8 CCR 1507-31 – Building, Fire, and Life Safety Code Enforcement and Certification of Inspectors for Health Facilities Licensed by the State of Colorado

DEPARTMENT OF PUBLIC SAFETY Division of Fire Prevention and Control BUILDING, FIRE, AND LIFE SAFETY CODE ENFORCEMENT AND CERTIFICATION OF INSPECTORS FOR HEALTH FACILITIES LICENSED BY THE STATE OF COLORADO 8 CCR 1507- 31 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ APPLICABILITY These rules and regulations apply to all health facilities pursuant to the provisions of §24-33.5-1201, C.R.S.

ARTICLE 1 – AUTHORITY TO ADOPT RULES AND REGULATIONS 1.1 Sections 24-33.5-1201, 24-33.5-1203, 24-33.5-1204.5 and 24-33.5-1206, C.R.S. establish the authority and duty of the Division of Fire Prevention and Control to conduct or oversee the necessary plan reviews, issue building permits, and cause the necessary inspections to be performed as required by the CRS Title 24 Article 33.5 Part 12 and the adopted codes for buildings and structures of health facilities licensed by the State of Colorado 1.2 Sections 24-33.5-1212.5 and 24-33.5-1213.5, C.R.S. establishes the authority and duty of the Division to certify persons to conduct Building Code plan reviews and inspections for health facilities licensed by the State of Colorado. Such persons are reviewed and certified as part of the third-party building inspector certification.

1.3 Section 24-33.5-1211 C.R.S. establishes the authority and duty of the Division of Fire Prevention and Control to certify persons to conduct Fire and Life Safety Code plan reviews and inspections for health facilities licensed by the State of Colorado.

1.4 The Director of the Division of Fire Prevention and Control is authorized by the provisions of section 24-33.5-1203.5, C.R.S., to promulgate rules in order to carry out the duties of the Division of Fire Prevention and Control 1.5 The Director of the Division of Fire Prevention and Control is authorized to establish fees and charges necessary to defray the anticipated costs of the program. ARTICLE 2 – DEFINITIONS 2.1 The definitions provided in 24-33.5-1202, C.R.S., apply to these rules. The following additional definitions also apply:

" Authority Having Jurisdiction " or (AHJ) means the Division, Building Department, Fire Chief, Fire Marshal, or other designated official of a county, municipality, special authority, or special district that has code enforcement responsibilities and employs a Certified Inspector. " Board " means the board of directors, owner(s), sole proprietor, board of managers, governing body, or other legal entity having authority over a Health Facility, subject to these rules. For the purposes of these rules the Board may elect to be represented by a designated representative through a written delegation of authority.

" Building Department " means the Building Department (or a contracted third party acting on their behalf) of an authority, county, town, city, or city and county. " Building Permit " means an official document issued by the Authority Having Jurisdiction which authorizes the erection, alteration, demolition and/or moving of buildings and structures. " Certificate of Compliance " means an official document issued by the Division, stating that materials and products meet specified standards, or that work was performed in compliance with approved construction documents.

" Certificate of Occupancy " means an official document issued by the Authority Having Jurisdiction which authorizes a building or structure to be used or occupied for a specified use. " Certified Inspector " means a Division or Third Party inspector who has been certified by the Division of Fire Prevention and Control to conduct building, fire, and/or life safety code inspections at the appropriate level for the task being performed " Certified Health Facility " means a Health Facility which has been certified (or is seeking certification) by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services to participate in Federal funding of health care services under the provisions of the Federal Medicare and/or Medicaid programs.

" CEU " means a continuing education unit.

" CMS " means the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.

" Core And Shell Permit " means an official document issued by the Authority Having Jurisdiction which is limited to authorizing the construction of foundation, columns, floor slabs, roof structure, exterior walls, and exterior glazing to the point of the building being weather tight. " Construction " means work that is not considered as maintenance or service, and that requires a permit as prescribed in the adopted codes and standards of the Division. " C.R.S. " means Colorado Revised Statutes.

" Demolition Permit " means an official document issued by the Authority Having Jurisdiction which is limited to authorizing the demolition of all or part of a building or structure. " Designated Representative " – means a person designated by the board to act on their behalf through a written delegation of authority, and where allowed to act in such manner by these rules. " Director " means the Director of the Division of Fire Prevention and Control. " Division " means the Division of Fire Prevention and Control. " Division of Fire Prevention and Control " means the Division of Fire Prevention and Control in the Department of Public Safety.

" Fire Code Official " means the designated authority charged with the administration and enforcement of the Fire Code. Refer to Article 5 for information pertaining to the definition of the Fire Code Official.

" Foundation " means work related to building footings, piers, foundation walls, slabs on grade, under slab and underground building services.

" Foundation Permit " means an official document issued by the Authority Having Jurisdiction which is limited to authorizing the construction of foundations. " Health Facility " means a general hospital, hospital unit as defined in section 25-3-101 (2), C.R.S., psychiatric hospital, community clinic, rehabilitation center, convalescent center, community mental health center, acute treatment unit, facility for persons with developmental disabilities, habilitation center for children with brain damage, chiropractic center and hospital, maternity hospital, nursing care facility, rehabilitative nursing facility, hospice care facility, dialysis treatment clinic, ambulatory surgical center, birthing center, home care agency, assisted living residence, or other facility of a like nature; except that " Health Facility " does not include a facility at which health services are not provided to individuals. " ICC " means the International Code Council.

" Individual " or " Person " means a person, including an owner, manager, officer, employee, or individual.

" Inspection, Testing, and Maintenance Program " means a program conducted by the building owner to satisfy the periodic inspection, testing, and maintenance requirements of fire protection and life safety systems as required by applicable codes and standards. " Installation " means the initial placement of equipment or the extension, modification or alteration of equipment after the initial placement.

