DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Health Facilities and Emergency Medical Services Division STANDARDS FOR SECURE TRANSPORTATION SERVICES 6 CCR 1011-4 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ Adopted by the Board of Health on June 15, 2022. Effective on August 14, 2022. These rules incorporate by reference the following materials: Federal Motor Vehicle Safety Standards 49 C.F.R. Part 567.4(a) for manufactured motor vehicles (except replica motor vehicles and vehicles manufactured in two (2) or more stages), 49 C.F.R. Part 567.5 for vehicles that are manufactured in two (2) or more stages, or 49 C.F.R. Part 567.7 for certified vehicles that are altered (2022);

and 42 CFR Part 2 Confidentiality of Substance Use Disorder Patient Records (2022). Such incorporation does not include later amendments to or editions of the referenced material. The Health Facilities and Emergency Medical Services Division of the Colorado Department of Public Health and Environment maintains copies of the incorporated federal regulations for public inspection during regular business hours and the referenced materials may also be accessed at https://www.ecfr.gov/current/title-49/subtitle-B/chapter-V/part-567/section-567.4 (Requirements for manufacturers of motor vehicles); https://www.ecfr.gov/current/title-49/section-567.5 (Requirements for manufacturers of vehicles manufactured in two or more stages); https://www.ecfr.gov/current/title- 49/section-567.7 (Requirements for persons who alter certified vehicles); and https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2 (Confidentiality of Substance Use Disorder Patient Records).

Interested persons may obtain certified copies of any non-copyrighted material from the department at cost upon request. Information regarding how the incorporated materials may be obtained or examined is available from the division by contacting:

Associate Division Director Health Facilities and EMS Division Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, Colorado 80246-1530 INDEX Part 1 – Statutory Authority and Applicability Part 2 – Definitions Part 3 – County Issuance of Licenses and Vehicle Permits Part 4 – Complaints Part 5 – Denial, Revocation, or Suspension of Licensure and/or Vehicle Permits Part 6 – Data Collection and Reporting Requirements Part 7 – Staffing Requirements Part 8 – Clinical, Medical, and Operating Standards and Procedures 1 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division Part 9 – Client Rights Part 10 – Quality Management Program Part 1. STATUTORY AUTHORITY AND APPLICABILITY 1.1 Statutory Authority The statutory authority for the promulgation of these rules is set forth in Sections 25-3.5-103, 25-3.5-309, 25-3.5-310, 25-3.5-311, and 25-3.5-313, C.R.S.

1.2 Applicability (A) Secure transportation services, as defined herein, shall comply with all applicable federal, state, and local laws and regulations, including but not limited to 6 CCR 1011-4 as it applies to the type of services provided.

(B) Contracted services performed on behalf of secure transportation services shall meet the standards established herein.

Part 2. DEFINITIONS 2.1 “Abuse” means any of the following acts or omissions: (A) The non-accidental infliction of bodily injury, serious bodily injury, or death; (B) Confinement or restraint that is unreasonable under generally accepted standards; or (C) Subjection to nonconsensual sexual conduct or contact. 2.2 “Administrator” means any person who is responsible for the overall operations of the secure transportation service as set forth in Part 7.2.

2.3 “Based” means a service area in a county where the client is picked up for secure transportation services.

2.4 “Behavioral health” means an individual’s mental and emotional well-being and actions that affect an individual’s overall wellness. Behavioral health issues and disorders include substance use disorders, serious psychological distress, suicide, and other mental health disorders, and range from unhealthy stress or subclinical conditions to diagnosable and treatable diseases. The term “behavioral health” is also used to describe service systems that encompass prevention and promotion of emotional health and prevention and treatment services for mental health and substance use disorders.

2.5 “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 further or serious deterioration in the person’s mental or physical health. 2.6 “Chemical Restraint” means giving an individual medication involuntarily for the purpose of restraining that individual; except that “chemical restraint” does not include the involuntary administration of medication pursuant to Section 27-65-111 (5), C.R.S., or administration of medication for voluntary or life-saving medical procedures. 2.7 “Class A” means secure transportation services licensed to use physical restraint during secure transport pursuant to the parameters set forth at Part 8.3. 2 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division 2.8 “Class B” means secure transportation services that are not licensed to use physical restraint during secure transport.

2.9 “Client” means an individual experiencing a behavioral health crisis who is eligible for urgent secure transportation services as defined at Part 2.22 and who meets the parameters set forth at Part 8.1.

2.10 “Direct client contact” means any staff member who interacts directly with clients either before, during, or after the secure transportation service and is qualified by training pursuant to Part 7.7(A)(1). This may include the driver or any other staff member who is not providing direct client support.

2.11 “Direct client support” means any staff member who interacts directly with clients and is qualified by training pursuant to Part 7.7(A)(2) in mental health first aid, basic first aid, and cardiopulmonary resuscitation (CPR) who is assigned to provide secure transportation services to individuals experiencing a behavioral health crisis.

