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Colorado · Home care agency survey · 6 CCR 1011-1 Ch. 26, 4.6-4.8 and Ch. 2, 2.10
CDPHE surveys every new Colorado home care agency before it issues the license, and its guidance describes issuing the license once that survey is completed with zero deficiencies. After licensing, it can survey again for re-licensure, inspect unannounced and investigate complaints. Here is what must be ready, what a deficiency is, when the provisional license and the isolated-event rule might matter, how plans of correction and disputes work, and what CDPHE can do beyond them.
Quick answer
After its fitness review, CDPHE holds a scheduled initial survey, typically on site at the address on your application, where you must have your manager’s training proof, background checks in personnel files, all required policies and procedures, malpractice loss information and your quality management plan ready. CDPHE guidance, step 6 The license is issued when the survey is completed with zero deficiencies, and Chapter 2 defines a deficiency as any failure to fully comply with a statute or rule. Ch. 2, 1.15
After licensing, CDPHE may inspect unannounced between 7 a.m. and 7 p.m. and investigate complaints at any time. Ch. 2, 2.10.1(A) If it cites deficiencies, your manager signs and sends a plan of correction within 10 calendar days of CDPHE’s notice, with corrections due within 30 days of the deficiency list unless CDPHE sets another date. Ch. 2, 2.10.4(B) CDPHE may also fine up to $10,000 per calendar year for all violations. Ch. 26, 4.8
CDPHE surveys
Checked against official sources on October 2, 2026.
The statute says CDPHE "shall determine an applicant’s compliance with this article and the rules adopted pursuant to section 25-27.5-104 before the department issues a license or registration." C.R.S. 25-27.5-106(2)(a)(I) CDPHE’s guidance: "The initial survey is a scheduled survey, typically onsite. A representative from the HFEMSD survey team will call the applicant to schedule a time for the survey." "There is typically a queue for surveys, and the wait time can vary depending on facility/agency type." CDPHE guidance, step 6
What must be ready. CDPHE lists five items:
What CDPHE has not published. We found no CDPHE survey tool or checklist for home care, and its guidance does not say what an applicant with no clients should show for consumer records, or whether caregivers must already be hired. Ask when the surveyor calls to schedule.
Where it happens. The survey is held at the physical address on your application, so CDPHE says any lease must be in effect before it. CDPHE guidance If you add the Medicaid certification with your initial application, CDPHE can combine the licensing and Medicaid surveys. CDPHE checklist
CDPHE then requests the initial survey. There is usually a queue, and the wait varies by agency type. CDPHE publishes no wait time for home care.
The initial survey is scheduled and typically on site, at the physical address on your application, so any office lease must be in effect before it.
Have ready: proof of the manager’s training and qualifications, employee background checks in personnel files, all required policies and procedures, malpractice loss information and your quality management plan.
The survey team tells the licensing team, and the licensing technician issues the license as a PDF in COHFI. Display it where clients who come to your office can see it.
CDPHE has not said; its guidance does not describe this path. Chapter 2 lets CDPHE ask a licensee (the rule does not say an applicant) for a plan of correction after any review, and by our reading the statute’s written correction plan could also reach an initial survey. Whether CDPHE uses a plan of correction and revisit, a provisional license, a new survey or a denial before a first license is a question for CDPHE.
Every licensing step, from the letter of intent to the license →
CDPHE’s guidance: "When the initial survey has been completed with zero deficiencies, the survey team will notify the licensing team that the applicant has successfully completed the initial survey." CDPHE guidance, step 7 Chapter 2 defines the word: "“Deficiency” means a failure to fully comply with any statutory and/or regulatory requirements applicable to a licensee." Ch. 2, 1.15 And: "No license shall be issued until the applicant conforms to all applicable statutes and regulations." Ch. 2, 2.8.1
By our reading, zero deficiencies means the survey cited no unmet requirement of any kind, not only no serious one. So everything the rules require should already be in place and in use at the survey, not just written down.
Open question
The statute says: "The department shall not cite as a deficiency in a report resulting from a survey or inspection of a licensed health facility any deficiency from an isolated event identified by the department that can be effectively remedied during the survey or inspection of the health facility, unless the deficiency caused harm or a potential for harm, created a life- or limb-threatening emergency, or was due to abuse or neglect." C.R.S. 25-1.5-103(1)(a)(I)(E)
It speaks of a licensed health facility. Nothing we found says whether it applies at an applicant’s initial survey, before there is a license. Our suggestion: fix anything a surveyor raises at once and record what you did, but do not count on the rule; prepare as if every gap would be cited.
