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WELD COUNTY
CODE ORDINANCE 2023-02
IN THE MATTER OF REPEALING AND REENACTING, WITH AMENDMENTS,
CHAPTER 12 LICENSES AND PERMITS OF THE WELD COUNTY CODE
BE IT ORDAINED BY THE BOARD OF COUNTY COMMISSIONERS OF THE COUNTY OF
WELD, STATE OF COLORADO:
WHEREAS, the Board of County Commissioners of the County of Weld, State of
Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with
the authority of administering the affairs of Weld County, Colorado, and
WHEREAS, the Board of County Commissioners, on December 28, 2000, adopted
Weld County Code Ordinance 2000-1, enacting a comprehensive Code for the County of Weld,
including the codification of all previously adopted ordinances of a general and permanent nature
enacted on or before said date of adoption, and
WHEREAS, the Weld County Code is in need of revision and clarification with regard to
procedures, terms, and requirements therein.
NOW, THEREFORE, BE IT ORDAINED by the Board of County Commissioners of the
County of Weld, State of Colorado, that Chapter 12 Licenses and Permits of the Weld County
Code be, and hereby is, repealed and re-enacted, with amendments, to read as follows.
CHAPTER 12
Licenses and Permits
ARTICLE I - Reserved Secure Transportation Services
Division 1 - General Provisions
Sec. 12-1-10. Purpose.
The purpose of this Chapter is to set forth the requirements for the inspection, licensure,
and operation of secure transportation services for individuals experiencing behavioral health
crises, in order to ensure high -quality behavioral health transportation within Weld County,
pursuant to C.R.S. §§ 25-3.5-103, 25-3.5-309, and 25-3.5-310, and 6 CCR 1011-4.
Sec. 12-1-20. Delegation.
A. The Board of County Commissioners designates and delegates to the Executive Director
of the Weld County Department of Public Health and Environment ("the Director") the
authority to manage the Secure Transportation Services Rules and Regulations as set out
in this Chapter. Inspections and permitting of individual Secure Vehicles, application
processing and review, other administrative functions necessary to implement this
Chapter, and issuance or denial of the license shall be the responsibility of the Director.
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The Director may not have any actual or apparent financial interest in or familial
relationship with a Secure Transportation Service applying for a License or Permit
pursuant to these rules and regulations.
B The Director shall enforce these rules and regulations for the operation and licensing of
secure transportation services in the County to provide for quality secure transportation
services and to ensure compliance with state law and any applicable Code provisions
adopted by the Board.
Sec. 12-1-30. Definitions.
The following definitions shall apply in the interpretation and enforcement of this Chapter.
Abuse means any of the following acts or omissions:
A. The non -accidental infliction of bodily injury, serious bodily injury, or death.
B. Confinement or restraint that is unreasonable under generally accepted standards.
C. Subjection to nonconsensual sexual conduct or contact.
Administrator means any person who is responsible for the overall operations of the
secure transportation service, as set forth in Sec. 12-1-330, below.
Based means a service area in a county where the client is picked up for secure
transportation services.
Behavioral health means an individual's mental and emotional well-being and actions that
affect an individual's overall wellness. Behavioral health issues and disorders include substance
use disorders, serious psychological distress, suicide, and other mental health disorders, and
range from unhealthy stress or subclinical conditions to diagnosable and treatable diseases. The
term "behavioral health" is also used to describe service systems that encompass prevention and
promotion of emotional health and prevention and treatment services for mental health and
substance use disorders.
Behavioral health crisis means a significant disruption in a person's mental or emotional
stability or functioning resulting in an urgent need for immediate assessment and treatment to
prevent a further or serious deterioration in the person's mental or physical health.
Chemical restraint means giving an individual medication involuntarily for the purpose of
restraining that individual; except that "chemical restraint" does not include the involuntary
administration of medication pursuant to C.R.S. § 27-65-111 (5), or administration of medication
for voluntary or life-saving medical procedures.
Class A means secure transportation services licensed to use physical restraint during
secure transport pursuant to the parameters set forth in Sec. 12-1-410, below.
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Class B means secure transportation services that are not licensed to use physical
restraint during secure transport.
Client means an individual experiencing a behavioral health crisis who is eligible for urgent
secure transportation services, as defined below, and who meets the parameters set forth in
Sec. 12-1-410, below.
Department means the Weld County Department of Public Health and Environment.
Direct client contact means any staff member who interacts directly with clients either
before, during, or after the secure transportation service and is qualified by training pursuant to
Sec. 12-1-360, below. This may include the driver or any other staff member who is not providing
direct client support.
Direct client support means any staff member who interacts directly with clients and is
qualified by training pursuant to Sec. 12-1-360, below, in mental health first aid, basic first aid,
and cardiopulmonary resuscitation (CPR) who is assigned to provide secure transportation
services to individuals experiencing a behavioral health crisis.
Director means Executive Director of Weld County Department of Public Health and
Environment.
Emergency Medical Services Facility means a licensed or certified facility that provides
emergency medical services, including, but not limited to, hospitals; hospital units as defined at
C.R.S. § 25-3-101; freestanding emergency departments as defined at C.R.S. § 25-1.5-114;
psychiatric hospitals; community clinics; behavioral health entities; and community mental health
centers, crisis stabilization units, or acute treatment units licensed as a behavioral health entity.
Exploitation means an act or omission committed by a person who:
A. Uses deception, harassment, intimidation, or undue influence for their personal
gain to, permanently or temporarily, deprive a client of the use, benefit, or
possession of anything of value.
B. Forces, compels, coerces, or entices a client for the profit or advantage of the
person or another person against the will of the client; or
Misuses the property of a client in a manner that adversely affects the client's ability
to receive services or care.
Facility, for the purposes of this chapter, means all facility types defined at Part 2.22 CC),
6 CCR 1011-4.
Harmful act means an act committed against a client by a secure transportation service
staff member when such act is not defined as abuse, neglect, or exploitation but causes harm to
the health, safety, or welfare of a client.
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Licensee means the person or business entity that is granted a license by the county to
operate a secure transportation service and that bears legal responsibility for compliance with all
applicable federal, state, and local statutes and regulations.