2.12 “Emergency Medical Services Facility” means a licensed or certified facility that provides emergency medical services, including but not limited to: hospitals, hospital units as defined at Section 25-3-101, C.R.S.; freestanding emergency departments as defined at Section 25-1.5- 114, C.R.S.; psychiatric hospitals; community clinics; behavioral health entities; and community mental health centers, crisis stabilization units, or acute treatment units licensed as a behavioral health entity.

2.13 “Exploitation” means an act or omission committed by a person who: (A) Uses deception, harassment, intimidation, or undue influence for their personal gain to permanently or temporarily deprive a client of the use, benefit, or possession of anything of value;

(B) Forces, compels, coerces, or entices a client for the profit or advantage of the person or another person against the will of the client; or (C) Misuses the property of a client in a manner that adversely affects the client’s ability to receive services or care.

2.14 “Facility”, for the purposes of this chapter, means all facility types defined at Part 2.22(C). 2.15 “Harmful act” means an act committed against a client by a secure transportation service staff member when such act is not defined as abuse, neglect, or exploitation but causes harm to the health, safety, or welfare of a client.

2.16 “Licensee” means the person or business entity that is granted a license by the county to operate a secure transportation service and that bears legal responsibility for compliance with all applicable federal, state, and local statutes and regulations. 2.17 “Manager” means any person who is responsible for supervising staff and the day-to-day operations of the secure transportation service as set forth in Part 7.3. 2.18 “Mistreatment” means abuse, neglect, exploitation, or a harmful act. 3 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division 2.19 “Neglect” means a staff member’s failure to provide behavioral health care, physical care, supervision, or any other service necessary for the health or safety of a client during the secure transportation service in a timely manner and with the degree of care that a reasonable person in the same situation would exercise. Neglect also means a staff member knowingly using harassment, undue influence, or intimidation to create a hostile or fearful environment for a client. 2.20 “Owner” means an officer, director, general partner, limited partner, or other person having a financial or equity interest in the secure transportation service. An owner may also serve as the manager and/or administrator of a licensed secure transportation service. 2.21 “Physical restraint”, for the purposes of this chapter, means a physical device used to involuntarily restrict the movement of an individual or the movement or normal function of a portion of their body.

2.22 “Secure transportation” or “Secure transportation services” means urgent transportation services provided to individuals experiencing a behavioral health crisis. Secure transportation includes: (A) An individual being transported pursuant to Section 27-65-103 or 27-65-105(1), C.R.S., transportation from the community to a facility designated by the Executive Director of the Department of Human Services (DHS) for treatment and evaluation pursuant to Article 65 of Title 27;

(B) An individual in need of services pursuant to Articles 81 and 82 of Title 27, transportation from any location to an approved treatment facility, as described in Section 27-81-106, C.R.S., or to a walk-in crisis center that is in operation as part of the behavioral health crisis response system;

(C) An individual who is receiving transportation across levels of care or to a higher or lower level of care, transportation between any of the following types of facilities: (1) An emergency medical services facility;

(2) A facility designated by the Executive Director of DHS for the treatment and evaluation pursuant to Article 65 of Title 27;

(3) An approved treatment facility, as described in Section 27-81-106, C.R.S. (4) A walk-in crisis center that is operating as part of the behavioral health crisis response system; or (5) A behavioral health entity (BHE) licensed pursuant to Section 25-27.6-106, C.R.S., with a current twenty-four (24) hour endorsement. (D) Secure transportation does not include urgent transportation services provided by law enforcement or personnel employed by or contracted with a law enforcement agency to individuals experiencing a behavioral health crisis.

(1) Except that any member of a co-responder team may provide urgent transportation services if that co-responder:

(a) Is not law enforcement or personnel employed by or contracted with a law enforcement agency; and (b) Holds a valid license for secure transportation by the county in which the secure transportation originates; and 4 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (c) Provides secure transportation in a vehicle:

(i) With a valid permit issued by the county in which the secure transportation originates, and (ii) That meets the minimum requirements for secure transportation services in this rule chapter.

2.23 “Serious injury” means brain or spinal cord injuries; bone breaks or fractures; any injury that threatens life or limb, impairs the function of any part or organ of the body, or results in permanent disfigurement; burns of the second or third degree; and/or physical or sexual abuse as described in Article 3 of Title 18.

2.24 “Type 1” means a permitted vehicle with a permanent safety partition that separates the driver from the passenger compartment.

2.25 “Type 2” means a permitted, non-partitioned vehicle. Part 3. COUNTY ISSUANCE OF LICENSES AND VEHICLE PERMITS 3.1 License Required (A) Except as provided in Part 3.2 of these rules, no secure transportation service, public or private, shall transport a person experiencing a behavioral health crisis from any point within Colorado to any point within or outside Colorado unless that secure transportation service holds a valid license and permits issued by the county or counties in which the secure transportation service is based.