" Life Safety Code Official " means the designated authority charged with the administration and enforcement of the Life Safety Code. Refer to Article 5 for information pertaining to the definition of the Life Safety Code Official.

" Limited Scope Project " means a project with limited impact to fire and life safety features of a facility as defined by the Division. Permits for Limited Scope Projects are issued for a maximum of three years and expire concurrent with the Certificate of Compliance for the Health Facility. " Maintenance " means to sustain in a condition of repair that will allow performance as originally designed or intended. Maintenance does not include replacement of elements of a system which alter the performance criteria of the system as approved by the Authority Having Jurisdiction. " Maintenance & Complaint Inspections " means periodic inspections or inspections conducted based on an allegation of nonconformance conducted by the local fire department or the Division to verify conformance with the adopted Codes, rules, and standards. Such inspections are not to be considered to relieve the building owner of the responsibility to conduct an inspection, testing, and maintenance program for fire protection and life safety systems as required by the adopted Codes and Standards.

" MOU " means memorandum of understanding.

" NICET " means the National Institute for Certification in Engineering Technologies. " NFPA " means the National Fire Protection Association. " Qualified Fire Department " means a fire department providing fire protection service for the buildings and structures of the Board that has Certified Fire Inspectors at the appropriate level for the fire prevention related task being performed.

" Service (Or Repair) " means to repair in order to return the system to operation as originally designed or intended.

" Temporary Certificate Of Occupancy " means an official document issued by the Authority Having Jurisdiction which authorizes a building or structure to be temporarily used or occupied for a period not to exceed 90 days, unless an extension has been granted by the Authority Having Jurisdiction.

" Temporary Construction Trailer/Office " means a temporary modular building, owned and operated by the contractor that is less than 1,000 square feet and only placed for the duration of the project. Trailers meeting this definition (except where medical services are provided) are exempt from this rule. Trailers not meeting this definition will be considered as a modular building and permitted as such.

" Third Party Inspector " means building inspectors that have been certified by the Division to perform third party inspection services in accordance with Article 10.1 of this rule. " Total Project Valuation " means the total value of work including materials and labor. For Certificates of Occupancy and Certificates of Compliance for currently unlicensed Health Facilities the Total Project Valuation also includes the acquisition cost of structures. The cost of the land does not affect the cost of related code enforcement activities and is not included in the Total Project Valuation. In the event that the space is leased, the Total Project Valuation also includes the total expenditure by the Board to occupy the facility during the first year of the lease. ARTICLE 3 – CODES, DOCUMENTS, AND STANDARDS INCORPORATED BY REFERENCE 3.1 The technical requirements of these rules are supported primarily by codes developed by the International Code Council and the National Fire Protection Association. These two organizations are membership associations dedicated to building safety and fire prevention. These rules establish minimum requirements where the Division is the Authority Having Jurisdiction for building systems using prescriptive and performance related provisions, which are widely used to construct residential and commercial buildings.

3.2 The following codes (and their referenced standards) are adopted and promulgated as minimum standards for the construction and maintenance of all property, buildings, and structures containing a Health Facility in the State of Colorado:

b) International Fire Code - 2012 Edition, First Printing: May 2011 (Copyright 2011 by International Code Council, Inc.), including Appendices B through I. c) International Mechanical Code - 2012 Edition, First Printing: April 2011 (Copyright 2011 by International Code Council, Inc.).

i) NFPA 101A Guide on Alternative Approaches to Life Safety – 2013 Edition, First Printing: June 2013 (Copyright 2013 by National Fire Protection Association). j) All electrical work must be conducted, inspected, and approved in accordance with the provisions of the State of Colorado’s Electrical Board’s rules and regulations. k) All plumbing work must be conducted, inspected, and approved in accordance with the provisions of the State of Colorado’s Examining Board of Plumber’s rules and regulations.

3.3 For all facilities submitting for construction permits after January 1, 2014, in addition to the above referenced codes and standards the 2010 Guidelines for Design and Construction of Health Care Facilities (Copyright 2010 by Facilities Guidelines Institute, Inc. - Chicago, Illinois) will guide design and construction of health facilities licensed by the State of Colorado. If the above adopted codes are silent, conflicting, or otherwise subject to interpretation, then the 2010 Guidelines may serve as basis for design related to that issue.

3.4 In any facility where the evacuation capability of the facility or resident population is required to be rated, the "Procedure for Determining Evacuation Capability" published by NFPA is to be used by the facility whether the facility is evaluated utilizing the NFPA 101A, Guide on Alternative Approaches to Life Safety (2013), or NFPA Standard 101, Life Safety Code (2012). The Level of Evacuation Difficulty for each facility will be determined by the scores developed in the Worksheet for Rating Residents completed by responsible staff for each resident and the level of staffing maintained at the facility. It is the responsibility of the owner or administrator to insure that the abilities of the residents are accurately rated in accordance with the published instructions. Each new resident shall be rated utilizing the Worksheet for Rating Residents within two (2) weeks of their admission to the facility. All resident rating scores shall be reviewed at least annually, or when there are significant changes in a resident's physical or cognitive abilities. 3.5 For Certified Health Facilities, the facility must also meet the requirements established by CMS or the State Medicaid Agency for such certification. In the event it is impractical to meet the requirements of both the above standards and those established by CMS, the standards established by CMS will prevail.

3.6 Certificates of Occupancy and Certificates of Compliance issued after July 1, 2013 by the Division for space not currently licensed by CDPHE will be based on compliance with the requirements for new construction within the applicable codes.