Manager means any person who is responsible for supervising staff and the day-to-day
operations of the secure transportation service, as set forth in Sec. 12-1-320, below.
Mistreatment means abuse, neglect, exploitation, or a harmful act.
Neglect means a staff member's failure to provide behavioral health care, physical care,
supervision, or any other service necessary for the health or safety of a client during the secure
transportation service in a timely manner and with the degree of care that a reasonable person in
the same situation would exercise. Neglect also means a staff member knowingly using
harassment, undue influence, or intimidation to create a hostile or fearful environment for a client.
Owner means an officer, director, general partner, limited partner, or other person having
a financial or equity interest in the secure transportation service. An owner may also serve as the
manager and/or administrator of a licensed secure transportation service.
Physical restraint, for the purposes of this chapter, means a physical device used to
involuntarily restrict the movement of an individual or the movement or normal function of a portion
of their body.
Secure transportation or secure transportation services means urgent transportation
services provided to individuals experiencing a behavioral health crisis. Secure transportation
includes:
A. An individual being transported pursuant to C.R.S. § 27-65-103 or 27-65-105(1),
transportation from the community to a facility designated by the Executive Director
of the Department of Human Services (DHS) for treatment and evaluation pursuant
to C.R.S. § 27-65-101, et seq.
B. An individual in need of services pursuant to C.R.S. § 27-81-101, et seq. and
§ 27-82-101, et seq., transportation from any location to an approved treatment
facility, as described in C.R.S. § 27-81-106, or to a walk-in crisis center that is in
operation as part of the behavioral health crisis response system.
C An individual who is receiving transportation across levels of care or to a higher or
lower level of care, transportation between any of the following types of facilities:
1. An emergency medical services facility.
2. A facility designated by the Executive Director of DHS for the treatment and
evaluation pursuant to C.R.S. § 27-65-101, et seq.
3 An approved treatment facility, as described in C.R.S. § 27-81-106.
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4 A walk-in crisis center that is operating as part of the behavioral health
crisis response system; or
5 A behavioral health entity (BHE) licensed pursuant to
C.R.S. § 25-27.6-106, with a current twenty-four (24) hour endorsement.
D Secure transportation does not include urgent transportation services provided by
law enforcement or personnel employed by, or contracted with, a law enforcement
agency to individuals experiencing a behavioral health crisis.
1. Except that any member of a co -responder team may provide urgent
transportation services if that co -responder:
a Is not law enforcement or personnel employed by, or contracted
with, a law enforcement agency;
b Holds a valid license for secure transportation by the county in
which the secure transportation originates; and
c. Provides secure transportation in a vehicle:
i. With a valid permit issued by the county in which the secure
transportation originates, and
ii. That meets the minimum requirements for secure
transportation services in this rule chapter.
Serious injury means brain or spinal cord injuries; bone breaks or fractures; any injury that
threatens life or limb, impairs the function of any part or organ of the body, or results in permanent
disfigurement; burns of the second or third degree; and/or physical or sexual abuse as described
in C.R.S. § 18-3-101, et seq.
Type 1 means a permitted vehicle with a permanent safety partition that separates the
driver from the passenger compartment.
Type 2 means a permitted, non -partitioned vehicle.
Division 2 — County Issuance of Licenses and Secure Vehicle Permits
Sec. 12-1-110. Secure transportation license required.
On or after the effective date of this Article I, in accordance with 6 CCR 1011-4, § 3.1, no
person or agency, public or private, shall transport a patient experiencing a behavioral health
crisis from any point within the County to any point within or outside the County unless that person
or agency holds a valid license issued by the county in which the secure transportation service is
based, except as provided in Sec. 12-1-160, below. Accordingly, every Secure Transportation
Service based in Weld County must secure a license issued by the County pursuant to these
Regulations.
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Sec. 12-1-120. Types of licenses.
A Secure Transportation Service shall elect either a Class A License, for services which
use physical restraint during the provision of secure transportation, or a Class B License, for
services which do not use physical restraint during the provision of secure transportation.
Sec. 12-1-130. Secure Vehicle permit required.
In addition to the requirement of licensure of any Secure Transport Service operating
within the County, per Sec. 12-1-100, above, every Secure Transportation Service based in Weld
County must secure a permit, issued by the County in which the Secure Transportation Service
is based, pursuant to these Regulations, for each vehicle it operates.
Sec. 12-1-140. Types of Secure Vehicle permits.
A Secure Transportation Service shall elect to permit each of its vehicles as either a
Type 1 Secure Vehicle, for a vehicle with a safety partition that separates the driver from the
passenger department, or a Type 2 Secure Vehicle, which does not contain a safety partition.
Sec. 12-1-150. Terms.
A. Each Secure Transportation Service License shall be valid for three (3) years from the
issue date, unless revoked or the Secure Transportation Service changes ownership. •
Licenses may not be sold, assigned, or otherwise transferred.
B. Each Secure Vehicle Permit shall be valid from one (1) year from issue date, unless earlier
revoked or the vehicle changes ownership. Permits may not be sold, assigned, or
otherwise transferred.
C Each application for Secure Transportation Service License or Secure Vehicle Permit
must be submitted no later than thirty (30) days before the requested effective date of the
License or Permit, for a new License or Permit, or thirty (30) days before the expiration of
the existing License or Permit, for renewals. Licensees or Permitees who do not comply
with this renewal application time requirement shall be treated as applying for a new
License or Permit rather than renewal.
Sec. 12-1-160. Exemptions from licensure and permit requirements.
The following entities may provide secure transportation services to an individual
experiencing a behavioral health crisis without first obtaining a Secure Transportation Service
License or Secure Vehicle Permit:
A. A Ground Ambulance Agency licensed pursuant to C.R.S. § 25-3.5-301, is exempt from
additional secure transportation licensing requirements and is eligible to receive
reimbursement pursuant to C.R.S. § 25.5-5-328, if the ambulance agency meets all of the
requirements set forth in 6 CCR 1011-4.
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B Transportation services provided by the Office of Behavioral Health within the Department
of Human Services.
C. Emergency service patrols established pursuant to C.R.S. § 27-81-115.
D. Law enforcement.
Sec. 12-1-170. Reciprocal agreements with other jurisdictions.