(B) Counties may enter into reciprocal licensing and permitting agreements: (1) With other counties; and (2) With neighboring states providing out-of-state secure transport services that comply with these rules or substantially equivalent out-of-state secure transport rules.

3.2 County Exemptions from Licensure or Permit Requirements (A) The following entities may provide secure transportation services to an individual experiencing a behavioral health crisis without a secure transportation license: (1) Ground Ambulance Agencies, licensed pursuant to Section 25-3.5-301, C.R.S., (2) Transportation services provided by the Office of Behavioral Health (OBH) within the DHS, (3) Emergency service patrols established pursuant to Section 27-81-115, C.R.S., and (4) Law enforcement.

(B) A ground ambulance agency licensed pursuant to Section 25-3.5-301, C.R.S. is exempt from additional secure transportation licensing requirements as set forth in Part 3.2(A) and is eligible to receive reimbursement pursuant to Section 25.5-5-328, C.R.S., if the ambulance agency meets all requirements set forth in 6 CCR 1011-4. 5 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (1) A ground ambulance agency shall notify the Department if it is providing secure transportation services under its ground ambulance license as part of its secure transportation service profile set forth at Part 6.4.

(C) In the event that all licensed secure transportation services are unavailable to provide secure transportation services in a county, the county may establish a process by which secure transportation services that are not licensed within the county’s jurisdiction are allowed to provide temporary secure transportation services to an individual experiencing a behavioral health crisis.

3.3 General Requirements for County Licensure of Secure Transportation Services and Permitting of Secure Transportation Vehicles (A) Counties shall adopt and periodically review, by resolution or regulations, requirements for licensure of secure transportation services. The licensure requirements shall include, but not be limited to:

(1) Compliance with all applicable laws and regulations to operate a secure transportation service in Colorado.

(2) Submission of a completed application form adopted by the county. (3) Submission of an application fee and vehicle permit fee(s), as defined in county resolution or regulation.

(4) Submission to the county, upon request, of copies of the secure transportation service’s written policy and procedure manual, operational and, if applicable, medical protocols, training procedures, or other documentation the county may deem necessary.

(5) Demonstration by the applicant of minimum vehicle insurance coverage as defined by Section 10-4-609 and Section 42-7-103(2), C.R.S. with the county(ies) identified as the certificate holder.

(6) Demonstration by the applicant of proof of general liability and applicable professional liability insurance coverage, at a minimum: (a) Liability insurance for injuries in the amount of $1,000,000 for each individual claim.

(b) Liability insurance in the amount of $3,000,000 for all claims made against the secure transportation service or against its personnel from an insurance company authorized to write liability insurance in Colorado. (c) Liability insurance coverage to the maximum extent required by Section 24-10-114, C.R.S., as applicable, if the secure transportation service is granted qualified immunity under the Colorado Governmental Immunity Act, Section 24-10-101, et seq., C.R.S.

(7) Demonstration by the applicant of proof of any additional insurance as identified in county resolution or regulations.

(8) Demonstration by the applicant of proof of a minimum level of worker’s compensation consistent with the Colorado Worker’s Compensation Act in Articles 40-47 of Title 8, C.R.S., as applicable.

6 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (9) A requirement that a new owner shall obtain a secure transportation license and vehicle permit(s) prior to beginning operations and upon change of ownership of a secure transportation service.

(10) Compliance with client and crew vehicle safety standards as follows: (a) All vehicles must demonstrate proof of compliance with Federal Motor Vehicle Safety Standards on the date of manufacture in accordance with the following:

(i) 49 C.F.R. Part 567.4(a) for manufactured motor vehicles (except replica motor vehicles and vehicles manufactured in two (2) or more stages), (ii) 49 C.F.R. Part 567.5 for vehicles that are manufactured in two (2) or more stages, or (iii) 49 C.F.R. Part 567.7 for certified vehicles that are altered. (b) All vehicles must undergo routine vehicle maintenance and periodic checks in accordance with manufacturer recommendations. (c) All vehicles must have the following safety features: (i) Four doors;

(ii) Ligature risk reduction measures;

(iii) Child safety and window safety locks;

(iv) Global Positioning System (GPS) tracking;

(v) Occupant protection, including seat belts, supplemental inflatable restraints, and child safety seats (as applicable);

(vi) Cabin temperature control and ventilation system;

(vii) Be absent any foreign items or instruments in the secured area that may be used to inflict harm; and (viii) Mirror for monitoring the client or capability for visual observation of the client.

(d) If a Type 1 vehicle with a safety partition that separates the driver from the passenger compartment is being used for the secure transportation service, then the vehicle must have the following additional safety features:

(i) Permanent installation of all safety partitions; and (ii) For vehicles with a cargo area, a safety partition must also be installed that separates the passenger compartment from the cargo area;

7 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (e) All vehicles must be equipped with the following:

(i) First aid kit;

(ii) Fire extinguisher;

(iii) Wireless two-way communication (public safety radio, commercial land mobile radio, or wireless telephone);

(iv) Biohazard bag;

(v) Personal protective equipment for each occupant as per public health recommendations; and (vi) Map of service area.

