Individuals will receive a complete copy of the participant materials/workbook associated with the
approved curriculum. The agency may charge for the curriculum.
L. Education and treatment sessions shall only consist of face-to-face (as defined in Section
21.240.1) contact and shall not include administrative procedures or breaks.
M. Agency staff working directly with individuals shall have documented qualifications and training in
forensic populations and criminal justice systems.
N. Drug and alcohol toxicology collection must be observed by trained staff when requested by the
referral source.
O. Records shall contain monthly documentation of communication with the criminal justice referral
source describing progress toward specific treatment goals. Agencies shall be responsible for
monitoring and reporting to referring courts or their representatives the individual's progress with
ancillary services.
P. Agencies shall have written documentation in an individual's record that the individual has
received services to assist in community reintegration, if applicable.
21.230.2 E NHANCED OUTPATIENT EDUCATION AND TREATMENT SERVICES FOR
PERSONS INVOLVED IN THE CRIMINAL JUSTICE SYSTEM [Eff. 5/1/16]
A. An agency may provide enhanced outpatient services if it:
1. Is licensed by the Department for education and treatment services for individuals
involved in the criminal justice system;
2. Is in compliance with Section 21.230.1; and,
3. Provides a minimum of four (4) hours over two (2) group sessions of scheduled treatment
per week.
B. Frequency and intensity of treatment activities shall be based on current assessments and
conducted in at least two (2) sessions per week.
C. Changes in frequency and intensity of education and treatment activities shall be assessed.
D. If, upon discharge from enhanced outpatient treatment, the minimum number of months required
by the referring criminal justice agency have not been met, the agency shall transfer the individual
to the appropriate level of care where remaining education and treatment requirements can be
met.
21.240 DUI/DWAI, BUI, AND FUI EDUCATION AND TREATMENT
21.240.1 DEFINITIONS
“ADDS” is the Alcohol and Drug Driving Safety program, established under Section 42-4-1301.3, C.R.S.
The Judicial Department administers an Alcohol and Drug Driving Safety program in each judicial district
that provides pre-sentence and post-sentence alcohol and drug evaluations on all persons convicted of
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Driving, Flying, and Boating Under the Influence (DUI, FUI, BUI) and Driving With Ability Impaired
(DWAI).
“Alcohol and Drug Evaluation Specialists” (ADES) are persons within the criminal justice system, qualified
to conduct pre- and post-sentence evaluations on, and provide supervision for, persons convicted of
Driving, Flying, and Boating Under the Influence (DUI, FUI, BUI) and Driving With Ability Impaired
(DWAI).
“BUI” means Boating Under the Influence.
“DUI” means Driving Under the Influence.
“DWAI” means Driving With Ability Impaired.
“Face-to-Face”, for purposes of this section 21.240, means that the individual is physically in the same
room as a professional person at an office of a behavioral health licensed or approved site or video
technology is being utilized.
“FUI” means Flying Under the Influence.
“Persistent Drunk Driver” defined in Section 42-1-102(68.5), C.R.S.
“Level I and Level II Education, Therapy or Treatment” means an approved alcohol and drug driving
safety education or treatment program as defined in 42-4-1301.3(3)(c)(IV) C.R.S.
21.240.2 GENERAL PROVISIONS [Eff. 5/1/16]
A. Agencies providing DUI/DWAI services shall develop and implement policies, procedures, and
individualized service planning demonstrating recognition of issues and treatment needs unique
to this individual population.
B. A lcohol and Drug Driving Safety (ADDS) education and treatment services shall be restricted to
those arrested, convicted of or receiving deferred prosecutions, sentences, or judgments for
alcohol/other drug offenses related to driving (Title 42, Article 4, Part 13, C.R.S. and Title 42,
Article 2, Part 1, C.R.S.), boating (Title 33, Article 13, Part 1, C.R.S.), or flying (Title 41, Article 2,
Part 1, C.R.S.).
C. Individuals who are admitted, educated, or treated for Driving Under the Influence (DUI), Driving
While Ability Impaired (DWAI), Boating Under the Influence (BUI), or Flying Under the Influence
(FUI) shall be screened, referred and placed in accordance with current ADDS program
screening, referral, and placement procedures.
1. If an agency does not have a copy of the ADDS referral paperwork, the agency shall
conduct a screening of the individual using an evidence-based screening or promising
practice process and instrument.
2. If an appropriate level of service has not been determined by the ADDS program
screening, the agency shall follow guidelines established by the Colorado Department OF
Human Services, Office of Behavioral Health, to determine the most appropriate level of
service.
D. Agencies that do not provide services as identified through the screening or in the individual's
court order shall:
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1. Refer the individual back to the Alcohol and Drug Evaluation Specialist with
documentation of which service(s) will not be provided on site and identified referrals and
suggestions for alternative services;
2. Have a written memorandum of understanding or contract with the ancillary provider to
make available agreed upon services and require specific data and exchange of
information related to the individualized services; and,
3. Be responsible for monitoring and reporting to referring courts or their representatives the
individual's progress with ancillary services.
E. Individuals with DUI/DWAI shall not be treated in groups with individuals with other offenses
unless they need these groups as determined by the assessment and supported by the service
plan.
F. Agencies providing Level I Education, Level II Therapeutic Education, and Level II Therapy shall
submit information using reporting formats and data systems approved by the Department when
appropriate to:
1. Sentencing courts;
2. The Department;
3. Probation departments;
4. Alcohol and Drug Evaluation Specialist;
5. Department of Revenue Hearing Section; and,
6. Motor Vehicle Division.
G. Information released shall be in accordance with federal and state confidentiality regulations and
shall include:
1. Enrollment;
2. C ooperation;
3. Attendance, hours and weeks completed;
4. Treatment status and progress;
5. Education/treatment levels;
6. Fee payment;
7. Compliance with ancillary services; and,
8. Discharge status.
H. Agencies shall establish written policies and procedures to ensure that individual data is accurate
and submitted within seven (7) business days of service or change in status.
I. Level I education, Level II therapeutic education, and Level II therapy shall not be combined, nor
shall hours completed for one count as hours completed in another.
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J. Individuals shall not be reported as finishing Level I education, Level II therapeutic education, or
Level II therapy until all required content/topics have been completed over the minimum required
hours and weeks.
K. Agencies shall provide proof of individual enrollment and report individual status in Level II
education and therapy, including discharge, to the Colorado Department of Revenue, Division of
Motor Vehicles, within seven (7) business days using Department prescribed reporting formats, in
accordance with Sections 42-2-132 and 42-2-144, C.R.S.
L. Agencies shall provide accurate and timely submission of DUI/DWAI referral summaries (DRS)
and other required data submitted through the Treatment Management System (TMS). Agency
staff having access to the Treatment Management System shall do so in accordance with federal
confidentiality laws.
M. Discharge DUI/DWAI Referral Summary
Agencies shall provide a copy of the discharge DUI/DWAI referral summary, validated with an
agency authorized signature, to individuals and referral sources within ten (10) business days
following discharge from education and/or treatment.
1. A copy of the discharge referral summary shall be provided to individuals at no charge;
2. The discharge referral summary shall not be withheld for any reason including, but not
limited to, collection of outstanding balances; and,
3. Ea ch discharge referral summary must reflect all DUI/DWAI services the individual
received in a given treatment episode.
N. Ignition Interlock
1. Agencies shall screen all individuals with DUI/DWAI's for ignition interlock usage and
requirements in accordance with the Department's interlock rules;
2. Agencies shall offer interlock counseling to those individuals who have installed, or plan
to install, an ignition interlock device in accordance with Department rules; and,
3. Interlock counseling shall be offered on site or by referral to another Department licensed
agency.
21.240.3 PROVISION OF SERVICES
A. Agencies shall use and adhere to a curriculum written in a manual form that is evidence-based or
a best practice specific to DUI/DWAI, and contains content and topic areas as determined by the
Department.
B. Agencies shall provide individuals with a complete copy of the participant materials and workbook
associated with the approved curriculum being used. The agency may charge individuals for the
curriculum materials.
C. Agencies shall assign individuals to a specific class, group or individual session throughout the
treatment episode. Individuals attending DUI/DWAI education may make up sessions missed by
attending other education sessions that cover the missed content. Make-up groups for DUI/DWAI
therapy are not allowed.
D. S taff conducting DUI/DWAI, BUI and FUI education and therapy shall:
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1. Receive training in the curriculum;
2. Meet the minimum staff qualifications per Sections 21.160 and 21.210.1, including
credentialing and competency in group processes; and,
3. Possess a CAS or LAC.
E. Hours of attendance shall only be granted for face-to-face contacts and shall not include
administrative procedures or breaks.
F. Drug and alcohol toxicology collection must be observed by trained staff when requested by the
referral source.
21.240.4 YOUTH DUI, DWAI, BUI and FUI EDUCATION AND TREATMENT [Eff. 5/1/16]
Licensed youth DUI/DWAI agencies shall comply with Section 21.200 Behavioral Health Services for
Children and Adolescents, the adult DUI, DWAI, BUI, FUI rules (21.240) as well as the following:
A. Youth under twenty-one (21) years of age that receive a DUI/DWAI are held to the same adult
requirements under Alcohol and Drug Driving Safety (ADDS) education and treatment services as
identified in (Title 42, Article 4, Part 13 and Title 42, Article 2, Part 1, C.R.S) boating (Title 33,
Article 13, Part 1,C.R.S.), or flying (Title 41, Article 2, Part 1, C.R.S.) and includes Section [42-4-
1301.3(3)(c)(IV)] , C.R.S.
B. Agencies licensed to provide Youth DUI, DWAI, BUI, and FUI education and treatment shall also
be licensed to provide DUI/DWAI education and treatment.
C. W henever possible providers shall hold a separate group for youth.
1. Providers shall use clinical judgement when determining age appropriate placement of
youth under twenty-one (21) years of age in an adult group.
2. When youth are placed in an adult group, individual sessions shall be offered to meet the
developmental needs of the youth, when applicable.
D. Youth under twenty-one (21) years of age shall receive a complete copy, age appropriate
materials/workbook, associated with the approved curriculum. The agency may charge for the
curriculum.
E. Parents, other supportive adults, or significant others, shall participate throughout the length of
treatment, unless contraindicated.
21.240.5 CONTENT OF RECORDS
Individual records shall be maintained for all levels of education and therapy and follow Section 21.170
(Records Care and Retention, General Provisions) and include:
A. Court documents regarding referral and classification and placement;
B. Attendance, individualized progress notes, and course completion data;
C. Descriptions of content and topics covered during each session;
D. Relevant reports and records of communication;
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E. Copies of Discharge DUI/DWAI Referral Summary;
21.240.6 Level I EDUCATION
A. Level I education shall be twelve (12) hours of face-to-face instruction; hours may include intake.
B. No more than four (4) hours shall be conducted in one (1) calendar day.
C. Level I education shall be conducted in outpatient settings.
21.240.7 Level II THERAPEUTIC EDUCATION [Eff. 5/1/16]
A. Agencies applying for approval to conduct Level II therapeutic education must also apply for
approval to conduct Level II therapy and meet the requirements of both.
B. Provision of Services for Level II therapeutic education shall:
1. Be conducted in outpatient settings;
2. Consist of twelve (12) attended weeks and a total of twenty-four (24) face-to-face contact
hours; and,
3. Not be conducted concurrently with Level II therapy unless clinical rationale is
documented. The combined time in Level II therapeutic education and Level II therapy
shall not be less than the minimum number of weeks required for Level II therapy.
C. Individuals shall not attend more than one (1) session of Level II education per week.
21.240.8 LEVEL II DUI/DWAI THERAPY
21.240.81 LEVEL II Outpatient [Eff. 5/1/16]
A. P rograms applying for approval to conduct Level II therapy must also apply for approval to
conduct Level II therapeutic education and meet the requirements for both.
B. Individuals in Level II therapy shall be assigned treatment tracks in accordance with the ADDS
program placement criteria or Department placement guidelines in the absence of the ADDS
placement criteria. If a track has not been assigned by the ADDS program, the agency shall
assign a track based on the Department's track guidelines. The Department track guidelines are
as follows:
1. TRACK A. Individuals whose blood alcohol content was below the statutorily defined
persistent drunk driving (PDD) level per Section 42- 1-102(68.5), C.R.S, and who have
one offense for DUI/DWAI, BUI, or FUI. Track A is a minimum forty-two (42) face-to-face
hours of group and/or individual Level II therapy conducted over twenty-one (21) or more
weeks.
2. TRACK B. Individuals whose blood alcohol content was at or above the statutorily
defined PDD level per Section 42-1-102(68.5), C.R.S., and who have one offense for
DUI/DWAI, BUI, or FUI. Track B is a minimum of fifty-two (52) face-to-face hours of group
and/or individual Level II therapy conducted over twenty-six (26) or more weeks.
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3. TRACK C. Individuals whose blood alcohol content was below the statutorily defined
PDD level per Section 42-1-102(68.5), C.R.S., and who have two or more offenses for
DUI/DWAI, BUI, or FUI. Track C is a minimum of sixty-eight (68) face-to-face hours of
group and/ individual Level II therapy conducted over thirty-four (34) or more weeks.
4. TRACK D. Individuals whose blood alcohol content was at or above the statutorily
defined PDD level per Section 42-1- 102 (68.5), C.R.S., and who have two or more
offenses for DUI/DWAI, BUI, or FUI. Track D is a minimum of eighty-six (86) face-to-face
hours of group and/or individual Level II therapy conducted over forty-three (43) or more
weeks.
C. Level II therapy shall be conducted only after Level II therapeutic education has been completed
unless there is documented assessment and clinical rationale.
D. Level II therapy group sessions (excluding enhanced or intensive outpatient) shall not be less
than two (2) hours of therapeutic contact, and shall not include administrative procedures and
breaks.
E. Individuals are expected to attend group one (1) time per week. Clinical rationale for any changes
in frequency of group attendance (fewer or more) shall be documented, and must reflect at least
one (1) session per month. Therapy hours attended shall be conducted over the minimum
number of weeks associated with the therapy track assigned.
F. T he assessment shall be updated at the onset of Level II therapy.
G. Using the initial service plan as a basis, a revised service plan and subsequent reviews shall be
developed for individuals in Level II therapy in accordance with Section 21.190.4.
21.240.82 DUI/DWAI Enhanced Outpatient THERAPY
A. An agency licensed to provide DUI/DWAI services may qualify to provide enhanced outpatient
therapy if it:
1. Is approved by the Department for Level II therapy;
2. Meets all the requirements in Sections 21.110 through 21.190, Sections 21.240.2,
21.240.3, and 21.240.5 and Section 21.240.81; and,
3. Demonstrates ability to provide eight (8) hours of scheduled treatment activities per
week.
B. Level II DUI/DWAI enhanced outpatient therapy shall:
1. Be based on assessments;
2. Include a minimum of three (3) to maximum eight (8) hours of treatment activities;
3. Be conducted over a minimum of two (2) calendar days per week; and,
4. Not include Level II education.
C. DUI/DWAI enhanced outpatient services shall be in addition to any DUI/DWAI level or track
requirements.
D. Treatment activities shall be conducted for a minimum of ninety (90) calendar days.
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E. Changes in frequency and intensity of Level II enhanced outpatient treatment shall be driven and
based on treatment service plan reviews.
21.240.83 DUI/DWAI Intensive Outpatient THERAPY
A. An agency licensed to provide DUI/DWAI services may qualify to provide DUI/DWAI intensive
outpatient therapy if it:
1. Is approved by the Department for Level II therapy;
2. Meets all the requirements in Sections 21.110 through 21.190, Sections 21.240.2,
21.240.3, and 21.240.5, and Section 21.240.81; and,
3. Demonstrates ability to provide at least nine (9) hours of scheduled treatment activities
per week.
B. DUI/DWAI intensive outpatient treatment therapy shall:
1. Be based on assessments;
2. Include a minimum of nine (9) hours of treatment activities;
3. Be conducted over a minimum of three (3) calendar days per week; and,
4. Not include Level II education.
C. DUI/DUI intensive outpatient services shall be in addition to any DUI/DWAI level or track
requirement.
D. The length of stay in level ii intensive outpatient shall be four (4) to six (6) weeks.
E. Any changes in frequency and intensity of Level II intensive outpatient treatment shall be based
on assessments and service plan reviews.
21.240.84 Pa rtial Hospitalization, Clinically Managed Low Intensity Residential Services,
Clinically Managed High Intensity Residential Services, and Medically Monitored Intensive
Residential Treatment [Eff. 5/1/16]
A. Partial Hospitalization, Clinically Managed Low Intensity Residential Services, Clinically Managed
High Intensity Residential Services, and Medically Monitored Intensive Residential Treatment
may qualify to provide DUI/DWAI therapy if they:
1. Meet all requirements under specific level of care in Section 21.210.5;
2. Meet all requirements in Sections 21.240.2 and 21.240.3; and,
3. Are affiliated with the Department licensed outpatient DUI/DWAI programs.
B. In order for individuals to receive DUI/DWAI therapy credit for participation in Partial
Hospitalization, Clinically Managed Low Intensity Residential Services, Clinically Managed High
Intensity Residential Services, and Medically Monitored Intensive Residential Treatment, the
assessed and identified DUI/DWAI treatment areas must be included in the individualized service
plan.
