DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
Health Facilities and Emergency Medical Services Division
6 CCR 1011-1
STANDARDS FOR HOSPITALS AND HEALTH FACILITIES
CHAPTER VI
ACUTE TREATMENT UNITS

Statutory Authority and Applicability 
1.101  (1)	Authority to establish minimum standards through regulation and to administer and enforce such regulations is provided by Section 25-1.5-103, C.R.S.
1.101  (2)	Acute treatment units, as defined herein, shall be in compliance with all applicable federal and state statutes and regulations, including but not limited to, the following:
101  (2)   (a)	This Chapter VI.
101  (2)   (b)	The following parts of 6 CCR 1011-1, Chapter II, General Licensure Standards:
	(i)	Parts 1, Review of Building Plans and Specifications
	(ii)	Part 2, Application for License
	(iii)	Part 3.2, Occurrence Reporting
	(iv)	Part 4, Waiver of Regulations for Health Facilities 
1.101  (3)	This chapter applies to services provided by acute treatment units, including services provided through contracts.
1.102	Definitions.  For purposes of this chapter, the following definitions shall apply, unless the context requires otherwise:
1.102  (1)	“Acute treatment unit” means a facility or a distinct part of a facility for short-term psychiatric care, which may include substance abuse treatment, and which provides a total, twenty-four-hour therapeutically planned and professionally staffed environment for persons who do not require inpatient hospitalization but need more intense and individual services than are available on an outpatient basis, such as crisis management and stabilization services.  
1.102  (2)	“Auxiliary aid” means any device used by persons to overcome a physical disability and includes but is not limited to a wheelchair, walker or orthopedic appliance.
1.102  (3)	“Client” means an individual who is age 18 and over in need of short-term psychiatric care. 
1.102  (4)	“Construction on-site review” means on-site inspection by the Department, or its designee, of new construction or substantial remodeling to determine compliance by the facility with the National Fire Protection Association (NFPA) Life Safety Code and with this Chapter VI. 
1.102  (5)	“Construction plan review” means the review by the Department, or its designee, of new construction or remodeling plans to determine compliance by the facility with the National Fire Protection Association (NFPA) Life Safety Code and with this Chapter VI.  
1.102  (6)	“Deficiency” means a violation of regulatory and/or statutory requirements governing acute treatment units, as cited by the Department.
1.102  (7)	“Deficiency list” means a listing of deficiency citations which contains:
102  (7)   (a)	a statement of the statute or regulation violated; and
102  (7)   (b)	a statement of the findings, with evidence to support the deficiency. 
1.102  (8)	“Department” means the Colorado Department of Public Health and Environment or its designee.
1.102  (9)	“Director” means a person who is responsible for the overall operation, daily administration, management and maintenance of the facility.
1.102  (10)	“Distinct part” means a contiguous section of a building dedicated to serving as an acute treatment unit.  
1.102  (11)	 “Facility” means an acute treatment unit.
1.102  (12)	“Governing body” means the board of trustees, directors or other governing body in whom the ultimate authority for the conduct of the facility is vested. 
1.102  (13)	“Licensee” means the person or entity to whom:
102  (13)   (a)	a license is issued by the Department pursuant to Section 25-1.5-103 (1) (a), C.R.S., to operate a facility within the definition herein provided, and
102  (13)   (b)	a “27-10” designation has been granted by the Department of Human Services pursuant to Section 27-10-101, et. seq. and 2 CCR 502-1. 
1.102  (14)	“Occurrences” means information reported to the Department in accordance with 25-1-124, C.R.S. and Chapter II, General Licensure, Part 3.2 occurrence Reporting.
1.102  (15)	“NFPA” means the National Fire Protection Association.
1.102  (16)	“Owner” means the entity in whose name the license 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.  For the purposes of this regulation, the term “owner” is used interchangeably with the terms “applicant” and “licensee.”