(f) If a licensed secure transportation service utilizes physical restraint as part of its services, the vehicle shall additionally be equipped with the following:

(i) Automated external defibrillator (AED);

(ii) Non-metal, soft posey-type restraints; and (iii) Device intended to prevent a client from spitting or biting that does not restrict the client’s airway or breathing ability and does not pose a ligature risk.

(B) The county shall verify that each vehicle is inspected annually by qualified representatives, as defined and appointed by the county commissioners, to assure compliance with these rules. Counties shall ensure that all such representatives do not have any disclosed or undisclosed actual or potential conflicts of interest with the secure transportation service or inspection process.

(1) Counties shall verify that all equipment on the vehicle is properly secured and supplies are maintained and stored in accordance with this chapter and any manufacturer recommendations.

(2) A county may delegate or contract the vehicle inspection process but not the responsibility of licensure as set forth in Section 25-3.5-309, et seq., C.R.S. (C) The county may impose, by resolution, additional requirements for the secure transportation service.

(D) A secure transportation service license or vehicle permit may not be assigned, sold, or otherwise transferred.

3.4 Licensure and Permitting Processes (A) Secure Transportation Service License. A secure transportation service license shall be issued by each county in which the secure transportation service is based, as defined in Part 2.3 above. The county shall ensure compliance with these rules, including minimum requirements for equipment, training, operating procedures, and all additional license requirements established by that county.

8 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (1) Licensure Classifications/Categories. The county shall create a process and procedure for the issuing of licenses for each secure transportation service. Secure transportation services have the following two (2) licensing options: (a) Class A – services that may use physical restraint during secure transport pursuant to the parameters set forth in Part 8.3, and (b) Class B – services that shall not use physical restraint during secure transport.

(2) Licensure Period. The licensure period for all secure transportation services shall be three (3) years.

(B) Vehicle Permits (1) The county shall create a process and procedure for the issuing of permits for each vehicle used to provide secure transportation services. (2) The type of permit issued will be determined by the type of vehicle that secure transportation services and their appropriate staff utilize when providing secure transportation services to clients. Secure transportation vehicles have the following two (2) permit options:

(a) Type 1 – vehicle with a safety partition that separates the driver from the passenger compartment, or (b) Type 2 – non-partitioned vehicle.

(3) Each county may include in its resolution or regulations the requirements for identification of the permitted level of service on each vehicle issued a permit. (4) The county shall renew each vehicle permit on an annual basis if the secure transportation service is in compliance with county regulations or resolution. (5) The county shall ensure each vehicle used by the licensee meets the minimum requirements for vehicle design and safety standards in accordance with Part 3.3(A)(10) of this chapter.

3.5 License and Permit Renewal. Counties shall create a license and vehicle permit renewal process. The licensure and vehicle permit renewal process shall require the receipt of applications for renewal no less than thirty (30) days before the date of license and/or permit expiration.

Part 4. COMPLAINTS 4.1 Each county shall have a written complaint and investigation policy and procedure to address: (A) Complaints against any secure transportation service in the county. (B) Allegations of unlicensed secure transportation services or vehicles without a valid permit operating within the county.

9 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division 4.2 The policy shall include, but not be limited to:

(A) The procedures concerning complaint intake, including posted information for the public concerning how to file a complaint.

(1) The county shall include written, verbal, and alternative methods of complaint intake. As part of its complaint process, the county shall include complaint intake methods that accommodate individuals in need of language and communication assistance.

(2) The county shall provide clients with contact information for the secure transportation service staff member(s) responsible for complaint intake and problem resolution.

(B) The county’s duty to provide the secure transportation service with a copy of the complaint at the time it is filed.

(C) The county’s responsibility to contact the complainant to verify the substance of the allegations.

(D) Criteria for initiating and conducting an investigation, including responding to and/or resolving complaints in a timely manner.

(E) The method for notifying the complainant about the resolution of the investigation and the secure transportation service’s plan to resolve the identified issue(s). (F) The method for notifying other counties with jurisdiction over secure transportation services, and, if applicable, the Colorado Department of Public Health and Environment (Department) and/or the Colorado Department of Regulatory Agencies (DORA) about complaints regarding licensed or certified staff members associated with the secure transportation service.

(G) The method for documenting the investigation of, and resolution process for, any complaint made.

4.3 The county shall notify the secure transportation service, its owner, manager, and administrator of the secure transportation service, in writing, of any:

(A) Known violation of the secure transportation licensing regulations by the secure transportation service, or (B) Known/alleged complaints or violations of the secure transportation licensing regulations by individual staff members, contractors, or licensed or certified providers operating on a secure transportation service.

