Chapter 4 Regulations

What Nurses Need to Know

The Colorado Department of Public Health and Environment (CDPHE) Health Facilities and Emergency Medical Services Division provides oversight on a number of regulatory standards related to health care. Included among those are the Standards for Hospitals and Health Facilities, and Chapter 4 focuses on “General Hospitals,” which includes all acute care hospitals.

The Chapter 4 regulations encompass a vast set of hospital regulatory standards divided into 29 categories covering everything from building and fire safety provisions to patient rights. Nursing Services are one component of the Chapter 4 regulations, and the most recent revisions to the entire set of regulations focused on the Nursing Services section in particular.

For Nurses

Recent revisions to Chapter 4 set a standard for nurse staffing while ensuring the ability of frontline nurses to contribute to decision making through shared governance. Revised regulations now require each open hospital inpatient unit and emergency department to implement a 24-hour nurse staffing plan based on a common standard, while still providing each hospital with the flexibility to determine its own unique needs. Simultaneously, the revised regulations protect the voices of nurse leaders and staff by allowing these frontline workers to share input and advocate for practical solutions.

Specifically, the updates to Chapter 4 that took effect October 2021:

  • Create new rules requiring hospitals to develop and implement a master nurse staffing plan using a staffing committee model with at least 50 percent of the members being frontline nurses
  • Require nurse leaders to share unit-based master nurse staffing plans with each nursing employee annually
  • Provide an avenue for nursing staff to raise concerns through an anonymous report to CDPHE if they feel that their work environment is unsafe or impacting quality of care
  • Increase the minimum staffing requirement to one nurse and one auxiliary staff on duty in each open inpatient care unit and add the Emergency Department to the regulation for the first time
    • Note: Critical Access Hospitals (CAHs) are exempt from these staffing requirements, as CAHs are governed instead by federal staffing regulations. However, Chapter 4 regulations may still be used as “best practice” guidance for exempt facilities.
  • Update language to require that a master nurse staffing plan includes 24-hour continuous registered nurse coverage, distribution of nursing and auxiliary personnel, and forecasting future needs
  • Add a requirement that each open inpatient care unit within a hospital must now have a 24-hour nurse staffing plan
  • Require that master nurse staffing plans and annual reports on staffing and patient outcomes are provided to CDPHE upon request
  • Require that an annual report with patient and staff outcomes is made to the hospital governing body on the master nurse staffing plan
  • Detail that hospitals found to be out of compliance with statute or regulations will be cited and must take corrective action; further noncompliance or subsequent deficiencies could result in actions against a hospital’s license


File a Complaint

If you believe your hospital to be out of compliance with the Chapter 4 regulations, you can file an anonymous compliant with CDPHE.

CHA Resources

CHA has developed the following resources for its member hospitals and their frontline nurses to better understand the Chapter 4 regulations:

Introduction to Chapter 4 Handout
Introduction to Chapter 4 PowerPoint