The County may enter into reciprocal licensing and permitting agreements with other
counties and neighboring states.
Sec. 12-1-180. Approval of application.
After receipt of an original application for a Secure Transportation Service License or
Secure Vehicle Permit, or a renewal thereof, the Department shall review the application and the
applicant's record and provide for an inspection of vehicles to determine compliance with this
Chapter. The Director shall issue the license on behalf of the Board of County Commissioners,
upon a finding that:
A. The secure transportation service staff, vehicles, records, insurance, protocols,
equipment, and location comply with the requirements of this Chapter.
The County may accept vehicle inspections from other Colorado counties for permitting of
Secure Vehicles operating in Weld County. Said inspections shall occur within the most
recent permit period (not to exceed twelve 112] months) by the inspecting county.
B. The issuance of the license will contribute to an efficient, effective, and coordinated
response to residents of the County. The Director shall consider the following:
1. The recommendation of the Department staff reviewing the application.
2. The facts presented in the application.
3. Any additional information offered by the applicant.
4. The applicant has complied in all respects with the requirements of this Chapter.
C Renewals of a Secure Transportation Service License or Secure Vehicle Permit shall
follow the requirements of the Department in terms of renewal form and fee submission.
Sec. 12-1-190. Appeal of application denial.
Any person or entity having been denied a license by the Director may appeal such denial
to the Board of County Commissioners pursuant to Sec. 2-4-10 of this Code.
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Sec. 12-1-200. Additional or replacement vehicles.
If a vehicle is added to a Secure Transportation Service's fleet, that Secure Vehicle permit
application shall be filed with the Department prior to the Vehicle being placed into service. The
completed application shall include a description of the vehicle replaced, if applicable. Upon
receipt of a new vehicle permit application, the Department shall inspect the new vehicle and the
Director will issue the new vehicle permit upon a finding that the vehicle meets all requirements
of Section 12-1-220, below.
Division 3 - Licensure and Permit Requirements
Sec. 12-1-210. Licensure requirements.
Before issuing a new or renewed license to a Secure Transportation Service pursuant to
these Regulations, the Department shall ensure the following requirements have been met:
A. The Secure Transportation Service has certified that it is compliant with all applicable laws
and regulations required to operate a secure transportation service in Colorado, and the
Department does not have information to the contrary.
B. The Secure Transportation Service has completed the County's application form and has
paid all applicable fees set by the County.
C The Secure Transportation Service has provided the following to the Department:
1. Name and contact information of the Manager and Administrator of the Secure
Transportation Service.
2 Submission of all written policies and procedures, including any operational
protocols, medical protocols, training procedures, client rights, background check
policy and other relevant documents.
3 Written statement of understanding that if the Secure Transportation Service is
sold or transferred, the new owner shall be required to obtain licensing and permits
prior to beginning operations.
4. List of current staff and certification that staffing requirements have been met.
D The Secure Transportation Service has demonstrated that it has the following insurance
coverage from an insurance company authorized to write liability insurance in Colorado,
and that the Board of County Commissioners of Weld County is identified as a certificate
holder and additional named insured:
1. General liability and applicable professional liability insurance coverage, in the
following minimum amounts:
a Liability insurance for iniuries in the amount of one million dollars
($1,000,000.00) for each individual claim.
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b. Liability insurance in the amount of three million dollars ($3,000,000.00) for
all claims made against the secure transportation service or against its
personnel.
E Demonstration by the applicant of proof of a minimum level of worker's compensation
consistent with the Colorado Worker's Compensation Act in Articles 40-47 of Title 8,
C.R.S., as applicable.
Sec. 12-1-220. Secure Vehicle Permit requirements.
Before issuing a new or renewed Secure Vehicle Permit to a Secured Transportation
Service pursuant to these rules and regulations, the County shall ensure the following
requirements have been met:
A. The Secure Transportation Service has completed the County's Secure Vehicle Permit
form.
B The Secure Transportation Service has provided the following to the County:
1. Certificate of Mechanical Inspection, completed by a qualified motor vehicle
mechanic, for each vehicle for which a permit is sought.
2 Certification of compliance signed by the Secure Transportation Service's
Administrator.
C The Secure Transportation Service has demonstrated that it has the following insurance
coverage, and that the Board of County Commissioners of Weld County is identified as a
certificate holder and additional named insured, for each vehicle for which a permit is
sought:
1. Automobile liability insurance coverage in the amount of one million dollars
($1 000.00.00) bodily injury for each person, two million dollars ($2,000.00.00)
bodily injury for each accident, and one million dollars ($1,000.000.00) for property
damage.
Compliance with client and crew vehicle safety standards as follows:
1. All vehicles must demonstrate proof of compliance with Federal Motor Vehicle
Safety Standards on the date of manufacture in accordance with the following:
a 49 C.F.R. Part 567.4(a) for manufactured motor vehicles (except replica
motor vehicles and vehicles manufactured in two (2) or more stages),
b 49 C.F.R. Part 567.5 for vehicles that are manufactured in two (2) or more
stages, or
c. 49 C.F.R. Part 567.7 for certified vehicles that are altered.
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2. All vehicles must undergo routine vehicle maintenance and periodic checks in
accordance with manufacturer recommendations.
3 All vehicles must have the following safety features:
a four doors;
b ligature risk reduction measures;
c child safety and window safety locks;
d. global Positioning System (CPS) tracking;
e occupant protection, including seat belts, supplemental inflatable
restraints, and child safety seats (as applicable);
f cabin temperature control and ventilation system;
g
absent of any foreign items or instruments in the secured area that may be
used to inflict harm; and
h mirror for monitoring the client or capability for visual observation of the
client.
4. If a Type 1 vehicle with a safety partition that separates the driver from the
passenger compartment is being used for the secure transportation service, then
the vehicle must have the following additional safety features:
a permanent installation of all safety partitions; and
b. a safety partition that separates the passenger compartment from the cargo
area (for vehicles with a cargo area).
5 All vehicles must be equipped with the following:
a first aid kit;
b. fire extinguisher;
c, wireless two-way communication (public safety radio, commercial land
mobile radio, or wireless telephone);
d biohazard bag;
e personal protective equipment for each occupant as per public health
recommendations; and
f map of service area.