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21.240.85 LEVEL II FOUR PLUS TREATMENT
A. Level II Four Plus Treatment is an approved alcohol and drug driving safety education or
treatment program as defined in Section 42-4-1301.3(3)(c)(IV) C.R.S. (2016), intended for
someone who has four (4) or more alcohol and/or drug impaired driving offenses.
B. In order to provide Level II Four Plus Treatment an agency must be licensed to provide:
1. Level II Therapeutic Education; and,
2. Level II Therapy.
C. Level II Four Plus Treatment must consist of not less than eighteen (18) months of attendance
which includes a minimum of one-hundred eighty (180) hours of treatment.
D. All Level II Four Plus Treatment shall be driven by the individual’s clinical assessment.
E. Level II Four Plus Staff Requirements
1. Staff providing Level II Four Plus Treatment must meet the requirements in Section
21.240.3(D), and:
a. CAS credentialed staff must be receiving clinical supervision or consultation by a
CAS or LAC; or,
b. Licensed staff must have at least one (1) year of documented addiction
counseling experience.
2. Staff providing specialized treatment services must hold current and valid credentials
and/or licensure in the area of service provision.
3. S taff providing assessment must hold current and valid credentials and/or licensure in the
area of service provision.
F. Level II Four Plus Clinical Assessment(s)
1. A full assessment must be administered in accordance with section 21.190.3.
2. In addition to the requirements in Section 21.190.3(D), the assessment must contain
information on:
a. Cognitive functioning;
b. Traumatic brain injury;
c. Adverse childhood experiences (ACES);
d. Grief and loss; and,
e. Co-occurring mental health issues.
3. Agencies shall utilize an assessment tool specifically designed to address co-occurring
mental health issues in the impaired driver population.
4. Agencies shall document results and coordinate further services as appropriate.
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G. Level II Four Plus Service Planning and Reviews
1. Level II Four Plus service planning and reviews must be administered in accordance with
Section 21.190.4.
2. Agencies providing Level II Four Plus Treatment shall conduct service plan reviews at a
minimum of every sixty (60) days in collaboration with supervising probation officers.
3. Consideration shall be given to clients’ needs for aftercare and peer recovery support
services.
H. Level II Four Plus Discharge Planning
Level II Four Plus discharge planning must be administered in accordance with Section 21.190.6.
I. Provision of Level II Four Plus services shall:
1. Be determined by the results of the screenings and clinical assessment.
2. Be a combination of education and treatment strategies that include, but not limited to:
a. Individual counseling;
b. Group therapy, unless clinically contraindicated;
c. Family/other supportive adult therapy, if applicable;
d. Interlock counseling, if the individual has an ignition interlock installed;
e. DUI Level II Education or Level II Therapy, if applicable;
f. Education, if applicable;
g. Medication assisted treatment, if applicable;
h. Residential treatment, if applicable;
i. Other treatment as indicated by the initial and ongoing clinical assessment.
3. A gencies providing Level II Four Plus Treatment shall provide case management
activities, where applicable, to ensure the coordination of client services and needs, and
the continuity of care, with other services.
J. Testing and Monitoring
1. All clients shall be tested and/or monitored for alcohol and drug use. Testing and/or
monitoring may include the following:
a. Urinalysis;
b. Breath analysis;
c. Continuous alcohol monitoring;
d. Mobile/remote breath testing;
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e. Direct and indirect biomarker testing;
f. Drug and other testing as appropriate.
2. Agency drug and alcohol toxicology collection shall be observed by trained staff.
3. If testing is not done by the agency, there must be documentation of the efforts to obtain
test results.
4. Testing and sharing of results shall be coordinated with probation.
21.240.9 DUI/DWAI BEHAVIORAL HEALTH SERVICES [Eff. 5/1/16]
Some behavioral health service contact hours and weeks may be included and reported as hours of Level
II therapy. Credit for DUI/DWAI therapy hours may be given if the DUI/DWAI agency conducts a current
comprehensive assessment and:
A. The assessment and service plan support the need for behavioral health services.
B. Supporting documentation that corresponds to requested hours and weeks of behavioral health
services from the ancillary provider is requested and documented in the record.
C. A discharge DUI/DWAI referral summary is completed for the hours and weeks granted.
21.250 [Repealed eff. 10/01/2020]
21.260 ALCOHOL AND DRUG EMERGENCY COMMITMENTS
A. Emergency commitment policies and procedures, based on and in compliance with Sections 27-
81-111 and 27-82-107, C.R.S., and these rules, shall be developed and implemented by the
licensed withdrawal management programs to:
1. A scertain if grounds for commitment exist;
2. Assure that individuals and their legal representatives receive copies of the application
for emergency commitment forms and be advised verbally and in writing of the right to
challenge commitment through the courts;
3. Determine when grounds for emergency commitment no longer exist.
B. The treatment facility administrator shall designate, in writing, qualified staff, who meet the criteria
established in Section 21.210.914(B), to assume responsibility for accepting, evaluating,
informing, and providing treatment to individuals on emergency commitment.
C. Applications for emergency commitments shall be prepared on Department designated forms.
D. Daily evaluations for emergency commitment continuance shall be documented.
E. If individuals on an emergency commitment require treatment in other licensed withdrawal
management programs, transfers may be managed by the programs that initially authorized the
commitments.
F. When transferring individuals, withdrawal management programs shall use Department
designated transfer forms. Completed copies shall be given to:
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1. Individuals or their legal representatives;
2. The withdrawal management programs to which individuals are being transferred.
G. When minors are transferred, parents or legal guardians who have given permission for treatment
shall receive copies of transfer forms.
H. When it is determined grounds for emergency commitment no longer exists, the individual shall
be transferred to voluntary status and the emergency commitment discontinued and documented.
A copy of the form shall be given to the individual and made part of the treatment record.
21.270 ALCOHOL AND DRUG INVOLUNTARY COMMITMENTS [Eff. 5/1/16]
A. All agencies funded by the Department or by a designated Managed Service Organization shall
be licensed to treat individuals on involuntary commitment in accordance with this section.
B. Involuntary commitment policies and procedures shall be developed and implemented based on
and in compliance with Sections 27-81-112 and 27-82-108, C.R.S.
C. The Department shall be the legal custodian of individuals involuntarily committed to treatment.
D. Passes shall be issued to individuals on involuntarily commitments in residential settings only if
they are directly related to treatment. Passes shall not be issued during the initial thirty (30) days
of treatment except in emergencies and with Department approval.
E. T he following information shall be reported to the Department:
1. Non-compliance with program requirements and/or court orders;
2. Failure to appear for admission to treatment;
3. Leaving treatment in violation of court orders;
4. Failure to return from passes;
5. Treatment status every thirty (30) days.
F. Discharge summaries, as outlined in Section 21.190.6 shall be submitted to the Department, the
referring source, and to the referral treatment or aftercare agency.
G. Requests for early discharge and/or transfer to other treatment programs shall be submitted to
the Department for approval.
21.270.1 STAFF REQUIREMENTS
A. Primary counselors for individuals on involuntary commitment shall:
1. Be Colorado certified addiction specialists; or,
2. Be Colorado licensed addiction counselors; or,
3. Possess a clinical master’s degree; and,
4. Complete fourteen (14) hours of training in interviewing techniques related to engaging
individuals in treatment.
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B. Copies of course certificates and other relevant documentation shall be retained in counselor
personnel files.
21.280 CARE AND TREATMENT OF PERSONS WITH A MENTAL HEALTH DISORDER IN A
DESIGNATED FACILITY
21.280.1 DEFINITIONS
“Facility” for the purposes of this section means any facility designated by the Department pursuant to
Title 27, Article 65, C.R.S.
“Facility or community based personnel” means:
A. A professional person;
B. A registered professional nurse as defined in Section 12-38-103 (11), C.R.S. who by reason of
postgraduate education and additional nursing preparation has gained knowledge, judgment, and
skill in psychiatric or mental health nursing;
C. A licensed marriage and family therapist, licensed professional counselor, or addiction counselor
licensed under Part 5, 6, or 8 of Article 43 of Title 12, C.R.S., who by reason of postgraduate
education and additional preparation has gained knowledge, judgment, and skill in psychiatric or
clinical mental health therapy, forensic psychotherapy, or the evaluation of mental health
disorders; or,
D. A licensed clinical social worker licensed under the provisions of Part 4 of Article 43 of Title 12,
C.R.S.
“Involuntary Medication” means psychiatric medication administered without an individual's consent.
“Li censed Independent Practitioner” for the purposes of this section means a practitioner permitted by law
and by the agency to provide care, treatment, or services, without direction or supervision, within the
scope of the practitioner license and consistent with assigned clinical responsibilities.
“Placement facility” means a public or private facility that has a written agreement with a designated
facility to provide care and treatment to any individual undergoing mental health evaluation or treatment
by a designated facility. A placement facility may be a general hospital, nursing care facility, or licensed
residential child care facility.
“Professional person” means a person licensed to practice medicine in Colorado, a psychologist certified
to practice in Colorado, or a person licensed and in good standing to practice medicine in another state or
a psychologist certified to practice and in good standing in another state who is providing medical or
clinical services at a treatment facility in Colorado that is operated by the armed forces of the United
States, the United States Public Health Service, or the United States Department of Veterans Affairs.
“Psychiatric medication” is a medication being used to treat psychiatric illness for the patient including, but
not limited to, anti-psychotics, antidepressants, and other medications that may have other medical uses
but are accepted within the medical profession for psychiatric use as well.
“S ecure Treatment Facility” for the purposes of these rules, means the Robert L. Hawkins High Security
Forensic Institute at the Colorado Mental Health Institute at Pueblo.
“Therapy or treatments using special procedures” means a therapy that requires an additional, specific
consent, including electro-therapy treatment (electro-convulsive therapy), and behavior modifications
using physically painful, aversive, or noxious stimuli.
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“Unduplicated” means an individual is counted only once, no matter how many specific services the
individual received during the calendar year.
21.280.2 ORGANIZATIONAL PROVISIONS
21.280.21 Employment of Persons Receiving Services in Designated Facilities [Eff. 11/1/13]
A. All labor, employment or jobs involving facility operation and maintenance which are of an
economic benefit to the facility, shall be treated as work and shall be compensated according to
applicable minimum wage or certified wage rates.
B. Maintaining a minimum standard of cleanliness and personal hygiene and personal
housekeeping, such as making one's bed or cleaning one's area, shall not be treated as work and
shall not be compensated.
C. Individuals shall not be forced in any way to perform work.
D. Privileges or release from a designated facility shall not be conditioned upon the performance of
work.
E. Vocational programs and training programs must comply with all applicable federal and state
laws.
F. Vocational programs are not subject to the provisions in Section 21.280.21, A, unless the
program is of economic benefit to the facility.
G. All work assignments, together with a specific consent form, and the hourly compensation
received, shall be noted in the individual’s record.
21.280.22 E nvironment and Safety [Eff. 11/1/13]
A. All individuals being treated under these regulations shall receive such treatment in a clean and
safe environment with opportunities for privacy.
B. A facility shall only place an individual in a bedroom with video monitoring due to good cause and
safety or security reasons. Individuals shall be notified when placed in bedrooms with video
monitoring capabilities.
C. Each facility shall maintain reasonable security capabilities to guard against the risk of
unauthorized departures. The least restrictive method to prevent an unauthorized departure shall
be used.
D. An unlocked facility may place an individual in seclusion to prevent an unauthorized departure
when such departure carries an imminent risk of danger for the individual or for others. Under
those circumstances, the seclusion procedures in Section 21.280.42, Use of Seclusion, shall be
followed.
E. Seclusion rooms must be a minimum of 100 square feet.
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21.280.23 Facility Designated Pursuant to Title 27, Article 65, C.R.S., Care and Treatment of
Persons with Mental Illness Data Requirements
A. Each facility designated by the Department, pursuant to Title 27, Article 65 C.R.S, shall file an
annual report with the Department. The report shall be submitted in the format and timeframe
required by the Department. This data shall include individuals being treated in placement
agencies under the auspices of the designated facility.
B. For each designated facility, the annual report shall include the name, county, and address of the
facility, as well as facility type as defined in 27-65-102(7), C.R.S.
C. The data report requirements shall include the following types of information as listed in 1 through
4:
1. Seventy-Two (72) Hour Treatment and Evaluation (Mental Health Holds)
The facility is required to maintain a data set sufficient to report the following aggregate
numbers to the Department annually by July 1, for the most recent, complete calendar
year covering January 1 through December 31:
a. The total number of unduplicated individuals, as defined in Section 21.280.1, who
were on a seventy-two hour hold status, as well as:
1) Total number of unduplicated individuals by gender;
2) T otal number of unduplicated individuals by race and ethnicity;
3) Total number of unduplicated individuals by age; and,
4) Total number of unduplicated individuals by county of residence.
B. The total number of seventy-two hour holds, as well as, the total number of
seventy-two hour holds grouped by:
1) Who initiated the seventy-two hour hold (each hold can only meet the
requirements of one category listed below):
a) Certified peace officer;
b) Court; or,
C) Facility or community based personnel as defined in section
21.280.1.
2) The reason(s) for the seventy-two hour hold (each hold can meet the
requirements of multiple categories listed below):
a) Dangerous to self;
b) Dangerous to others; or,
c) Gravely disabled.
3) Disposition of the seventy-two hour hold (each hold can only meet the
requirements of one category listed below):
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A) Released without need for further mental health services;
B) Referred for further mental health care and treatment on a
voluntary basis;
C) Certified for treatment pursuant to 27-65-107, C.R.S.; or,
D) Transferred to another designated facility while still on the
seventy-two hour hold.
C. The total number of involuntary transportation holds, as defined in Section
21.281.1, received by the facility, as well as total numbers by outcome of the
required screening, including at least:
1) Total number of involuntary transportation hold screenings resulting in
the placement of a seventy-two hour hold;
2) Total number of involuntary transportation hold screenings resulting in a
referral for further mental health care and treatment on a voluntary basis:
and,
3) Total number of involuntary transportation hold screenings resulting in a
release without need for further mental health services.
2. Short and Long-Term Certifications
The facility is required to maintain a data set sufficient to report the following aggregate
numbers to the Department annually by July 1, for the most recent, complete calendar
year covering January 1 through December 31:
a. The total number of unduplicated individuals, as defined in Section 21.280.1, who
were on a certification, as well as:
1) T otal number of unduplicated individuals by gender;
2) Total number of unduplicated individuals by race and ethnicity;
3) Total number of unduplicated individuals by age; and,
4) Total number of unduplicated individuals by county of residence.
B. The total number of certifications, as well as, the total number of certifications
grouped by:
1) Type of certification (each certification can only meet the requirements of
one category listed below):
a) Short-term;
b) Extended short-term;
c) Long-term; or,
d) Extended long-term.
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2) Reason for the certification (each certification can meet the requirements
of multiple categories listed below):
a) Dangerous to self;
b) Dangerous to others; or,
c) Gravely disabled.
3) Outcome of the certification (each certification can only meet the
requirements of one category listed below):
A) Released without need for further mental health services;
B) Referred for further mental health care and treatment on a
voluntary basis; or,
c) Certification extended; or,
d) Certification transferred.
3. Voluntary Individuals
The facility is required to maintain a data set sufficient to report the following aggregate
numbers to the Department annually by July 1 for the most recent, complete calendar
year covering January 1 through December 31, the total number of unduplicated
individuals, as defined in Section 21.280.1, who accessed mental health treatment
voluntarily pursuant to 27-65-103, C.R.S., as well as:
A. Total number of unduplicated individuals by gender;
B. Total number of unduplicated individuals by race and ethnicity;
C. Total number of unduplicated individuals by age; and,
D. Total number of unduplicated individuals by county of residence.
4. Additional Reporting Requirements
The facility is required to maintain data sets sufficient to report the following aggregate
numbers to the Department annually by July 1 for the most recent, complete calendar
year covering January 1 through December 31.
a. I nvoluntary Medications
Total number of involuntary psychiatric medication procedures, including type of
order:
1) Emergency; or,
2) Court-ordered.
b. Involuntary Treatments
1) Total number of restraint and/or seclusion episodes.
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2) Total number by type of restraint.
3) Length of seclusion and/or restraint episode per individual.
c. Total number of electroconvulsive therapy procedures.
d. Imposition of Legal Disability or Deprivation of a Right
Total Number of court orders for:
1) Imposition of Legal Disability; and,
2) Deprivation of a Right.
D. Pursuant to § 27-65-121, C.R.S., and HIPAA, as defined in Section 21.100, the facility must
maintain confidentiality over the data sets. The reports generated from these data sets are also
confidential; but the Department may release aggregated information contained in the reports so
long as the total number of individuals in any aggregate data group (including county or facility
name) is greater than thirty (30). If the total number in such a data group is less than or equal to
thirty (30), the Department may release this information by redacting such number.
21.280.24 Staff Training Requirements [Eff. 11/1/13]
In addition to Section 21.160, facilities designated under these rules shall develop a training curriculum
and schedule in order to meet the following requirements. Facilities may choose to use a certification of
competency in lieu of training, and shall develop appropriate policies, procedures and testing to assure
competency.
A. Al l staff participating in the provision of the care and treatment for individuals with mental health
disorders shall receive annual training or annual facility certification of competency on the
provisions of these rules and the requirements of Section 27-65-101, et seq., C.R.S.