3.7 The Division shall maintain copies of the complete texts of the adopted codes, which are available for public inspection during regular business hours. Interested parties may inspect the referenced incorporated materials by contacting the Division at 690 Kipling Street, Lakewood, Colorado, 80215 or by phone at (303) 239-4600.

3.8 In the event that a new edition of the code is adopted, the code current at the time of permit application shall remain in effect throughout the work authorized by the permit. 3.9 This rule does not include later amendments or editions of the incorporated material. ARTICLE 4 – AUTHORITY OF LOCAL BUILDING DEPARTMENTS 4.1 Where there is a local Building Department the authority to conduct the necessary plan reviews, issue building permits, conduct inspections, issue certificates of occupancy, issue Temporary Certificates of Occupancy, and take enforcement action to ensure that a building or structure has been constructed in conformity with the locally adopted codes remains the responsibility of the local Building Department. Under these circumstances, the Division will accept a completed Building Permit and associated Certificate of Occupancy from the local Building Department as demonstration of compliance with the locally adopted building codes. 4.2 Where there is not a local Building Department the authority to conduct the necessary plan reviews, issue building permits, conduct inspections, issue certificates of occupancy, issue Temporary Certificates of Occupancy, and take enforcement action to ensure that a building or structure has been constructed in conformity with these rules is the responsibility of the Division. Under these circumstances, the Division will issue the applicable Building Permits and associated Certificates of Occupancy as demonstration of compliance with the Division’s adopted building codes. ARTICLE 5 – DEFINITION OF FIRE AND LIFE SAFETY CODE OFFICIALS 5.1 The Division is the Fire and Life Safety Code Official for Health Facilities. 5.2 For non-Certified Health Facilities where the local fire department has Certified Fire Inspectors at the appropriate level for the task, conducting the necessary construction plan reviews and inspections remains the responsibility of the local fire department for the location of the structure. Under these circumstances, the local fire department will be considered as the Fire and Life Safety Code Official.

5.3 If the local fire department declines to perform the plan review or any subsequent inspection, or if a Certified Fire Inspector is not available, the Division will perform the construction plan reviews and inspections required by the Division’s adopted Fire and Life Safety Codes and will be considered as the Fire and Life Safety Code Official.

5.4 For Certified Health Facilities where the local fire department has Certified Fire Inspectors at the appropriate level for the task, the responsibility of conducting the necessary construction plan reviews and inspections remains the responsibility of the local fire department over the location of the structure. Under these circumstances, the local fire department will be considered as the Fire Code Official. In this instance, the Division will perform the construction plan reviews and inspections required for Life Safety Code compliance by these rules and will be considered as the Life Safety Code Official.

ARTICLE 6 – BUILDING PERMIT APPLICATION SUBMITTAL TO THE DIVISION 6.1 Notification of submittal to a local Building Department. 6.1.1 For projects that require a permit that will be reviewed and inspected by a local Building Department, the Board must notify the Division and the State licensing authority prior to beginning construction. Notification should include:

A) Name of project;

B) Location of project;

C) Scope of work;

D) Projected cost;

E) Planned construction start and end dates;

F) Identification of Fire Code Official (Name of the Qualified Fire Department or the Division);

G) Identification of Building Code Official;

H) A description of the proposed health services to be provided and the type of licensure being sought through the state licensing authority;

I) A copy of the life safety code plan sheets submitted in the format as prescribed by the Division.

6.2 Permit Application Submittal to the Division 6.2.1 For all construction (including adding previously unlicensed space to a health facility license) or operational permits not covered under a Limited Scope Project permit as defined by this Article, the Board must submit a complete plan review application package to the Division for Life Safety Code compliance review, if there is not a local building department the Board must also submit a complete plan review application package to the Division for building code compliance review. 6.2.2 The plan review application package must be submitted to the Division in the format defined by the Division.

6.2.3 The building permit application package must be concurrently submitted to the Division and to the local fire department. Either the Qualified Fire Department or the Division will review the submittal for compliance with the applicable codes. Permit issuance is contingent upon the review and approval of the submittal by the Fire Code Official. The Board is required to contact the local fire department to determine the submittal items other than those listed in this rule.

6.3 Plan Review and Permitting by the Division 6.3.1 The Division will notify the Board if the building permit application is incomplete. 6.3.2 The Building Code plan review will be completed by a certified building plans examiner within the Division.

6.3.3 The Fire Code plan reviews will be completed by an individual certified as a Fire Inspector III – Plans Examiner within the Division, or by the Qualified Fire Department. 6.3.4 The Life Safety Code plan reviews will be completed by an individual certified as a Fire Inspector III – Plans Examiner and CMS Certified Life Safety Code Inspector within the Division.

6.3.5 Upon completion of the building code review, the Division will provide to the Board a comprehensive list of corrections to be addressed prior to the issuance of a Building Permit. This list of corrections should not be considered all-inclusive, and may not be considered as approval of any condition in violation of applicable code. Once all corrections have been satisfactorily addressed, the Division will issue the Building Permit. 6.3.6 Upon completion of the fire and life safety codes review, the Division will provide to the Board a comprehensive list of corrections to be addressed prior to the issuance of a permit. This list of corrections should not be considered all-inclusive, and may not be considered as approval of any condition in violation of applicable code. Once all corrections have been satisfactorily addressed, the Division will issue the applicable permits.

