Regulatory Compliance

Colorado Health Facilities Licensure, Certification and Registration
Health facility licensing is a mandatory process that providers must go through in order to operate in Colorado. Certification through Medicare and Medicaid is an optional process that allows providers to bill for reimbursement. The Colorado Department of Public Health and Environment (CDPHE) does the entire process for licensing and the survey portion for certifications.

Colorado State Board of Health Rule 6 CCR 1009-5
Preparations for a Bioterrorist Event, Pandemic Influenza, or an Outbreak by a Novel and Highly Fatal Infectious Agent or Biological Toxin. The purpose of this rule is to provide emergency preparedness direction for local health jurisdictions, hospitals, rural health clinics and federally qualified health centers, regional emergency medical and trauma services advisory councils, and the Colorado Department of Public Health and Environment (CDPHE).

Joint Commission Unveils Emergency Management Checklist
A new Emergency Management Health Care Environment Checklist was developed by an internal Joint Commission workgroup at the request of the Office of the Assistant Secretary for Preparedness and Response.  The comprehensive tool supports all health care organizations as they navigate the reopening of a facility following a disaster and aligns with Joint Commission Emergency Management standards. The checklist covers both clinical and environmental issues and addresses post-disaster elements of critical importance for a health care organization to provide the level of care needed for the community. The checklist is also available online here.

EMTALA Fact Sheet
This fact sheet, created by the Assistant Secretary for Preparedness and Response, addresses several frequently asked questions regarding the Emergency Medical Treatment and Labor Act (EMTALA) and disasters. The document also has multiple links to resources for more information.

HIPAA Privacy in Emergency Situations
A bulletin released by the U.S. Department of Health and Human Services Office for Civil Rights, to ensure that HIPAA covered entities and their business associates are aware of the ways in which patient information may be shared under the HIPAA Privacy Rule in an emergency situation, and to serve as a reminder that the protections of the Privacy Rule are not set aside during an emergency.

HIPAA and the Red Cross
When providing client services, Red Cross workers may need to obtain information from health care providers about patients that providers are treating due to disaster-related conditions. Hospitals may share patient information with the Red Cross because the Health Insurance Portability and Accountability Act (HIPAA), which is the federal law that addresses medical record privacy, specifically authorizes hospitals to do so to help it carry out its disaster-related mission.

CMS Emergency Preparedness Final Rule Interpretive Guidelines and Survey Procedures, Appendix Z
On September 16, 2016, the final rule on Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers was published. This rule affects all 17 provider and supplier types eligible for participation in Medicare and was implemented on November 15, 2017.

CMS 1135 Waivers
When the President declares a major disaster or an emergency under the Stafford Act or an emergency under the National Emergencies Act, and the HHS Secretary declares a public health emergency, the Secretary is authorized to take certain actions in addition to his regular authorities under section 1135 of the Social Security Act. He may waive or modify certain Medicare, Medicaid, Children’s Health Insurance Program (CHIP) and Health Insurance Portability and Accountability Act (HIPAA) requirements to ensure that individuals have access to appropriate health care during an emergency and that providers are reimbursed and exempted from sanctions.

Disaster Preparedness Toolkit for State Medicaid Agencies
To help Medicaid agencies prepare for such disasters in the future, the Centers for Medicare and Medicaid Services (CMS) Coverage Learning Collaborative developed a set of tools on the strategies available to support Medicaid operations and enrollees in times of crisis.

CMS and Disasters: Resources at Your Fingertips
The Centers for Medicare & Medicaid Services issued the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule to establish consistency for health care providers participating in Medicare and Medicaid, increase patient safety during emergencies and establish a more coordinated response to natural and human-caused disasters. This document provides links to numerous related resources applicable to a variety of providers and suppliers.

NIMS Compliance
Homeland Security Presidential Directive 5 (HSPD-5) requires that all Federal Departments and agencies make adoption of the National Incident Management System (NIMS) a condition to receive federal preparedness funding. The directive memo and document “NIMS Implementation for Healthcare Organizations Guidance” can be found here.