B. All staff who administer involuntary medications shall receive annual training or annual facility
certification of competency on Section 21.280 of these rules and the legal rationale underlying
involuntary medication of individuals.
C. All direct care staff shall receive annual training or annual facility certification of competency in
the recognition and response to common side effects of psychiatric medications. These staff shall
be trained to respond to emergency drug reactions in accordance with the facility's policies.
D. All staff who administer restraint/seclusion techniques shall receive annual facility training or
annual certification of competency on lower level behavioral interventions and Section 21.280.4 of
these rules.
E. All staff involved in the administration of the treatment program shall receive annual training or
annual facility certification of competency on alternative or representative medical decision
making, including, but not limited to advance directives, medical durable powers of attorney, and
proxy decision making, and guardianships.
F. S pecific staff of placement facilities, as determined by the designated facility, shall receive annual
facility training or annual certification of competency on the provisions of these rules and the
requirements of Section 27-65-101, et seq., C.R.S.
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21.280.25 Placement Facilities [Eff. 5/1/16]
A. Facilities designated for seventy-two (72) hour evaluation and treatment, short-term, and long-
term treatment may provide mental health services directly or through the use of placement
facility contract. Whenever a placement facility is used there must be a written agreement with the
designated facility. In either case, the designated facility is responsible for assuring an
appropriate treatment setting for each individual and services provided in accordance with these
rules. Whenever a placement facility is used, the designated facility shall be responsible for the
care provided by the placement facility.
B. All agreements between designated facilities and placement facilities and all supplemental
agreements and amendments shall be submitted in writing to the Department no later than ten
(10) business days after the effective date of the agreement or amendment.
C. Only the following Colorado licensed facilities are eligible to be a placement facility:
1. Nursing homes;
2. Residential Child Care Facilities providing mental health services;
3. Non-psychiatric hospitals providing in-patient medical services.
4. Alternative Care Facilities.
D. Emergency departments are not eligible to be, nor are considered placement facilities.
E. Whenever a designated facility uses a placement facility, the agreement shall include:
1. An a nnual training plan for placement facility staff that provides at a minimum training
regarding mental health disorders, these rules, Title 27, Article 65, C.R.S., and
appropriate, safe behavioral interventions. The implementation of the training plan shall
be monitored by the designated facility;
2. A requirement that supervision of direct care staff be provided by professional persons
licensed in Colorado to practice medicine or a certified Colorado psychologist employed
by or under contract with the designated facility, or designated professional person
licensed in Colorado to practice medicine or a certified Colorado psychologist employed
by the placement facility to be responsible for direct care supervision provided that the
placement facility and the designated facility are operated by the same corporate entity;
3. A requirement that assures the necessary availability and supervision of placement
facility staff in order to carry out the contract; and,
4. A requirement that the placement facility adheres to these rules through the placement
facility agreement.
F. Placement facilities agreements shall be executed and signed bi-annually when the designated
facility submits its application for designation.
G. A placement facility can be used by a designated facility, at its discretion under the provisions of
these regulations, in order to provide care to any individual undergoing mental health evaluation
or treatment. Designated facilities shall not place individuals in a placement facility unless all of
the applicable provisions of these rules are met and placement in such facility is appropriate to
the clinical needs of the individual. When a placement facility is required, the least restrictive
facility possible and available must be used, consistent with the clinical needs of the individual.
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H. A placement facility shall not provide services beyond the scope of its license.
21.280.26 Individual Rights of Persons Receiving Evaluation Care or Treatment Pursuant to
Title 27, Article 65, C.R.S. [Eff. 11/1/13]
A. Individuals shall be informed they have the same rights as any individual, except as limited by
law. Among these are the rights to:
1. Receive services in the least restrictive setting, subject to available funding.
2. Have an individualized service plan and the right to participate in the development and
subsequent changes.
3. Review the clinical record, as allowed by law.
4. Designate a representative(s) verbally or in writing, to represent the individual’s interests
in matters related to grievances.
5. Have access to a representative within the designated facility who provides assistance to
file a grievance.
6. Be informed by the designated facility that there will be no retaliation against an individual
for exercising his or her rights.
B. Facilities shall post individual rights in prominent places frequented by individuals receiving
services.
C. For Individuals receiving treatment in facilities designated pursuant to Title 27, Article 65, C.R.S.:
1. The facility shall furnish all individuals receiving evaluation, care or treatment under any
provisions of Title 27, Article 65, C.R.S., with a written copy of the rights listed under
Subsection 21.280.26, C, 2 (translated into a language that the individual understands)
upon admission. If the individual is not able to read the rights, the individual shall be read
the rights in a language that s/he understands. These rules shall be interpreted by the
Department in accordance with a standard of reasonableness.
2. T he facility shall post the following list of rights (in appropriate languages) in prominent
places frequented by individuals and their families receiving services:
a. To receive and send sealed correspondence. No incoming or outgoing
correspondence shall be opened, delayed, held or censored by the personnel of
the facility;
b. To have access to letter writing materials, including postage, and to have staff
members of the facility assist him/her if unable to write, prepare and mail
correspondence;
c. To have reasonable and frequent access to a telephone, both to make and
receive calls in privacy;
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d. To have frequent and convenient opportunities to meet with visitors. The facility
may not deny visits by the individual’s attorney, religious representative or
physician at any reasonable time. The facility will provide privacy to maintain
confidentiality of communication between an individual and spouse or significant
other, family member(s), staff member(s), attorney, physician, certified public
accountant and religious representative, except that if disclosure is required by
law, then such privacy may be terminated;
e. To wear his or her own clothing, keep and use his/her own individual
possessions within reason and keep and be allowed to spend a reasonable sum
of his/her own money;
f. To refuse to take psychiatric medications, unless the individual is an imminent
danger to self or others or the court has ordered administration of such
medications;
g. To not be fingerprinted unless required by law;
h. To refuse to be photographed except for facility identification and the
administrative purposes of the facility. Photographs and/or video recordings shall
be confidential and shall not be released by the facility except pursuant to court
order. No other non-medical photographs and/or video recordings shall be taken
or used without appropriate consent or authorization (Section 27-65-117(4),
C.R.S.).
i. F or individuals who are under certification for care and treatment, to receive
twenty-four (24) hour notice before being transferred to another designated or
placement facility unless an emergency exists, and the right to have the
transferring facility notify someone chosen by the individual about the transfer;
j. To confidentiality of treatment records except as required by law;
k. To accept treatment voluntarily, unless reasonable grounds exist to believe the
individual will not remain in treatment on this basis;
l. To receive medical and psychiatric care and treatment in the least restrictive
treatment setting possible, suited to meet the individual's needs and subject to
available resources;
m. To request to see his/her clinical record, to see the records at reasonable times,
and if denied access, to be given the reason upon which the request was denied
and have documentation of such placed in the individual record;
n. To retain and consult with an attorney at any reasonable time; and,
o. Every individual who is eighteen (18) years of age or older shall be given the
opportunity to exercise his/her right to vote in primary and general elections. The
staff of the designated or placement facility shall assist each individual in
obtaining voter registration forms and applications for absentee or mail ballots,
and in complying with any other prerequisite for voting.
D. W ith every mental health hold (M-1) and petition to court for involuntary treatment resulting in a
change of legal status, the facility shall advise an individual of his or her rights set forth in this
Section 21.280.26, and there shall be evidence of such advisement in the individual’s clinical
record.
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E. Individual Rights Restrictions in Facilities Designated Pursuant to 27-65
1. As set forth in Section 27-65-117,C.R.S., an individual's statutory rights, Section
21.280.26, C, 2, a-e may be limited or denied for good cause by the Colorado licensed
physician or psychologist who is providing treatment, as follows:
a. Except as otherwise provided in Section 21.280.26, E, 2, each denial of an
individual's right shall be made on a case by case basis and the reason for
denying the right shall be documented in the individual record and shall be made
available, upon request, to the individual or his/her attorney.
b. Except as otherwise provided in Section 21.280.26, E, 2, restrictions on rights in
Section 21.280.26, C, 2, a-e, shall be evaluated for therapeutic necessity on an
ongoing basis and the rationale for continuing the restriction shall be documented
at least every seven (7) calendar days.
2. Secure Treatment Facilities
A Colorado licensed physician or psychologist treating persons in a secure treatment
facility may limit or deny rights for good cause based upon the safety and security needs
of the staff and other individuals in the facility. Safety and security policies applicable to
the unit shall be incorporated into the individual’s service plan. The following procedures
shall be adhered to:
a. T he Department shall approve of safety and security policies for each facility unit
that places any limit on the rights set forth in Section 21.280.26 as well as the
policy and criteria for placement of an individual committed under Title 27, Article
65, C.R.S., in secure treatment facilities.
b. The safety and security policies for each facility unit shall be posted in the unit.
The secure facility staff shall provide a copy of the unit policy upon an individual’s
request.
c. Any good cause restriction of rights based upon the safety and security policy of
the facility unit shall be noted in the individual’s record. The order for restriction
shall be signed by the Colorado licensed physician or psychologist providing care
and treatment, and shall be reviewed at least every thirty (30) days.
d. No safety or security policy may limit an individual's ability to send or receive
sealed correspondence. However, to prevent the introduction of contraband into
the secure treatment facility, the policy may provide that the individual open the
correspondence in the presence of unit staff.
e. No safety or security policy may limit an individual’s right to see his or her
attorney, clergy, or physician at reasonable times. However, the safety and
security policy may provide that advance notice be given to the secure treatment
facility for such visits so that the secure facility can adequately staff for the
private visit, and take any measures necessary to ensure the safety of the visit.
f. F or the purposes of this rule, placement of individuals in secure treatment
facilities on units that are locked at night:
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1) Individuals transferred to a secure treatment facility from the Department
of Corrections, who are serving a sentence in the Department of
Corrections, may be placed on units in which the bedroom doors are
locked during sleeping hours.
2) All other individuals who are newly admitted to a secure treatment facility
may be placed on units in which the bedroom doors are locked during
sleeping hours, for a time period not to exceed sixty (60) calendar days.
After sixty (60) calendar days, these individuals will not be placed on a
unit with locked doors during sleeping hours unless an individualized
assessment is made and the treatment team determines that the
individual is imminently dangerous to him/herself or to others.
3) Sleeping hours shall begin no earlier than 9:00 p.m., end no later than
8:00 a.m., and shall not exceed 8-1/2 hours.
4) Individuals shall be provided an effective means of calling for assistance
when in a locked room during sleeping hours. The secure treatment
facility shall provide staff to promptly assist an individual with his or her
individual needs including, but not limited to, staff assigned to a day hall
where staff will be able to hear and respond to individuals who knock on
their room doors. An intercom call system may also be used. Staff shall
monitor each individual’s well-being through visual observation checks
every fifteen (15) minutes.
F. As s et forth in Sections 27-65-104 and 27-65-127, C.R.S., an individual's rights may be limited or
denied under court order by an imposition of legal disability or deprivation of a right.
G. Information pertaining to the denial of any right shall be made available, upon request, to the
individual or his/her attorney.
21.280.3 MEDICAL AND MEDICATION TREATMENT PROVISIONS
21.280.31 Medical/Dental Care [Eff. 11/1/13]
A. Seventy-Two (72) Hour Treatment and Evaluation Facilities
The facility shall ensure the availability of emergency medical care to meet the individual needs of
each individual. The facility shall have and adhere to a written plan for providing emergency
medical care to include at least:
1. A qualified licensed independent practitioner responsible for the completion of physical
examinations within twenty-four (24) hours of admission.
2. The availability of a physician or access to an emergency medical facility on a twenty-four
(24) hour, seven (7) days a week basis.
3. Emergency medical treatment, when indicated, shall be accessed immediately (within
one hour) upon determination that an emergency exists.
4. Whenever indicated, an individual shall be referred to an appropriate specialist for either
further assessment or treatment. The facility shall be responsible for securing an
appropriate assessment to determine the need for further specialty consultation. This
information shall be contained in the clinical record.
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B. Short-Term and Long-Term Treatment Facilities
The facility shall ensure the availability of medical care and emergency dental care to meet the
individual needs of each individual. The facility shall have and adhere to a written plan for
providing medical and emergency dental care to include at least:
1. A qualified licensed independent practitioner responsible for the completion of physical
examinations within twenty-four (24) hours of admission. Subsequent physical
examinations shall be completed annually. This information shall be included in the
clinical record.
2. The availability of a qualified licensed independent practitioner or emergency medical
facility on a twenty-four (24) hour, seven (7) days a week basis.
3. Emergency medical treatment, when indicated, shall be accessed immediately (within
one hour) upon determination that an emergency exists.
4. Whenever indicated, an individual shall be referred to an appropriate specialist for either
further assessment or treatment. The facility shall be responsible for securing an
appropriate assessment to determine the need for further specialty consultation. This
information shall be contained in the clinical record.
5. Ongoing appraisals of the general health of each individual, including need for
immunizations in accordance with applicable state and federal law and need for
corrective and assistive devices such as glasses, hearing aids, prostheses, dentures,
walkers, etc. This information shall be contained in the clinical record.
C. T he obligation to ensure the availability of emergency medical services shall not be construed as
the obligation to pay for such services; however, the facility shall secure these services
regardless of source of payment.
21.280.32 Psychiatric Medications [Eff. 11/1/13]
A. In all instances where prescription psychiatric medications are to be ordered as a part of a mental
health treatment program, the following information shall be provided to the individual and legal
guardian(s). For children under the age of fifteen (15), the following information shall be provided
to the child's parent(s) or legal guardian(s). When an individual has designated another to act
concerning medication issues pursuant to a medical durable power of attorney, advanced
directive, or proxy, the information shall be provided to that individual also.
1. The name(s) of the medication being prescribed.
2. The usual uses of the medication(s).
3. The reasons for ordering the medication(s) for this individual.
4. A description of the benefits expected.
5. The common side effects and common discomforts, if any.
6. The major risks, if any.
7. The probable consequences of not taking the medication(s).
8. Any significant harmful drug or alcohol interactions, or food interactions.
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9. Appropriate treatment alternatives, if any.
10. That s/he may withdraw agreement to take the medication at any time.
B. The facility shall have policies and procedures for documenting in the clinical record that the
required information was given to the individual, custodian, or guardian and consent obtained
before administration of medication(s).
C. The provider with prescriptive authority or his/her designee shall offer to answer inquiries
regarding the medication(s).
D. No individual shall be threatened with or subjected to adverse consequences by facility staff
solely because of a failure to accept psychiatric medication voluntarily.
E. If an individual has established an advance directive concerning psychiatric medication and the
advance directive is still in effect, the Colorado licensed physician or psychologist shall follow the
directive unless contraindicated in a psychiatric emergency.
F. Prescribing, Handling, Administration of Psychiatric Medication(s)
All psychiatric medication(s) shall be administered on the written order of a physician or other
professional authorized by statute to order such medications. Verbal medication orders may be
given according to facility policies.
1. The facility shall have written policies and procedures regarding Section A, above, and
the following:
a. Documentation of the administration of medication, medication variances/errors,
and adverse medication reactions related to medication administration;
b. N otification to a physician or other professional authorized by statute to order
such medications in case of medication errors and/or medication
reactions/events;
c. Discontinuance of medication;
d. Disposal of medications; and,
e. Acceptance of verbal, fax, or electronically transmitted medication orders.
2. The facility shall note in the individual clinical record all prescription medications
administered to the individual by the facility including:
a. The name and dosage of medication;
b. The reason for ordering the medication;
c. The time, date and dosage when medication(s) is administered;
d. The name and credentials of the individual who administered the medication;
e. The name of the prescribing professional authorized by statute to order such
medication; and,
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f. If the medication is administered as an emergency medication or a court-ordered
medication.
21.280.33 Involuntary Psychiatric Medications [Eff. 11/1/13]
These rules do not apply to refusal of non-psychiatric medications or medical emergencies. If an
individual refuses medications intended to treat general medical conditions and that refusal is likely to
cause or precipitates a medical emergency, those professionals who are authorized to order and
administer medications may take action in accordance with generally accepted medical practice in an
emergency situation.
21.280.34 Psychiatric Emergency Conditions [Eff. 11/1/13]
A. Individuals who are detained pursuant to Sections 27-65-105, 106, 107, 108 or 109, C.R.S., and
refuse psychiatric medication may be administered psychiatric medication(s) ordered up to
twenty-four (24) hours without consent under a psychiatric emergency condition.
B. An emergency condition exists if:
1. The individual is determined to be in imminent danger of harming herself/himself or
others, as evidenced by symptoms which have in the past reliably predicted imminent
dangerousness in that particular individual; or,
2. By a recent overt act, including, but not limited to, a credible threat of bodily harm, an
assault on another individual or self-destructive behavior.
C. A r easonable attempt to obtain voluntary acceptance of psychiatric medication shall be made
prior to the use of involuntary medication.
21.280.35 Continuation of a Psychiatric Emergency
A. If the psychiatric emergency has abated because of the effect of psychiatric medications and the
physician is of the opinion that psychiatric medication is necessary to keep the emergency in
abeyance beyond seventy-two (72) hours, then within that seventy-two (72) hours the following
steps shall be taken:
1. The facility shall send a written request for a court hearing for an order to administer the
medication involuntarily; and,
2. A documented concurring consultation with another physician shall be obtained. The
consultation shall include an examination of the individual and a review of the clinical
record including an assessment as to whether the psychiatric emergency condition
continues to exist.