6.4 Phased Construction 6.4.1 Upon request by the Board, the Division may issue individual permits for demolition, construction of foundations, and construction of core and shell, provided that construction documents for that portion of the building or structure being permitted have been submitted per Article 6-3. The holder of such permit for demolition, or the construction of foundations or vertical construction may then proceed at the holder’s own risk with building operation and without assurance that a permit for the entire structure will be granted. Issuance of this permit should not be considered all inclusive and may not be considered as approval of any condition in violation of applicable codes. 6.5 Deferred Design/Build Submittals / Shop Drawings 6.5.1 Deferred design/build (shop drawing) submittals for fire protection and life safety systems are permitted, however construction documents must provide sufficient information to show compliance with Fire and Life Safety Code requirements and coordination between fire systems and other building systems (i.e., HVAC systems, security systems). 6.5.2 Shop (Installation) drawings for fire protection and life safety systems must be submitted to the Fire and Life Safety Code Official(s) for review and approval prior to beginning installation of the system.

A) Fire sprinkler and fire alarm shop drawings must be submitted to the Fire and Life Safety Code Officials in accordance with the requirements of the adopted codes in the format as prescribed by the Division and the local fire department. B) Shop (installation) drawings for other systems regulated by the Fire and Life Safety Codes must be submitted to the Division in accordance the appropriate reference standard for the system.

6.5.3 Minimum qualifications for fire protection and life safety system design and installation. A) Fire Suppression Systems Any installation, modification, alteration, or repair of a fire suppression system must be in accordance with C.C.R. 1507-11 - Colorado Fire Suppression program.

B) Fire Alarm Systems (1). The design of any new system or alteration of an existing fire alarm system using the prescriptive requirements of NFPA 72 must be performed by a person who is currently a professional engineer or certified by NICET at a level III or level IV in fire protection engineering technologies - fire alarm systems, or another nationally recognized organization approved by the Division.

(2). The design of any new system or alteration of an existing fire alarm system using performance based design methods as described by NFPA 72 or alternative materials and methods as described by the adopted Fire Code must be performed by a person who is currently a professional engineer.

(3). The installation of a fire alarm system must be performed by or supervised by a person who is currently certified at a minimum of NICET level II in fire protection engineering technologies – fire alarm systems, or another nationally recognized organization approved by the Division. C) Other Fire Protection Systems regulated by the Fire or Life Safety Code. The design and installation must be performed by a company or individual with manufacturer or factory approved training for the specific system, or as otherwise required by the applicable Code section or referenced standard. 6.7 Limited Scope Project Permit 6.7.1 In lieu of an individual fire/life safety code permit for each limited scope project the Division may issue a Limited Scope Project Permit, upon approved application. Limited Scope Project Permits are valid for a period of up to 36 months from the issuance date but in no case longer than the expiration date of the currently issued Certificate of Compliance. The Board must notify the Local Fire Department prior to the commencement of work conducted under a Limited Scope Project Permit. .

6.7.2 Limited Scope Project Permits are restricted to those projects identified by the Division . 6.7.3 The Board to whom a Limited Scope Project Permit is issued must keep a detailed record, including stamped engineered drawings (if applicable), of all modifications made under such Permit.

6.7.4 All work completed under an Limited Scope Project Permit must be inspected by a local building department inspector, a Third Party Inspector or a Qualified Tradesperson (as specified by the installation standards adopted by the Division or the manufacturer’s installation recommendations) within 10 days of completion of a project, and such inspections must be recorded on an inspection log. The Division must have access to all inspection logs at all times and such records must be submitted to the Division or the within 30 days of the expiration date of the Limited Scope Project Permit. 6.7.5 If the inspection logs associated with the Limited Scope Project Permit demonstrate compliance with the Limited Scope Project Permit requirements, the Division may issue a Certificate of Compliance for projects completed under that permit. 6.7.6 If the inspection logs associated with the Limited Scope Project Permit demonstrate noncompliance with the Limited Scope Project Permit requirements, the Division will issue a correction notice and may withhold issuing another Limited Scope Project Permit or Certificate of Compliance to the Board until all corrections have been satisfied. ARTICLE 7 – CONSTRUCTION INSPECTIONS 7.1 Building Code Inspections conducted by the Division 7.1.1 Construction or work for which a permit is required is subject to inspection by the Division or a Third Party Inspector contracted by the Board. Such construction or work must remain accessible and exposed for inspection purposes until approved. Neither the Division, nor a Third Party Inspector contracted by the Board is liable for expense entailed in the removal or replacement of any material required to allow inspection. 7.1.2 Third Party Inspections: The Division may contract with third-party inspectors who are certified in accordance with Article 10 of these rules to perform inspections. A Health Facility may hire and compensate third-party inspectors under contract with the Division or hire and compensate other third-party inspectors who are certified in accordance with Article 10 of these rules to perform inspections.

A) Prior to commencement of construction on projects requiring third party inspections, the Board must notify the Division of the designated Third Party Inspector for the permitted project. The notification must be made in writing using a form provided by the Division. The Division may request a preconstruction meeting with the Board, the contractor hired to perform the work, and the certified Third Party Inspector.

B) The Division will require a sufficient number of third-party inspection reports to be submitted by the inspector based upon the scope and cost of the project to ensure quality inspections are performed. Concurrent with the permit approval, the Division will issue an Inspection Card specifying the applicable required inspections as set forth in Chapter 1 of the Building Code or as determined by the Division. The inspection card must be on site throughout the duration of the project.

C) Violation of Third-Party Inspection Requirements: If the Division finds that inspections are not completed satisfactorily, or that all violations are not corrected, the Division will take enforcement action against the appropriate Board pursuant to Article 11. In such case the Division may also require that all inspections for the next project undertaken by the Board be conducted by the Division’s inspectors. 7.1.3 For permits issued by the Division, the final inspection will be conducted only by the Division, after all work required by the building permit is completed. Mid-construction inspections may be performed to observe progress and verify compliance with third-party inspection requirements as deemed necessary by the Division. 7.1.4 Third Party Inspectors must include their printed name and state certification number in the appropriate location on the inspection report or card.

