FGI Information

BHE Licensing in Relation to FGI Reviews: Frequently Asked Questions 

1. Do I have to get a new Behavioral Health Entity (BHE) license if I’m already licensed with CDPHE? 

All BHEs who are currently licensed with CDPHE as an ATU, CSU, Community Mental Health Center, or Community Mental Health Clinic will need to convert that license to the BHE license with CDPHE between July 1, 2021 through June 30, 2022 when the current license is due for renewal. You are not required to undergo an FGI Plan Review so long as those physical spaces were historically included within your previous CDPHE licensing parameters (see 6 CCR 1011-1 Chapter 3, Part 2.2.1 (A). If the BHE later conducts new construction or renovation, an addition of a new endorsement, a new location, or the addition of new service types, an FGI plan review will be required for those additions (see 6 CCR 1011-1 Chapter 3, Part 2,2,1 (C) 1-4). 

2. If I’m converting my existing license to a BHE license, do I have to have an FGI Plan Review of my existing licensed facilities? 

If an entity was previously licensed by CDPHE pursuant to 6 CCR 1011-1, Chapter 2, 6 CCR 1011-1, Chapter 6, or 6 CCR 1011-1, Chapter 9 as a community mental health center, community mental health clinic, crisis stabilization unit, or acute treatment unit, and is transitioning to an initial BHE License with CDPHE, it will not be required to have an FGI Plan Review. This again assumes that there have been no new additions of space or new service types (as stated above within #1). 

3. Which state licensing chapter will my existing licensed facility need to meet? 

Currently, Community Mental Health Clinics (CMHCc) and Centers (CMHC) are licensed under 6 CCR 1011-1 Chapter 2; Acute Treatment Units (ATUs) are licensed under 6 CCR 1011-1 Chapter 6, and Crisis Stabilization Units (CSUs) are licensed under 6 CCR 1011-1 Chapter 9. However, effective July 1, 2022, all four will be licensed under 6 CCR 1011-1 Chapter 3, which governs the BHE licenses. This change in licensing chapters will not require an FGI Review. 

4. I’ve heard the new BHE license described as a ‘cafeteria style’ license. What does that mean? 

There will be two endorsements that a facility may be licensed for. The first endorsement is the Outpatient Endorsement which includes outpatient treatment services and walk-in services. The second endorsement is the 24-Hour/Overnight endorsement, which includes Crisis Stabilization Services and Acute Treatment Services. The services provided will determine which ‘endorsement’ the facility will be required to have. If it is an existing facility that was previously licensed and new services are not being offered in either endorsement, these existing facilities will not be required to have an FGI Review. 

5. My facility was previously licensed, but that license has lapsed. Do we still have to go through an initial license process? 

Facilities required to apply include any entity that was previously licensed by CDPHE prior to July 1, 2021 or is presently designated by the Behavioral Health Administration (BHA) specifically as a community mental health center, community mental health clinic, acute treatment unit, or crisis stabilization unit. This will include receiving a Certificate of Compliance from the Colorado Department of Public Safety (CDPS) and an FGI Plan Review and Approval from CDPHE for each facility individually being licensed as part of the overall entity. 

6. I’m being told that even though my entity/facility was previously licensed, I need to have an FGI Review, but I don’t understand why. 

Not all previously licensed entities will be exempt from an FGI Review. There are four instances where an FGI Review of the relevant building or space will be required (see 6 CCR 1011-1 Chapter 3, Part 2,2,1 (C) 1-4). 

a. New construction or renovation needs to be reviewed for FGI 

            compliance. 

b. An addition of a new endorsement to an existing license, the 

facility with the new endorsement needs to be reviewed for FGI 

compliance. 

c. A new facility being added to an existing license needs to be 

    reviewed for FGI compliance based on the endorsements of the 

            new location. 

d. New service added to an existing location, with or without a 

    change in endorsement, needs to be reviewed for FGI compliance. 

Please note that physical locations that do not provide client services will not be required to undergo an FGI Plan Review. (see 6 CCR 1011-1 Chapter 3, Part 2,2,1 (D)). 