1.102  (17)	“Plan of correction” means a written plan to be submitted by facilities to the Department for approval, detailing the measures that shall be taken to correct all cited deficiencies. 
1.102  (18)	“Seclusion room” means a room where a client is placed alone and from where egress is involuntarily prevented. 
1.102  (19)	“Short-term psychiatric care” means services provided to treat persons with mental illness for an average of 3-7 days, but generally no longer than 30 days. 
1.102  (20)	“Staff” means employees; and contract staff intended to substitute for, or supplement staff who provide client care services.  
1.102  (21)	“Therapeutic diet” means a diet ordered by a physician as part of a treatment of disease or clinical condition, or to eliminate, decrease, or increase specific nutrients in the diet.  Examples include, but are not limited to:  a calorie counted diet, a specific sodium gram diet, and a cardiac diet.
1.102  (22)	“Unit” means a locked treatment setting that serves a maximum of sixteen persons. 
1.102  (23)	“Warewashing” means the cleaning and sanitizing of equipment and utensils.  For the purposes of this definition, equipment includes but is not limited to kitchen appliances and tables with which food normally comes into contact.  For the purposes of this definition, utensils are implements used to prepare, store, transport or serve food. 
1.103	Department Oversight 
1.103  (1)	General  
103  (1)   (a)	Facility Compliance.  The governing body shall be responsible for the operation of the facility and for compliance with these regulations.  The governing body shall delegate the responsibility for day-to-day operations to the director.
103  (1)   (b)	Issuing Licenses.  The Department shall issue or renew a license after it is satisfied that the license applicant or licensee is in compliance with the requirements set forth in this Chapter VI and the requirements established by the Division of Mental Health, Department of Human Services.  Such license issued or renewed pursuant to this section, other than a provisional license, shall expire one year from the date of issuance or renewal.
1.103  (2)	Licensure Fees.  Licensure fees are specified in Section 25-3-105 (1)(c), C.R.S.  
1.103  (3)	Construction Plan Review.  In reference to the National Fire Protection Association requirements, the Department is the authority having jurisdiction for state licensure.  
103  (3)   (a)	When Plan Review is Required
	(i)	Application for an initial license, when such initial license is not a change of ownership.  This includes new facility construction and existing structures.
	(ii)	Substantial remodeling which includes, but is not limited to: 
(A)	Structural additions, of any size or type (including pre-fabricated structures) to or adjacent to the structure and on the property controlled by the facility. 
(B)	Alteration of an existing space, room, structure, or area of the facility not previously used for providing client services to space used for the delivery of services to clients. 
(C)	Any structural alteration that affects 25% or more of the square footage of the existing habitable1 floor space, as determined by the Department. 
 (D)	Installation or substantial alteration2 of the following systems:  fire alarm, sprinkler, kitchen-hood fire-suppression and security.
1 Areas, such as unfinished basements and garages, not used for habitable space shall not be included in the calculation of habitable existing building area.
2 Substantial alteration does not include repairs, replacement in kind, or additions of a single device to a required Life Safety Code system.  Substantial alteration does include permanent de-activation of a system.
103  (3)   (b)	Process for Submission and Approval of Building Plans
(i)	General.  The building plans and plans for the security system, fire alarm system and automatic fire suppression system, subject to plan review under this Chapter VI, shall be submitted in accordance with 6 CCR 1011-1, Chapter II, Part 1, Review of Building Plans and Specifications, Sections 1.1.1, 1.1.4, and 1.3.
(ii)	Locked areas.  The following shall also be submitted as part of the plan review:
(A)	Locking devices for egress doors, egress access doors, and seclusion room doors.
(B)	Location of locked egress and locked egress access doors.
(C)	Drawings and information detailing how the facility will install or construct fencing or other enclosures around all secured outdoor areas, to prevent elopement and maintain the safety of the clients.
(D)	Location, size, and distance from the structure(s) of any secured exterior point of safety used for emergency evacuation purposes.
1.103  (4)	Citing Deficiencies 
103  (4)   (a)	The Department is authorized to cite deficiencies.