7.2 Fire and Life Safety Code Inspections 7.2.1 Project sites must be inspected by the Fire and Life Safety Code Officials to verify compliance with the Fire and Life Safety Codes and approved construction documents. Construction inspections must be conducted by a person certified as Fire Inspector II or Fire Inspector III – Plans Examiner. Third-party inspection provisions do not apply to the required Fire and Life Safety Code inspections. Either the Division or the Qualified Fire Department must perform fire inspections.

7.2.2 A Certified Fire Suppression System Inspector must perform inspections of fire suppression systems in accordance with C.C.R. 1507-11 – Colorado Fire Suppression Program. A) If the Certified Fire Inspector II or Fire Inspector III – Plans Examiner also holds a Fire Suppression System Inspector certification, the inspector may perform both inspections.

B) If the Certified Fire Inspector II or Fire Inspector III – Plans Examiner is not also a Certified Fire Suppression System Inspector, the Fire Code Official must obtain the services of a Certified Fire Suppression System Inspector to perform the suppression system inspections.

7.2.3 Results of all inspections must be documented on the job site inspection card and in the official records of the inspecting entity, including type of inspection, date of inspection, identification of the responsible individual making the inspection, and comments regarding approval or disapproval of the inspection. Inspection records must be retained by the inspecting entity for two years after the Certificate of Compliance or Certificate of Occupancy is issued.

7.2.4 Certified Fire Inspectors must include their printed name and state fire inspector certification number in the appropriate locations on the inspection report or card. 7.3 Inspection Request Notification to the Division.

7.3.1 The Division must be provided with notification in writing no later than noon of the Thursday in the week preceding the requested inspection. The Division will make reasonable efforts to provide the inspection on the requested day or time, provided an inspector is available. If the inspection schedule is full, an alternate day and time will be proposed for the inspection to be completed within the next 30 days, unless otherwise negotiated. 7.3.2 It is the duty of the permit holder to provide access to and means for inspections of such work that are required by the inspector.

7.3.3 Work will not be done beyond the point indicated in each successive inspection without first obtaining the approval from the appropriate inspection entity. The inspector, upon notification, will perform the requested inspections. In the case that the Division cannot complete the inspection within the timeframe requested the Board may elect to hire a Third Party Inspector to conduct that inspection at their own expense. Upon completion of the inspection, the inspector will either indicate the portion of the construction that is satisfactory as completed, or notify the permit holder or their agent wherein the same fails to comply with the codes adopted in these rules. Any portions that do not comply must be corrected and such portion must not be covered or concealed until authorized by the appropriate inspection entity. The re-inspection must be requested in accordance with Article 7.3.1.

ARTICLE 8 – CERTIFICATE OF OCCUPANCY AND CERTIFICATE OF COMPLIANCE 8.1 The Board will not occupy or use a Health Facility or portion thereof until a Certificate of Occupancy or a Temporary Certificate of Occupancy has been issued by Division or the local building department.

8.2 The Division or the local building department may issue a Temporary Certificate of Occupancy if a Board requires immediate occupancy, and if the Board has passed the appropriate inspections, including fire inspections, that indicate there are no life safety issues. If no renewal of the Temporary Certificate of Occupancy is issued or a permanent Certificate of Occupancy is not issued, the building must be vacated upon expiration of the Temporary Certificate of Occupancy. 8.3 No Health Facility will provide health services as without a valid Certificate of Compliance that has been issued by the Division for that portion of the Health Facility. If no renewal of the Certificate of Compliance is issued, the building must be vacated upon expiration of the Certificate of Compliance.

8.4 Certificates of Occupancy and Certificates of Compliance will be issued based on the codes in effect during the most recent inspection of the facility. No Certificate of compliance will be issued until compliance with the applicable codes and standards has been demonstrated through record review of Board submitted local AHJ documents of inspection and certificate, Division inspection and certification, or other appropriate documentation showing the building to be in conformance with applicable codes and standards applicable at the time of issuance. 8.5 For the initial issuance of the Certificates of Compliance after July 1, 2013 the Certificate will be based on the codes as adopted and enforced by CDPHE during the last inspection of the facility conducted within the Five years prior to July 1, 2013. For facilities which have not been inspected within the last Five years the Certificate will be issued based on the codes as adopted and enforced by CDPHE as of June 30, 2013.

ARTICLE 9 – MAINTENANCE AND COMPLAINT INSPECTIONS AND INSPECTION, TESTING AND MAINTENANCE PROGRAMS.

9.1 Maintenance and Complaint Inspections.

9.1.1 The Division may perform inspections of the buildings and structures when deemed necessary to assure that they are maintained in accordance with the appropriate chapters of the adopted Fire and Life Safety Codes. If the Health Facility is not certified or seeking certification to participate in Medicare or Medicaid funding, the Local Qualified Fire Department providing fire protection service will conduct these maintenance inspections A) If the Local Qualified Fire Department is unable or unwilling to perform maintenance or complaint inspections, the Division has the authority and duty to perform them. B) If the Local Qualified Fire Department does not have an inspector certified as a Fire Inspector I or above, the Division will perform regular maintenance inspections for the Board to ensure compliance with this rule and the applicable statutes. In this instance the Division inspector will attempt to contact the local Fire Authority to ascertain any concerns the local fire authority might have related to the health facility.