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6. If a licensed secure transportation service utilizes physical restraint as part of its
services, the vehicle shall additionally be equipped with the following:
a automated external defibrillator (AED);
b non-metal, soft posey-type restraints; and
c. device intended to prevent a client from spitting or biting that does not
restrict the client's airway or breathing ability and does not pose a ligature
risk.
Division 4 - Staffing Requirements
Sec. 12-1-310. Manager and administrator minimum qualifications.
Each Secure Transportation Service based in Weld County must have a Manager and an
Administrator. The Manager and Administrator positions may be held by the same person. Each
Manager and Administrator must meet the following minimum requirements:
A. Be at least twenty-one (21) years of age and possess a high school diploma or GED.
B. Have at least one (1) year documented supervisory experience in the provision of secure
transportation services, or be qualified by education, knowledge, and experience to
oversee the secure transportation services provided.
C Be able to communicate, understand, and respond effectively to the client, family
representatives, and other providers and be able to use appropriate translator services as
needed.
D. Be familiar with all applicable local, state, and federal laws and regulations concerning the
operation and provision of secure transportation services.
E. Be in good standing with any state regulatory agency if the manager or administrator is
licensed or certified with the Colorado Department of Regulatory Agencies or the Colorado
Department of Public Health and Environment.
F Have passed a background check that was performed by the Secure Transportation
Service or owner prior to the assumption of responsibilities. The manager or
administrator shall not conduct his or her own background check or any required follow-up.
Sec. 12-1-320. Manager responsibilities.
The responsibilities of the manager include, but are not limited to:
A. Supervising staff and the day-to-day operations of the service.
B Completing the applicable annual training and core competencies in Sec. 12-1-360, below.
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C. Ensuring annual training completion and core competencies for every staff member with
direct client contact.
D Implementing a quality management program in accordance with Article VII of these rules.
E Maintaining appropriate records and ensuring accurate completion of records, including,
but not limited to:
1. Personnel records.
2. Client records, including individual trip logs and the data reporting requirements in
accordance with Part 6, 6 CCR 1011-4.
F. Implementing all policies and procedures of the secure transportation service.
Sec. 12-1-330. Administrator responsibilities.
The responsibilities of the administrator include, but are not limited to:
A. Managing the business affairs and overall operation of the secure transportation service,
including planning, organizing, developing, controlling, and/or maintaining the service's
operations.
B. Organizing and directing the service's ongoing functions.
C Overseeing a budgeting and accounting system.
D Designating, in writing, a qualified back up administrator to act in the administrator's
absence or requiring the administrator or their qualified designee to be available in person
or remotely to assist secure transportation service staff members with urgent matters that
arise during all hours that staff are providing services.
E Ensuring the secure transportation service follows all applicable federal, state, and local
laws.
F Ensuring the completion, maintenance, and submission of such reports and records as
required by the County and/or Colorado Department of Public Health and Environment.
G Developing and implementing a quality management program in accordance with Part 10,
6 CCR 1011-4.
H Maintaining appropriate records and all policies and procedures of the service, including,
but not limited to:
1. Personnel records, including verification of each staff member's compliance with
orientation and annual training requirements set forth in Sec. 12-1-360, below, and
verification of any applicable active professional licensure or certification.
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2 Client records, including individual trip logs and the data reporting requirements in
accordance with Part 6, 6 CCR 1011-4.
3. Financial and administrative records, including certificates of insurance for the
secure transportation service.
Sec. 12-1-340. Notification of change in Manager or Administrator.
The Secure Transportation Service must notify the Department of any changes regarding
the Manager or Administrator during the licensing term. Such notification must be provided within
14 days of the change.
Sec. 12-1-350. Secure Transportation Service staffing.
Every Secure Transportation Service shall have, at a minimum, staffing requirements
which include:
A. All drivers must possess a current and valid driver's license.
B. If a Type 1 (partitioned) vehicle is being used for the secure transport, then the following
shall apply:
1. A 1:1 ratio of client to staff member shall be maintained during the transport, which
staff member may also be the driver in the case of a Type 1 vehicle transportation.
2. If one (1) client is being transported, then one (1) staff member with a current and
valid certification for all training topics listed in Sec. 12-1-360, below, is required to
staff a vehicle permitted for each secure transport.
3. If more than one (1) client is being transported, then one (1) staff member who
possesses a current and valid certification for all training topics listed in
Sec. 12-1-360, below, is required to accompany each individual client during
transport.
C. If a Type 2 (non -partitioned) vehicle is being used for the secure transport, then the
following shall apply:
1. A 1:1 ratio of client to staff member shall be maintained during the transport, in
addition to the driver, who may not be included in the staffing ratio requirement in
the case of a Type 2 vehicle transportation.
2. If one (1) client is being transported, then two (2) staff members are required to
staff the vehicle. At a minimum, the staff member who is not the driver must have
a current and valid certification for all training topics listed in Sec. 12-1-360, below.
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3 If more than one (1) client is being transported, then one (1) staff member who
possesses a current and valid certification for all training topics listed in
Sec. 12-1-360, below, is required to accompany each individual client during
transport.
D Each staff member with direct client contact must possess a certification or proof of having
completed all required coursework.
E Each Secure Transportation Service must have a policy related to background checks for
all staff members. Such background checks shall take place prior to an individual
providing secure transportation services. The policy shall include, at a minimum:
1. The Secure Transportation Service's responsibility to conduct a background check
on every existing and prospective staff member.
a If any background check reveals prior convictions of a violent, fraudulent,
or abusive nature, the manager or administrator shall inquire further to
determine the potential impact on client safety in accordance with policies
developed by the secure transportation service.
b. If an individual is hired despite a background check that reveals a prior
conviction of a violent, fraudulent, or abusive nature, the Manager or
Administrator shall document the reasons for hire and plans for
supervision.
Sec. 12-1-360. Staff training.
A. Prior to providing secure transportation services, and annually thereafter, or as
recommended by relevant training organizations, all Secure Transportation Service staff
with direct client contact, shall complete orientation and achieve core competencies in the
following topics:
1. Cultural competencies including, but not limited to, supporting persons with
physical or cognitive disabilities, language accessibility, and accessing interpretive
services.