3. If a concurring consultation is not obtained within seventy-two (72) hours, then
emergency psychiatric medication shall be discontinued until such concurring
consultation is obtained and documented, except in cases where life threatening
consequences could result from an abrupt medication discontinuation. Under these
circumstances, the individual shall be safely taken off the medication according to
standards of medical practice, with corresponding clinical documentation.
4. In no ca se shall an individual receive emergency psychiatric medication(s) involuntarily
for a period exceeding ten (10) days without an order from a court of competent
jurisdiction, including continuation orders from the court.
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5. The individual shall be notified of the right to contact his or her attorney and/or the court
of competent jurisdiction at the time the written request for court-ordered medication is
made. This notification shall be documented in the clinical record. If an individual chooses
to exercise this right, the designated facility shall aid the individual if necessary, in
accomplishing the foregoing.
B. The specific facts outlining behaviors supporting the finding of the emergency condition shall be
detailed in the clinical record. Every twenty-four (24) hours thereafter until such time a final court
order is issued, the emergency is resolved, or the individual accepts psychiatric medications
voluntarily, the facility shall document the behaviors that substantiated the need to continue the
emergency medication, and the physician shall reorder the psychiatric medications.
C. During the course of emergency medication administration, the individual shall be offered the
medication on a voluntary basis each time the medication is given. If the individual voluntarily
consents to take the medication(s), and the attending physician determines that the individual will
likely continue to accept the medication on a voluntary basis and no longer requires involuntary
medications, this shall be documented in the record and the involuntary medication procedures
shall be terminated.
D. If the individual again refuses to voluntarily accept medication(s) and his or her clinical condition
returns to an emergency situation as defined in Section 21.280.34, the emergency psychiatric
medication procedures may be re-instituted.
21.280.36 Non-Emergency Involuntary Medications [Eff. 11/1/13]
A. In non-emergency situations in which an individual who is detained pursuant to Sections 27-65-
106, 107, 108, or 109, C.R.S., would benefit from the administration of a psychiatric medication,
but the individual does not consent, the facility shall petition the court to obtain permission to
administer such medication. The following conditions must be documented in the petition:
1. The individual is incompetent to effectively participate in the treatment decision;
2. Treatment by psychiatric medication is necessary to prevent a significant and likely long-
term deterioration in the individual's mental condition or to prevent the likelihood of the
individual causing serious harm to him/herself or others;
3. A less intrusive appropriate treatment alternative is not available; and,
4. The individual's need for treatment by psychiatric medication is sufficiently compelling to
override any bona fide and legitimate interest of the individual in refusing treatment.
B. The petition shall specify what class or name of psychiatric medication is being recommended as
potentially beneficial to the individual.
C. No ps ychiatric medications shall be administered without the individual's consent until a court
order is received authorizing involuntary use, except under emergency conditions under Section
21.280.34.
21.280.37 Involuntary Medication Data [Eff. 11/1/13]
If the facility uses a medication administration record or another mechanism which meets the criteria
listed in Section B, below, can correlate this information as required in Section C, below, and places the
information in the clinical record, that mechanism may be used in lieu of a separate log.
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A. The designated facility must maintain a log of all cases where involuntary medications were
administered.
B. The record shall contain, at a minimum, the following:
1. Individual's name and identifying number.
2. Specified use of involuntary medication.
3. Physician or other professional authorized by law ordering involuntary medication.
4. Date/time each involuntary medication was administered.
5. Date/time involuntary medication was discontinued.
6. Reason for discontinuation of involuntary medication(s).
C. The facility shall have the ability to determine, at a minimum, the aggregate number of individuals
receiving emergency and involuntary psychiatric medications during a specified period of time,
the start and stop dates for each individual's involuntary medication treatment, and shall
incorporate the use of this data into the quality improvement program.
21.280.4 SECLUSION, RESTRAINT, AND PHYSICAL MANAGEMENT FOR 27-65
DESIGNATED FACILITIES [Eff. 11/1/13]
The following rules covering seclusion and restraint apply to all areas of the designated facility including
emergency departments and to placement facilities. If a facility is authorized to use physical
management, restraint or seclusion at the facility, the facility shall use physical management, restraint or
seclusion only in accordance with the following rules unless the specific rules prohibit, limit or modify the
requirements placed upon the facility.
A. I ndividuals being detained under Sections 27-65-105 through 109, C.R.S., may be secluded or
restrained over their objection under the conditions in Section 21.280.4; otherwise, there must be
a signed informed consent for such an intervention as outlined in Section 21.280.5 of these rules.
B. These rules do not supersede any requirements under Section 26-20-101, et seq., C.R.S.
C. Staff shall ensure that no individual will harm or harass an individual who is secluded and/or
restrained.
D. These measures may only be used in accordance with a service plan developed in consultation
with and based on a written order by a Colorado licensed physician or psychologist. The service
plan, which shall document if less restrictive measures were unsuccessful, shall be evaluated by
a Colorado licensed physician or psychologist every twenty four (24) hours.
21.280.41 Definitions [Eff. 11/1/13]
“Mechanical Restraint” means a physical device used to involuntarily restrict the movement of an
individual or the movement or normal function of a portion of his or her body. Types of mechanical
restraints include, but are not limited to: restraint sheets, camisoles, belts attached to cuffs, leather
armlets, restraint chairs, and shackles.
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“Physical Management” means the physical action of placing one’s hands on an individual. Physical
management may be used to gain physical control in order to protect the person or others from harm after
all attempts to verbally direct or de-escalate the person have failed. Physical management may be utilized
when an emergency situation exists. The physical management continuum may include:
A. Utilizing transitional measures.
B. Placing one’s hands on a person to physically guide and/or physically control the person.
C. Use of an approved restraint method to control or contain the person.
D. Placing of a person into an approved prolonged restraint method.
E. Physical management may be used to move or escort a person into seclusion. Seclusion, in itself,
is not a form of physical management.
“Physical Restraint” means the use of bodily, physical force to involuntarily limit a person’s freedom of
movement, except that “physical restraint” does not include the holding of a child by one adult for the
purpose of calming or comforting the child.
“Seclusion” means the confinement of a person alone in a room from which egress is prevented.
Seclusion does not include the placement of persons, who are assigned to an intake unit in a secure
treatment facility, in locked rooms during sleeping hours pursuant to Section 21.280.26.E thru G.
21.280.42 U se of Seclusion [Eff. 11/1/13]
A. Seclusion may be used only for the purpose of preventing imminent injury to self or others, or to
eliminate prolonged and serious disruption of the treatment environment. Any time an individual is
placed alone in a room and not allowed to leave, it shall be construed as seclusion.
B. An unlocked designated facility may place an individual in seclusion to prevent an unauthorized
departure when such departure carries an imminent risk of dangerousness for the individual or for
others. Under those circumstances, the seclusion procedures in this section shall be followed.
C. Any decision to seclude shall be based on a current clinical assessment, and may also be based
on other reliable information including information that was used to support the decision to take
the individual into custody for treatment and evaluation. The fact that an individual is being
evaluated or treated under Sections 27-65-105 through 27-65-109, C.R.S., shall not be the sole
justification for the use of seclusion.
D. Seclusion shall be used only when other less restrictive methods have failed. Documentation of
less restrictive methods and the outcome shall be contained in the clinical record.
E. S eclusion rooms shall be lighted, clean, safe, and have a window for staff to observe.
F. Seclusion shall only be ordered by a Colorado licensed physician or psychologist.
G. Seclusion shall not be used for punishment, for the convenience of staff, or as a substitute for a
program of care and treatment.
21.280.43 Use of Restraint [Eff. 11/1/13]
Restraint may be used in emergency circumstances, wherein the individual presents a serious, probable
imminent threat of bodily harm and has the ability to affect such harm.
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A. The decision to restrain shall be based on a current clinical assessment, and may also be based
on other reliable information including information that was used to support the decision to take
the individual into custody for treatment and evaluation. The fact that an individual is being
evaluated or treated under Sections 27-65-105 through 27-65-109, C.R.S., shall not be the sole
justification for the use of restraint.
B. Mechanical restraints may be used only for the purpose of preventing such bodily movement that
is likely to result in imminent injury to self or others. Mechanical restraint shall not be used solely
to prevent unauthorized departure.
C. Restraint of a single limb is not permitted, unless court-ordered or approved by the
superintendent and the executive body of the secure treatment facility, utilizing the assessment
standards set forth in Section 26-20-101, et seq., C.R.S.; Section 21.280.43, A, of these rules;
and the secure treatment facility’s policies.
D. Restraint of an individual by a chemical spray is not permissible.
E. The type of restraint shall be appropriate to the type of behavior to be controlled, the physical
condition of the individual, the age of the individual and the type of effect restraint may have upon
the individual.
F. R estraint shall be applied only if alternative interventions have failed. Alternative interventions
shall be documented in the clinical record; however, alternative techniques are not required if the
alternatives would be ineffective or unsafe, when the individual is physically combative or actively
assaultive or self-destructive.
G. Justification for immediate use of restraint shall be documented in the clinical record.
H. Restraint shall only be ordered by a Colorado licensed physician or psychologist.
I. Restraint shall not be used for punishment, for the convenience of staff, or as a substitute for a
program of care and treatment.
J. Restraint does not include restraints used while the facility is engaged in transporting an
individual from one facility or location to another facility or location within a facility when it is within
the scope of that facility's powers and authority to effect such transportation pursuant to Section
26-20-101, et seq., C.R.S.
21.280.44 Explanation to Individual [Eff. 11/1/13]
In any situation, information shall be given to the individual, and guardian when applicable, as soon as
possible after s/he has been secluded or restrained. The individual shall be given a clear explanation of
the reasons for use of such intervention, the observation procedure, the desired effect, and the
circumstances under which the procedure will be terminated. The fact that this explanation has been
given to the individual shall be documented in the clinical record.
In an em ergency situation, information given to the individual pursuant to this rule regarding the desired
effect and the circumstances under which the procedure(s) will be terminated may not be as detailed as
in a non-emergency situation. However, as the individual's condition improves, staff shall promptly
supplement the information given and this shall be documented in the clinical record.
21.280.45 Continued Use of Seclusion and/or Restraint [Eff. 11/1/13]
A. Staff shall document efforts to assure that the use of seclusion/restraint shall be as brief as
possible.
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B. If the seclusion/restraint episode goes beyond one (1) hour, a Colorado licensed physician or
psychologist must provide an order. A verbal order, including telephone or other electronic orders,
may be used if followed by a written order by the Colorado licensed physician or psychologist.
C. Seclusion and/or restraint shall not be ordered on an “as needed” basis.
D. If the individual has not been examined by a Colorado licensed physician or psychologist within
the previous twenty-four (24) hours, seclusion and/or restraint continued in excess of four (4)
hours will require a face-to-face examination and a new written order by Colorado licensed
physician or psychologist. If there has been a documented examination by a Colorado licensed
physician or psychologist within the previous twenty-four (24) hours, seclusion/restraint continued
in excess of fourteen (14) hours will require a face-to-face examination and a new written order
by a Colorado licensed physician or psychologist prior to each succeeding twenty-four (24) hours
of seclusion/restraint to assure that the need for these interventions is still present. The reasons
for continuation shall be documented in the clinical record by the Colorado licensed physician or
psychologist.
E. An episode of seclusion/restraint is terminated when the individual has been out of
seclusion/restraint for a continuous period of two (2) hours.
F. C ontinued seclusion/restraint in excess of twenty-four (24) hours shall require an administrative
review by the medical/clinical director of the facility or his/her designee, other than the Colorado
licensed physician or psychologist in charge of treatment. The reviewer shall be an individual with
the authority and knowledge necessary to review clinical information and reach a determination
that the extension of a seclusion and/or restraint episode beyond twenty four (24) hours is
clinically necessary.
G. If the reviewer does not concur with the order for continuation of seclusion/restraint, the order
shall be discontinued and the professional person in charge of treatment shall be notified of such
discontinuation.
H. An administrative review shall be initiated at the conclusion of each twenty four (24) hour period
of continuous use of seclusion/restraint, and shall be completed prior to the expiration of each
twenty four (24) hour period.
21.280.46 Chart Documentation for the Use of Seclusion and/or Restraint [Eff. 11/1/13]
A. A staff member shall record each use of seclusion and/or restraint and the clinical justification for
the use in the individual's chart. The justification shall include:
1. The individual's specific behavior(s) and the nature of the danger;
2. D escribe attempts made to control the individual's behavior prior to using seclusion
and/or restraint;
3. Describe the circumstances under which seclusion/restraint will be terminated and
evidence that these criteria were given to the individual; and,
4. Notification to a Colorado licensed physician or psychologist within one (1) hour of the
seclusion/restraint intervention.
B. Administrative review shall document the clinical justification for the continued use of
seclusion/restraint in the individual's chart. The justification shall include:
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1. Documentation that the professional person ordering the continuous use of
seclusion/restraint in excess of twenty-four (24) hours has conducted a face-to-face
evaluation of the individual within the previous twenty-four (24) hours.
2. Documentation of the ongoing behaviors or findings that warrant the continued use of
seclusion/restraint and other assessment information as appropriate.
3. Documentation of a plan for ongoing efforts to actively address the behaviors that
resulted in the use of seclusion/restraint.
4. A determination of the clinical appropriateness of the continuation of seclusion/restraint.
5. A summary of the information considered by the reviewer and the result of the
administrative review with the date, time and signature of the individual completing the
review.
C. Information regarding use of seclusion/restraint shall be readily accessible to authorized
individuals for review. Facilities shall have the ability to gather data as follows:
1. Each seclusion/restraint episode including date and time the episode started and ended,
specific to each individual.
2. Aggregated data to include total number of individuals secluded/restrained and average
length of time of the episodes over the period of one year.
21.280.47 Observation and Care [Eff. 11/1/13]
A. An individual who is in seclusion/restraint shall be observed in person by staff at least every
fifteen (15) minutes, and such observation, along with the behavior of the individual, shall be
recorded each time. Unless contraindicated by the individual's condition, such observation shall
include efforts to interact personally with the individual.
B. O ngoing provisions shall be made for nursing care, hygiene, diet and motion of any restrained
limbs. For individuals in mechanical restraints, the facility shall provide relief periods, except when
the individual is sleeping, of at least ten (10) minutes as often as every two hours, so long as
relief from the mechanical restraint is determined to be safe. Staff shall note in the record relief
periods granted. The individual shall have access to food at least every four (4) hours and shall
have access to fluids and toileting upon request or during relief periods, but at least every two (2)
hours, unless sleeping.
C. Cameras and other electronic monitoring devices shall not replace the face-to-face observations.
D. An individual in physical restraint shall be released from such restraint within fifteen (15) minutes
after the initiation of physical restraint, except when precluded for safety reasons pursuant to
Section 26-20-101, et seq., C.R.S.
E. To the extent that the duties specified in Section 26-20-101, et seq., C.R.S. are more protective of
individual rights, the provisions 26-20-101, et seq., C.R.S. shall apply.
21.280.48 Facility Policies and Procedures for Seclusion/Restraint [Eff. 11/1/13]
The fa cility shall have and shall implement written policies and procedures that describe the situations in
which the use of seclusion and/or restraint are considered appropriate within each specific program and
the staff members who can order their use. The policies and procedures shall include the requirements in
Section 21.280.4 of these rules and Section 26-20-101, et seq., C.R.S.
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In the event a facility does not authorize the use of seclusion and/or restraint of any type, the policy
statement shall note the prohibition.
The policies and procedures shall include implementing administrative review including a process for
terminating the seclusion and/or restraint episode when the reviewer does not concur with the order for
continuation. If the reviewer is not a Colorado licensed physician or psychologist, then the order must be
discontinued by a Colorado licensed physician or psychologist.
21.280.5 THERAPY OR TREATMENT USING SPECIAL PROCEDURES
21.280.51 Informed Consent [Eff. 11/1/13]
Therapies using stimuli such as electroconvulsive therapy (ECT), and behavior modifications using
physically painful, aversive or noxious stimuli, require special procedures for consent and shall be
governed by this rule.
A. Prior to the administration of a therapy listed above, written informed consent shall be obtained
and documented in the clinical record reflecting agreement by both the individual being treated
and his/her legal guardian, if one has been appointed or alternative decision maker if one exists.
If the individual undergoing treatment using special procedures is a child age sixteen (16) to
eighteen (18), the clinical record shall reflect informed consent by both the child and his/her
guardian(s).
B. In th e case of electroconvulsive therapy, a consent form prescribed by the Department shall be
used and procedures set forth in Sections 13-20-401through 13-20-403, C.R.S., shall be
followed. An informed consent means:
1. It is freely and knowingly given and expressed in writing.
2. That the following has been explained to the individual:
a. The reason for such treatment information;
b. The nature of the procedures to be used in such treatment, including their
probable frequency and duration;
c. The probable degree and duration of improvement or remission expected with or
without such treatment;
d. The nature, degree, duration, and probability of the side effects and significant
risks of such treatment commonly known by the medical profession, the possible
degree and duration of memory loss, the possibility of permanent irrevocable
memory loss, and the remote possibility of death;
e. The reasonable alternative treatments, if any, and why the Colorado licensed
physician or psychologist is recommending the specific treatment;
f. That the individual has the right to refuse or accept the proposed treatment and
has the right to revoke his consent for any reason at any time, either orally or in
writing;
g. T hat there is a difference of opinion within the medical profession on the use of
some treatments;
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h. An offer to answer any inquiries concerning the recommended special
procedures; and,
i. The number of treatments expected over a specified period of time to achieve
maximum benefit.
