Colorado Code § 27-50-502

Behavioral health entities - minimum standard - rules
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(1) No later than
January 1, 2024, the BHA shall promulgate rules pursuant to section 24-4-103 providing
minimum standards for the operation of behavioral health entities within the state, including the
following:
(a) Requirements to be met by all behavioral health entities to ensure the health, safety,
and welfare of all behavioral health entity consumers, including, at a minimum:
(I) Requirements for consumer assessment, treatment, care coordination, patient rights,
and consumer notice;
(II) Administrative and operational standards for governance; consumer records and
record retention; personnel; admission and discharge criteria; policies and procedures to ensure
compliance with regulatory and contract requirements; and quality management;
(III) Data reporting requirements;
(IV) Physical plant standards, including infection control; and
(V) Occurrence reporting requirements pursuant to section 27-50-510;
(b) Service-specific requirements that apply only to behavioral health entities electing to
provide that service or set of services, including, at a minimum, standards for the specific types
of behavioral health safety net services and other behavioral health services along the continuum
of care created by the BHA pursuant to part 3 of this article 50, including but not limited to:
(I) Essential behavioral health safety net provider standards; and
(II) Comprehensive community behavioral health provider standards;
(c) Procedures for mandatory BHA inspections of behavioral health entities;
(d) Procedures for written plans for a behavioral health entity to correct violations found
as a result of inspections;
(e) Intermediate enforcement remedies;
(f) Factors for behavioral health entities to consider when determining whether an
applicant's conviction of or plea of guilty or nolo contendere to an offense disqualifies the
applicant from employment with the behavioral health entity. The state board of human services
may determine which offenses require consideration of these factors.
(g) Timelines for compliance with behavioral health entity standards that exceed the
standards under which a behavioral health entity was previously licensed or approved.
(2) In approving or rejecting an essential behavioral health safety net provider for
eligibility for enhanced service delivery payment, the commissioner shall:
(a) Require training on and provision of culturally competent and trauma-informed
services;
(b) Consider the adequacy and quality of the services provided, taking into consideration
factors such as geographic location, local community need, and availability of workforce;
(c) Require written policies and procedures on admitting, discharging, triaging, and
denying services to clients in alignment with the standards determined by the BHA pursuant to
sections 27-50-302 and 27-50-303;
(d) Require that overall responsibility for the administration of an essential behavioral
health safety net provider be vested in a director who is a physician or a member of one of the
licensed mental health professions, unless the provider is only providing recovery support
services. If the director is not a licensed physician or licensed mental health professional, the
provider shall employ or contract with at least one licensed physician or licensed mental health
professional to advise the director on clinical decisions.
(e) Require that essential behavioral health safety net provider staff include, wherever
feasible and appropriate in the discretion of the commissioner, medical staff able to provide
medical clearance on site, and other professional staff workers such as psychologists, social
workers, educational consultants, peers, community health workers, and nurses, with such
qualifications, responsibilities, and experience that corresponds with the size and capacity of the
provider; and
(f) Require that each essential behavioral health safety net provider from which services
may be purchased:
(I) 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, or a political subdivision of the state;
(II) Be free of conflicts of interest; and
(III) Enter into a contract developed pursuant to section 27-50-203 and accept publicly
funded clients.
(3) In approving or rejecting a comprehensive community behavioral health provider for
eligibility for enhanced service delivery payment, the commissioner shall adhere to the standards
for essential behavioral health safety net providers established in subsection (2) of this section,
and the commissioner shall also:
(a) Require that treatment programs of the comprehensive community behavioral health
provider 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 a physician or licensed mental health professional, the provider
shall contract with at least one licensed physician or licensed mental health professional to
advise the director on clinical decisions.
(b) Consider whether the comprehensive community behavioral health provider has
historically served medically needy or medically indigent patients and demonstrates a
commitment to serve low-income and medically indigent populations or, in the case of a sole
community provider, serves the medically indigent patients within its medical capability;
(c) Require the comprehensive community behavioral health provider to waive charges
or charge for services on a sliding scale based on income and require that the provider not
restrict access or services because of an individual's financial limitations;
(d) Require the comprehensive community behavioral health provider to serve priority
populations;
(e) Encourage the comprehensive community behavioral health provider to emphasize
the care and treatment of individuals recently released from incarceration and hospitals or
facilities directed toward assisting individuals with behavioral or mental health disorders in the
individual's adjustment to and functioning in the community;
(f) Require a process for tracking and reporting denials of care; and
(g) Require that the board in control and direction of the comprehensive community
behavioral health provider include voting members that have lived experience with mental health
disorders and substance use disorders and parents of children with mental health disorders and
substance use disorders.
(4) In approving or rejecting local general or psychiatric hospitals, nontraditional
facilities, innovative care models, and other behavioral health facilities or programs for the
purchase or designation of services not provided by essential or comprehensive community
behavioral health providers, the commissioner shall consider the following factors:
(a) The general quality of care provided to patients by such agencies;
(b) The organization of the medical staff to provide for the integration and coordination
of the psychiatric treatment program;
(c) The provisions for the availability of nursing, psychological, and social services and
the existence of an organized program of activities under the direction of an occupational
therapist or another qualified person;
(d) The licensure of such entity by the department of public health and environment or
another state agency where applicable;
(e) The methods by which the agency coordinates its services with those rendered by
other agencies to ensure an uninterrupted continuum of care to individuals with behavioral or
mental health disorders; and
(f) The availability of such services to the general public.
(5) In approving or rejecting behavioral health safety net providers pursuant to
subsections (2) and (3) of this section, or other agencies pursuant to subsection (4) of this
section, for the purchase of services, the commissioner shall ensure the behavioral health safety
net providers and agencies comply with federal financial participation requirements for
department-administered programs.
(6) In addition to these duties, the BHA may promulgate rules related to additional
competencies related to serving priority populations. Behavioral health safety net providers
approved by the BHA as demonstrating these additional competencies may be eligible for
enhanced rates. State agencies shall consider such approved status in determining payment
methodologies for services provided.

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