103  (4)   (b)	The facility shall respond to a life or limb-threatening deficiency by immediately removing the cause of the life or limb threatening risk and provide evidence, either verbal or written as required by the Department, that the risk has been removed.
1.103  (5)	Plans of Correction (POCs).  The Department shall require and the facility shall submit a plan of correction in response to cited deficiencies.  
103  (5)   (a)	General
(i)	The facility shall develop a POC, in the format required by the Department, for every deficiency cited by the Department in the deficiency list.
(ii)	The POC shall be typed or printed legibly in ink. 
(iii)	The date of correction for deficiencies shall be no longer than 30 calendar days from the date of the mailing of the deficiency list to the facility, unless otherwise required or approved by the Department. 
103  (5)   (b)	Process for Submission and Approval of POC  
(i)	A facility shall submit a POC to the Department no later than ten (10) working days of the date of the deficiency list letter sent by the Department.
(ii)	If an extension of time is needed to complete the POC, the facility shall request an extension in writing from the Department prior to the POC due date.  An extension of time may be granted by the Department not to exceed seven (7) calendar days.
(iii)	The POC is subject to Department approval. 
1.103  (6)	Facility Reporting Requirements.  The facility shall develop and implement policies and procedures for complying with the following reporting requirements.
103  (6)   (a)	Occurrences  
(i)	Reporting.  The facility shall be in compliance with occurrence reporting requirements pursuant to 6 CCR 1011, Chapter II, Section 3.2.
(ii)	Facility investigation of occurrences
(A)	Occurrences shall be investigated to determine the circumstances of the event and institute appropriate measures to prevent similar future situations.
(B)	Documentation regarding investigation, including the appropriate measures to be instituted, shall be made available to the Department, upon request.
(C)	A report with the investigation findings will be available for review by the Department within five working days of the occurrence.
(D)	Nothing in this Section 1.103 (6)(a) shall be construed to limit or modify any statutory or common-law right, privilege, confidentiality or immunity. 
103  (6)   (b)	Notification Regarding Relocations.  The facility shall notify the Department within 48 hours of the relocation of one or more clients occurs due to any portion of the facility becoming uninhabitable as a result of fire or other disaster.
103  (6)   (c)	Facility Closure.  If the closure of a facility by a licensee is pending, the licensee shall notify the Department in writing at least 30 days prior to such closure.  
1.104	Facility Operations
1.104  (1)	Medications.  Medications shall be stored in a manner that prevents unauthorized access and drug diversion.  
1.104  (2)	Staffing Requirements:  Communicable Diseases
104  (2)   (a)	General.  All staff and volunteers shall be free of communicable disease that can be readily transmitted in the workplace.
104  (2)   (b)	Tuberculosis 
(i)	All staff shall be required to have a tuberculin skin test prior to direct contact with the clients.  In the event of a positive reaction to the skin test, evidence of a chest x-ray and other appropriate follow-up shall be required in accordance with community standards of practice. 
(ii)	The facility personnel files for staff members as well as for volunteers who have direct contact with clients shall include documentation evidencing TB testing and results.
1.104  (3)	Emergency Preparedness  
104  (3)   (a)	The facility shall develop, update as necessary, and implement a plan for emergency preparedness that addresses the facility response to the following emergencies:
(i)	Severe weather, including but not limited to floods, blizzards, and tornados.
(ii)	Fire.
(iii)	Bomb threats. 
(iv)	Explosions. 
(v)	Hazardous material spills.
(vi)	Internal system failures, such as electrical outages. 
(vii)	Communicable disease outbreaks.
104  (3)   (b)	Staff shall receive training regarding their responsibilities under the plan.
(i)	Within three (3) working days of date of hire or commencement of volunteer service, the facility shall provide training in emergency preparedness.  
(ii)	Every two (2) months, there shall be a review of all components of the emergency preparedness plan, including each individual employee’s responsibilities under the plan, with the staff of each shift.    