3. The consent agreement entered into by the individual or other individual(s) shall not
include exculpatory language through which the individual or other individual(s) is made
to waive, or appear to waive, any of his/her legal rights, or to release the facility or any
other party from liability for negligence.
4. Informed consent for the special procedure shall be renewed each time the maximum
number of treatments is given or the specified amount of time has expired. No informed
consent for special procedures shall be valid for more than thirty (30) days.
5. No one under the age of sixteen (16) shall undergo electroconvulsive treatment.
6. Electroconvulsive treatment requires a concurring consultation by a licensed psychiatrist
prior to administration of the treatment. Such consultation shall be noted in the clinical
record.
7. All provisions of Sections 13-20-401 through 13-20-403, C.R.S., shall be followed.
21.280.52 Involuntary Treatment Using Special Procedures [Eff. 11/1/13]
In the event the individual or the legal guardian refuses to or cannot consent, treatments referenced in
Section 21.280.51 using special procedures shall be administered only under the following
circumstances:
A. W ith a prior court order for the treatments using special procedure; or,
B. In an emergency in which the life of the individual is in imminent danger because of the
individual's condition. In an emergency situation in which the individual is unable to grant
informed consent and sufficient time does not exist to petition the court for an order prior to the
administration of the specific therapy, the individual's physician, in consultation with the director of
the facility or his/her designee, may, after careful and informed deliberation and under procedures
adopted by the facility, order a special procedure without consent.
21.280.53 Documentation of Special Procedures [Eff. 11/1/13]
Along with the evidence of informed consent as delineated in this section, the reason for the use of any
special procedure shall be fully documented in the individual’s record. The administration and outcome of
such special procedure shall also be documented in the clinical record.
21.280.54 Procedures [Eff. 11/1/13]
Each designated facility shall adopt written procedures for administration of special procedures in
accordance with these rules and applicable statutes.
21.280.6 CONTINUITY OF CARE [Eff. 11/1/13]
Each facility shall adopt and implement a written policy for continuity of care. The policy shall include at a
minimum the following:
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A. Access to all necessary care and services within the facility, and coordination with any other
current mental health care providers or other systems of care or support as appropriate.
B. Coordination of care with the individual's previous mental health care providers or medical
providers as appropriate, including retrieval of psychiatric and medical records.
C. Coordination of the individual's care with family members, guardians and other interested parties
as appropriate and in a manner that reflects the individual's culture and ethnicity.
D. The facility is not responsible for providing non-psychiatric medical care under these rules, but
shall facilitate access to proper medical care and shall be responsible for coordinating mental
health treatment with medical treatment provided to the individual.
21.280.7 TRANSFER OF CARE AND TRANSPORTATION
21.280.71 Transfer of Care [Eff. 11/1/13]
A. The individual shall only be transferred to another designated or placement facility when
adequate arrangements for care by the receiving facility have been made and documented in the
clinical record. Transfer coordination shall include at least one discharge planning conference,
face-to-face or by telephone, with participants from both facilities and the individual and his/her
guardian, whenever possible.
B. At least twenty-four (24) hours advance notice of transfer shall be given to individuals under
certification, unless knowingly waived in writing by the individual and guardian as appropriate,
except in cases of a medical emergency. Notice of such transfer shall also be provided to the
court of competent jurisdiction and the individual's attorney.
C. T he transferring facility shall ask the individual to indicate two (2) individuals to whom notification
of transfer should be given and shall notify such individuals within twenty-four (24) hours of
notification to the individual. Such notification shall be made by the transferring facility with the
appropriate written authorization. Actions taken under this section shall be documented in the
clinical record.
21.280.72 Transportation [Eff. 11/1/13]
Whenever transportation of an individual is required, the treating staff of the facility shall assess the
individual for dangerousness to self or others and potential for escape. Whenever clinically and safely
appropriate, the individual may be transported by other means such as ambulance, care van, private
vehicle, and restraints shall not be used, unless authorized as necessary by the treating physician. If the
treating staff assesses the individual as dangerous to self or others or as an escape risk, the staff may
request transportation by the local Sheriff's Department.
A. A request for transportation from the Sheriff's Department shall be filed with the court of
appropriate jurisdiction and shall include:
1. Statements from the treating Colorado licensed physician or psychologist supporting the
need for transportation by the Sheriff's Department;
2. R ecommendations concerning the use of mechanical restraints and the impact that
handcuffs or shackles would have on the individual;
3. Recommendations for soft restraints, not handcuffs or shackles, if the findings of the
assessment support the use of mechanical restraint;
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4. Recommendations concerning the placement and management of the individual during
the time s/he will be absent from the designated facility due to court hearings;
5. Recommendations of considerations for management of the individual based on the
individual's age, physical abilities, culture, medical and psychiatric status and/or stability.
B. Notice of the request for transportation by the Sheriff's Department shall be given to the individual
and his/her attorney at least twenty-four (24) hours prior to the time it is filed with the court. This
notice shall not be required during the time a seventy-two hour hold is in effect or in an
emergency situation with an individual under certification or when the individual signs a waiver
which has been clearly explained.
C. Requesting transportation by the Sheriff's Department does not require a finding of
dangerousness to self or others or an escape risk if the Sheriff's Department is willing to transport
the individual without the use of mechanical restraints.
21.280.8 CERTIFICATION FOR TREATMENT ON AN OUTPATIENT BASIS [Eff. 11/1/13]
An individual who has been treated as an inpatient under a short-term or long-term certification for mental
health treatment at a designated facility may be treated on an outpatient basis if the following conditions
are met:
A. A C olorado licensed physician or psychologist who has evaluated the individual and who is on the
staff of the designated facility which has been treating the individual, determines that while the
individual continues to meet the requirements for certification, professional judgment is that with
appropriate treatment modalities in place the individual is unlikely to act dangerously in the
community.
B. Certification on an outpatient basis is the appropriate disposition suited to the individual's needs.
C. The designated facility that will hold the certification on an outpatient basis has documentation of
the results of a recent physical examination.
D. Arrangements have been made for the individual to have access to:
1. Case management;
2. Medication management;
3. Essential food, clothing, shelter; and,
4. Medical care and emergency dental care.
E. The service plan shall reflect the outpatient certification status, the arrangements under D, 1-4,
above, and meet the requirements in Sections 21.190.4 and 21.280.92 Service Planning.
F. Content of the individual’s outpatient record shall meet the requirements in Sections 21.190 and
21.280.9, Documentation in Individual Records.
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21.280.81 Enforcement of Certification [Eff. 11/1/13]
A. If the individual on outpatient certification substantially fails to comply with the requirements
specified in his/her service plan, the Colorado licensed physician or psychologist or staff of the
designated facility that holds the certification, shall make reasonable efforts, including outreach,
to obtain the individual's compliance with the plan. As part of these efforts, reasonable attempts
shall be made to advise the individual that s/he may be picked up and taken into custody for
appraisal of the individual's need for continued certification and ability to receive treatment on an
outpatient basis.
B. If the designated facility's medical director or the treating Colorado licensed physician or
psychologist reasonably believes that there is a significant risk of deterioration in the individual's
condition or that the individual may pose a risk of harm to self or the community, and reasonable
efforts to obtain the individual's compliance with the service plan have been unsuccessful, the
medical director or the treating professional person shall make arrangements to have the
individual transported to a designated facility or the emergency room of a hospital. The individual
shall be assessed for current clinical needs and modifications made in legal status or treatment
as necessary, including readmission to an inpatient facility.
C. T he individual shall not be physically forced to take prescribed psychiatric medication during this
appraisal process, unless an emergency situation exists or the individual is court-ordered to do so
as set forth in Section 21.280.33 through 21.280.36.
D. Following the assessment, if the individual is not detained, the facility holding the certification
shall arrange transportation for the individual to return to the individual's residence or other
reasonable location, if the individual so desires.
21.280.9 DOCUMENTATION IN INDIVIDUAL RECORDS
21.280.91 Assessment [Eff. 11/1/13]
Records shall include:
A. Assessment information in accordance with Section 21.190.3.
B. Evidence of ongoing assessment that at a minimum shall be included in the monthly service plan
review process.
C. Evidence of an assessment update for continued certification every six months for individuals
being treated under an outpatient certification or a long-term certification.
21.280.92 Service Planning Requirements [Eff. 11/1/13]
Service plans shall follow requirements in 21.190.4 (noting the exception in 21.280.92, G, below, of
monthly service plan reviews), and:
A. The service plan shall contain specific criteria required for discharge from treatment or to
progress to less restrictive treatment alternatives.
B. For individuals receiving care through outpatient certification, the plan shall assure the individual
has access to medical and emergency dental care, case management, medication management,
food, clothing, and shelter.
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C. If an individual is discharged during a seventy-two (72) hour hold without certification by the
facility, and a service plan has not been completed, then pertinent information shall be included in
the discharge summary.
D. The facility shall appoint a clinical staff person to be responsible for the formulation,
implementation, review, and revision of the service plan. The name of the responsible staff
person shall be specified in the plan and that individual shall sign the plan. The plan shall also be
signed by the treating Colorado licensed physician or psychologist, if he or she is not the
responsible staff person.
E. A physician or other professional person authorized by law to prescribe the medications shall be
responsible for the component of the plan requiring medication management services.
F. Service plans shall be readily identifiable and shall be maintained in a place readily accessible to
treatment staff.
G. The service plan shall be reviewed, and revised if necessary, at least monthly by the staff person
responsible for the plan, the treating Colorado licensed physician or psychologist, the individual
and the legal guardian. This review shall be documented in the record and include progress
toward meeting the criteria for termination of treatment and the need for continued involuntary
treatment if the individual is certified. If the monthly review is delayed, the reason for such delay
shall be noted in the record and the review shall be completed as promptly as possible.
21.280.93 T reatment Progress and Documentation Requirements [Eff. 11/1/13]
Records shall contain treatment progress notes per Section 21.190.5 and the following:
A. Documentation of all treatment procedures including, but not limited to: brief physical restraint,
seclusion, mechanical restraint, medications voluntary and involuntary, and other therapies or
interventions.
B. Information regarding the serious injury of or by the individual and the circumstances and
outcome.
C. Documentation of all transfers and reasons for transfer.
D. Legal status and all legal documents related to treatment under Section 27-65-101, et seq.,
C.R.S.
E. Consultations and/or case reviews.
F. Pertinent information from outside agencies or persons or from the individual.
G. Correspondence to and from relevant agencies and individuals.
H. Monthly documentation of the results of a Colorado licensed physician or psychologist’s review of
certification, effectiveness of mental health treatment, legal status of the individual and
considerations of less restrictive treatment alternatives.
I. Consent forms as appropriate for alternative treatments or voluntary treatment.
J. Use or non-use of advance directives.
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21.280.94 Discharge Planning Requirements [Eff. 11/1/13]
A. Records shall include documentation that written information has been given to the individual
upon discharge. This information shall include provision of Section 21.190.6, and:
1. If the individual is being transferred to another facility, information regarding that transfer
and the facility shall be included.
2. Information if the discharge is being made against the advice of the treating Colorado
licensed physician or psychologist.
B. Discharge Summary
Records shall contain a discharge summary to include the provisions of Section 21.190.62 and
the following information:
1. A summary of treatment received including: involuntary treatments, advance directives,
progress made, and case management activities.
2. For transfers between facilities, documentation of appropriate clinical information and
coordination of services between the two facilities, including mode of transportation.
21.281 INVOLUNTARY TRANSPORTATION FOR IMMEDIATE SCREENING
21.281.1 DEFINITIONS
“Facility” means any outpatient mental health facility or other clinically appropriate facility designated by
the office of behavioral health as a seventy-two (72) hour treatment and evaluation facility that has walk-in
capabilities and provides immediate screenings. If such a facility is not available, an emergency medical
services facility, as defined in Section 27-65-102(5.5), C.R.S., may be used.
“I mmediate screening” means the determination if an individual meets criteria for seventy-two (72) hour
treatment and evaluation.
“Intervening professional” as defined in section 27-65-105(1)(a)(II), C.R.S., means a certified peace
officer; a professional person; a registered professional nurse as defined in section 12-38-103(11), C.R.S.
who by reason of postgraduate education and additional nursing preparation has gained knowledge,
judgment, and skill in psychiatric or mental health nursing; a licensed marriage and family therapist,
licensed professional counselor, or addiction counselor licensed under Part 5, 6, or 8 of Article 43 of Title
12, C.R.S., who by reason of postgraduate education and additional preparation has gained knowledge,
judgment, and skill in psychiatric or clinical mental health therapy, forensic psychotherapy, or the
evaluation of mental health disorders; or a licensed clinical social worker licensed under the provisions of
Part 4 of Article 43 of Title 12, C.R.S.
“Involuntary transportation form” means the report and application allowing for immediate transport of an
individual, in need of an immediate screening for treatment, to a clinically appropriate facility.
“Involuntary transportation hold” means the ability to transport an individual in need of an immediate
screening to determine if the individual meets criteria for seventy-two (72) hour treatment and evaluation.
Pursuant to Section 27-65-105(1)(a)(I.5), C.R.S., an intervening professional may involuntary transport an
individual in need of an immediate screening from the community to an outpatient mental health facility or
other clinically appropriate facility. The involuntary transportation hold does not extend or replace the
timing or procedures related to a seventy-two (72) hour treatment and evaluation hold or an individual’s
ability to voluntarily apply for mental health services.
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21.281.2 PROCEDURE
A. An individual may be placed on an involuntary transportation hold pursuant to section 27-65-
105(1)(a)(I.5), C.R.S.
1. The involuntary transportation form shall be completed by an intervening professional
and contain:
a. The circumstances under which the individual’s condition was called to the
intervening professional’s attention;
b. The date and time the individual was placed on the involuntary transportation
hold;
c. The name of the facility to which the individual will be transported; and,
d. The signature of the intervening professional placing the involuntary
transportation hold.
2. A copy of the involuntary transportation form must be given to the facility and made part
of the individual’s medical record.
3. A copy of the involuntary transportation form must be given to the individual who was
placed on the involuntary transportation hold.
B. The involuntary transportation hold expires:
1. Six (6) hours after it was placed; or,
2. Upon the facility receiving the individual for screening; thereby resolving the involuntary
transportation hold.
C. The facility shall ensure that the immediate screening is completed to determine if the individual
meets criteria for seventy-two (72) hour treatment and evaluation and follow standard procedures
pursuant to section 27-65-105(1)(A)(I), C.R.S.
21.282 EM ERGENCY MEDICAL SERVICES FACILITY DATA REPORTING REQUIREMENTS
A. An emergency medical services facility, as defined in 27-65-102(5.5), C.R.S., providing care to an
individual pursuant to Title 27, Article 65, C.R.S. is required to maintain a data set sufficient to
report the following aggregate numbers to the Department annually pursuant to 27-65-105(7),
C.R.S., in the format and timeframe required by the Department.
B. For each facility, the annual report shall include:
1. The name, county, and address of each facility site where the service was provided.
2. The total number of unduplicated individuals, as defined in Section 21.280.1, who had a
seventy-two hour hold resolved (this includes release without need for further mental
health services, or referral for voluntary treatment) at the facility, as well as:
A. Total number of unduplicated individuals by gender;
B. Total number of unduplicated individuals by race and ethnicity;
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C. Total number of unduplicated individuals by age; and,
D. Total number of unduplicated individuals by county of residence.
3. The total number of seventy-two hour holds transferred to a designated facility for
continued involuntary services.
4. The total number of involuntary transportation holds, as defined in Section 21.281.1,
received by the facility, as well as total numbers by outcome of the required screening,
including at least:
A. Total number of involuntary transportation hold screenings resulting in the
placement of a seventy-two hour hold;
B. Total number of involuntary transportation hold screenings resulting in a referral
for further mental health care and treatment on a voluntary basis: and,
C. Total number of involuntary transportation hold screenings resulting in a release
without need for further mental health services.
5. The total number of seventy-two hour holds where the involuntary status was resolved at
the facility, as well as, the total number of seventy-two hour holds where the involuntary
status was resolved at the facility grouped by:
A. Who initiated the seventy-two hour hold (each hold can only meet the
requirements of one category listed below):
1) Certified peace officer;
2) C ourt; or,
3) Facility or community based personnel as defined in Section 21.280.1.
B. The reason for the seventy-two hour hold (each hold can meet the requirements
of multiple categories listed below):
1) Dangerous to self;
2) Dangerous to others; or,
3) Gravely disabled.
C. Disposition of the seventy-two hour hold (each hold can only meet the
requirements of one category listed below):
1) Released without need for further mental health services; or,
2) Referred for further mental health care and treatment on a voluntary
basis.
