8 CCR 1507-31, art. 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 ensure 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, is not seeking certification, or cannot potentially seek 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 qualified as a Fire Inspector I or above, the Division will perform regular maintenance inspections for the Business Entity 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 Business Entity is required to notify the Division that such inspections are being performed. The Business Entity shall 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 prohibits the local fire department providing fire protection services from conducting routine assessments of buildings and structures or from correcting violations that pose an immediate threat to life safety. Additionally, nothing in this Article prohibits the local fire department from seeking enforcement under defined local procedures and rules.

9.1.4 A local Qualified Fire Department providing fire protection service for buildings and structures of a Health Facility 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 shall 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 Business Entity shall 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 Business Entity 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.

Exception: Work conducted on system components that would require permits, licensing, or certifications under any adopted codes, laws, or rules shall be conducted in accordance with those requirements.

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

9.2.4 The Business Entity shall report or cause to be reported in the manner and method required by the Division all fires that occur within any Health Facility subject to regulation by the Division in the State of Colorado. This requirement shall be met anytime a fire occurs that causes any one of the following conditions:

A) Activates one of the fire and life safety systems installed in the building or structure (e.g.- fire alarm system, fire suppression system, etc.).

B) Causes a response from the Fire Department

C) Causes the evacuation of any occupants located in the building or structure.

D) Results in the deployment and use of a fire extinguisher.

Notes

8 CCR 1507-31, art. 9

40 CR 04, February 25, 2017, effective 3/17/2017 42 CR 05, March 10, 2019, effective 3/30/2019 43 CR 14, July 25, 2020, effective 8/14/2020 44 CR 22, November 25, 2021, effective 12/15/2021