NOTE: The governor signed this measure on 6/8/2016. SENATE BILL 16-069 BY SENATOR(S) Garcia, Newell, Donovan, Lambert, Lundberg, Guzman, Kerr, Merrifield, Ulibarri, Aguilar, Carroll, Crowder, Heath, Hodge, Johnston, Kefalas, Todd; also REPRESENTATIVE(S) Pabon, Williams, Esgar, Hamner, Lebsock, Salazar, Young, Duran, Ginal, Kraft-Tharp, Lee, Lontine, Melton, Mitsch Bush, Primavera, Ryden, Vigil, Winter, Hullinghorst. Concerning measures to provide community-based out-of-hospital medical services, and, in connection therewith, making an appropriation. Be it enacted by the General Assembly of the State of Colorado: SECTION 1. In Colorado Revised Statutes, 25-3.5-103, add (4.3) and (4.5) as follows: 25-3.5-103. Definitions. As used in this article, unless the context otherwise requires: (4.3) "Community integrated health care service" means the provision of certain out-of-hospital medical services, as determined by rule, that a community paramedic may provide. (4.5) "Community paramedic" means an emergency medical service provider who obtains an endorsement in community paramedicine pursuant to section 25-3.5-206. SECTION 2. In Colorado Revised Statutes, add 25-3.5-203.5 as follows: 25-3.5-203.5. Community paramedic endorsement - rules. (1) On or before January 1, 2018, the board shall adopt rules in accordance with article 4 of title 24, C.R.S., for community paramedics including standards for: (a) The department's issuance of an endorsement in community paramedicine to an emergency medical service provider; (b) Verifying an emergency medical service provider's competency to be endorsed as a community paramedic. The standards must include a requirement that the emergency medical service provider has obtained from an accredited paramedic training center or an accredited college or university a certificate of completion for a course in community paramedicine with competency verified by a passing score on an examination offered nationally and recognized in Colorado for certifying competency to serve as a community paramedic; and (c) Continuing competency to maintain a community paramedic endorsement. (2) Rules adopted under this section supersede any rules of the Colorado medical board regarding the matters set forth in this part 2. SECTION 3. In Colorado Revised Statutes, 25-3.5-206, add (4) (a.5) as follows: 25-3.5-206. Emergency medical practice advisory council - creation - powers and duties - emergency medical service provider scope of practice - rules. (4) (a.5) (I) On or before January 1, 2018, the director, or, if the director is not a physician, the chief medical officer shall adopt rules in accordance with article 4 of title 24, C.R.S., concerning the scope of practice of a community paramedic. An emergency medical service provider's endorsement as a community paramedic, issued pursuant to the rules adopted under section 25-3.5-203.5, is valid for as long as the emergency medical service provider maintains his or her certification by the department. (II) The rules must establish the tasks and procedures that an emergency medical service provider with a community paramedic endorsement is authorized to perform in addition to an emergency medical service provider's scope of practice, including: (A) An initial assessment of the patient and any subsequent assessments, as needed; (B) Medical interventions; (C) Care coordination; (D) Resource navigation; (E) Patient education; (F) Inventory, compliance, and administration of medications; and (G) Gathering of laboratory and diagnostic data. SECTION 4. In Colorado Revised Statutes, add parts 12 and 13 to article 3.5 of title 25 as follows: PART 12 COMMUNITY ASSISTANCE REFERRAL AND EDUCATION SERVICES (CARES) PROGRAM 25-3.5-1201. Short title. The short title of this part 12 is the "Community Assistance Referral and Education Services (CARES) Program Act". 25-3.5-1202. Definitions. As used in this part 12, unless the context otherwise requires: (1) "Authorized entity" means: (a) A licensed ambulance service; (b) A fire department of a town, city, or city and county; (c) A fire protection district, ambulance district, health assurance district, health service district, or metropolitan district, or special district authority; or (d) A health care business entity, including a licensed or certified health care facility that is subject to regulation under article 3 of this title. (2) "Medical direction" means the supervision over and direction of individuals who perform acts on behalf of a CARES program by a physician or advanced practice registered nurse who is licensed in Colorado and in good standing and who is identified as being responsible for assuring the competency of those individuals in the performance of acts on behalf of the CARES program. (3) "Program" or "CARES program" means a community assistance referral and education services program established in accordance with this part 12. 25-3.5-1203. Community assistance referral and education services programs - authorization - scope - repeal. (1) To improve the health of residents within its jurisdiction, prevent illness and injury, or reduce the incidence of 911 calls and hospital emergency department visits made for the purpose of obtaining nonemergency, nonurgent medical care or services, an authorized entity may establish a community assistance referral and education services program to provide community outreach and health education to residents within the authorized entity's jurisdiction. (2) (a) On or after July 1, 2018, an authorized entity that operates or plans to operate a CARES program in Colorado shall notify the department of its CARES program in the form and manner required by the department. (b) The department shall maintain a list of all authorized entities that operate a CARES program and make the list accessible to the public. (c) An authorized entity operating a CARES program shall not assert that it is licensed or certified by the department. (3) Subject to medical direction, an