If the initial survey finds a deficiency. CDPHE has not said; its guidance does not describe what happens next. Chapter 2 lets CDPHE ask a licensee for a plan of correction after any review, and the rule speaks of a licensee, not an applicant (Ch. 2, 2.10.4(B)). The statute requires a home care agency to submit a written plan to correct violations CDPHE finds in the inspections it makes under the subsection that also covers its review of original applications, so by our reading that correction plan is one possible route after a failed initial survey (C.R.S. 25-27.5-106(2)(a)(II); more on the application page). A revisit fee applies to the second and each later on-site inspection about the same harmful deficiency (Ch. 26, 4.5(E)). Whether CDPHE uses a plan of correction and revisit, a provisional license, a new survey or a denial before a first license is not stated. Ask CDPHE.
The statute says "The department may issue a provisional license to an applicant for the purpose of operating a home care agency for a period of ninety days if the applicant is temporarily unable to conform to all of the minimum standards required under this article 27.5", but not if operating the agency would adversely affect its consumers, and "As a condition of obtaining a provisional license, the applicant shall show proof to the department that attempts are being made to conform and comply with applicable standards." C.R.S. 25-27.5-106(6) Chapter 2 frames it as CDPHE’s choice, where an applicant is making a substantial good faith attempt to comply: "the Department may refuse to issue an initial license and instead grant the applicant a provisional license upon payment of the non-refundable provisional license fee." Ch. 2, 2.4.1
CDPHE’s licensing guidance does not mention provisional licenses for new home care agencies, so we cannot say when it uses one. It is not a route an applicant chooses: plan for a survey with zero deficiencies.
The license lasts one year and is renewed every year. Ch. 2, 2.1 Neither Chapter 26 nor Chapter 2 says how often a home care agency is surveyed for re-licensure. What they do say:
Your quality management plan must be available at every re-licensure survey. CDPHE guidance, step 6
Proposed · not in force · comments by November 12, 2026 · hearing November 18, 2026
On September 21, 2026 a notice was filed with the Secretary of State for amendments to Chapter 2, which the Board of Health will hear on November 18, 2026. eDocket 2026-00434
What it means for a new agency, by our reading. Nothing changes before your first survey, since the cycle needs three years of licensure. From your first client, occurrence reports and license paperwork would count toward it. The proposal, like the current rule, does not say how often an agency that does not qualify is surveyed.
To comment: Email written testimony to cdphe.bohrequests@state.co.us or mail it to the Colorado Board of Health, ATTN: Board of Health Program Assistant, 4300 Cherry Creek Drive South EDO-A5, Denver, CO 80246-1530, by 5 p.m. on Thursday, November 12, 2026. Remote oral testimony sign-up closes November 17, 2026 on the Board’s website. Contact: Alexandra Haas, 303-691-4934, alexandra.haas@state.co.us.
"In addition to licensure inspections, the Department may conduct supplemental inspections at any time in response to complaints alleging noncompliance with the regulations contained in this chapter." Ch. 26, 4.6(A)(1) CDPHE may review a licensee unscheduled or unannounced for reasons including a routine compliance inspection, reasonable cause to question its fitness, a complaint, newly discovered information about owners, managers or staff, or omitted or false information. Ch. 2, 2.10.4(A)
CDPHE’s consumer rights form gives 303-692-2910 or 1-800-842-8826 for complaints. CDPHE rights notice You post a notice that complaints may be made to you, CDPHE and the relevant DORA board, Ch. 2, 7.1.4 and keep a complaint log for at least two years, available for inspection. Ch. 26, 5.7(A)(5) A plan of correction can follow any review, including a complaint investigation, Ch. 2, 2.10.4(B) and a substantiated complaint that finds significant deficiencies would count against the extended survey cycle for the next three years. Ch. 2, 2.10.2(A)(4) We did not find a published CDPHE description of how it runs home care complaint investigations; its complaint page did not load for us.
The Colorado guide covers abuse reporting to law enforcement and protective services, which is separate. CareRulebook’s manual covers complaints in Policy 3.1 and occurrence reports in Policy 3.2.