C. Process of data reporting
1. Facilities must submit their annual data report to the Department by July 1 of each year
covering the most recent, complete calendar year covering January 1 through December
31. The report must meet the requirements in section 24-1-136(9), C.R.S.
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2. The Department will annually request from the Department of Public Health and
Environment a list of licensed facilities that may provide emergency services pursuant to
Title 27, Article 65, C.R.S. the facility list shall include, but is not limited to: general
hospitals; hospital units; psychiatric hospitals; and, community clinics.
3. If a facility on the list provided by the Department of Public Health and Environment does
not report to the Department, the Department will contact the facility to confirm that the
facility did not provide involuntary care to an individual pursuant to Title 27, Article 65,
C.R.S. during the reporting cycle. If a facility is found to have provided involuntary care to
an individual pursuant to Title 27, Article 65, C.R.S. and did not submit an annual report,
an annual report will be requested. If a facility refuses to provide the statutorily required
report, the Department may submit a complaint to the Office of the Ombudsperson for
Behavioral Health Access to Care.
D. Pursuant to § 27-65-121, C.R.S. and HIPAA, as defined in Section 21.100, the facility must
maintain confidentiality over the data sets. The reports generated from these data sets are also
confidential; but the Department may release aggregated information contained in the reports so
long as the total number of individuals in any aggregate data group (including county or facility
name) is greater than thirty (30). If the total number in such a data group is less than or equal to
thirty (30), the Department may release this information by redacting such number.
21.290 ACUT E TREATMENT UNITS
21.290.1 DEFINITIONS [Eff. 11/1/13]
“Acute Treatment Unit” (ATU) means a facility or a distinct part of a facility for short-term psychiatric care,
which may include substance use disorder treatment. An ATU provides a twenty-four (24) hour,
therapeutically planned and professionally staffed environment for individuals who do not require inpatient
hospitalization but need more intense and individualized services, such as crisis management and
stabilization services, than are available on an outpatient basis. The average lengths of services are from
three (3) to seven (7) days.
“Auxiliary Aid” means any device used by individuals to overcome a physical disability and includes, but is
not limited to, a wheelchair, walker or orthopedic appliance.
“Bedridden” means an individual who is unable to ambulate or move about independently or with the
assistance of an auxiliary aid, who also requires assistance in turning and repositioning in bed.
“Director” means an individual who is responsible for the overall operation and daily administration,
management, and maintenance of the facility.
“Emergency Contact” means one of the individuals identified on the face sheet of the individual record to
be contacted in the case of an emergency.
“F acility ” means an acute treatment unit.
“Licensee” means the individual or entity to whom a license is issued by the Colorado Department of
Public Health and Environment pursuant to Section 25-1.5-103(1)(a), C.R.S., and certification as a 27-65
designated facility has been granted by the Department to operate a facility within the definition herein
provided.
“Medical or Nursing Care” means care provided under the direction of a physician and maintained by on-
site nursing personnel.
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“Owner” means the entity in whose name the license and designation is issued. The entity is responsible
for the financial and contractual obligations of the facility. “Entity” means any corporation, Limited Liability
Corporation, firm, partnership, or other legally formed body, however organized.
“Personal services” means those services that the director and employees of an acute treatment unit
provide for each individual including, but not limited to:
A. An environment that is sanitary and safe from physical harm;
B. Assistance with transportation whether by providing transportation or assisting in making
arrangements for the individual to obtain transportation; and,
C. Assistance with activities of daily living.
“Protective Oversight” means guidance as required by the needs of the individual or legal representative
or as reasonably requested by the individual including the following:
A. Being aware of an individual’s general whereabouts, although the individual may travel
independently in the facility; and,
B. Monitoring the activities of the individual on the premises to ensure the individual’s health, safety,
and well-being, including monitoring the individual’s needs and ensuring that s/he receives the
services and care necessary to protect health, safety, and well-being.
“S hort -Term Psychiatric Care” means services that average from three to seven (3-7) days provided to
individuals with mental health disorders in accordance with Title 27, Section 65, C.R.S.
21.290.2 DESIGNATION OF ACUTE TREATMENT UNITS [Eff. 11/1/13]
Facilities applying for designation as an acute treatment unit (ATU) must be in compliance with Section
21.280 and the requirements in the following Subsections 21.290.21 through 21.290.58.
21.290.21 Director Minimum Education, Training and Experience Requirements [Eff. 11/1/13]
Any individual serving as a director shall meet the minimum education, training, and experience
requirements in one of the following ways:
A. The director shall have received a Bachelor’s degree from an accredited college or university and
have three years of verified experience in the human services field, one of which was in a
supervisory or administrative position; or,
B. The director shall have received a Master’s degree from an accredited college or university and
have two years of verified experience in the human services field, one of which was in a
supervisory or administrative position.
C. Training in the following areas:
1. Individual rights;
2. Environment and fire safety, including emergency procedures and First Aid;
3. A ssessment skills;
4. Identifying and dealing with difficult situations and behavior management; and,
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5. Nutrition.
21.290.22 Director Responsibilities [Eff. 11/1/13]
The director shall be responsible for the following:
A. Overall direction and responsibility for the individuals, program, facility, and fiscal management;
B. Overall direction and responsibility for supervision of staff;
C. The selection and training of a capable staff member who can assume responsibility for
management of the facility in the director’s absence; and,
D. The establishment of relationships and maintaining contact with allied agencies, services, and
mental health resources within the community.
21.290.23 Assistant or Acting Director [Eff. 11/1/13]
A. In each facility, there shall be a specifically designated staff member, age twenty one (21) or over,
capable of acting as a substitute for the director during his/her absence. The duties and
responsibilities of the acting director shall be clearly defined in order to avoid confusion and
conflict among other staff and individuals.
B. If the director is regularly absent from the facility more than fifty percent (50%) of his/her working
hours, an assistant director shall be appointed who meets the same qualifications as the director
found at Sections 21.290.21.
21.290.24 Administrative Coverage [Eff. 11/1/13]
When there is a change in director, or when the director has left the facility permanently without a
replacement, the facility shall notify the Department in writing, within twenty four (24) hours. When a
possible change in director is anticipated, the facility shall notify the Department prior to the change.
Either th e director or assistant or acting director shall be available at all times.
21.290.25 Clinical Director [Eff. 11/1/13]
A. The clinical director is responsible for assuring that there is adequate training and supervision for
staff.
B. Qualifications of a Clinical Director
1. The clinical director shall possess a Master’s degree or Ph.D. in a mental health related
field or a Bachelor’s degree in a mental health related field and five (5) years of work
experience.
2. Additionally, the clinical director shall receive training on:
a. Individual rights;
b. Environment and fire safety, including emergency procedures and First Aid;
c. Assessment skills; and,
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d. Identifying and treating individuals who have received diagnoses from the most
current diagnostic and statistical manual of mental disorders and who display
behaviors that are common to people with severe and persistent mental health
disorders.
21.290.3 PERSONNEL
21.290.31 Physical or Mental Impairment [Eff. 11/1/13]
Any individual who is physically or mentally unable to adequately and safely perform duties that are
essential functions may not be assigned duties as a direct care staff member or volunteer at an ATU.
21.290.32 Alcohol or Substance Use [Eff. 11/1/13]
The facility shall not employ or allow any individual who is under the influence of a controlled substance,
as defined in Sections 18-18-203, 18-18-204, 18-18-205, 18-18-206, and 18-18-207, C.R.S., or who is
under the influence of alcohol in the workplace. This does not apply to employees using controlled
substances under the direction of a physician and in accordance with their health care provider’s
instructions, as long as it does not pose a safety risk to the employee, other employees, or individuals.
21.290.33 Access to Policies and Procedures [Eff. 11/1/13]
A. The facility shall have a written statement of personnel policies that include:
1. S alary range and provisions for increases;
2. Hours of work and holiday, vacation, sick and other applicable leave information;
3. Conditions of employment, tenure and promotion;
4. Employment benefits; including medical/dental/life insurance, workers compensation
insurance, retirement plan, and any other available benefits;
5. Employee performance evaluation procedures;
6. Grievance procedures that may be used by staff; and,
7. Discipline and/or termination procedures.
B. A copy of the personnel policy shall be given to each staff member at the time of his/her
employment.
21.290.34 Specialized Training Requirements for ATU [Eff. 11/1/13]
A. In addition to the personnel training standards in Sections 21.160 and 21.280.24 for designated
facilities, prior to providing direct care, the facility shall provide training on:
1. First Aid and injury response;
2. The care and services for the current individuals; and,
3. The recognition and response to common side effects of psychiatric medications, and
response to emergency drug reactions in accordance with facility policies.
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B. Within one month of the date of hire, the facility shall provide training for staff on each of the
following topics:
1. Assessment skills;
2. Infection control;
3. Behavior management and de-escalation techniques, to include incidents involving
suicide, assault, or elopement.
4. Health emergency response; and,
5. Behavioral/psychiatric emergency response training.
21.290.35 Staffing Requirements [Eff. 11/1/13]
A. The facility shall employ sufficient staff to ensure that the provision of services meets the needs of
individuals. The facility shall maintain at least a one to six (1:6) trained staff member(s) to
individual resident ratio at all times.
B. In determining the staffing levels, the facility shall give consideration to factors including, but not
limited to:
1. Services to meet the individuals’ needs; and,
2. Services to be provided under the individual service plan.
C. Each facility shall ensure that, at minimum, an individual qualified as described in Section
21.290.57 is available to administer medications at all times.
D. Residents of the facility may volunteer in performing housekeeping duties and other tasks suited
to the individual’s abilities; however, these persons who provide services for the facility on a
regular basis may not be included in the facility’s staffing plan in lieu of facility employees.
E. V olunteers may be utilized in the facility, but may not be included in the facility’s staffing plan in
lieu of facility employees.
21.290.4 POLICIES AND PROCEDURES FOR ATU
21.290.41 Emergency Plan and Fire Escape Procedures [Eff. 11/1/13]
A. Emergency plan: The emergency plan shall include planned responses to fire, gas explosion,
bomb threat, power outages, and tornado. Such plan shall include provisions for alternate
housing in the event evacuation is necessary.
B. Fire escape procedures: The fire escape procedures shall include a diagram developed with local
fire department officials which shall be posted in a conspicuous place.
C. Within three (3) days of admission, emergency procedures, including the plan and diagram of fire
exits, shall be explained to each individual.
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21.290.42 Serious Illness, Serious Injury, or Death [Eff. 11/1/13]
A. The policy shall describe the procedures to be followed by the facility in the event of serious
illness, serious injury, or death of persons receiving services, including incident reporting
requirements.
B. The policy shall include a requirement that the facility notify an emergency contact when the
individual’s injury or illness warrants medical treatment or face-to-face medical evaluation. In the
case of an emergency room visit or unscheduled hospitalization, a facility must notify an
emergency contact immediately.
21.290.43 Physical Health Assessment [Eff. 11/1/13]
The facility shall develop policies and procedures that identify when a physical health assessment by a
qualified licensed independent practitioner will be required, including the following indicators:
A. Within twenty-four (24) hours of admission;
B. A significant change in the individual’s condition;
C. Evidence of possible infection (open sores, etc.);
D. Injury or accident sustained by the individual that might cause a change in the individual’s
condition;
E. Known exposure of the individual to a communicable disease; or,
F. Development of any condition that would have initially precluded admission to the facility.
21.290.44 Smoking [Eff. 11/1/13]
A. F acilities’ policies for smoking shall address individuals, staff, volunteers and visitors, and shall
comply with applicable state laws and regulations.
B. Prior to admission or employment, individuals and staff shall be informed of any prohibitions.
21.290.45 Discharge [Eff. 11/1/13]
A. The facility's discharge policy shall include all of the following:
1. Circumstances and conditions under which the facility may require the individual to be
involuntarily transferred or discharged;
2. An explanation of the notice requirements;
3. A description of the relocation assistance offered by the facility; and,
4. The right to call advocates, such as the Governor’s protection and advocacy for
individuals with mental health disorders, the adult protection services of the appropriate
county department of social or human services, and/or the Colorado Department of
Human Services, Office of Behavioral Health.
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B. Disclosure to Individuals
Upon admission, the facility shall document that the individual or legal representative, as appropriate, has
read or had explained the discharge policy.
21.290.46 Management of Personal Funds and Personal Property [Eff. 11/1/13]
The facility shall develop written policies that include the procedures for managing individual funds or
property.
A. Upon admission, a written inventory of all personal belongings shall be conducted. This inventory
shall be signed and reviewed by facility staff and the individual, and shall be maintained in the
individual’s clinical record.
B. All inventoried items shall be stored in a secure location during the individual’s stay in the facility.
C. All inventoried property shall be returned to the individual upon discharge. The individual and
facility staff shall sign the inventory form indicating that all items were returned.
21.290.5 ADMINISTRATIVE FUNCTIONS
21.290.51 Admissions [Eff. 11/1/13]
A. The facility shall develop written admission criteria based on the facility’s ability to meet the
individual’s needs. Admission criteria shall be based upon a comprehensive pre-admission
assessment of the individual’s mental health, physical health, substance use, and capacity for
self- care. The assessment shall determine the level of intervention and supervision required,
including medication management, behavioral health services and stabilization prior to return to
the community.
B. Ac ute treatment units shall not admit individuals with a mental health disorder into a locked
setting unless there is no less restrictive alternative and unless they are otherwise in compliance
with the requirements of Title 27, Article 65, Colorado Revised Statutes.
C. Individuals may be admitted to a locked setting as a voluntary or involuntary individual. If
voluntary, the individual shall sign a form that documents the following information:
1. The individual is aware that the facility is locked.
2. The individual may exit the facility with staff assistance and/or permission.
3. The individual may leave the facility at any point in time, unless he/she presents as a
danger to self or others, or is gravely disabled as defined in Section 27-65-101, et seq.,
C.R.S.
D. An individual who is imminently suicidal or homicidal shall only be admitted to the locked facility,
upon completion of the facility’s assessment and the facility’s determination that the individual’s
safety and the safety of others can be maintained by the facility. If an individual is admitted and
facility staff determine that his/her behavior cannot be safely and successfully treated at the ATU,
then staff shall make arrangements to transfer the individual to the nearest hospital for further
assessment and disposition.
E. A fa cility shall not admit or keep any individual who meets the following exclusion criteria:
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1. Is consistently incontinent unless the individual or staff is capable of preventing such
incontinence from becoming a health hazard.
2. Is under the age of eighteen (18).
3. Is bedridden with limited potential for improvement.
4. Has a communicable disease or infection that is:
a. Reportable under the Department of Public Health and Environment's regulations
(6 CCR 1009-1 and 2); and,
b. Potentially transmittable in a facility, unless the individual is receiving medical or
drug treatment for the condition and the admission is approved by a physician.
5. Has acute withdrawal symptoms, is at risk of withdrawal symptoms, or is incapacitated
due to a substance use disorder.
F. Facilities shall not admit an individual diagnosed with a developmental disability unless he/she
has a mental health disorder and has been diagnosed using the most current diagnostic and
statistical manual of mental disorders, and whose behaviors can be managed and/or modified by
facility staff during the designated length of stay, and whose behaviors will not endanger the
safety of the individual, staff or other individuals.
G. The facility shall maintain a current list of individuals and their assigned room.
21.290.52 Acknowledgements and Disclosures [Eff. 11/1/13]
There s hall be written evidence of consent to treat as outlined in Section 21.170.4 and the following upon
admission to the individual or individual’s legal representative, as appropriate:
A. Acknowledgements shall specify the understanding between the parties regarding, at a minimum:
1. Charges;
2. Services included in the rates and charges;
3. Types of services provided by the facility, those services which are not provided, and
those which the facility will assist the individual in obtaining;
4. Transportation services;
5. Therapeutic diets;
6. A physically safe and sanitary environment;
7. Personal services;
8. Protective oversight;
9. Social and recreational activities; and,
10. A provision that the facility must give individuals thirty (30) calendar days’ notice of
closure.
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B. Disclosure to individuals shall include:
1. Management of personal funds and property;
2. Facility rules, established pursuant to Section 21.290.53;
3. Staffing levels based on individual needs;
4. Types of daily activities, including examples of such activities that will be provided.
21.290.53 Facility Rules [Eff. 11/1/13]
The facility shall establish written policies, which shall list all possible actions that may be taken by the
facility if any policy is knowingly violated by an individual. Facility policies may not violate or contravene
any rule herein, or in any way discourage or hinder an individual’s rights.
The facility shall prominently post its policies in writing, which shall be available at all times to individuals.
Such policies shall address at least the following:
A. Smoking;
B. Cooking;
C. Visitors;
D. Telephone usage including frequency and duration of calls;
E. Use of common areas, including the use of television, radio;
F. Consumption of alcohol and/or illicit drugs;
G. Dress;
H. Pets, which shall not be allowed in the facility; however, in no event shall such rules prohibit
service or guide animals.
21.290.54 Content of Record [Eff. 11/1/13]
Records s hall include Section 21.190.2, Content of Records, and the following:
A. Demographic and medical information;
B. A cover sheet to contain the following information:
1. Individual’s full name, including maiden name if applicable;
2. Individual’s sex, date of birth, marital status and social security number, where needed
for Medicaid or employment purposes;
3. Individual’s current address of residence;
4. Date of admission;
5. Name, address and telephone number of relatives or legal representative(s), or other
individual(s) to be notified in an emergency;
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6. Name, address and telephone number of individual’s primary physician, and case
manager if applicable, and an indication of religious preference, if any, for use in
emergency;
7. Individual’s diagnoses, at the time of admission;
8. Current record of the individual’s allergies;
C. Medication administration record;
D. Physician’s orders.
21.290.55 Service Planning [Eff. 11/1/13]
The facility shall develop and implement a written service plan in accordance with Section 21.190.4 and
include the following:
A. An initial written safety and stabilization plan for each individual detailing risk issues and the
stabilization process resulting in discharge shall be completed at the time of admission.