FGI Specific Questions 

1. Which book and section of FGI do I use? 

Which FGI book and section used will be determined by the endorsements required for the facility and what services are being provided. 

a. If the facility is being licensed with the Outpatient Endorsement, it will be required to meet the building standards as required in Part 2.2 of licensing Chapter 3 (Find it here) and 2018 FGI Chapter 2.11 of the Guidelines for Design and Construction of Outpatient Facilities (Purchase the Guidelines - FGI). 

b. If the facility is being licensed with the 24-Hour/Overnight 

Endorsement Standards, it will be required to meet the building 

standards as required in Part 2.2 of licensing Chapter 3 (Find it 

here) and 2018 FGI Chapter 4.3 of the Guidelines for Design and 

Construction of Residential Health, Care and Support Facilities 

(Purchase the Guidelines - FGI).

2. I’ve noticed there are a few contradictions or additional requirements between the licensing requirements and the FGI requirements. Which do I follow? 

When the Colorado Board of Health elects to adopt certain elements of the FGI Guidelines or when they choose to add additional requirements above and beyond those found in the 2018 FGI Guidelines, those changes will be noted within the licensing chapter. Where Chapter 3 specifies different requirements or additions to the 2018 FGI requirements, those changes will supersede the ones outlined within FGI. 

3. Is there anything different between the licensing requirements and the 2018 FGI requirements that I need to be aware of for the Outpatient Endorsement? 

There are a few exceptions and/or clarifications to specific FGI Outpatient endorsement requirements provided for in Chapter 3. The outpatient endorsement would be reviewed to 2018 FGI Chapter 2.11 (Purchase the Guidelines - FGI) of the Guidelines for Design and Construction of Outpatient Facilities. 

a. Section 2.11-3.8.11 requires clean storage be provided that meets 2.1-3.8.12 of the guidelines. The exception to this requirement 

provided for in Chapter 3 is that this clean storage will only be 

required if that storage is applicable to the particular services 

being provided at that physical location. 

b. Section 2.11-3.9.1.1 requires separate staff and patient toilets be provided. The BHE is exempt from providing separate facilities 

but is still required that the appropriate number be provided to 

meet the needs of all the people served in the facility. It does 

not, however, exempt the facility from providing a staff lounge 

that is separate from public and client areas. That is still required to be provided.

4. Are there any exceptions or additions to the licensing requirements and FGI requirements that I need to be aware of for the 24-Hour/Overnight Endorsement? 

Overall, the facilities with this endorsement will be reviewed to FGI Chapter 4.3 of the Guidelines for Design and Construction of Residential Health, Care, and Support Facilities. However, there are exceptions and additions in the licensing Chapter 6 CCR 1011-1 Chapter 3, Part 4.1.6 (Find it here) that should be reviewed prior to construction documents being completed. 

5. Is there anything significant between the licensing requirements and FGI requirements that I need to be aware of for the 24-Hour/Overnight Endorsement?

There is one major additional requirement that is provided for in Chapter 3, in Part 4.1.7 (Find it here). This requirement is that where one or more seclusion rooms are provided in the facility where restraint, as defined in 6 CCR 1011-1, Chapter 2, Part 1.54, either chemical, mechanical, or physical, limits the person’s freedom of movement, is required to meet the FGI requirements in Section 2.11-3.2.7 in the Guidelines for Design and Construction of Outpatient Facilities, and not the Residential book. There are also a couple of clarifications/additions provided in Chapter 3 in regard to FGI Section 2.11-3.2.7.

These modifications to FGI include:

 a. The required view panel may either be in the door or in close proximity to the door. 

 b. The room must be a minimum of 100 square feet in size. 

For additional information regarding the Division’s FGI Guidelines plan review process, please visit Facility Guidelines Institute (FGI) | Department of Public Health & Environment. 

There you will find valuable information including the following links… “Request an FGI Plan Review” 

“FGI Basics for Health Facilities” 

“FGI Frequently Asked Questions” 

If you are unable to find answers to your questions after reviewing these resources please email us at FGIreview@state.co.us.