authorized entity operating a program may, within the scope of practice of its practitioners: (a) Provide the following services: (I) Health education and information available on relevant services; and (II) Referrals for and information concerning low-cost medication programs and alternative resources to the 911 system; (b) To provide services in accordance with paragraph (a) of this subsection (3) and to ensure nonduplication of the services, collaborate with appropriate community resources, including: (I) Health care facilities licensed or issued a certificate of compliance pursuant to section 25-1.5-103 or subject to regulation by the department pursuant to article 1 or 3 of this title; (II) Primary care providers; (III) Other health care professionals; or (IV) Social services agencies. (4) (a) An authorized entity operating a CARES program shall not provide services that would require a license or certification pursuant to part 13 of this article or article 3 or 3.5 of this title. (b) In the form and manner prescribed by the department and before referring a service or provider to a recipient of a CARES program service, an authorized entity operating a CARES program shall disclose, at a minimum, in writing, the following information to the recipient: (I) Any relationship that the CARES program has with an individual or entity to which it refers a recipient of CARES program service; and (II) Whether the authorized entity directs, controls, schedules, or trains any provider to which it refers a recipient of CARES program services. (5) The department may investigate an authorized entity as it deems necessary to ensure: (a) The protection of the health, safety, and welfare of a recipient of CARES program services; and (b) That the authorized entity is not providing services through its CARES program that require a license or certification pursuant to part 13 of this article or article 3 or 3.5 of this title. (6) A person working directly or indirectly for a CARES program, whether as an employee or a contractor, may only provide services consistent with the requirements of subsection (3) of this section; except that nothing in this section prohibits a licensed, certified, or registered health care or mental health provider or certified emergency medical service provider from acting or providing services within his or her scope of practice if necessary to respond to an emergent situation. (7) (a) If an entity offered community outreach and health education before January 1, 2015, the entity may continue and need not comply with the requirements of this part 12. The entity may voluntarily provide reports consistent with the requirements of section 25-3.5-1204. (b) This subsection (7) is repealed, effective July 1, 2021. 25-3.5-1204. Reports. (1) (a) If an authorized entity develops a program under this article, the authorized entity shall report to the department, in the form and manner determined by the department, on the progress of the program on or before December 31 in the year following the year in which the program commenced and on or before December 31 of each subsequent year in which the program continues to operate. (b) An authorized entity's report must include: (I) The number of residents who have used program services and the types of program services used; (II) A measurement of any reduction in the use of the 911 system for nonemergency, nonurgent medical assistance by residents within the authorized entity's jurisdiction; and (III) A measurement of any reduction in visits to the emergency department in a hospital for nonemergency, nonurgent medical assistance by residents within the authorized entity's jurisdiction. (c) An authorized entity's report pursuant to this section must not include any personally identifiable information concerning a program client or prospective client. (2) On or before March 31 of each year, the department shall compile annual reports received from authorized entities in the previous year into a single report and post the report on its website. PART 13 COMMUNITY INTEGRATED HEALTH CARE SERVICE AGENCIES 25-3.5-1301. Definitions. As used in this part 13, unless the context otherwise requires: (1) "Community integrated health care service agency" or "agency" means a sole proprietorship, partnership, corporation, nonprofit entity, special district, governmental unit or agency, or licensed or certified health care facility that is subject to regulation under article 1.5 or 3 of this title that manages and offers, directly or by contract, community integrated health care services. (2) "Manager" or "administrator" means any person who controls and supervises or offers or attempts to control and supervise the day-to-day operations of a community integrated health care service agency. (3) "Medical direction" means the supervision over and direction of individuals who perform acts on behalf of an agency by a physician or advanced practice registered nurse who is licensed in Colorado, is in good standing, and is identified as being responsible for assuring the competency of those individuals in the performance of acts on behalf of the agency; except that, if the agency hires or contracts with a community paramedic, only a licensed physician in good standing may provide medical direction. (4) "Owner" means an officer, director, general partner, limited partner, or other person having a financial or equity interest of twenty-five percent or greater. 