1.104  (4)	Infection Control.  The facility shall adopt and implement policies and procedures regarding infection control that shall address, at minimum:
104  (4)  (a)	housekeeping,
104  (4)  (b)	dietary services, and
104  (4)  (c)	linen and laundry services.
1.104  (5)	Unit Safety Checks.  The facility shall conduct unit safety checks every shift to identify and remedy hazards that could be used by clients to harm themselves or others.  There shall be documentation of these safety checks.  
1.105	Dietary Services 
1.105  (1)	Supervision.  The governing body shall appoint an individual to be in charge of dietary services.  Such individual shall have knowledge of foodbourne disease prevention, including but not limited to hygienic practices and food safety techniques pertaining to preparation, food storage and warewashing.
1.105  (2)	Sanitary Conditions.  Food shall be prepared, handled and stored in a sanitary manner, so that it is free from spoilage, filth or other contamination, and shall be safe for human consumption.
1.105  (3)	Dishwashing.  Warewashing shall be conducted in a safe and sanitary manner.  Unless commercial grade dishwashers are used, a two-compartment sink or a single-compartment sink shall be used in conjunction with a domestic dishwashing machine. Dishwashing machines shall be used in accordance with manufacturer's instructions. 
1.105  (4)	Meals and Snacks 
105  (4)   (a)	Meals
(i)	Menus shall vary daily and shall be adjusted for seasonal changes and holidays.
(ii)	At least three nutritionally balanced meals in adequate portions, using a variety of foods shall be made available at regular times daily.  
(iii)	In the event the meal provided is unpalatable, a nutritionally balanced substitute shall be available. 
105  (4)   (b)	Snacks.  Between meal snacks of nourishing quality shall be available, to the extent that such availability does not conflict with a client’s service plan.  
105  (4)   (c)	Therapeutic Diets.  This provision is only applicable to facilities that admit clients who require therapeutic diets.  If the facility admits such clients, the following requirements shall apply.
(i)	Therapeutic diets shall be prescribed by a physician. 
(ii)	The facility shall implement a system in order to ensure that the proper diet is provided.
1.105  (5)	Food Supply.  There shall be enough food and water on hand to prepare three nutritionally balanced meals for four days.  
1.106	Linen and Laundry Services 
1.106  (1)	Provision of Laundry Services. The facility shall make laundry services available for clients’ personal laundry in one of the following ways, and in accordance with these regulations:
106  (1)   (a)	Providing laundry service for clients’ personal items.
106  (1)   (b)	Providing a designated laundry room for use by clients.  Clients may do their personal laundry as part of their treatment plan. 
1.106  (2)	Clean Linen Supply.  The facility shall maintain a sufficient supply of clean linen, including sheets and towels.  
1.106  (3)	Sanitary Conditions 
106  (3)   (a)	Linen and laundry services shall be conducted in a manner designed to prevent contamination of patients and personnel.  
106  (3)   (b)	Staff shall wash their hands after handling soiled linen and before handling clean linen.  
106  (3)   (c)	Storage
(i)	Soiled linen shall be stored separately from clean linen.  Soiled linen and clean linen shall be stored in separate enclosed areas.
(ii)	Laundry room(s) shall not be used for storage of soiled or clean laundry unless the laundry room is over 100 square foot in area and meets the requirements of NFPA 101, Chapter 18, Section 18.3.2.
1.107	Interior and Exterior Environment 
1.107  (1)	Interior Environment
107  (1)   (a)	General.  The facility shall provide a clean, sanitary interior environment, free of hazards to health and safety.  The facility shall have a layout, finishes, and furnishings that minimize the opportunity for residents to injure themselves or others. 
107  (1)   (b)	Maintenance.  Interior areas shall be in good repair. 
107  (1)   (c)	Finishes  
(i)	All finishes shall promote maintenance of sanitary conditions.  