Chapter 26 defines a plan of correction as "a written plan prepared by the home care agency or home care placement agency and submitted to the Department for approval that specifies the measures the agency shall take to correct all cited deficiencies." Ch. 26, 2.23 The statute requires one, in CDPHE’s form, for violations found at inspections. C.R.S. 25-27.5-106(2)(a)(II) Chapter 26 applies Chapter 2’s rule. Ch. 26, 4.7
What goes in it. How you will correct each deficiency (where it was cited for particular consumers, the measures or systemic changes that stop it recurring for them and others), how you will monitor the correction, and a completion date. Ch. 2, 2.10.4(B)(1) CDPHE may approve, impose, modify or reject a plan of correction. It sends a written notice of acceptance, or says in writing that a plan is unacceptable and sets a time to resubmit. Ch. 2, 2.10.4(B)(3) Missing plan requirements or deadlines, not sending requested changes, or not carrying out the actions by the approved correction date can lead CDPHE to reject the plan and impose disciplinary sanctions. Ch. 2, 2.10.4(B)(3)(c)-(d)
| What | Deadline | Counted from | Source |
|---|---|---|---|
| Plan of correction, signed by the manager | 10 calendar days | The date of CDPHE’s written notice of deficiencies | Ch. 2, 2.10.4(B)(2) |
| Request for more time on the plan | Before the plan is due, in writing | CDPHE may grant it | Ch. 2, 2.10.4(B)(2)(b)(i) |
| Corrections completed | No more than 30 calendar days, unless CDPHE requires or approves otherwise | The issuance of the deficiency list | Ch. 2, 2.10.4(B)(1)(c) |
| Informal dispute resolution request | 10 calendar days; an extension of no more than 7 calendar days from the plan due date, if asked for on or before it | Your receipt of the statement of deficiencies | CDPHE IDR policy |
| Written plan for an intermediate restriction or condition | No later than 10 days | Your receipt of CDPHE’s notice | Ch. 26, 4.8(B) |
| A serious and immediate threat | Immediately | Notice in writing, by phone or in person | Ch. 26, 4.8(C) |
| Hearing on a denied application | Petition within 30 days | Receiving the notice of denial | C.R.S. 25-27.5-108(1) |
Two different starting points. The plan counts from the date of CDPHE’s notice, the IDR request from the day you receive the statement of deficiencies. Our suggestion: diary both from the notice date.
"Informal dispute resolution (IDR) is the right and opportunity to dispute survey findings." IDR is a desk review of the provider’s written argument and documents, the surveyor’s response and the disputed deficiency; it is not an evidentiary hearing, and it cannot challenge the survey process or the survey team’s professional judgment. CDPHE IDR policy (October 2024)
"The IDR request and all documentation supporting the facility’s dispute must be received within 10 calendar days from the provider’s receipt of the Statement of Deficiencies." An extension must be asked for on or before the plan of correction due date and is at most 7 calendar days from it. CDPHE IDR policy
Statements of deficiencies are public. The policy says that if IDR changes a finding, "the original Statement of Deficiencies will be amended to reflect the change and reposted to the Internet." By our reading, CDPHE publishes statements of deficiencies online. CDPHE IDR policy
Our suggestion: unless CDPHE tells you otherwise, send the plan of correction on time even while you ask for IDR.
CareRulebook
CareRulebook’s Colorado manual includes Policy 1.6, CDPHE surveys, inspections and plans of correction: what to have ready for the initial survey, producing records within 30 minutes, home visits with consent, plans of correction and informal dispute resolution, with a survey-day checklist and a plan of correction worksheet. Every other policy CDPHE expects at the survey comes with it.
$199CareRulebook founding price for the first 50 Colorado agencies, then $249. Not a CDPHE fee.
A plan of correction is the usual answer to a deficiency. For completeness, here is what the statute and rules allow beyond it.
Retaining a consultant, monitoring by CDPHE for a set period, extra training, a directed written plan of correction, or a civil fine of up to $10,000 per calendar year for all violations. Fines are CDPHE penalties, not CareRulebook charges.
After an approved written plan, you may appeal through CDPHE’s informal review; you may ask for a stay of a fine until final disposition, which CDPHE must grant; and no restriction is imposed until you have had the chance of a hearing if you skip or disagree with the informal review.
CDPHE may put conditions on a license before issuing it or during its term. You comply at once, post the conditions where the public can see them, and pay CDPHE’s conditional license fee, $1,938.29 on the 2026/27 schedule.