Part 5. DENIAL, REVOCATION, OR SUSPENSION OF LICENSURE AND/OR VEHICLE PERMITS 5.1 Each county shall develop policies and procedures for the denial, suspension, or revocation of a secure transportation service license or secure transportation vehicle permit(s). 5.2 Each county shall develop policies and procedures for the temporary suspension or permanent revocation of a secure transportation service license and secure transportation vehicle permit(s). The policy shall include a written process by which the board of county commissioners, upon determining that any secure transportation service has violated or failed to comply with any provision of these rules, may:

10 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (A) Temporarily suspend a license or vehicle permit, for a period not to exceed thirty (30) days, whereby the licensee receives a written notice of temporary suspension and a hearing no later than ten (10) days after temporary suspension; (B) Suspend any license or vehicle permit after the temporary suspension period, for any portion of or for the remainder of the license or permit period; or (C) Permanently revoke such a license or vehicle permit upon the licensee receiving a second violation.

Part 6. DATA COLLECTION AND REPORTING REQUIREMENTS 6.1 All secure transportation services in Colorado shall provide the Department with the required data and information as specified in Parts 6.2 and 6.4 below in a form and manner determined by the Department.

6.2 Beginning in 2024, all secure transportation services shall submit, in the form and manner determined by the Department, the following data no later than March 1 for the previous calendar year:

(A) The total number of transports (individual trips and trips with multiple clients as allowed in Part 8.4) that the service’s vehicles made for the previous calendar year; (B) The total number of adults (18+) served by the secure transportation service for the previous calendar year;

(C) The total number of minors (17 and under) served by the secure transportation service for the previous calendar year;

(D) The type of location where individuals were picked up and dropped off for the previous calendar year;

(E) The total number of individuals who were transported by the secure transportation service more than one time for the previous calendar year; (F) The total number of transports (individual trips and trips with multiple clients as allowed in Part 8.4) that the secure transportation service declined due to lack of secure transportation service resources for the previous calendar year; and (G) Demographic information for the previous calendar year, including, but not limited to: (1) The total number of clients served by residential zip code; (2) The total number of clients served by pickup location zip code; and (3) The total number of clients served by gender, race, and ethnicity. (H) The total number of clients the service transported who were not on involuntary holds (M1, M.5, and M8) for the previous calendar year.

11 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division 6.3 Any secure transport resulting in the serious injury, illness, or death of a client or staff member during transport or resulting in injury to the client as a result of the use of physical restraint during transport shall be reported to the receiving facility immediately and to the county within twenty- four (24) hours of the incident in the manner and method determined by the county. Each report shall identify and describe the circumstances leading to the serious injury, illness, or death of a client or staff member during transport.

6.4 The secure transportation service shall complete and submit to the Department a secure transportation service profile in the manner and method determined by the Department. The profile shall include, but not be limited to: contact information for the licensee and its owner, manager, and/or administrator, demographics of the service area, number and types of responding staff, number of calls, counties served, organizational type, and number and type of vehicles.

(A) Secure transportation services shall update the profile data whenever changes occur and at least annually.

(B) As part of its profile, a licensed ground ambulance agency shall notify the Department if it is providing secure transportation services under its ground ambulance license. 6.5 Upon Department request, the county shall provide a list of secure transportation services it licenses and a list of all vehicles for which it has issued permits to provide urgent transportation services.

6.6 The Department may establish procedures to monitor and enforce compliance regarding submission of secure transportation service profile information as described in Part 6.4 and annual submission of utilization data as described in Part 6.2. 6.7 If a secure transportation service fails to comply with these rules, the Department may report this lack of compliance to any counties in which the service is licensed. 6.8 The Department may establish procedures to allow outside agencies, institutions, or individuals to obtain information from the secure transportation data system. 6.9 A secure transportation service may request the annual data that it has submitted to the Department.

Part 7. STAFFING REQUIREMENTS 7.1 Manager and Administrator Minimum Qualifications. The county shall require each secure transportation service operating within its jurisdiction to have a manager and administrator who meet the following minimum qualifications:

(A) Be at least twenty-one (21) years of age, possess a high school diploma or GED, and: (1) Have at least one (1) year documented supervisory experience in the provision of secure transportation services; or (2) Be qualified by education, knowledge, and experience to oversee the secure transportation services provided;

(B) Be able to communicate, understand, and respond effectively to the client, family representatives, and other providers and be able to use appropriate translator services as needed;

12 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (C) Be familiar with all applicable local, state, and federal laws and regulations concerning the operation and provision of secure transportation services; (D) Be in good standing with any state regulatory agency if the manager or administrator is licensed or certified with DORA or the Department; and (E) Have passed a background check that was performed by the secure transportation service or owner prior to the assumption of responsibilities in accordance with Part 7.6(C). The manager or administrator shall not conduct their own background check or any required follow up.