(ii)	Floor surfaces and coverings shall promote mobility in areas used by individuals and shall promote maintenance of sanitary conditions.  
107  (1)   (d)	Furnishings.  The furnishings shall be clean, dry, free of foul orders, safe and well-maintained.
107  (1)   (e)	Windows.  Windows that can be accessed by clients shall have security glazing or other appropriate security features to reduce the possibility of patient injury or escape.
107  (1)   (f)	Potential Infection/Injury Hazards 
(i)	Sharps.  Sharp knives and other objects that could be used for self-harm or harm to others shall be secured in a manner inaccessible to clients.
(ii)	Insect/rodent infestations.  The facility shall be maintained free of infestations of insects and rodents and all openings to the outside shall be screened.
(iii)	Storage of hazardous substances.  Solutions, cleaning compounds and hazardous substances shall be labeled and stored in a safe manner, in an area inaccessible to the clients.
107  (1)   (g)	Heating, Lighting, Ventilation 
(i)	Each room in the facility shall be installed with heat, lighting and ventilation sufficient to accommodate its use and the needs of the clients.
(ii)	All interior and exterior steps and interior hallways and corridors shall be adequately illuminated.
107  (1)   (h)	Water 
(i)	Potable water.  There shall be an adequate supply of safe, potable water available for domestic purposes. 
(ii)	Hot water  
(A)	Hot water shall not measure more than 120 degrees Fahrenheit at taps which are accessible by clients.
(B)	There shall be a sufficient supply of hot water during peak usage demands. 
107  (1)   (i)	Telephone.  There shall be a telephone available for use by residents and staff.
1.107  (2)	Exterior Environment
107  (2)   (a)	General.  The facility shall provide a clean, sanitary, and secure, exterior environment, free of hazards to health and safety.
107  (2)   (b)	Potential Hazards.  Exterior areas shall be well maintained.
(i)	Maintenance of the grounds.  Exterior premises shall be kept free of high weeds and grass, garbage and rubbish.  Grounds shall be maintained to prevent hazardous slopes, holes, or other potential hazards.
(ii)	Staircases.  Exterior staircases of three (3) or more steps and porches shall have handrails.  Staircases and porches shall be kept in good repair.
1.108	Physical Plant 
1.108  (1)	Compliance with State and Local Laws/Codes.  Facilities shall be in compliance with all applicable:
108  (1)   (a)	Local zoning, housing, fire and sanitary codes and ordinances of the city, city and county, or county where the facility is situated to the extent that such codes are consistent with the federal "Fair Housing Amendment Act of 1988", as amended, 42 U.S.C., sec. 3601, et seq. 
108  (1)   (b)	State and local plumbing laws and regulations.   Plumbing shall be maintained in good repair, free of the possibility of backflow and backsiphonage, through the use of vacuum breakers and fixed air gaps, in accordance with state and local codes.
108  (1)   (c)	Sewage disposal requirements.  Sewage shall 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. 
1.108  (2)	Common Areas 
108  (2)   (a)	Common areas sufficient to reasonably accommodate all clients shall be provided.
108  (2)   (b)	All common areas and dining areas shall be accessible to clients utilizing an auxiliary aid without requiring transfer from a wheelchair to walker or from a wheelchair to a regular chair for use in the dining area.  All doors to those rooms requiring access shall be at least 32 inches wide.
108  (2)   (c)	A minimum of two entryways shall be provided for access and egress from the building by clients utilizing a wheelchair. 
1.108  (3)	Dining Areas.  A designated dining area accessible by all clients shall be provided in a separate area or areas capable of comfortably seating all clients.
1.108  (4)	Bedrooms 
108  (4)   (a)	Bedroom Assignment.  No client shall be assigned to any room other than a regularly designated bedroom.
108  (4)   (b)	Occupancy Ratios.  No more than two (2) clients shall occupy a bedroom.  