If a deficiency cited at a licensure inspection or substantiated complaint investigation caused harm, or could have, and is not shown corrected at the first revisit, CDPHE charges a revisit fee for the second and each later on-site inspection about it: 100% of the initial or renewal fee on its schedule.
Grounds include not complying with applicable laws and rules, false statements, slow responses, refusing any part of an inspection, and failing to complete an acceptable plan of correction. A denied applicant may petition for a hearing within 30 days.
For good cause, including impeding CDPHE’s work, late or incomplete reports, not completing a plan of correction in the time or manner specified, or falsifying records. Summary suspension is for deliberate or willful violations or emergencies.
Serious and immediate threats: Ch. 26, 4.8(C); summary suspension: Ch. 2, 2.11.3(A); revisit fee amount: CDPHE fee schedule. Operating without a license is separate: a misdemeanor and a CDPHE civil penalty of up to $10,000 per violation. C.R.S. 25-27.5-103(1) Chapter 26, 4.10 refers to civil fines "pursuant to Part 4.7", the plan of correction rule; the fines themselves are in 4.8.
Our practical suggestions, not rule text. Each card links the source it helps you meet and the manual policy that covers it.
The fitness review, before the survey, may already look at your policies and procedures, and the survey expects all of them ready for review.
Ch. 2, 2.7.1(D)Manual: Policy 1.3
Criminal history check, CAPS check, any DORA license check, training and competency records, job description. CDPHE names background checks in personnel files for the survey.
CDPHE guidance, step 6Manual: Policy 4.8
The course certificate (or the documented equivalent) and evidence of the experience route that qualifies them.
CDPHE guidance, step 6; Ch. 26, 7.2(B)Manual: Policy 1.2
Have the governing body (or designee) approve it before the survey; CDPHE asks for it at the initial survey and every re-licensure survey.
CDPHE guidance, step 6Manual: Policy 5.4
A dated statement of whether there has been any malpractice judgment, settlement or award, so you have something to show for this item even when the answer is none.
CDPHE guidance, step 6Manual: Policy 1.6
CDPHE has not said what an agency with no clients should show for consumer records. A complete set of blank forms is our suggestion; ask the surveyor when they call.
Ch. 2, 2.8.1Manual: Policy 5.1
Keep a short index of where each record lives, paper or electronic, so whoever is in the office can start producing records within 30 minutes.
Ch. 26, 4.6(A)(1)(b)Manual: Policy 1.6
The plan of correction counts from the date of CDPHE’s notice, and an IDR request from the day you receive the statement of deficiencies. Count both from the notice date.
Ch. 2, 2.10.4(B)(2); CDPHE IDR policyManual: Policy 1.6
Late or missed occurrence reports would count against the proposed three-year survey cycle, and the occurrence rules apply from your first client.
Ch. 2, 4.2.2Manual: Policy 3.2
Renew at least 60 days before expiry. Timely license documents and fees are among the proposed criteria for the three-year cycle.
Ch. 2, 2.5.1Manual: Policy 1.5
It depends. Not on the path CDPHE’s guidance describes. It says the license is issued when the initial survey is completed with zero deficiencies, and Chapter 2 bars issuing a license until the applicant conforms to all applicable statutes and rules. The statute does let CDPHE issue a 90-day provisional license to an applicant temporarily unable to meet every standard, but CDPHE’s guidance does not say when it uses one for new agencies. Plan to have every required policy, the personnel files and background checks, and your quality management plan ready before the survey.
"When the initial survey has been completed with zero deficiencies, the survey team will notify the licensing team that the applicant has successfully completed the initial survey."
It depends. Sometimes not. The statute says CDPHE does not cite an isolated event that can be effectively remedied during the survey or inspection, unless it caused harm or a potential for harm, created a life- or limb-threatening emergency, or was due to abuse or neglect. It speaks of a licensed health facility, and nothing we found says whether it applies at an applicant’s initial survey, where CDPHE’s guidance asks for zero deficiencies. Fix anything raised at once, but prepare as if every gap would be cited.
"The department shall not cite as a deficiency in a report resulting from a survey or inspection of a licensed health facility any deficiency from an isolated event identified by the department that can be effectively remedied during the survey or inspection of the health facility"
It depends. The rules do not say. Chapter 2 sets no standard re-licensure survey frequency for home care. It says that, for licensees with three years of licensure and a clean record, CDPHE will extend the survey cycle up to three years or use a tiered inspection, and the statute says the annual fee reflects whether a survey is planned for the year based on compliance history. A proposed amendment (hearing November 18, 2026) would schedule eligible licensees on a three-year cycle. CDPHE can still inspect at any time in response to a complaint.