2 In -person or online verbal de-escalation training sessions that prioritize client and
staff safety and inform restraint requirements set forth in Part 8.3, 6 CCR 1011-4.
3. Trauma -informed care principles.
Evade and escape violent encounter strategies.
5 Internal policies and procedures applicable to the secure transportation service
and staff, including, but not limited to, the staff disciplinary policy.
Client rights.
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7. Compliance with applicable privacy laws.
B. In addition to completing the minimum training requirements set forth in this Section, all
Secure Transportation Service staff members who provide direct client support shall also
complete training during orientation and achieve core competencies in the following topics:
1. Adult and Youth Mental Health First Aid as offered by educational institutions or by
professional organizations such as www.mentalhealthfirstaid.org, or the
equivalent.
2. Basic First Aid and CPR.
3. Care of clients with substance use disorders.
C All secure transportation staff members who may utilize physical restraint, as defined in
Sec. 12-1-30, above, during secure transportation of clients under Class A services shall
also complete training during orientation and achieve core competencies in the following
topics:
1. Circumstances and protocols governing the permissible application of individual
physical restraint during secure transport.
2. Safe application of individual physical restraint on clients during secure transport.
Sec. 12-1-370. Training documentation.
All staff training must be documented by the Secure Transportation Service and provided
to the County during the initial application process and at each renewal.
Division 5 — Clinical, Medical, and Operating Standards and Procedures
Sec. 12-1-410. Parameters for secure transportation.
Secure transport clients may only be transported under the following circumstances:
A. The client is experiencing a behavioral health crisis.
B. The client needs urgent transportation to a facility that is defined Sec. 12-1-30, above.
C. The client does not and will not need either:
1. Medical treatment during transport, or
2. Active or ongoing medical monitoring.
D The client does not and will not need to be chemically restrained during secure transport
as a behavioral intervention.
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Sec. 12-1-420. Required policies and procedures.
A. Each licensed Secure Transportation Service must have established policies and
procedures that follow national best practice guidelines where available, and address, at
a minimum:
1. Appropriate procedures to assess initially whether the client requires a higher level
of transport than the service can provide.
2 Appropriate procedures to follow when, during a secure transport, it becomes
apparent that a client needs medical attention or a higher level of transport than
the service can provide.
3 Appropriate procedures to confirm the receiving facility's acceptance of the client
prior to initiation of the secure transport.
4 Criteria used for pickup and drop-off, including the circumstances that determine
a secure transport client's eligibility.
5 The level of support and protection needed for both client and staff safety.
Compliance with vehicle safety standards and procedures.
7 Proper evacuation of the vehicle during emergencies if the windows and/or exits
of the vehicle are blocked or inaccessible.
8 Infection prevention and control, including the decontamination of the vehicle after
each transport.
9. Parental and/or guardian level of support and involvement.
10. Meeting client needs on extended transports including meals, water, and bathroom
breaks.
11. Documentation of all steps in the process from initial pickup request to drop-off,
including, but not limited to, documenting all stops made during the secure
transportation service.
B In addition, each Class A Secure Transportation Service must have in place the following
policies and procedures that address, at a minimum:
1. The circumstances under which staff who provide direct client support may apply
individual physical restraint during the course of the secure transportation service,
given the parameters outlined in Sec. 12-1-430, below.
2 The application of individual physical restraint, including training protocols and
safety precautions, to ensure the restraints do not restrict the client's airway or
breathing ability.
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Sec. 12-1-430. Use of restraints.
A. No chemical restraint may be administered during a secure transport. If chemical restraint
is needed to ensure client safety, then the client shall receive an ambulance transport.
B Physical restraint, as defined in Sec. 12-1-30, above, shall only be utilized for health and
safety purposes under the following circumstances:
1. In cases of emergency, when the client is at risk of causing serious, probable, and
imminent threat of bodily harm to themselves or to others and where there is the
present ability to affect such bodily harm; and
2 After the failure of less restrictive alternatives, including verbal de-escalation; or
3 After a determination that such alternatives would be inappropriate or ineffective
under the circumstances.
C If physical restraint is utilized during a transport, the service shall document the time at
which the physical restraint was applied and removed (if applicable) and the type of
physical restraint used.
Sec. 12-1-440. Capacity, documentation, and availability.
A. The Secure Transportation Service shall transport one (1) client per vehicle transport,
except under the following circumstances:
1. Each client has received behavioral health clearance from the treating provider at
the sending facility, no physical restraint is needed, and there is a low probability
of behavioral destabilization.
2 Each client has received medical clearance from the treating provider at the
sending facility, is medically stabilized, and has a low probability of medical
destabilization.
3. Each client has received an assessment from the treating provider at the sending
facility that the client is an appropriate candidate for a transport with one or more
individuals.
4. The transport is an inter -facility transport as defined in Sec. 12-1-30, above.
5. Each client has given their consent to be transported with another individual(s).
B The Secure Transportation Service shall create and maintain accurate and detailed logs of
client transports, including professional incident reports.
C To ensure the needs of clients are met, secure transportation services that do not provide
24/7 services shall provide the client with their after-hours contact information and with
contact information for the Secure Transportation Service's back-up providers.
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Division 6 - Client Rights
Sec. 12-1-510. Written client rights.
Each Secure Transportation Service shall have written client rights which assure that each
client has the right to be treated with consideration, respect, and full recognition of human dignity
and individuality, and that includes, at a minimum:
A. The right of the client and their property to be treated with respect.
B. The right of the client to have access to basic comfort items and their personal mobile
phone provided the direct client support staff member establishes and documents that
those items do not pose a danger to the client or staff member.
C. The right of the client to wear their own clothes provided the direct client support staff
member establishes and documents that those items do not pose a danger to the client
or staff member.
D The right of the client to receive secure transportation services by the least restrictive
means necessary to assure the safety of the client.
E The right of the client to be free from discrimination in the provision of services.
F The right of the client to be free from neglect, financial exploitation, and verbal, physical,
and psychological abuse, including humiliation, intimidation, or punishment.
G For clients who request voluntary transport, the right of the client to discontinue secure
transportation services.