25-3.5-1302. Community integrated health care service agency license required - rules - civil and criminal penalties - liability insurance. (1) On or after July 1, 2018, a person shall not operate or maintain a community integrated health care service agency unless the person has submitted to the department a completed application for licensure as a community integrated health care service agency. On or after December 31, 2018, a person shall not operate or maintain an agency without a community integrated health care service agency license issued by the department. (2) (a) A person who violates subsection (1): (I) Is guilty of a misdemeanor and, upon conviction thereof, shall be punished by a fine of not less than fifty dollars nor more than five hundred dollars; and (II) May be subject to a civil penalty assessed by the department, after conducting a hearing in accordance with section 24-4-105, C.R.S., of up to ten thousand dollars for each violation of this section. The department shall transmit all fines collected pursuant to this subparagraph (II) to the state treasurer, who shall credit the moneys to the general fund. (b) An owner, manager, or administrator of an agency is subject to the penalties in this subsection (2) for any violation of subsection (1). (3) A license applicant shall submit to the department, in the manner determined by the board by rule, proof that the agency and any staff that it employs or contracts is covered by general liability insurance in an amount determined by the board by rule, but not less than the amount calculated in accordance with section 24-10-114 (1) (a) (I) and (1) (b), C.R.S. 25-3.5-1303. Minimum standards for community integrated health care service agencies - rules. (1) In addition to the services that the board, by rule, authorizes a community integrated health care service agency to perform, an agency may perform any of the services that may be provided through a CARES program pursuant to section 25-3.5-1203 (3) and the tasks and procedures that a community paramedic is authorized to perform within his or her scope of practice in accordance with section 25-3.5-206 and rules promulgated pursuant to that section. On or before January 1, 2018, the board shall promulgate rules providing minimum standards for the operation of an agency within the state. The rules must include the following: (a) A requirement that the agency have medical direction; (b) Inspection of agencies by the department or the department's designated representative; (c) Minimum educational, training, and experience standards for the administrator and staff of an agency, including a requirement that the administrator and staff be of good moral character; (d) (I) Fees for agency applications and licensure based on the department's direct and indirect costs in implementing this part 13. The department shall transmit the fees to the state treasurer, who shall credit the fees to the community integrated health care service agencies cash fund created in section 25-3.5-1304. (II) The department shall collect fees from any entity that applies to operate a community integrated health care service agency, including an agency wholly owned and operated by a governmental unit or agency. The department shall transmit the fees to the state treasurer who shall credit the fees to the community integrated health care service agencies cash fund created in section 25-3.5-1304. (e) The amount of general liability insurance coverage that an agency shall maintain and the manner in which an agency shall demonstrate proof of insurance to the department. The board may establish by rule that an agency may obtain a surety bond in lieu of liability insurance coverage. (f) Establishing occurrence reporting requirements pursuant to section 25-1-124; (g) Requirements for retaining records, including the time that agencies must maintain records for inspection by the department; and (h) A requirement that agencies report to the department on an annual basis. 25-3.5-1304. Community integrated health care service agencies cash fund - created. There is created the community integrated health care service agencies cash fund, referred to in this section as the "fund". The department shall transmit fees collected pursuant to this part 13 to the state treasurer for deposit in the fund. The money in the fund is subject to annual appropriation by the general assembly to the department for the department's direct and indirect costs in implementing and administering this part 13. Any unencumbered or unexpended money in the fund at the end of a fiscal year remains in the fund and shall not be credited or transferred to the general fund or any other fund. 25-3.5-1305. License - application - inspection - criminal history records check - issuance. (1) A community integrated health care service agency license expires after one year. The department shall determine the form and manner of initial and renewal license applications. (2) (a) The department shall inspect an agency as it deems necessary to ensure the health, safety, and welfare of agency consumers. An agency shall submit in writing, in a form and manner prescribed by the department, a plan detailing the measures that the agency will take to correct any violations found by the department as a result of an inspection. (b) The department shall keep all medical records and personally identifying information obtained during an inspection of an agency confidential. All records and information obtained by the department through an inspection are exempt from disclosure pursuant to sections 24-72-204, C.R.S., and 25-1-124. (3) (a) (I) With the submission of an application for a license pursuant to this section, each owner, manager, and administrator of an agency applying for an initial or renewal license shall submit a complete set of his or her fingerprints to the Colorado bureau of investigation for the purpose of conducting a state and national fingerprint-based criminal history record check utilizing the records of the Colorado bureau of investigation and the federal bureau of investigation. The Colorado bureau of investigation shall forward the results of a criminal history record check to the department. (II) Each owner, manager, or administrator of an agency is responsible for paying the fee established by the Colorado bureau of investigation for conducting the fingerprint-based criminal history record check to the bureau. (III) The department may acquire a name-based criminal