"For each licensee that is eligible, the Department will either extend the standard licensure survey cycle up to three (3) years or utilize a tiered licensure inspection system."
No. The plan, signed by your manager, is due within 10 calendar days after the date of CDPHE’s written notice of deficiencies; ask in writing before the due date if you need more time. The 30 days is the latest completion date for the corrections themselves, counted from the issuance of the deficiency list, unless CDPHE requires or approves another date.
"Submitted to the Department within ten (10) calendar days after the date of the Department’s written notice of deficiencies."
After its fitness review is approved and your application is complete. CDPHE then requests the initial survey; there is usually a queue, and a member of the survey team calls you to schedule it. It is typically on site at the address on your application. CDPHE issues the license once the survey is completed with zero deficiencies. CDPHE does not publish a waiting time for home care surveys.
CDPHE’s licensing guidance says the agency must have ready: proof of the administrator or manager’s training and qualifications, employee background checks in personnel files, all required policies and procedures ready for review, medical malpractice loss information, and the quality management plan. Chapter 2 also bars issuing a license until the applicant conforms to all applicable statutes and rules, so by our reading the surveyor can look at anything the rules require. CDPHE publishes no survey checklist for home care.
CDPHE has not said. Its guidance describes the license being issued after a survey completed with zero deficiencies, and Chapter 2 defines a deficiency as any failure to fully comply with a statute or rule. Chapter 2 lets CDPHE ask a licensee for a plan of correction after any review, due within 10 calendar days of its written notice; the statute requires a home care agency to submit a written plan to correct violations CDPHE finds in its inspections; and the statute lets CDPHE issue a 90-day provisional license to an applicant temporarily unable to conform. By our reading those could be used before a first license, but whether CDPHE uses a plan of correction and revisit, a provisional license, a new survey or a denial is a question for CDPHE. Ask when the surveyor calls.
Possibly not. The statute says CDPHE does not cite an isolated event that can be effectively remedied during the survey, unless it caused harm or a potential for harm, created a life- or limb-threatening emergency, or was due to abuse or neglect. It speaks of a licensed health facility, and nothing we found says whether it applies at an applicant’s initial survey. Fix anything raised straight away, and prepare as if every gap would be cited.
The rules do not set a standard frequency for home care. Chapter 2 says that for an eligible licensee (licensed three years, with no enforcement, no pattern of deficient practice and no substantiated complaint finding significant deficiencies in three years) CDPHE will extend the survey cycle up to three years or use a tiered inspection. A proposal heard on November 18, 2026 would schedule eligible licensees on a three-year cycle. CDPHE can also inspect unannounced between 7 a.m. and 7 p.m., and at any time in response to a complaint.
Ten calendar days after the date of CDPHE’s written notice of deficiencies, signed by your manager. If you need more time, ask in writing before the due date. The corrections themselves must be completed within 30 calendar days of the deficiency list being issued, unless CDPHE requires or approves another date. To dispute a finding, an informal dispute resolution request must reach CDPHE within 10 calendar days of your receiving the statement of deficiencies.
Yes, as an intermediate restriction or condition: a civil fine of up to $10,000 per calendar year for all violations. You may ask for a stay of the fine until the matter is finally decided, and CDPHE must grant it. CDPHE can also impose conditions on a license (with a $1,938.29 conditional license fee on its 2026/27 schedule) and charge revisit fees. Operating without a license is separate: a misdemeanor and a civil penalty of up to $10,000 per violation. These are CDPHE’s fines and fees, not CareRulebook charges.
Yes. Policy 1.6, CDPHE surveys, inspections and plans of correction, covers the initial survey and what must be ready, zero deficiencies, the isolated-event rule, later inspections, records within 30 minutes and 2 hours, home visits with consent, plans of correction, informal dispute resolution, revisit fees and intermediate restrictions, with a survey-day checklist and a plan of correction worksheet.
CDPHE has proposed a three-year survey cycle for eligible licensees in Chapter 2 (written comments due November 12, 2026; hearing November 18, 2026). Leave your email and we will tell you when a Colorado change affects your surveys or your policies.
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