108  (4)   (c)	Square Footage Requirements 
(i)	Each designated bedroom shall have at least 100 square feet for single occupancy bedrooms and 60 square feet per person for double occupancy bedrooms.  Bathroom areas and closets shall not be included in the determination of square footage. 
108  (4)   (d)	Storage Space.  Each client shall have within his or her room separate storage facilities adequate for clothing and personal articles such as a closet or a locker.  When the treatment program indicates, shelves for folded garments shall be used instead of hanging garments.
108  (4)   (e)	Windows.  Each bedroom shall have at least one window of eight (8) square feet with a sill height not to exceed 36 inches. 
108  (4)   (f)	Furnishings  
(i)	Each client bedroom shall be equipped as follows for each client:
(A)	A comfortable, standard-sized bed equipped with a comfortable, clean mattress, mattress protector, and pillow.  Rollaway type beds, cots, folding beds or bunk beds shall not be permitted.
(B)	A standard-sized chair in good condition.
(C)	A safe and sanitary method to store the client’s towel, such as a breakaway towel rack.
108  (4)   (g)	Electrical Hazards.  Extension cords and multiple use electrical sockets shall be prohibited in client bedrooms.
1.108  (5)	Bathrooms 
108  (5)   (a)	Number of Bathrooms Per Client.  There shall be at least one full bathroom for every six (6) clients.  A full bathroom shall consist of at least the following fixtures: toilet, handwashing sink, toilet paper dispenser, mirror, tub or shower, and towel rack.  Bathrooms shall be equipped with soap dispensers or the facility shall have a procedure in place that prevents clients from sharing soap.
108  (5)   (b)	Bathroom Accessibility.  There shall be a bathroom on each floor having client bedrooms which is accessible without requiring access through an adjacent bedroom.
108  (5)   (c)	Bathrooms for Clients using Auxiliary Aids.  The facility shall provide at least one full bathroom as defined herein with fixtures positioned so as to be fully accessible to any client utilizing an auxiliary aid.   Grab bars shall be properly installed at each tub and shower, and adjacent to each toilet.
108  (5)   (d)	Fixtures
(i)	Non-skid surfaces.  Bathtubs and shower floors shall have non-skid surfaces.
(ii)	Toilet seats.  Toilet seats shall be constructed of non-absorbent material and free of cracks.
108  (5)   (e)	Supplies
(i)	Individualized supplies.  The use of common personal care articles, including soap and towels, is prohibited.
(ii)	Toilet paper.  Toilet paper in a dispenser shall be available at all times in each bathroom of the facility.
(iii)	Liquid soap and paper towels.  Liquid soap and paper towels shall be available at all times in the common bathrooms of the facility.  
1.108  (6)	Seclusion rooms
108  (6)   (a)	Client Safety 
(i)	The seclusion room shall be constructed to prevent patient hiding, escape, injury, or suicide. 
(ii)	The seclusion room shall be free of all protrusions, sharp corners, hardware, fixtures or other devices, and furnishings which may cause injury to the occupant.
108  (6)   (b)	Temperature.  The seclusion room shall maintain temperatures appropriate for the season.
108  (6)   (c)	Location.  The room shall be located in a manner affording direct observation of the patient by the nursing staff.
108  (6)   (d)	Square Footage.  The seclusion room shall have an area of at least 100 square feet.
108  (6)   (e)	Windows.  The seclusion room shall have a window that allows someone outside to see into all of the corners of the room.  Windows in the seclusion room shall be constructed to prevent breakage and otherwise prevent the occupant from harming himself.  
108  (6)   (f)	Doors.  Doors to the seclusion room shall be at least 32 inches wide, shall open outward.  
108  (6)   (g)	Electrical Outlets  
(i)	Light fixtures and other electrical outlets in the seclusion room shall be limited to those required and necessary, shall be recessed, and shall be constructed as to prevent the occupant from harming himself. 
(ii)	All electrical outlets, devices, and circuits accessible from inside the seclusion room shall be controlled by on/off switches located outside the seclusion room, in a secure location that is within the line of vision of the seclusion room.  The switches shall be durably labeled as to their function.