9.1.2 Where a local Qualified Fire Department is performing maintenance and complaint inspections the Board is required to notify the Division that such inspections are being performed. The Board must provide a copy of the Local Qualified Fire Department’s inspection report and documentation that all identified deficiencies have been corrected within 30 days of the inspection and subsequent re-inspections until compliance is demonstrated. If such documentation is not provided, the Division will assume that the inspections have not been performed and will have the duty to perform them. 9.1.3 Nothing in this Article 9.1 prohibits the fire department providing fire protection services from conducting routine assessments of buildings and structures, or prevents the department from correcting violations that pose an immediate threat to life safety. Additionally, nothing in this Article 9.1 prohibits the Fire Department from seeking enforcement action in a court of competent jurisdiction. 9.1.4 A local Qualified Fire Department providing fire protection service for buildings and structures of a Board that chooses to perform Fire and Life Safety Code inspections may refer notices of deficiencies to the Division for evaluation and enforcement. Notices of deficiencies and requests for evaluation and enforcement must be submitted in writing to the Division as described in Article 11 of this Rule. 9.2 Inspection, Testing and Maintenance Programs.

9.2.1 The Board must ensure that building systems are inspected, tested, and maintained as required by the adopted codes and referenced standards. 9.2.2 Personnel employed by a Board performing inspection, testing, and maintenance programs are not required to be Certified Fire Inspectors, but must be qualified to perform the actions as required by the standards or listings of the devices or systems. A) Exception: Work conducted on system components that would require permits, licensing, or certifications under any adopted codes, laws, or rules must be conducted in accordance with those requirements.

9.2.3 Inspection, Testing, and Maintenance Records must be retained for at least three years. Records must indicate the procedure or inspection performed by the organization that performed the procedure or inspection, the results, and the date. The Board must provide these records for review by the local Qualified Fire Department or to the Division upon request.

ARTICLE 10 – BUILDING CODE AND FIRE CODE INSPECTOR CERTIFICATION 10.1 Division and Third Party Building Code Inspectors 10.1.1 Division and Third Party Building Inspectors must be certified as Third-Party Building Inspectors in accordance with this Article 10.1.

10.1.2 Third Party Building Inspector Certification Applicants seeking such certification must have the following minimum qualifications: (1) Hold current appropriate building inspector certifications from ICC or other similar national organization, and have demonstrated education, training, and experience, or (2) Have at least five years of demonstrated education, training, and experience in commercial building inspections and receive national certification within one year after the date of certification. Qualified applicants that have at least five years of demonstrated education, training, and experience in appropriate building inspections will be issued certifications for one year. Certification renewal will be contingent on the applicant obtaining commercial building inspector certification from ICC or other similar national organization, prior to the expiration date of the applicant’s inspector certification.

10.1.3 Duties of Third Party Inspectors A) Third Party Inspectors, contracted by the Board, must conduct the required inspections, and require corrections or modifications as necessary to ensure that a building or structure is constructed in conformity with the building code adopted by the Division.

B) Third Party Inspectors, contracted by the Board, must enforce only the codes adopted by the Division C) The Board must only use inspectors that are certified by the Division to work on Health Facility projects.

D) Third Party Inspectors contracted by the Board must send copies of their inspection reports to the Division.

E) If all inspections are not completed and a building requires immediate occupancy, and if the Board has passed the appropriate inspections that indicate there are no life safety issues, the certified Third Party Inspectors contracted by the Board must notify the Division of the same so that a Temporary Certificate of Occupancy may be issued to allow the Board to occupy the buildings and structures. F) Third Party Inspectors contracted by the Board must attest that inspections are complete and all violations are corrected before the Division issues the Board a Certificate of Occupancy. The certified Third Party Inspectors must retain inspection records for three years after the Certificate of Occupancy is issued. 10.1.4 Applicants must complete the process as defined by the Division. 10.2 Fire Inspector Certification 10.2.1 Fire Inspectors performing construction plan review and inspections must be "Certified Fire Inspectors" as defined in section 24-33.5-1202 (2.5), C.R.S. 10.2.2 There are three levels of certification for Fire Inspectors. Inspectors must be certified to the appropriate level defined in Sections A through C of this Article for the task performed. A) FIRE INSPECTOR I - In order to become certified as Fire Inspector I, a person must meet at least one of the following criteria:

(1) Possess current and valid inspector certification(s) issued by a nationally recognized organization, which includes knowledge in fire protection and life safety systems, plan review and inspection. The following certifications are approved:

(a) ICC Fire Inspector I (b) NFPA Fire Inspector I (2) Submit documentation to the Division to demonstrate that they have the requisite skills and knowledge specified in NFPA 1031 – Standard for Professional Qualifications for Fire Inspector and Plans Examiner for Fire Inspector I, including education, training and experience. The following list identifies examples of education, training, and experience that may be considered as equivalent to the requisite skills and knowledge for Fire Inspector I. This list should not be considered all- inclusive.

(a) Current Colorado license as a registered professional engineer specializing in fire protection.

(b) Submit evidence of current and valid certification in another state, which is determined by the Division to be at least equivalent to the requirements listed herein.

B) FIRE INSPECTOR II - In order to become certified as Fire Inspector II, a person must meet at least one of the following criteria:

(a) ICC Fire Inspector II (b) NFPA Fire Inspector II (2) Submit documentation to the Division to demonstrate that they have the requisite skills and knowledge specified in NFPA 1031 – Standard for Professional Qualifications for Fire Inspector and Plans Examiner for Fire Inspector II including education, training, and experience. The following list identifies examples of education, training, and experience that may be considered as equivalent to the requisite skills and knowledge for Fire Inspector II. This list should not be considered all- inclusive.

(a) Current Colorado license as a registered professional engineer specializing in fire protection.

(b) Submit evidence of current and valid certification in another state, which is determined by the Division to be at least equivalent to the requirements listed herein.