history record check for an owner, manager, or administrator who has twice submitted to a fingerprint-based criminal history record check and whose fingerprints are unclassifiable. (b) The department may deny a license or renewal of a license if the results of a criminal history record check of an owner, manager, or administrator demonstrates that the owner, manager, or administrator has been convicted of a felony or a misdemeanor involving conduct that the department determines could pose a risk to the health, safety, or welfare of community integrated health care service consumers. (c) If an agency applying for an initial license is temporarily unable to satisfy all of the requirements for licensure, the department may issue a provisional license to the agency; except that the department shall not issue a provisional license to an agency if operation of the agency will adversely affect the health, safety, or welfare of the agency's consumers. The department may require an agency applying for a provisional license to demonstrate to the department's satisfaction that the agency is taking sufficient steps to satisfy all of the requirements for full licensure. A provisional license is valid for ninety days and may be renewed one time at the department's discretion. 25-3.5-1306. License denial - suspension - revocation. (1) Upon denial of an application for an initial license, the department shall notify the applicant in writing of the denial by mailing a notice to the applicant at the address shown on the application. If an applicant, within sixty days after receiving the notice of denial, petitions the department to set a date and place for a hearing, the department shall grant the applicant a hearing to review the denial in accordance with article 4 of title 24, C.R.S. (2) The department may suspend, revoke, or refuse to renew the license of a community integrated health care service agency that is out of compliance with the requirements of this part 13 or rules promulgated pursuant to this part 13. Before taking final action to suspend, revoke, or refuse to renew a license, the department shall conduct a hearing on the matter in accordance with article 4 of title 24, C.R.S. The department may implement a summary suspension before a hearing in accordance with section 24-4-104 (4) (a), C.R.S. (3) After conducting a hearing on the matter in accordance with article 4 of title 24, C.R.S., the department may revoke or refuse to renew an agency license where the owner, manager, or administrator of the agency has been convicted of a felony or misdemeanor involving conduct that the department determines could pose a risk to the health, safety, or welfare of the agency's consumers. (4) The department may impose intermediate restrictions or conditions on an agency that may require the agency to: (a) Retain a consultant to address corrective measures; (b) Be monitored by the department for a specific period; (c) Provide additional training to its employees, owners, managers, or administrators; (d) Comply with a directed written plan to correct the violation, in accordance with the procedures established under section 25-27.5-108 (2) (b); or (e) Pay a civil penalty of up to ten thousand dollars per violation. The department, after providing the agency with the opportunity for a hearing in accordance with section 24-4-105, C.R.S., on any penalties assessed, shall transmit all penalties collected pursuant to this paragraph (e) to the state treasurer, who shall credit the money to the general fund. The agency may request, and the department shall grant, a stay in payment of a civil penalty until final disposition of the restriction or condition. 25-3.5-1307. Repeal of article - review of functions. This part 13 is repealed, effective September 1, 2025. Before the repeal, the department's functions under this part 13 shall be reviewed as provided for in section 24-34-104, C.R.S. SECTION 5. In Colorado Revised Statutes, 24-34-104, add (56) (d) as follows: 24-34-104. General assembly review of regulatory agencies and functions for termination, continuation, or reestablishment. (56) The following agencies, functions, or both, terminate on September 1, 2025: (d) The functions of the department of public health and environment regarding community integrated health care service agencies pursuant to part 13 of article 3.5 of title 25, C.R.S. SECTION 6. Appropriation. (1) For the 2016-17 state fiscal year, $73,986 is appropriated to the department of public health and environment. This appropriation is from the general fund. To implement this act, the department may use this appropriation as follows: (a) $70,184 for use by the health facilities and emergency medical services division for the state EMS coordination, planning and certification program, which amount is based on an assumption that the division will require an additional 1.0 FTE; and (b) $3,802 for the purchase of legal services. (2) For the 2016-17 state fiscal year, $3,802 is appropriated to the department of law. This appropriation is from reappropriated funds received from the department of public health and environment under paragraph (b) of subsection (1) of this section. To implement this act, the department of law may use this appropriation to provide legal services for the department of public health and environment. SECTION 7. Safety clause. The general assembly hereby finds, determines, and declares that this act is necessary for the immediate preservation of the public peace, health, and safety. ____________________________ ____________________________ Bill L. Cadman Dickey Lee Hullinghorst PRESIDENT OF SPEAKER OF THE HOUSE THE SENATE OF REPRESENTATIVES ____________________________ ____________________________ Effie Ameen Marilyn Eddins SECRETARY OF CHIEF CLERK OF THE HOUSE THE SENATE OF REPRESENTATIVES APPROVED________________________________________ _________________________________________ John W. Hickenlooper GOVERNOR OF THE STATE OF COLORADO