H The right of the client to receive disclosure about any video and/or audio recording that
occurs during the delivery of service in accordance with applicable privacy laws.
I The right of the client to have personally identifying health information protected from
unnecessary disclosure.
J The right of the client or their representative to file a complaint against the Secure
Transportation Service with the Secure Transportation Service and County concerning
services or care that is or is not furnished, and receive documentation of the existence of
the investigation and resolution of the complaint, including providing the complainant with
the results of the investigation and the secure transportation service's plan to resolve any
identified issues.
K. The right of the client to file a complaint with the Secure Transportation Service and county
without fear of discrimination or retaliation by the secure transportation service's owner,
manager, administrator, or any staff members.
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Sec. 12-1-520. Client rights policies and procedures.
Each Secure Transportation Service shall have an established client rights policies and
procedures that include, at a minimum:
A. Procedures for identifying, reporting, reviewing, and investigating all allegations of abuse,
mistreatment, neglect, and exploitation.
B Procedures for timely communicating all investigation results to the client and county in
which the secure transportation service is licensed.
C Procedures for timely and appropriate disciplinary action up to, and including, termination
of staff and appropriate legal recourse against any staff member who has engaged in
abuse, mistreatment, neglect, or exploitation of a client.
D Procedures the direct client support staff member must follow to document their decision
to withhold any basic comfort items and/or the client's personal mobile phone or prohibit
a client from wearing their own clothes.
Sec. 12-1-530. Provision of client rights and policies and procedures to client.
The Secure Transportation Service shall provide each client with written documentation
of its Client Rights and Client Rights' Policies and Procedures, including the right to file a
complaint with the Department, to clients at the initiation of the Secure Transportation Service. If
the client is unable to read the rights, they shall be read the rights in a language they understand.
Sec. 12-1-540. Designation of staff member responsible for complaint intake and problem
resolution.
The Secure Transportation Service shall designate a staff member as responsible for
complaint intake and problem resolution, and shall inform the Department of that person's name,
title, and contact information at the time of licensing or renewal, or in the event of any changes in
that position.
Division 7 - Quality Management Program ("QMP")
Sec. 12-1-610. QMP requirements.
Each Secure Transportation Service must have an ongoing quality management program
("QMP") that is appropriate to the size and type of the service. The Secure Transportation
Service shall make their QMP plan available to the Department during the initial license
application and include with renewal applications if the plan has been revised. The Department,
the Colorado Department of Public Health and Environment, or any other appropriate regulatory
agency having jurisdiction for disciplinary or licensing sanctions shall have access to any records,
reports, and other information of the QMP.
The QMP shall incorporate a plan that evaluates the quality of client care and safety and
has, at a minimum, the following policies and procedures:
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A. The incorporation of the substantiated findings of any complaint into its QMP for the
purpose of evaluating and implementing systemic changes where needed.
B. The general description of the types of cases, problems, or risks to be reviewed and
criteria for identifying potential risks.
C Identification of the staff members responsible for coordinating quality management
activities.
D A description of the method(s) for:
1. Investigating and analyzing the frequency and causes of individual problems and
patterns of problems.
2 Taking corrective action to address the problems, including prevention, and
minimizing problems or risks.
3 Evaluating corrective action(s) to determine the effectiveness of such action(s).
4 Coordinating all pertinent case, problem, or risk review information with other
applicable quality assurance and/or risk management activities, such as review of
client care, review of staff conduct, the client complaint system as described in
Section 8.2(D) of this Policy, and education and training programs.
E Documentation of required quality management activities, including cases, problems, or
risks identified for review; findings of investigations; and any actions taken to address
problems or risks.
F A schedule for program implementation not to exceed ninety (90) days after the date of
the issuance of the secure transportation service license.
G A schedule for program evaluation to periodically assess the effectiveness of services and
review the clinical and operational protocols and compliance with such protocols.
H. The utilization or application of data collected pursuant to 6 CCR 1011-4 to inform the
quality management plan.
I. A written disciplinary policy that addresses a process for staff quality improvement.
Division 8 - Complaints
Sec. 12-1-710. Complaints against Secure Transportation Services.
A. An alleged violation of the rules and regulations set forth in this Article I by a Licensed
Secure Transportation Service or an allegation of a Secure Transportation Service
operating in the County without a license, may be made by any person or agency or may
be initiated by the Department on its own volition.
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B Such Complaint shall be made to the Department and may be made in writing or verbally.
C The Department shall provide to the complainant the name and contact information of the
person who is designated to handle complaints for the Secure Transportation Service, but
will also evaluate the complaint internally.
D. Any individual bringing a matter of medical competency to the Department shall waive the
right of patient confidentiality as a condition of complaint submission and subsequent
investigation.
E If any legal action is filed against a licensed secure transportation service in a court of the
United States, the State of Colorado or any of its political subdivisions, the licensee shall
notify the Department within ten (10) business days. A violation of these Regulations shall
not be presumed based on an allegation. If a judgment is entered against the licensee,
the licensee shall file a copy of the findings of fact, conclusions of law and order of the
court with the Department within ten (10) business days.
F If an action against a Secure Transportation Service is undertaken by another jurisdiction,
the licensee shall notify the Department within ten (10) business days. A violation of these
rules and regulations shall not be presumed based on the action. If the action results in a
suspension or revocation of the Secure Transportation Service license by another
jurisdiction, the licensee shall file a copy of the record of the adverse action with the
Department within ten (10) business days.
Sec. 12-1-720. Validation of complaints.
A. The Department shall provide a copy of the complaint to the Secure Transportation
Service within seven (7) days of its receipt.
B. The Department shall complete an initial review of the complaint and interview the
complainant within seven (7) days of receipt to determine if, on the face of the complaint,
it may constitute a violation of this Article I and has sufficient foundation to warrant a
complete investigation. The Director shall check with the complainant and with the
Secure Transportation Service to determine if the complaint has been resolved or is likely
to be resolved.
C If the Department determines that the complaint has sufficient factual basis of a violation
of these rules and regulations, the Director shall proceed to a full investigation. Allegations
of violations outside the purview of the Department or this Article I shall be returned to the
complainant for referral to the appropriate authority or jurisdiction.