C) FIRE INSPECTOR III – PLANS EXAMINER - In order to become certified as Fire Inspector III – Plans Examiner, a person must meet at least one of the following criteria:

(a) ICC Fire Inspector II and ICC Fire Plans Examiner (b) ICC Fire Inspector II and ICC Building Plans Examiner (c) NFPA Fire Inspector II and NFPA Plans Examiner (2) Submit documentation to the Division to demonstrate that they have the requisite skills and knowledge specified in NFPA 1031 – Standard for Professional Qualifications for Fire Inspector and Plans Examiner for Fire Inspector II and for Fire Plans Examiner II, including education, training, and experience. The following list identifies examples of education, training, and experience that may be considered as equivalent to the requisite skills and knowledge for Fire Inspector III. This list should not be considered all-inclusive.

(a) A combination of five (5) years of education and work experience in fire protection and/or code enforcement is required. Education must be an Associate Degree or above in Fire Science, Fire Prevention, Fire Protection Engineering or other approved related major. Work experience must be specifically in fire prevention, fire protection, code enforcement, or inspection. (b) Current Colorado license as a registered professional engineer specializing in fire protection.

(c) Submit evidence of current and valid certification in another state, which is determined by the Division to be at least equivalent to the requirements listed herein.

10.2.3 Duties of Certified Fire Inspectors A) Where there is a qualified local fire department, local Fire Inspectors must conduct the required plan reviews and inspections, and require corrections or modifications as necessary to ensure that a building or structure is constructed in conformity with the locally adopted Fire Codes.

B) Where there is not a qualified local fire department, Division Fire Inspectors must conduct the required plan reviews and inspections, and require corrections or modifications as necessary to ensure that a building or structure is constructed in conformity with the Division’s adopted Fire and Life Safety Codes. C) If all inspections are not completed and a building requires immediate occupancy, and if the Board has passed the appropriate inspections that indicate there are no life safety issues, the Fire Inspector may recommend to the Division or the local Building Department that a Temporary Certificate of Occupancy be issued to allow the Board to occupy the buildings and structures. D) The Board must maintain records of all plan reviews and inspections for a period of no less than five years. Said records must be made available for review by the Division, upon request.

ARTICLE 11 – ENFORCEMENT 11.1 The Division will enforce the requirements of the codes adopted in Article 3 in accordance with the provisions of Section 24-33.5-1213, C.R.S.

11.1.1 The Division may issue a notice of violation to a person who is believed to have violated the provisions of the Codes as determined by an inspection in accordance with the procedures described in Section 24-33.5-1213, C.R.S.

11.1.2 An enforcement order issued pursuant to Section 24-33.5-1213, C.R.S. may impose a civil penalty, depending upon the severity of the alleged violation, not to exceed five hundred dollars per violation, for each day of violation; except that the Division may impose a civil penalty not to exceed one thousand dollars per violation, for each day of violation, that results in, or may reasonably be expected to result in, serious bodily injury. 11.1.3 The Director may file suit in the district court in the judicial district in which a violation is alleged to have occurred to judicially enforce an enforcement order issued pursuant to Section 24-33.5-1213, C.R.S.

11.2 A person who is the subject of, and is adversely affected by, a notice of violation or enforcement order issued pursuant to Article 11 may appeal such action to the Director. The Director will hold a hearing to review such notice or order and take final action in accordance with Title 24, Article 4, C.R.S. Final agency action is subject to judicial review pursuant to Title 14, Article 4, C.R.S. 11.3 It is not the intent of this Article 11 to remove, limit, or modify enforcement authority of the fire department providing fire protection service for buildings or structures of a Board. ARTICLE 12 – APPEALS 12.1 A Board who is the subject of, and is adversely affected by, a decision or interpretation made by a Division inspector or Third Party Inspector that conducts a plan review or inspection pursuant to these rules, may appeal such action to the Board of Appeals formed by Section 24-33.5-1213.7, C.R.S.

12.1.1 The affected Board must first appeal to the Division. After consideration, the Division will issue its written decision on the matter.

12.1.2 If the Board still disagrees, it may appeal to the Board of Appeals. The appeal must be filed within fifteen days after the date of the final written decision by the Division. Upon receipt of an appeal, the Division will notify the Chair of the Board of Appeals and schedule a hearing no more than fifteen days after the date the appeal was filed. 12.1.3 An application for appeal must be based on a claim that the true intent of this code or the standards legally adopted therein have been incorrectly interpreted, the provisions of this code do not fully apply or an equally good or better form of construction is proposed. The Board of Appeals may not waive any requirements of the codes or standards; however the Board of Appeals may recommend alternative materials or methods as provided in the codes or standards. The final written decision of the Board of Appeals is final agency action for purposes of section 24-4-106, C.R.S.

ARTICLE 13 – FEES AND CHARGES 13.1 Third Party Inspector Certification Fees: The Division will charge the following fees for Third Party Inspector certifications Third Party Inspector Certification Fees Certification of Third $75.00 Party Inspectors equivalent qualification review Renewal of Third Party $50.00 Inspector certification 13.2 Plan review, construction permit and inspection fees. 13.2.1 The Division will charge fees to cover the actual, reasonable, and necessary expenses of the Division.

13.2.2 The plan review, construction permit and inspection fees are calculated based on the Total Project Valuation.

A) The building inspection component of this fee in 13.2.4.A only includes one oversight (interim) inspection and a final inspection conducted by the Division prior to the issuance of a Certificate of Occupancy and Certificate of Completion. In the event that additional inspections by the Division are necessary, additional fees may be assessed.

B) The Fire and Life Safety inspection component of this fee in 13.2.4.C only includes one oversight (interim) inspection and a final inspection conducted by the Division prior to the issuance of a Certificate of Occupancy and Certificate of Completion. In the event that additional inspections by the Division are necessary, additional fees may be assessed.

C) Division inspection fees do not include costs associated with inspections conducted by local fire departments or third-party inspectors.