7.2 Administrator Responsibilities. The responsibilities of the administrator include, but are not limited to:

(A) Managing the business affairs and overall operation of the secure transportation service, including planning, organizing, developing, controlling, and/or maintaining the service’s operations;

(B) Organizing and directing the service’s ongoing functions; (C) Overseeing a budgeting and accounting system;

(D) Designating in writing a qualified back up administrator to act in the administrator’s absence or requiring the administrator or their qualified designee to be available in person or remotely to assist secure transportation service staff members with urgent matters that arise during all hours that staff are providing services; (E) Ensuring the secure transportation service is in compliance with all applicable federal, state, and local laws;

(F) Ensuring the completion, maintenance, and submission of such reports and records as required by the county and/or Department;

(G) Developing and implementing a quality management program in accordance with Part 10 of these rules; and (H) Maintaining appropriate records and all policies and procedures of the service, including, but not limited to:

(1) Personnel records, including verification of each staff member’s compliance with orientation and annual training requirements set forth in Part 7.7 and verification of any applicable active professional licensure or certification; (2) Client records, including individual trip logs and the data reporting requirements in accordance with Part 6 of these rules; and (3) Financial and administrative records, including certificates of insurance for the secure transportation service.

7.3 Manager Responsibilities. The responsibilities of the manager include, but are not limited to: (A) Supervising staff and the day-to-day operations of the service; (B) Completing the applicable annual training and core competencies at Part 7.7; 13 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (C) Ensuring annual training completion and core competencies for every staff member with direct client contact;

(D) Implementing a quality management program in accordance with Part 10 of these rules; (E) Maintaining appropriate records and ensuring accurate completion of records, including, but not limited to:

(1) Personnel records; and (2) Client records, including individual trip logs and the data reporting requirements in accordance with Part 6 of these rules; and (F) Implementing all policies and procedures of the secure transportation service. 7.4 The manager and administrator may be the same person. 7.5 The county shall require the secure transportation service to inform the county within fourteen (14) business days, in writing, of changes regarding the manager or administrator of record. 7.6 Secure Transportation Service Staffing (A) At a minimum, the county shall establish by resolution or regulations the following secure transportation staffing requirements:

(1) Any secure transportation vehicle driver must possess a current and valid driver’s license.

(2) If a Type 1 vehicle is being used for the secure transport, then the following shall apply:

(a) If one (1) client is being transported, then one (1) staff member who possesses a current and valid certification for all training topics listed in Part 7.7(A)(1) and (2) is required to staff a vehicle permitted for each secure transport. This staff member may also be the driver. (b) If more than one (1) client is being transported, then one (1) staff member who possesses a current and valid certification for all training topics listed in Part 7.7(A)(1) and (2) shall be assigned to accompany each individual client during transport. A 1:1 ratio of client to staff member shall be maintained during the transport. One of these staff members may also be the driver.

(3) If a Type 2 vehicle is being used for the secure transport, then the following shall apply:

(a) If one (1) client is being transported, then two (2) staff members are required to staff the vehicle. At minimum, the staff member who is not the driver shall possess a current and valid certification for all training topics listed in Part 7.7(A)(1) and (2).

14 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (b) If more than one (1) client is being transported, then one (1) staff member who possesses a current and valid certification for all training topics listed in Part 7.7(A)(1) and (2) shall be assigned to accompany each individual client during transport. A 1:1 ratio of client to staff member shall be maintained during the transport, in addition to the driver who is not included in this staffing ratio requirement. (B) Each staff member with direct client contact must possess a certification or proof of having completed the required coursework in Part 7.7, as applicable. (C) The county shall ensure that the secure transportation service has a policy related to background checks for all staff members. Such background checks shall take place prior to an individual providing secure transportation services. The policy shall include, at a minimum:

(1) The secure transportation service’s responsibility to conduct a background check on every existing and prospective staff member.

(a) If any background check reveals prior convictions of a violent, fraudulent, or abusive nature, the manager or administrator shall inquire further to determine the potential impact on client safety in accordance with the policies developed by the secure transportation service. (b) If an individual is hired despite a background check that reveals a prior conviction of a violent, fraudulent, or abuse nature, the manager or administrator shall document the reasons for hire and plans for supervision.

7.7 Staff Training (A) The county shall establish by resolution or regulations the following minimum staff training requirements for all staff with direct client contact: (1) All staff shall complete orientation and achieve core competencies in training topics before providing secure transportation services. Orientation shall include, but is not limited to, required coursework in the following topics: (a) Cultural competencies including, but not limited to, supporting persons with physical or cognitive disabilities, language accessibility, and accessing interpretive services;

(b) In-person or online verbal de-escalation training sessions that prioritize client and staff safety and inform restraint requirements set forth in Part 8.3;

(c) Trauma-informed care principles;

(d) Evade and escape violent encounter strategies;

(e) Internal policies and procedures applicable to the secure transportation service and staff, including, but not limited to the staff disciplinary policy; (f) Client rights; and 15 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (g) Compliance with applicable privacy laws, including, but not limited to Confidentiality of Substance Use Disorder Patient Records set forth at 42 CFR Part 2 for the support of clients with substance use disorders. (2) In addition to completing the minimum training requirements set forth in Part 7.7(A)(1), all secure transportation staff members who provide direct client support shall also complete training during orientation and achieve core competencies in the following topics:

(a) Adult and Youth Mental Health First Aid as offered by educational institutions or by professional organizations such as mentalhealthfirstaid.org, or the equivalent;

(b) Basic First Aid and CPR; and (c) Care of clients with substance use disorders.