108  (6)   (h)	Fire Detection and Suppression Equipment.  Any sprinkler head in a seclusion room shall be tamper proof, either by being recessed and covered at all times with the manufacturer’s recommended cover or institutional style
1.108  (7)	Linen and Laundry  
108  (7)   (a)	The facility may have laundry room(s) no larger than 100 square feet in area equipped with residential style washer(s) and one residential style dryer without such laundry rooms being classified as a hazardous area.  These laundry rooms shall not be used for storage of soiled or clean linen.
108  (7)   (b)	Facilities shall have 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.  Enclosed areas located inside the structure or attached to the structure, used for soiled linen, shall meet the requirements of NFPA 101, Chapter 18, Section 18.3.2 for hazardous areas.  Enclosed areas located inside the structure or attached to the structure, that are over 50 square feet and used for clean linen, shall meet the requirements of NFPA 101, Chapter 18, Section 18.3.2.
108  (7)   (c)	There shall be hand-washing facilities in each area where un-bagged, soiled linen is handled.
1.109	Fire Safety  
These regulations incorporate by reference the National Fire Protection Association’s NFPA 101, Life Safety Code, 2006 Edition.  Such incorporation does not include later amendments to or editions of the referenced material.  The Department of Public Health and Environment maintains copies of the complete text of the incorporated materials for public inspection during regular business hours, and shall provide certified copies of the incorporated material at cost upon request.  Information regarding how the incorporated material may be obtained or examined is available from:	
Division Director
Health Facilities and Emergency Medical Services Division 
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80246
Phone:  303-692-2800
Copies of the incorporated materials have been provided to the State Publications Depository and Distribution Center, and are available for interlibrary loan.  Any incorporated material may be examined at any state publications depository library.
1.109  (1)	General 
109  (1)   (a)	Multiple Buildings Under One License.  Any facility operating under one license but comprised of multiple buildings shall have the Life Safety Code requirements determined for each building on an individual basis.
1.109  (2)	Compliance with NFPA 101, Life Safety Code Requirements 
109  (2)   (a)	Except as noted in Section 109 (2) (b), facilities shall meet the requirements of Chapter 18 “New Health Care Occupancies” of NFPA 101, Life Safety Code.  In addition, facilities shall meet the requirements referenced in NFPA 101, Chapter 2 “Referenced Publications.”
109  (2)   (b)	Exceptions.  Facilities that have the exceptions listed under subsections (i) Smoke Barriers and (ii) Minimum Construction Requirements, below, shall have a minimum staffing ratio of 1:6 to ensure timely evacuation in case of fire.
(i)	Smoke Barriers.  A facility is exempted from the requirements of NFPA 101, Chapter 18, Section 18.3.7.1 (smoke barriers) if:
(A)	The facility is equipped with a complete fire alarm system that includes smoke detectors in all corridors, sleeping rooms, and habitable spaces, and
(B)	The facility maintains a travel distance of 200 feet or less from any point in the facility to the exterior of the structure, through a required exit, and the required exits lead to an approved, secured exterior point of safety.
(ii)	Minimum Construction Requirements.  In addition to the acceptable types of building construction listed in NFPA 101, Chapter 18, Table 18.1.6.4, facilities may be type V (000) construction if:
(A)	The structure is one-story in height, and
(B)	The facility is equipped with a complete fire alarm system that includes smoke detectors in all corridors, sleeping rooms, and habitable spaces.
1.109  (3)	Locking devices
109  (3)   (a)	Egress and egress access doors.  Locking devices, used to secure facility egress doors and egress access doors, shall be in compliance with the following: 
(i)	NFPA 101, Chapter 7, Section 7.2.1.6.1, Delayed Egress Locks, or
(ii)	NFPA 101, Chapter 7, Section 7.2.1.6.2, Access Controlled Egress Doors, or 
(iii)	Doors in the required means of egress may have locking arrangements without delayed egress provided that all staff can readily unlock such doors at all times.