B. Within twenty four (24) hours of admission, an individualized service plan for each individual shall
be written and shall include, but not be limited to:
1. Special dietary instructions, if any;
2. Any physical or cognitive limitations; and,
3. A description of the services which the facility will provide to meet the needs identified in
the comprehensive assessment.
C. The individual may request a modification of the services identified in the service plan at any time.
D. The individual and his/her service plan shall be reassessed on an ongoing basis to address
significant changes in the individual’s physical, behavioral, cognitive and functional condition, and
identify the services that the facility shall provide to address the individual’s changing needs. The
service plan shall be updated to reflect the results of the reassessment.
21.290.56 D ischarge [Eff. 11/1/13]
A. An individual shall be discharged for one or more of the following reasons:
1. When the facility cannot protect the individual from harming him or herself or others;
2. When the facility is no longer able to meet the individual’s identified needs;
3. When the individual is no longer in need of this level of care; or,
4. Failure of the individual to comply with facility rules, which contain notice that discharge
may result from violation of same.
B. Notice of discharge shall be provided to the individual or individual’s legal representatives as
follows:
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1. At least twenty-four (24) hours in advance of discharge or transfer, in accordance with the
rules governing the care and treatment of persons with a mental health disorder in
Sections 21.280.7 and 21.280.8.
2. In cases of a medical or psychiatric emergency, the emergency contact shall be notified
as soon as possible.
C. Discharge shall be coordinated with the individual, and, with permission, the individual’s family,
legal representative, or appropriate agency.
21.290.57 Medication
21.290.571 Storage, Disposition, and Disposal [Eff. 11/1/13]
A. Storage and Disposition
1. All personal medication must be surrendered to the facility to be logged in and stored by
the facility. Individuals are not allowed to self-administer medication in the facility.
2. Personal medication shall be returned to the individual or individual’s legal
representative, upon discharge or death, except that return of medication to the individual
may be withheld if specified in the individual’s service if a physician or other authorized
medical practitioner has determined that the individual lacks the decisional capacity to
possess or administer such medication safely.
3. Medications shall be labeled with the individual’s full name, pursuant to Article 42.5 of
Title 12.
4. An y medication container that has a detached, excessively soiled or damaged label shall
be returned to the issuing pharmacy for re-labeling or disposed of appropriately.
5. All medication shall be stored in a manner that ensures the safety of all individuals.
6. Medication shall be stored in a central location, including refrigerators, and shall be kept
under lock and shall be stored in separate or compartmentalized packages, containers,
or shelves for each individual in order to prevent intermingling of medication.
7. Individuals shall not have access to medication that is kept in a central location.
8. Medications that require refrigeration shall be stored separately in locked containers in
the refrigerator. If medication is stored in a refrigerator dedicated to that purpose, and the
refrigerator is in a locked room, then the medications do not need to be stored in locked
containers.
9. Prescription and over the counter medication shall not be kept in stock or bulk quantities,
unless such medication is administered by a licensed medical practitioner.
B. Disposal
1. The return of medication shall be documented by the facility.
2. Medication that has a specific expiration date shall not be administered after that date
and shall be disposed of appropriately.
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21.290.572 Administration of Medication [Eff. 11/1/13]
Facilities shall follow psychiatric medication standards as outlined in Section 21.280.32 and the following:
A. To be qualified to administer medication, an individual shall be a licensed practical nurse,
registered nurse, physician, physician’s assistant, or pharmacist.
B. Only a licensed nurse may accept telephone orders for medication from a physician or other
authorized practitioner. All telephone orders shall be evidenced by a written and signed order and
documented in the individual’s record and the facility’s medication administration record.
C. These rules apply to medications and treatment which do not conflict with state law and
regulations pertaining to acute treatment units and which are within the scope of services
provided by the facility, as outlined in the individual agreement or the facility rules.
D. The facility shall be responsible for complying with physician orders associated with the
administration of medication or treatment. The facility shall implement a system that obtains
clarification from the physician, as necessary and documents that the physician:
1. Has been asked whether refusal of the medication or treatment should result in physician
notification.
2. Has been notified, where such notification is appropriate.
3. Has provided documentation of such notification shall be made in the individual’s clinical
record.
4. C oordinates with external providers or accepts responsibility to perform the care using
facility staff.
5. Trains staff regarding the parameters of the ordered care as appropriate.
6. Documents the delivery of the care, including refusal by the individual, of the medication
or treatment.
21.290.58 Administration of Oxygen [Eff. 11/1/13]
Individuals may administer oxygen, if the individual is able to manage the administration himself or herself
and staff shall assist with the administration as needed for safety, when prescribed by a physician and if
the facility follows appropriate safety requirements regarding oxygen herein.
A. Oxygen tanks shall be secured upright at all times to prevent falling over and secured in a
manner to prevent tanks from being dropped or from striking violently against each other.
B. Tank valves shall be closed except when in use.
C. Transferring oxygen from one container to another shall be conducted in a well-ventilated room
with the door shut. Transfer shall be conducted by a trained staff member or by the individual for
whom the oxygen is being transferred, if the individual is capable of performing this task safely.
When the transfer is being conducted, no individual, except for an individual conducting such
transfer, shall be present in the room.
D. T anks and other oxygen containers shall not be exposed to electrical sparks, cigarettes or open
flames.
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E. Tanks shall not be placed against electrical panels or live electrical cords where the cylinder can
become part of an electric circuit.
F. Tanks shall not be rolled on their side or dragged.
G. Smoking shall be prohibited in rooms where oxygen is used or stored. Rooms in which oxygen is
used shall be posted with a conspicuous “no smoking” sign.
H. Tanks shall not be stored near radiators or other heat sources. If stored outdoors, tanks shall be
protected from weather extremes and damp ground to prevent corrosion.
21.400 BEHAVIORAL HEALTH CRISIS RESPONSE SYSTEM
21.400.1 DEFINITIONS [Eff. 11/1/16]
“Assessment” means a formal and continuous process of collecting and evaluating information about an
individual for service planning, treatment and referral. Assessments establish justification for services.
“Chief complaint/presenting problem” means the reason/concern/motivation which prompts the client to
seek services or that which their referral source identifies as the issue which requires intervention, usually
in the person’s own words. Also includes, onset, duration, other symptoms noted, progression of the
problem, solutions attempted at alleviating the problem, how the person’s life has been impacted and how
the person views responsibility for the problem. This information can be from a referral source, family
member or other professional.
“C risis stabilization unit” or “CSU” means a facility, utilizing a restrictive egress alert device, which serves
individuals requiring 24-hour intensive behavioral health crisis intervention for up to five days and cannot
be accommodated in a less restrictive environment. Crisis stabilization units are licensed by the Colorado
department of public health and environment as an acute treatment unit, pursuant to 6 CCR 1011-1,
Chapter 6, or as a Community Clinic, pursuant to 6 CCR 1011-1, chapter 9.
“Integrated care model” means the systematic coordination of mental health, substance use, and primary
care services.
“Licensed mental health professional” means a psychologist licensed pursuant to Section 12-43-301, et
seq., C.R.S., a psychiatrist licensed pursuant to Section 12-36-101, et seq., C.R.S., a clinical social
worker licensed pursuant to Section 12-43-401, et seq., C.R.S., a marriage and family therapist licensed
pursuant to Section 12-43-501, a professional counselor licensed pursuant to Section 12-43-601, et seq.,
C.R.S., or an addiction counselor licensed pursuant to Section 12-43-801, et seq., C.R.S.
“Peer specialist,” or peer support specialist, recovery coach, peer and family recovery support specialist,
peer mentor, family advocate or family systems navigator, means an individual who uses his or her lived
experience of recovery from mental illness and/or addiction, plus skills learned in formal training, to
deliver services in behavioral health settings. A family advocate or family systems navigator uses his or
her lived experience of having a family member with a mental illness or substance use disorder and the
knowledge of the behavioral health care system gained through navigation and support of that family
member.
“P eer support” means recovery-oriented services provided by peer specialists that promote self-
management of psychiatric symptoms, relapse prevention, treatment choices, mutual support,
enrichment, and rights protection. Peer support also provides social supports and a lifeline for individuals
who have difficulties developing and maintaining relationships.
“Physician” is defined in Section 27-65-102(16), C.R.S.
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“Restrictive egress alert device” means a device used to prevent the elopement of a resident who is at
risk if he or she leaves the facility unsupervised. Egress alert devices are not considered restrictive when
used only to alert staff regarding the ingress and egress of residents, visitors, and others.
“Screening” means a brief process used to identify current behavioral health needs, including
assessment, referral, or immediate intervention services, and is typically documented through the use of
a standardized instrument.
“Skilled professional” means a person who has a minimum of a master’s degree in a behavioral health
field, has completed a pre-service training program specific to their modality of service and has clinical
crisis intervention experience.
“Supervision” means weekly clinical guidance from a licensed mental health professional.
“Triage” means a dynamic process of evaluating and prioritizing the urgency of crisis intervention needed
based on the nature and severity of the individuals’ presenting situation.
“Trauma informed” means being aware of and responsive to the presence of trauma and the potential
effects of past and current traumatic experiences in an individual’s life.
“Warm line/support line” means a telephonic service where individuals can “opt in” from the statewide
crisis line to receive individualized screening and resources by peer specialists.
21.400.2 G ENERAL PROVISIONS [Eff. 11/1/16]
A. The Behavioral Health Crisis Response System is based on the following principles, established
pursuant to Section 27-60-103(1)(a)(I) through (VII), C.R.S.:
1. Cultural competence;
2. Strong community relationships;
3. The use of peer supports;
4. The use of evidence based practices;
5. Building on existing foundations with an eye towards innovation;
6. Utilization of an integrated system of care; and,
7. Outreach to students through school-based clinics.
B. Each component within the behavioral health crisis response system must be capable of serving:
1. Children, adolescents, adults and older adults;
2. Individuals with co-occurring conditions; including:
a. Mental health conditions;
b. Substance use disorders;
c. Medical needs;
d. Intellectual/developmental disabilities;
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e. Physical disabilities;
f. Traumatic brain injuries; and/or,
g. Dementia.
3. Individuals demonstrating aggressive behavior;
4. Individuals who are uninsured or unable to pay for services; and,
5. Individuals who may lack Colorado residency or legal immigration status.
C. Each component within the Behavioral Health Crisis Response System must provide services in a
culturally competent manner.
D. Each modality of service within the Behavioral Health Crisis Response System must incorporate
peer support into the services they provide, when clinically appropriate.
21.400.3 TELEPHONE CRISIS SERVICES [Eff. 11/1/16]
The Department shall maintain a comprehensive telephonic system capable of assessing any individual
experiencing a self-defined crisis situation and making appropriate referrals. Telephone crisis services
must be accessible to all individuals throughout the state of Colorado 24 hours per day, 7 days per week,
and 365 days per year.
A. The telephone crisis service must provide:
1. Screening and triage;
2. Psycho-social support;
3. Connection to appropriate resources;
4. Follow-up capability to callers as clinically appropriate; and,
5. Access to a support line (also known as a warm line) provided by peer specialists. Peer
specialists must have the ability to seamlessly transfer individuals to the crisis line when
urgent clinical intervention is warranted.
B. T he telephone crisis service must be staffed by skilled professionals capable of assessing and
making culturally competent, appropriate referrals.
C. The telephone crisis service must use trauma-informed screenings and assessments and
incorporate this information into safety planning, referrals and follow-up interventions.
D. The telephone crisis service must initiate mobile crisis services when appropriate and be linked
with walk-in crisis service facilities.
21.400.4 WALK-IN CRISIS SERVICES [Eff. 11/1/16]
Walk-in crisis services facilities offer confidential, in-person support for anyone experiencing a self-
defined crisis. Every walk-in crisis services facility must have the ability to provide information and
referrals to anyone in need, including, if appropriate, access and clinically appropriate transportation to
crisis stabilization for up to five days in a crisis stabilization unit.
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A. Each walk-in crisis services facility, including crisis stabilization units, must be designated
pursuant to Title 27, Article 65, C.R.S., Care and Treatment of Persons with Mental Illness, and
be in compliance with Section 21.280.
B. Walk-in crisis services must employ an integrated care model based on evidence-based practices
that consider an individual’s physical and emotional health.
C. Walk-in crisis services must include screening, assessment, and referrals to appropriate
resources.
1. Screening.
a. Screening must collect at least the following information from an individual
seeking crisis services:
1) Identifying information;
2) Chief complaint/presenting problem;
3) Medical concerns/chronic health issues; and,
4) Current healthcare providers.
b. Screenings must be reviewed by a skilled professional who is licensed or
receiving supervision from a licensed mental health professional.
2. Assessment.
A full assessment must be administered in accordance with Section 21.190.3, if clinically
indicated by the initial screening in Section 21.340.4(C)(1).
3. Referrals.
The facility shall refer all individuals seeking crisis services to appropriate resources
based on the level of care indicated by the screening or assessment.
D. Crisis stabilization units
1. Services provided on a crisis stabilization unit must include:
a. Full psychiatric evaluation;
1) By a physician or other professional authorized by statute to order
medications; and,
2) Within 24 hours of admission.
b. Medical and medication treatment in accordance with Section 21.280.3;
c. Service planning in accordance with Section 21.190.4;
d. Peer support, when clinically appropriate;
e. Treatment, to include:
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1) Individual counseling; and/or,
2) Groups.
f. Coordination with medical services;
g. Case management;
h. Service coordination and referral; and,
i. Discharge planning.
2. Crisis stabilization unit staffing requirements
a. In addition to the walk-in crisis service staffing requirements listed in 21.400.41,
crisis stabilization units must have:
1) Access to a physician or other professional authorized by statute to order
medications upon admission; and,
2) At minimum, one on-site staff member qualified to administer
medications.
21.400.41 Walk-In Crisis Services Staffing Requirements [Eff. 11/1/16]
A. A walk-in crisis services facility must be staffed 24 hours per day, 7 days per week, and 365 days
per year.
B. A walk-in crisis services facility must employ sufficient staff to ensure that the provision of
services meets the needs of individuals. At minimum, a facility must have two staff on-site at all
times.
C. A walk-in crisis services facility must be staffed by skilled professionals who are licensed or
receiving supervision from a licensed mental health professional.
D. If a walk-in crisis services facility is staffed by unlicensed skilled professionals, a licensed mental
health professional must be on-call and able to respond to the facility within thirty (30) minutes.
E. A w alk-in crisis services facility must have the ability to provide peer support on-site when
clinically appropriate.
21.400.5 MOBILE CRISIS SERVICES AND UNITS [Eff. 11/1/16]
Mobile crisis services provide a timely in-person response to a behavioral health crisis in the community.
Mobile crisis services must collaborate with telephone crisis services, walk-in crisis services, and crisis
residential and in-home respite services.
A. A mobile crisis unit must have the capacity to:
1. Intervene wherever the crisis occurs;
2. Serve individuals unknown to the system;
3. Coordinate multiple simultaneous requests for services; and,
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4. Work closely with police, crisis hotlines, schools, and hospital emergency departments;
B. A mobile crisis unit must operate 24 hours per day, 7 days per week, and 365 days per year in
providing community-based crisis intervention, screening, assessment, and referrals to
appropriate resources.
1. In screening the individual in crisis, the mobile crisis unit must collect at least the
following information:
a. Identifying information;
b. Chief complaint/presenting problem;
c. Medical concerns/chronic health issues; and,
d. Current healthcare providers.
2. The mobile crisis unit must administer a full assessment in accordance with Section
21.190.3 if clinically indicated by the initial screening in Section 21.400.5(C)(1).
C. A mobile crisis unit must be staffed by skilled professionals who are licensed themselves or
receiving supervision from a licensed mental health professional.
D. If a mobile crisis staff member is an unlicensed skilled professional, he or she must have, at
minimum, immediate phone access to a licensed mental health professional.
E. A mobile crisis unit must utilize peer supports, in conjunction with a skilled professional, in a
mobile response when clinically appropriate.
21.400.6 RESIDENTIAL AND IN-HOME RESPITE CRISIS SERVICES [Eff. 11/1/16]
Residential an d in-home respite crisis services allow an individual experiencing a crisis to stabilize,
resolve problems, and link with resources for ongoing support in a safe environment.
A. Residential and in-home respite services include a range of short-term, not to exceed 14 calendar
days, services 24 hours per day, 7 days per week, and 365 days per year.
B. In order to be eligible for residential or in-home respite services, an individual experiencing a
behavioral health crisis must:
1. Be referred by a walk-in crisis services professional or a mobile crisis services
professional;
2. Agree to residential or in-home respite services;
3. Not meet emergency procedure criteria outlined in Section 27-65-105, C.R.S., Care and
Treatment for Persons with Mental Illness;
4. Present a minimal risk of significant withdrawal complications;
5. Cooperate with program guidelines; and,
6. Be able and willing to participate in forming a service plan.
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C. Residential and in-home respite providers will utilize peer specialists to provide support, when
appropriate.