(3) All secure transportation staff members who may utilize physical restraint, as defined at Part 2.21, during secure transportation of clients under Class A services shall, in addition to completing training set forth in Part 7.7(A)(1) and (2), also complete training during orientation and achieve core competencies in the following topics:

(a) Circumstances and protocols governing the permissible application of individual physical restraint during secure transport in accordance with Part 8 of these rules; and (b) Safe application of individual physical restraint on clients during secure transport.

(B) All staff members shall complete orientation and achieve core competencies in training topics prior to providing secure transportation services, and annually thereafter or as recommended by the relevant training organizations.

(C) The secure transport service shall record and document each staff member’s compliance with these orientation and annual training requirements and shall make them available to the county(ies) upon request.

Part 8. CLINICAL, MEDICAL, AND OPERATING STANDARDS AND PROCEDURES 8.1 Parameters for Secure Transportation. Secure transport clients shall only be transported under the following circumstances:

(A) The client is experiencing a behavioral health crisis. (B) The client is in need of urgent transportation to a facility that is defined at Part 2.22(C). (C) The client does not and will not need either:

(1) Medical treatment during transport, or (2) Active or ongoing medical monitoring.

(D) The client does not and will not need to be chemically restrained during secure transport as a behavioral intervention.

16 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division 8.2 Policies and Procedures (A) The county shall ensure that all secure transportation services have policies and procedures that follow national best practice guidelines where available, that address, at a minimum:

(1) Appropriate procedures to assess initially whether the client requires a higher level of transport than the service can provide;

(2) Appropriate procedures to follow when, during a secure transport, it becomes apparent that a client needs medical attention or a higher level of transport than the service can provide;

(3) Appropriate procedures to confirm the receiving facility’s acceptance of the client prior to initiation of the secure transport;

(4) Criteria used for pickup and drop-off, including the circumstances that determine a secure transport client’s eligibility as set forth in Part 8.1; (5) The level of support and protection needed for both client and staff safety; (6) Compliance with vehicle safety standards and procedures set forth in Part 3.3(A)(10);

(7) Proper evacuation of the vehicle during emergencies if the windows and/or exits of the vehicle are blocked or inaccessible;

(8) Infection prevention and control, including the decontamination of the vehicle after each transport;

(9) Parental and/or guardian level of support and involvement; (10) Meeting client needs on extended transports including meals, water, and bathroom breaks;

(11) Documentation of all steps in the process from initial pickup request to drop-off, including but not limited to documenting all stops made during the secure transportation service.

(B) In addition, the county shall ensure that all Class A secure transportation services have the following policies and procedures that address, at a minimum: (1) The circumstances under which staff who provide direct client support may apply individual physical restraint during the course of the secure transportation service, given the parameters outlined in Part 8.3, and (2) The application of individual physical restraint, including training protocols and safety precautions, to ensure the restraints do not restrict the client’s airway or breathing ability.

8.3 Restraint (A) No chemical restraint shall be administered during a secure transport. If chemical restraint is needed to ensure client safety, then the client shall receive an ambulance transport.

17 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (B) Physical restraint, as defined at Part 2.21 for the purposes of this chapter, shall only be utilized for health and safety purposes under the following circumstances: (1) In cases of emergency, when the client is at risk of causing serious, probable, and imminent threat of bodily harm to themselves or to others and where there is the present ability to effect such bodily harm; and (2) After the failure of less restrictive alternatives, including verbal de-escalation; or (3) After a determination that such alternatives would be inappropriate or ineffective under the circumstances.

(C) If physical restraint is utilized during a transport, the service shall document the time at which the physical restraint was applied and removed (if applicable) and the type of physical restraint used.

8.4 The secure transportation service shall transport one (1) client per vehicle transport, except under the following circumstances:

(A) Each client has received behavioral health clearance from the treating provider at the sending facility, no physical restraint is needed, and there is a low probability of behavioral destabilization;

(B) Each client has received medical clearance from the treating provider at the sending facility, is medically stabilized, and has a low probability of medical destabilization; (C) Each client has received an assessment from the treating provider at the sending facility that the client is an appropriate candidate for a transport with one or more individuals; (D) The transport is an inter-facility transport as defined at Part 2.22(C); and (E) Each client has given their consent to be transported with another individual(s). 8.5 The secure transportation service shall create and maintain accurate and detailed logs of client transports, including professional incident reports.