D) If the submitted Total Project Valuation appears to be below market value for the project the Division reserves the right to request documentation to verify the Total Project Valuation submitted by the Board. The Board has the right to mark documents submitted to verify the Total Project Valuation as proprietary information.

13.2.3 The Division will review the fund balance periodically and may reduce or increase the amount of the fee, if necessary, pursuant to section 24-75-402 (3) and 24-75-402 (4), C.R.S.

13.2.4 A fee calculator posted on the Division website, enables determination of total fees (plan review and construction permit fees, including two inspection fees) prior to submittal of a project. Additional inspections, beyond the two included inspections, will be assessed a fee of $800.00 per onsite inspection. The fee schedule applied to a project will be the fee schedule in effect on the date of application submittal. A) Fees for Building Code reviews performed by the Division Building Code Plan Review, Permit and Inspection Fees Total Project Valuation Fee Up to $100,000 $1,600.00 $100,001 to $500,000 $1,601.00 to $4,337 $500,001 to $1,000,000 $4,338 to $6,532 $1,000,001 to $2,000,000 $6,533 to $9,345 $2,000,001 to $4,000,000 $9,346 to $12,952 $4,000,001 to $8,000,000 $12,593 to $17,577 $8,000,001 to $17,578 to $23,505 $16,000,000 $16,000,001 to $23,506 to $31,105 $32,000,000 $32,000,001 to $31,106 to $40,848 $64,000,000 $64,000,001 + $40,849 + B) Limited Scope Project Permit: $500 C) Fees for Fire and/or Life Safety Code reviews by the Division Fire and Life Safety Code Plan Review, Permit and Inspection Fees Total Project Valuation Fee Up to $100,000 $1,600.00 $100,001 to $500,000 $1,601.00 to $4,337 $500,001 to $1,000,000 $4,338 to $6,532 $1,000,001 to $2,000,000 $6,533 to $9,345 $2,000,001 to $4,000,000 $9,346 to $12,952 $4,000,001 to $8,000,000 $12,593 to $17,577 $8,000,001 to $17,578 to $23,505 $16,000,000 $16,000,001 to $23,506 to $31,105 $32,000,000 $32,000,001 to $31,106 to $40,848 $64,000,000 $64,000,001 + $40,849 + D) Both Building and Fire and Life Safety Code Reviews performed by the Division Fees will equal the sum of both the Building review fees in Article 13.2.4.A and the Fire and Life Safety review fees in Article 13.2.4.C. 13.2.5 Half of the fees must be submitted at the time of project submittal and the remaining half must be submitted prior to permit issuance. Inspections will not be performed until the required fee has been paid. Additional inspection fees must be submitted prior to issuance of Certificate of Occupancy or Certificate of Compliance. 13.2.6 Re-inspection fees: The Division may assess an $800 re-inspection fee for each inspection or re-inspection, when such portion of work for which the inspection is called is not completed, or when corrections previously called for are not made. Upon request of the Board one re-inspection fee per project may be waived at the discretion of the Division. It is intended to control the practice of calling for inspections before the work is ready for such inspection or re-inspection. 13.2.7 Off-hours inspections: The Division may assess an additional off-hours inspection fee of $400 for inspections requested outside of normal business hours. A) Normal inspection hours are Monday through Friday between 8:00 am and 5:00 pm. B) Off-hours inspections are scheduled on an "as-available" basis. The Division is not obligated to provide inspections outside of normal operating hours if an inspector is not available.

13.2.8 The Division may assess a fee of $100 for the replacement of a lost inspection record card.

13.3 Hospital Fire and Life Safety Certificate of Compliance Inspection Fees The following fees will be charged for Hospital Fire and Life Safety Certificate of Compliance inspections performed by the Division:

Certificate of Compliance $4500.00 inspection On-site re-visit inspection $ 800.00 Documentation review $ 200.00 13.3.1 Fees are charged per street address. In the case of an off campus location of a Hospital or a separate building on a hospital campus (meaning the building does not have any patient sleeping rooms or critical care areas) the fees as set forth for non-hospital health facilities will apply.

13.3.2 Failure to pay for Fire and Life Safety Code inspections performed will result in a notice of violation and enforcement in accordance with Article 11 of this rule and the Division withholding issuance of the Certificate of Occupancy and/or Certificate of Compliance. 13.3.3 In the event that the Division receives reimbursement from CMS for a portion of the Certificate of Compliance inspection a pro-rated amount directly related to the shared benefit of a coordinated inspection will be deducted from the above fees due from the Board.

13.4 Non-Hospital Health Facilities Fire and Life Safety Certificate of Compliance Inspection Fees The following fees will be charged for Non-Hospital Health Facility Fire and Life Safety Certificate of Compliance inspections performed by the Division:

Certificate of Compliance $1,500.00 inspection On-site re-visit inspection $ 800.00 Documentation review $ 200.00 13.4.1 Fees are charged per street address.

13.4.2 Failure to pay for Fire and Life Safety Code inspections performed will result in a notice of violation and enforcement in accordance with Article 11 of this rule and the Division withholding issuance of the Certificate of Occupancy and/or the Certificate of Compliance.

13.4.3 In the event that the Division receives reimbursement from CMS for a portion of the Certificate of Compliance inspection a pro-rated amount directly related to the shared benefit of a coordinated inspection will be deducted from the above fees due from the Board.

ARTICLE 14 – SEVERABILITY 14.1 If any provision, or application of these rules are held invalid, all other provisions and applications of these rules, will remain in effect.

ARTICLE 15 – INQUIRIES 15.1 All questions or requests for interpretation of these rules should be submitted in writing to the Colorado Division of Fire Prevention and Control, Health Facilities Section Chief. _________________________________________________________________________ Editor’s Notes History Entire rule emer. rule eff. 07/01/2013.