D The Department shall notify the complainant and the Secure Transportation Service, in
writing, upon such a determination, whether it is determined that the allegation shall be
investigated or that it lacks sufficient basis to warrant investigation.
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Sec. 12-1-730. Investigation of complaints.
A. Upon initiation of a full investigation, the Director shall take actions to investigate the
complaint, which investigation may include interview of witnesses, collection of records,
and any other lawful action deemed appropriate by the Director. Such investigation shall
be completed no later than thirty (30) days after the decision to investigate.
B. The Director shall present his or her investigative findings, in writing, to the Board of
County Commissioners within thirty (30) days of the decision to investigate. A copy of
the Director's findings shall be mailed to the complainant and the Secure Transportation
Service.
Sec. 12-1-740. Review by the Board of County Commissioners.
A. Upon receipt of the written report regarding the complaint, the Board of County
Commissioners shall meet within fourteen (14) days and shall vote: 1) to take no further
action on the complaint; 2) to allow a reasonable time for the Secure Transportation
Service to cure its violation; or 3) to hold a public hearing regarding the complaint. The
Board's decision shall be communicated to the Secure Transportation Service and
complainant in writing.
B If the Board determines that a hearing is warranted, such a hearing shall be held within
fourteen (14) days of such a determination, or within fourteen (14) days of a temporary
suspension of any license.
C All hearings before the Board shall be open to the public and shall be conducted in
accordance with the Colorado Open Meetings Act. The Board shall be authorized to
administer oaths and issue subpoenas to require the attendance of witnesses and the
production of papers, books, and records necessary to the determination of any issue at
any hearing. The Secure Transportation Service shall be given the opportunity to be heard
at the hearing.
D At the conclusion of the hearing, the Board may dismiss the complaint, or make findings
that the complaint is substantiated. In the event of a substantiated complaint, the Board
may suspend or revoke the Secure Transportation Service's license or require remediation
of the violation, as specified in Sec. 12-1-750, below. The Emergency Manager shall
bear the burden of proof of a violation justifying any suspension or revocation of a license
or permit.
E. The outcome of the public hearing shall be documented and sent to the Secure
Transportation Service and complainant in writing.
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F In the event of a revocation or suspension of the license of a Secure Transportation
Service, the County shall notify the Colorado Department of Public Health and
Environment and/or the Colorado Department of Regulatory Agencies, other counties in
which the Secure Transportation Service is known to operate, other relevant jurisdictions,
local law enforcement authorities, dispatch centers, hospitals, fire departments, and any
other entities to whom the Secure Transportation Service provides services, or other
interested parties, as applicable.
Sec. 12-1-750. Suspension or revocation of license or permit.
The Board has the authority to suspend or revoke, temporarily or permanently, any license
or permit issued pursuant to these rules and regulations.
A. Temporary Suspension. Without prior notice to the Secure Transportation Service, if the
Board determines, based on the complaint, that there is an immediate threat to the public
health, safety, and/or welfare by continued operations, the Board may, without a hearing,
temporarily suspend any license or permit issued pursuant to these Regulations. Such
temporary suspension shall be effective upon delivery of written notice to the licensed
secure transportation service by the Board. No temporary suspension shall be valid for
more than thirty (30) days or until a final decision by the Board concerning suspension or
revocation, after a hearing pursuant to Sec. 12-1-740, above, whichever period is longer.
Any written notice of temporary suspension shall also provide notice of the time, date, and
place of a hearing before the Board to consider the suspension or revocation of the
license. Except upon written consent of the licensee, the hearing shall be held not more
than ten (10) business days following the effective date of the temporary suspension.
B. Suspension for Definite Period or Revocation of License. Following notice to the Secure
Transportation Service and a hearing at which the licensee is afforded an opportunity to
be heard, pursuant to Sec. 12-1-740, above, the Board may suspend or revoke any license
or permit. Any suspension or revocation shall require a finding by the Board of a violation
of these Regulations based upon the evidence presented at the hearing. Issuance of a
temporary suspension shall not be a prerequisite to the conduct of a hearing to consider
the suspension or revocation of a license or permit.
C. Length of Suspension or Revocation. For a first complaint, suspension shall be for a
specific and definite period not to exceed any remaining current license period. If the
license or permit is revoked for the remainder of its life, the Secure Transportation Service
may reapply for the license or permit during the next licensing period. However, if a
second complaint regarding the same Secure Transportation Service is subsequently
received and sustained, the Board may permanently revoke the related license or permit,
and the Secure Transportation Service may, at the Board's discretion, be prohibited from
obtaining a license or permit in the future.
D Surrender of License or Permit. Following receipt of a written notice of suspension or
revocation, the licensee shall surrender and deliver its license and all secure
transportation vehicle permits to the Director of the Weld County Department of Public
Health and Environment within forty-eight (48) hours.
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E. Time to Remediate. If the Board determines that a Secure Transportation Service has
violated these Regulations, it may, in its sole discretion, allow the Secure Transportation
Service a period to remedy the violation. Such period shall not exceed thirty (30) days.
If the violation is not cured within that time, the Board shall reconvene and make a
subsequent determination regarding whether the license or permit of the Secure
Transportation Service should be revoked or suspended.
Division 9 - Data Collection and Reporting Requirements
Sec. 12-1-810. Report of injury, illness, or death.
Any secure transport resulting in the serious injury, illness, or death of a client or staff
member during transport or resulting in injury to the client because of the use of physical restraint
during transport shall be reported to the receiving facility immediately and to the County within
twenty-four (24) hours of the incident. The Department must be notified by calling or emailing
the Director. Each report shall identify and describe the circumstances leading to the serious
injury, illness, or death of a client or staff member during transport.
Sec. 12-1-820. Compliance with Part 6, 6 CCR 1011-4.
A licensed Secure Transportation Service shall comply with all of the data collection and
reporting requirements of Part 6, 6 CCR 1011-4.
Division 10 - Enforcement
Sec. 12-1-910. Violations and penalties.
The Department, through the Director, may enforce this Chapter through methods
included in this Chapter, or through other methods adopted by the Board of County
Commissioners.
Sec. 12-1-920. Criminal penalties.