8.6 To ensure the needs of clients are met, secure transportation services that do not provide 24/7 services shall provide the client with their after-hours contact information and with contact information for the secure transportation service’s back-up providers. Part 9. CLIENT RIGHTS 9.1 The county shall ensure that each secure transportation service has written client rights that assure a client has the right to be treated with consideration, respect, and full recognition of human dignity and individuality, and that include, at a minimum: (A) The right of the client and their property to be treated with respect; (B) The right of the client to have access to basic comfort items and their personal mobile phone provided the direct client support staff member establishes and documents that those items do not pose a danger to the client or staff member; (C) The right of the client to wear their own clothes provided the direct client support staff member establishes and documents that those items do not pose a danger to the client or staff member;

18 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division (D) The right of the client to receive secure transportation services by the least restrictive means necessary to assure the safety of the client;

(E) The right of the client to be free from discrimination in the provision of services; (F) The right of the client to be free from neglect; financial exploitation; and verbal, physical, and psychological abuse, including humiliation, intimidation, or punishment; (G) For clients who request voluntary transport, the right of the client to discontinue secure transportation services;

(H) The right of the client to receive disclosure about any video and/or audio recording that occurs during the delivery of service in accordance with applicable privacy laws; (I) The right of the client to have personally identifying health information protected from unnecessary disclosure;

(J) The right of the client or their representative to file a complaint against the secure transportation service with the secure transportation service and county concerning services or care that is or is not furnished, and receive documentation of the existence of the investigation and resolution of the complaint, including providing the complainant with the results of the investigation and the secure transportation service’s plan to resolve any identified issues; and (K) The right of the client to file a complaint with the secure transportation service and county without fear of discrimination or retaliation by the secure transportation service’s owner, manager, administrator, or any staff members.

9.2 The county shall ensure that each secure transportation service has client rights’ policies and procedures that include, at a minimum:

(A) Procedures for identifying, reporting, reviewing, and investigating all allegations of abuse, mistreatment, neglect, and exploitation.

(B) Procedures for timely communicating all investigation results to the client and county in which the secure transportation service is licensed.

(C) Procedures for timely and appropriate disciplinary action up to and including termination of staff and appropriate legal recourse against any staff member who has engaged in abuse, mistreatment, neglect, or exploitation of a client. (D) Procedures the direct client support staff member must follow, pursuant to Parts 9.1(B) and (C), to document their decision to:

(1) withhold any basic comfort items and/or the client’s personal mobile phone, or (2) prohibit a client from wearing their own clothes.

9.3 The secure transportation service shall provide written documentation of client rights and client rights’ policies and procedures, including the right to file a complaint with the county, to clients at the initiation of the secure transportation service.

(A) If the client is unable to read the rights, they shall be read the rights in a language they understand.

19 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division Part 10. QUALITY MANAGEMENT PROGRAM (QMP)

10.1 The county shall require each secure transportation service operating within its jurisdiction to have an ongoing quality management program (QMP) that is appropriate to the size and type of the service. The program shall incorporate a plan that evaluates the quality of client care and safety and has the following policies and procedures including, at a minimum: (A) The incorporation of the substantiated findings of any complaint into its QMP for the purpose of evaluating and implementing systematic changes where needed; (B) The general description of the types of cases, problems, or risks to be reviewed and criteria for identifying potential risks;

(C) Identification of the staff members responsible for coordinating quality management activities;

(D) A description of the method(s) for:

(1) Investigating and analyzing the frequency and causes of individual problems and patterns of problems;

(2) Taking corrective action to address the problems, including prevention and minimizing problems or risks;

(3) Evaluating corrective action(s) to determine the effectiveness of such action(s); and (4) Coordinating all pertinent case, problem, or risk review information with other applicable quality assurance and/or risk management activities, such as review of client care; review of staff conduct; the client complaint system outlined in Part 4 of these rules; and education and training programs;

(E) Documentation of required quality management activities, including cases, problems, or risks identified for review; findings of investigations; and any actions taken to address problems or risks;

(F) A schedule for program implementation not to exceed ninety (90) days after the date of the issuance of the secure transportation service license; (G) A schedule for program evaluation to periodically assess the effectiveness of services and review the clinical and operational protocols and compliance with such protocols; (H) The utilization or application of data collected pursuant to Part 6.2 to inform the quality management plan; and (I) A written disciplinary policy that addresses a process for staff quality improvement. 10.2 The secure transportation service shall make available the quality management plan to the county in which it seeks to be licensed during the initial and renewal licensure applications. 10.3 The county, Department, or any other appropriate regulatory agency having jurisdiction for disciplinary or licensing sanctions shall have access to any records, reports, and other information of the quality management program.

20 CODE OF COLORADO REGULATIONS 6 CCR 1011-4 Health Facilities and Emergency Medical Services Division _________________________________________________________________________ Editor’s Notes History New rule eff. 08/14/2022.

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