21.410 COMMUNITY TRANSITION SPECIALIST PROGRAM
A. Pursuant to Title 27, Article 66.5, C.R.S. the Community Transition Specialist Program is a
statewide program that receives referrals from hospitals and withdrawal management facilities
and coordinates services for individuals prior to their release or discharge to the community.
B. The Office is responsible for the administration and oversight of the Community Transition
Specialist Program. Pursuant to § 27-66.5-103(5), C.R.S., the Office may contract with a vendor
to provide the referral and coordination services required for statewide implementation of the
Community Transition Specialist Program. The Office shall coordinate the vendor-provided
services with other relevant state supported programs and services.
C. The Community Transition Specialist Program will coordinate services for individuals meeting the
section 27-66.5-102(3), C.R.S. definition of a “high-risk individual”. “High-risk individual” means a
person who:
1. Is under:
A. An emergency procedure for a seventy-two-hour hold pursuant to section 27-65-
105, C.R.S.;
B. A certification for short-term treatment or extended short-term treatment pursuant
to section 27-65-107, C.R.S. or section 27-65-108, C.R.S.;
C. Long -term care and treatment pursuant to section 27-65-109, C.R.S.;
D. An emergency commitment pursuant to section 27-81-111, C.R.S. or section 27-
82-107, C.R.S.; or,
E. An involuntary commitment pursuant to section 27-81-112, C.R.S. or section 27-
82-108, C.R.S.;
2. Has a significant mental health or substance use disorder, which means:
A. The individual has had two (2) or more seventy-two hour holds or emergency
commitments in the previous twelve (12) months;
B. The individual has been certified for short-term treatment pursuant to section 27-
65-107, C.R.S., certified for extended short-term treatment pursuant to section
27-65-108, C.R.S. or, ordered for long-term care and treatment pursuant to
section 27-65-109, C.R.S. one (1) or more times in the previous twelve (12)
months; or,
C. The individual has been arrested or detained two (2) or more times related to an
alcohol or substance use disorder in the last twelve (12) months and does not
have a probation or parole officer; and,
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3. Is not currently engaged in consistent behavioral health treatment, which means the
individual has not received any local or available outpatient behavioral health treatment
services in the last forty-five (45) calendar days or has been terminated from outpatient
behavioral health services within the last forty-five (45) calendar days. Outpatient
behavioral health treatment services do not include crisis services, emergency care,
withdrawal management services, initial intake appointments, assessments, or inpatient
hospitalization.
21.500 RECOVERY RESIDENCE CERTIFICATION PROGRAM
21.500.1 STATUTORY AUTHORITY
The statutory authority to promulgate these rules is set forth in Sections 25-1.5-108.5(4), C.R.S. and 27-
80-122(4), C.R.S.
21.500.2 DEFINITIONS
“Recovery residence certifying body” means an entity that has been approved by the office of behavioral
health to certify recovery residences pursuant to 25-1.5-108.5, C.R.S.
“Recovery residence”, “sober living facility”, or “sober home” as defined in 25-1.5-108.5(1), C.R.S., means
any premises, place, facility, or building that provides housing accommodation for individuals with a
primary diagnosis of a substance use disorder that: is free from alcohol and nonprescribed or illicit drugs;
promotes independent living and life skill development; and provides structured activities and recovery
support services that are primarily intended to promote recovery from substance use disorders. A
“recovery residence” does not include: a private residence in which an individual related to the owner of
the residence by blood, adoption, or marriage is required to abstain from substance use or receive
behavioral health services for a substance use disorder as a condition of residing in the residence; the
supportive residential community for individuals who are homeless operated under Section 24-32-724,
C.R.S. at the Fort Lyon property for the purpose of providing substance abuse supportive services,
medical care, job training, and skill development for the residents; a facility approved for residential
treatment by the office of behavioral health in the department of human services; or permanent supportive
housing units incorporated into affordable housing developments.
“T he NARR Standard” means the National Standard for Recovery Residences Version 3.0 (2018)
established by the National Alliance of Recovery Residences, which is hereby incorporated by reference.
No later additions or amendments are incorporated. The National Standard for Recovery Residences
Version 3.0 (2018) is available at https://narronline.org and is also available for public inspection at the
Colorado Department of Human Services, Office of Behavioral Health, 3824 West Princeton Circle,
Denver, Colorado 80236, during regular business hours.
21.500.3 RECOVERY RESIDENCE CERTIFYING BODY APPROVAL PROGRAM
A. Recovery residence certifying body obligations prior to approval
1. A recovery residence certifying body applicant must submit an application to the office of
behavioral health for approval as a recovery residence certifying body. The application
must contain information on how the recovery residence certifying body applicant will
meet the standards established in Section 21.500.3(B).
B. Recovery residence certifying body obligations after approval
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1. A recovery residence certifying body must ensure that any premises, place, facility, or
building they certify meets minimum standards that provide safe and healthy housing
environments that support individuals in achieving and sustaining substance use disorder
recovery.
2. A recovery residence certifying body must ensure that each recovery residence that it
certifies in Colorado, complies with The NARR Standard as defined in 21.500.2 for
providing the appropriate level of support and housing accommodations for individuals
with a primary diagnosis of a substance use disorder.
3. A recovery residence certifying body must ensure recovery residences comply with the
standards established in 25-1.5-108.5, C.R.S.
4. A recovery residence certifying body must have written policies and procedures that must
be posted on the recovery residence certifying body’s website. At minimum, the written
policies and procedures must include:
a. The certification process;
b. Application submission requirements, including the cost for certification;
c. How certification fees relate to service delivery and how recovery residences are
informed about changes to certification fees;
d. The application review process;
e. The approval, revocation, denial, suspension, limitation, or modification process
for certification;
f. The right and process to appeal decisions made by the recovery residence
certifying body;
g. Re-a pplication timeframes; and,
h. How grievances will be managed.
5. A recovery residence certifying body must maintain a website that contains, at minimum:
a. Information on how a recovery residence can apply for certification, as outlined in
21.500.3(b)(3);
b. The standards a recovery residence must meet to obtain differing levels of
certification as defined by The NARR Standard as defined in 21.500.2, including
the cost of certification for each level.
c. Board information as outlined in 21.500.3(B)(5);
d. Contact information for how individuals can submit a grievance to the recovery
residence certifying body; and,
e. A list of certified recovery residences to ensure people throughout Colorado have
access to information and locations of certified recovery residences; and,
f. The written policies and procedures outlined in 21.500.3(B)(3).
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6. A recovery residence certifying body must have a board that has approval oversight of
the recovery residence certifying body’s practices, policies, and procedures. At minimum,
the recovery residence certifying body must ensure:
a. A representative from the office of behavioral health is on the board;
b. A minimum of twenty-five percent (25%) of board members must represent
recovery residences that are certified and do not otherwise have a conflict of
interest with the certifying body;
c. The board includes at least two board members that represent individuals in
recovery. The representatives for individuals in recovery must not own, volunteer
at, or be employed by the recovery residence certifying body or a certified
recovery residence;
d. That board members disclose any potential conflict of interest and have
standards for how a conflict of interest is acknowledged, determined, and
reconciled in regard to the execution of board duties;
e. That board meetings are open to the public, except as to the portion of the
meeting that information that is confidential pursuant to state or federal statute is
being discussed; and,
f. That board information is publicly posted on the recovery residence certifying
body’s website, including:
1) A l ist of board members, each board member’s representative role on
the board, and each board member’s term limit;
2) The board member application and selection process;
3) Board bylaws;
4) Board meeting dates, times, and locations posted at least one (1) week
prior to the board meeting; and,
5) Board agendas and minutes.
7. On or before February 1, of each year, a recovery residence certifying body must submit
an annual report to the Office of Behavioral Health that covers the previous calendar
year. At minimum, the annual report must include:
a. The total number of recovery residences certified in Colorado, as of the previous
January 1.
b. The percentage of certified recovery residences which are also members of the
approved recovery residence certifying body’s association;
c. The total number of recovery residences which applied for certification in the
previous calendar year;
d. The total number of recovery residences which applied for certification and were
granted certification;
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e. The total number of recovery residences which applied for certification and were
denied certification, including the reason(s) why each recovery residence was
denied;
f. The total number of recovery residences which certification was revoked, denied,
suspended, or modified, including the reason(s) for the certification change;
g. The total number of grievances received, including the topic and outcome of
each grievance;
h. Increases or decreases in certification fees, including justification for each fee
change; and,
i. Any changes to the makeup, structure, and/or duties of the certifying body’s
board.
C. An approval from the Office of Behavioral Health as a recovery residence certifying body is not
time limited, with the exception that at the Office of Behavioral Health’s discretion, an approval as
a recovery residence certifying body may be revoked, denied, suspended, or modified. Written
notification of the basis for action must be sent by certified mail to the last known address of the
recovery residence certifying body. If the affected recovery residence certifying body disagrees
with the decision, it has the right to appeal to the Colorado Department of Personnel and
Administration, Office of Administrative Courts in accordance with the regulations set forth at 2
CCR 502-1 § 21.105, except that the time for answering the notice of charges will be thirty (30)
days after the mailing of such notice. An affected recovery residence certifying body may
subsequently seek judicial review of the Office of Behavioral Health’s action in accordance with
Section 24-4-101, et seq., C.R.S.
21.500.4 R ECOVERY RESIDENCE CERTIFICATION GRANT PROGRAM
Subject to available appropriations as established in 27-80-122(3), C.R.S., a recovery residence may be
eligible for a grant from the Office of Behavioral Health to pay a portion of, or all, application for
certification and/or membership fees and/or dues required by a recovery residence certifying body.
21.500.41 RECOVERY RESIDENCE CERTIFICATION GRANT PROGRAM CRITERIA
A. A recovery residence seeking a recovery residence certification grant must complete, in its
entirety, the recovery residence certification grant application available on the Colorado
Department of Human Services website.
B. A recovery residence certification grant must only be used to pay fees related to gaining
certification and/or membership from a recovery residence certifying body, which may include the
payment of membership dues.
C. A recovery residence certification grant application must be submitted to the Office of Behavioral
Health by the last business day of each month.
D. Recovery residence certification grant applications received by the Office of Behavioral Health
within the time frame established in 21.500.41(C), must be reviewed by the Office of Behavioral
Health to determine approval or denial. Grants will be awarded in alignment with state fiscal rules
created pursuant to 24-30-202, C.R.S.
E. R ecovery residence certification grant applications that are not complete, contain inaccurate or
false information, or express intent to use the recovery residence certification grant money in a
manner that does not comply with state statutes or regulations, may be denied.
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F. A recovery residence which previously received a recovery residence certification grant must
submit a new application each time they are seeking another recovery residence certification
grant.
G. A recovery residence which applies for a recovery residence certification grant must provide the
office of behavioral health with documentation of the paid certification fees and/or membership
dues from the approved recovery residence certifying body. A recovery residence that does not
provide the required documentation may have their current or any subsequent recovery residence
certification grant applications denied.
H. The Office of Behavioral Health’s decision regarding the recovery residence certification grant
application is a final agency decision. If the affected recovery residence disagrees with the final
agency decision, it may seek judicial review of the Office of Behavioral Health’s action in
accordance with Section 24-4-101, et seq., C.R.S.
21.700 (NONE)
_________________________________________________________________________
Editor’s Notes
History
Rules SB&P, 19.500 eff. 11/01/2007.
Rules SB&P, 19.421.3 eff. 09/01/2013.
Entire rule eff. 11/01/2013.
Rules SB&P, 21.900-21.950 emer. rules eff. 11/06/2015.
Rules SB&P, 21.900-21.950 eff. 02/01/2016.
Rules SB&P, 21.000-21.120.35, 21.190-21.210.59, 21.230-21.280.25, 21.330-21.330.2 eff. 05/01/2016.
Rules SB&P, 21.120.3-21.120.31, 21.400 eff. 11/01/2016.
Rules 21. 240.1, 21.240.85 eff. 07/01/2017.
Rule 21.281 eff. 06/01/2018.
Rules 21.100, 21.120.36 eff. 08/01/2018.
Rules 21.160.2 A.3, 21.200.53 K.1 emer. rules eff. 08/03/2018.
Rules 21.160.2 A.3, 21.200.53 K.1 emer. rules eff. 11/02/2018.
Rules 21.100, 21.120.1 G, 21.120.24 A, 21.120.24 C-F, 21.120.42 A-G, 21.140 A.2, 21.170.1 A, 21.170.3
A, 21.200.53 K.6, 21.210.1 E.1.a, 21.210.2 A.1-2, 21.210.43 A, 21.210.51 D, 21.210.52 C,
21.210.53 C, 21.210.54 D, 21.210.55, 21.210.56 I, 21.210.57 G, 21.210.58 D, 21.210.59,
21.230.1 D, 21.240.5 F, 21.240.6 A, 21.240.82 B.5, 21.240.83 B, 21.280.1, 21.280.23, 21.282,
21.410 eff. 01/01/2019.
Rules 21.160.2 A.3, 21.200.53 K.1, 21.200.4 eff.02/01/2019.
Rules 21.160.1 A.4, 21.250.5 C, 21.260 B, 21.500 eff. 12/01/2019.
Rules 21.100, 21.120.1 D, 21.120.22 B, 21.120.23 C, 21.120.26 D, 21.120.4 D-E, 21.120.42 E, 21.170.4,
21.200.13 B, 21.200.4, 21.200.41, 21.240.1, 21.280.35 A.4, 21.300.22 C, 21.300.23 D, 21.200.5,
21.320.31 A.5 emer. rules eff. 04/03/2020.
Rules 21.100, 21.120.1 D, 21.120.22 B, 21.120.23 C, 21.120.26, 21.120.4 D-E, 21.120.42 E, 21.170.4,
21.200.13 B, 21.200.4, 21.200.41, 21.240.1, 21.280.35 A.4, 21.300.22 C, 21.300.23 D, 21.200.5,
21.320.31 A.5 eff. 08/01/2020.
Rules 21.100, 21.210, 21.210.1 A-E, 21.210.43-21.210.924, 21.260 B eff. 10/01/2020. Rules 21.250,
21.310 repealed eff. 10/01/2020.
Rules 21. 300.1, 21.300.2, 21.300.21-21.300.23, 21.300.24 A.2, 21.300.3 A, 21.300.3 C, 21.300.3 I-J,
21.300.6, 21.300.7, 21.300.8 A, 21.320, 21.320.1, 21.320.2, 21.320.31, 21.320.32, 21.320.41,
CODE OF COLORADO REGULATIONS 2 CCR 502-1
Behavioral Health
549
21.320.42 D, 21.320.5, 21.320.61, 21.320.62, 21.320.63 A, 21.320.63 B.2, 21.320.7, 21.320.81,
21.320.9 eff. 03/02/2021.
Rules 21.100, 21.210.1 C, 21.240.3 D, 21.240.85 E, 21.270.1 A, 21.330-21.331.3 eff. 04/01/2021. Rules
21.330.3-21.330.92 repealed eff. 04/01/2021.
Rules 21.120.1 D, 21.120.22 B, 21.120.23 C, 21.120.4 D-e, 21.120.42 E, 21.240.1 emer. rules eff.
08/06/2021.
Rules 21.100, 21.120.1 D, 21.120.22 B, 21.120.23 C, 21.120.4 D-E, 21.120.42 E, 21.200.11, 21.200.12,
21.200.13 C, 21.240.1 eff. 11/01/2021.
Rules 21.300.1, 21.300.21, 21.300.22 D-F, 21.300.23-21.300.25, 21.300.9, 21.320.1, 21.320.2 A-B,
21.320.21, 21.320.31, 21.320.32, 21.320.41, 31.320.5 A, 31.320.61, 21.320.62, 21.320.63 A,
21.320.64, 21.320.7 G, 21.320.81 eff. 02/01/2022.
Rules 21.330.1, 21.330.31, 21.330.32 eff. 03/02/2022. Rules 21.330.4, 21.331-21.331.3 repealed eff.
03/02/2022.
Rules 21.600-21.600.9 eff. 07/01/2022.
Rules 21.800-21.900 repealed eff. 07/30/2023.
Rules Chapters 1-12 eff. 01/01/2024.
Rules 1.2, 2.5.1 D.12.12.1 C.5.d(1), 2.12.1 D, 2.12.2 A, 2.12.3 A, 2.13.1 A.3, 2.13.1 A.5, 2.24.1 B, 2.27.5
A, 3.4 A, 4.2.4 F, 4.3.4 G, 5.2.2 E, 6.3.3 A-B, 6.3.4 B, 6.3.4 D-E, 6.5.4 A, 6.6.2 A, 6.6.4 C, 10.6 C,
10.7 C, 10.8 C, 11.3.1 B, 11.8.3 A-B, 11.8.4 A, 11.9.6, 11.10.1, 11.13, 11.17.2 E, 12.3.2 B.8.d(1),
12.5.1 E, 12.5.4, 12.6.1 F-J, Chapter 13, Chapter 14 eff. 08/01/2025. Rules 21.200.4, 21.200.41-
45, 21.200.47-48, 21.200.481-482 recodified as 2 CCR 502-6 eff. 08/01/2025.
Rules 2.15 A-B, 11.16.8 D, Chapter 15 eff. 01/01/2026.