(iv)	Facilities may use electric or electronic locking devices if:
(A)	All staff can readily unlock such doors at all times. 
(B)	For emergency purposes, the facility evacuates clients to an approved, secured, exterior, point of safety, OR, the facility is equipped with smoke barriers as required by NFPA 101, Chapter 18, Section 18.3.7.1 of.
(v)	Doors in the required means of egress that are equipped with electronic or electrical locking devices must:
(A)	Unlock upon loss of power controlling the lock or locking mechanism, and
(B)	Unlock upon actuation of the approved supervised automatic sprinkler system, and 
(C)	Unlock upon activation of no more than two smoke detectors of the approved automatic fire detection system. 
109  (3)   (b)	Seclusion Rooms.  Seclusion rooms are permitted to have door-locking arrangements, provided that at all times keys are carried by the staff, responsible for client care and treatment.  These keys shall have a distinct color and feel.
109  (3)   (c)	Secure Outdoor Area  
(i)	In addition to the interior common areas required by this regulation, the facility shall provide a safe and secure outdoor area for the use of clients year round.  
(ii)	Fencing or other enclosures  
(A)	Fencing or other enclosures, that prevent elopement and protect the safety and security of the clients, shall be installed around secure outdoor areas.  
(B)	Where a locked outdoor fence gate restricts access to the public way, all staff must carry gate lock keys on their person at all times while on duty, unless the gate is locked using electronic or electrical devices authorized under Section 1.109 (3)(a)(v). 
1.109  (4)	Fire Drills  
109  (4)   (a)	During the first year of operation, fire drills shall be conducted once per shift per month.  
109  (4)   (b)	After the first year of operation, fire drills shall be conducted once per shift per quarter.  
109  (4)   (c)	Fire drills conducted during normal sleeping hours do not require the activation of the fire alarm system.  All other fire drills shall include the activation of the fire alarm system.
109  (4)   (d)	Clients should, whenever possible, participate in daytime fire drills.  Client participation in fire drills conducted during normal sleeping hours is not required.  
1.109  (5)	Equipment
109  (5)   (a)	First Aid.  First aid equipment shall be maintained on the premises in a readily available location and staff shall be instructed in its use.
109  (5)   (b)	Telephone  
(i)	There shall be at least one telephone, not powered by the facility’s electrical system, for use by the staff for emergencies.
(ii)	Current phone number and location of the nearest hospital, and current phone numbers of ambulance service, poison control center, fire station and the police shall be shall be readily accessible to staff.
1.109  (6)	Fire Suppression or Detection Equipment.  Any fire suppression or detection equipment shall be operational and functional.  The facility must fully document all inspections for fire alarm and smoke detection systems, automatic fire sprinkler systems and fixed kitchen systems with written records maintained at the facility for review.  All inspections and documentation shall be per NFPA requirements.
109  (6)   (a)	Fire alarm and smoke detection systems must be inspected by trained and qualified personnel at least annually. 
109  (6)   (b)	Automatic fire sprinkler systems must be inspected annually, by a sprinkler contractor currently registered with the State of Colorado – Division of Fire Safety to perform inspection and maintenance services.  The facility shall perform and document, main drain tests and flow tests on a quarterly basis.
109  (6)   (c)	Fixed kitchen extinguishing systems must be inspected by trained and qualified personnel on a semi-annual basis. 
109  (6)   (d)	Portable fire extinguisher. The facility shall have a portable fire extinguisher of the ABC type and of at least 3-pound capacity3, located in the kitchen area, common area, and at least one on every level of the facility. Fire extinguishers shall be checked monthly to ensure that they are mounted in a location that is easily accessible and that the pressure gauge is within the safe zone. Portable fire extinguishers shall be inspected annually, and tagged by a qualified fire extinguisher maintenance contractor. 
3 Capacity is defined as the capacity of the extinguishment agents.