A. Any person, firm, corporation, or secure transportation service violating any provision of
this Chapter is guilty of a misdemeanor and, upon conviction thereof, shall be punished
by a fine of not more than one hundred dollars ($100.00) or by imprisonment in the County
Jail for not more than ten (10) days, or by such fine and imprisonment for each offense or
✓ iolation. Each day during which such violation continues shall be deemed a separate
offense.
B Whenever the Department, through one (1) of its employees, has personal knowledge of
any violation of this Chapter, it shall give written notice to the violator to correct such
✓ iolation within fifteen (15) days after the date of the notice. Should the violator fail to
correct the violation within such fifteen -day -period, the Director may request that the
Sheriffs Office issue a summons and complaint to the violator, stating the nature of the
✓ iolation with sufficient particularity to give notice of said charge to the violator. The
summons and complaint shall require that the violator appear in court at a definite time
and place stated therein to answer and defend the charge. One (1) copy of the summons
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and complaint shall be served upon the violator by the Sheriff's Office in the manner
provided by law for the service of a criminal summons. One (1) copy each shall be retained
by the Sheriffs Office and the Director, and one (1) copy shall be transmitted to the Clerk
of the Court.
C It is the responsibility of the County Attorney to enforce the provisions of this Section. In
the event the Board of County Commissioners deems it appropriate, the Board of County
Commissioners may appoint the District Attorney to perform such enforcement duties in
lieu of the County Attorney.
Sec. 12-1-930. Equitable relief in civil action.
If any secure transportation service is being operated within the County in violation of any
provision of this Chapter, the County Attorney, or where the Board of County Commissioners
deems it appropriate, the District Attorney, in addition to the other remedies provided by law,
ordinance or resolution, may institute an injunction, mandamus or other appropriate action or
proceeding to prevent or enjoin such violation.
Sec. 12-1-940. Civil penalties.
A. In addition to any penalties imposed pursuant to Sec. 12-1-910, above, any person, firm,
corporation, or Secure Transportation Service violating any regulation or provision
contained in this Chapter may be subject to the imposition, by order of the County Court,
of a civil penalty in an amount of not less than two hundred fifty dollars ($250.00), nor
more than five hundred dollars ($500.00). It is within the discretion of the County Attorney
to determine whether to pursue the civil penalties set forth in this Article. Each day after
the issuance of the order of the County Court during which such violation continues shall
be deemed a separate violation and shall, in accordance with the subsequent provisions
of this Section, be the subject of a continuing penalty in an amount not to exceed
fifty dollars ($50.00) for each such day.
B The Department, through one (1) of its employees, shall, upon personal information and
belief that a violation of any regulation or provision of this Chapter has occurred, give
written notice to the violator to correct such violation within fifteen (15) days after the date
of such notice. If the violator fails to correct the violation within such fifteen -day period or
within any extension period granted by the Director, the Director may request that the
County Sheriff or the County Attorney issue a summons and complaint to the violator,
stating the nature of the violation with sufficient particularity to give notice of such charge
to the violator.
C One (1) copy of the summons and complaint issued pursuant to Subsection B, above,
shall be served upon the violator in the manner provided by law for the service of a County
Court civil summons and complaint in accordance with the Colorado Rules of County
Court Civil Procedure. The summons and complaint shall also be filed with the Clerk of
the County Court, and thereafter the action shall proceed in accordance with the Colorado
Rules of County Court Civil Procedure.
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D If the County Court finds, by a preponderance of the evidence, that a violation of any
provision of this Chapter, as enacted and adopted by the Board of County Commissioners,
has occurred, the Court shall order the violator to pay a civil penalty in an amount allowed
pursuant to Subsection A above. Such penalty shall be payable immediately by the violator
to the County Treasurer. In the event that the alleged violation has been cured or otherwise
removed at least five (5) days prior to the appearance date in the summons, then the
County Attorney shall so inform the Court and request that the action be dismissed without
fine or appearance of the defendant.
E Upon the filing with the Court of a receipt issued by the County Treasurer showing
payment in full of a civil penalty assessed pursuant to this Section and upon the filing of
an affidavit that the violation has been cured, removed, or corrected, the Court shall
dismiss the action and issue a satisfaction in full of the judgment.
F If a receipt showing full payment of the civil penalty or the affidavit required by
Subsection E, above, is not filed, the action shall continue, and the Court shall retain
jurisdiction to impose an additional penalty against the violator in the amount specified in
Subsection A, above. Such additional penalty shall be imposed by the Court upon motion
filed by the County and proof that the violation has not been corrected. Thereafter, the
action shall continue until the penalty and any additional penalties are assessed, and the
filing of an affidavit of the Department of Public Health and Environment verifies that the
violation has been corrected.
BE IT FURTHER ORDAINED by the Board that the Clerk to the Board be, and hereby is,
directed to arrange for Municode to supplement the Weld County Code with the amendments
contained herein, to coincide with chapters, articles, divisions, sections, and subsections as they
currently exist within said Code; and to resolve any inconsistencies regarding capitalization,
grammar, and numbering or placement of chapters, articles, divisions, sections, and subsections
in said Code.
BE IT FURTHER ORDAINED by the Board, if any section, subsection, paragraph,
sentence, clause, or phrase of this Ordinance is for any reason held or decided to be
unconstitutional, such decision shall not affect the validity of the remaining portions hereof. The
Board of County Commissioners hereby declares that it would have enacted this Ordinance in
each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective
of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or
phrases might be declared to be unconstitutional or invalid.
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The above and foregoing Ordinance Number 2023-02 was, on motion duly made and
seconded, adopted by the following vote on the 1st day of February, A D , 2023
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST
Mike Freeman, Chair
Weld County Clerk to the Board
'BY
Deputy Clerk to the Board
APPROVED AS TO FORM
Perry L Buck, Pro-Tem
Scott K James
Kevin D Ross
County Attorney
Lori Same
Dof signature
,pate
First Reading January 4, 2023
Publication January 8, 2023, in'the Greeley Tribune
Second Reading January 18, 2023
Publication January 22, 2023, in the Greeley Tribune
Final Reading February 1, 2023
Publication February 5, ,2023, in the Greeley Tribune
Effective February 10, 2023
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