[Updated 12.08.2020] – For the last 3-weeks – the CCA has been fighting to change the language that was listed in the 2nd amended Public Health Order 20-36. Today we are happy to report that because of the CCA’s efforts, the language requiring a “medical, dental or veterinarian” referral has been REMOVED from the third amended public health order 20-36.

Here are the changes:

Old language from PHO 20-36 (2nd amended version):
g. Limited Healthcare Settings that provide services that are ordered by a medical, dental or veterinary practitioner in accordance with Public Health Order 20-29 may operate at 10% of the posted occupancy limit, not to exceed25 people, per room to provide those services. All other services offered by Limited Healthcare Settings are closed for in-person work but may continue to carry out Minimum Basic Operations.

Here is the summary of the change:
Section II.G.g: removed the requirement that services rendered in limited healthcare settings in Level Purple may only be open to provide services that have been ordered by a medical provider.

The new language reads from PHO 20-36 (3rd amended version) released 12.08.2020:
g. Limited Healthcare Settings that provide services may operate at 10% of the posted occupancy limit, not to exceed 25 people, per room to provide those services.

You can find the full Public Health Order 20-36 (third amended version) here.

We want to thank the coalition of “limited healthcare settings” professions – the American Physical Therapy Association, American Massage Therapy Association, Acupuncture Association of Colorado, Colorado Speech Language Hearing Association, Occupational Therapy Association of Colorado and Associated Bodywork & Massage Professionals for their work and efforts in helping to change this language.

Moving forward – we urge you to keep an eye on your county for any changes and what level your county is in. We must still comply with Appendix G of Public Health Order 20-36. Appendix G is listed below. The link to the state’s dial is directly below to locate your specific county. Currently about 30 counties are in level red as of 12.08.2020.

12.09.2020 Video update from CCA President Dr. Craig Pearson:

The levels are as follows:

Level Green: – Protect Our Neighbors: for counties that are able to locally contain surges. Most businesses are open with generous capacity limits. 
Level Blue – Caution: for counties with low transmission levels that aren’t quite ready for Protect Our Neighbors. Capacity limits are more permissive than yellow.
Level Yellow – Concern: the baseline level for counties with elevated transmission levels but stable hospitalizations. 
Level Orange – High Risk:  for counties where numbers are going up but not to the point where everything needs to be shut down. The capacity limits are moderate.
Level Red – Severe Risk: for counties with high levels of transmission, hospitalizations, and positivity rates. Most indoor activities are prohibited or strictly limited, and outdoor activities are encouraged as an alternative. The capacity limits are significant.
Level Purple – Extreme Risk: for counties where hospital capacity is at extreme risk of being overrun. At this level, all businesses must significantly curtail in person functions and people must stay at home except for necessary activities.

Here are all the levels for the state’s dial related to Limited Healthcare Settings as of 12.08.2020:

Level Green:

Counties and regions certified for Level Green may allow any business or activity within their jurisdiction to operate at 50% of their pre-pandemic capacity not to exceed 500 people…

Level Blue:

Limited Healthcare Settings may operate at 50% of the posted occupancy limit, not to exceed 50 people, whichever is less, per room.

Level Yellow:

Limited Healthcare Settings may operate the same as Level Blue.

Level Orange:

Limited Healthcare Settings may operate at 25% of the posted occupancy limit, not to exceed 25 people, whichever is less, per room.

Level Red:

Limited Healthcare Settings may operate at 25% of the posted occupancy limit, not to exceed 25 people, per room to provide those services.

Level Purple:

g. Limited Healthcare Settings that provide services may operate at 10% of the posted occupancy limit, not to exceed 25 people, per room to provide those services.

APPENDIX G: LIMITED HEALTHCARE SETTINGS

I.         Limited Healthcare Settings may operate at the level described in Section II of this Order for which the county in which they operate is approved, and must follow the requirements included in Section III.C of this Order, as well as all of the requirements of this Appendix. Limited Healthcare Settings may conduct voluntary and elective surgeries and procedures in limited healthcare facilities and offices with required personal protective equipment (PPE) in accord with the priorities, requirements, and specific criteria below.

A. Employers and sole proprietors of Limited Healthcare Settings must implement the following measures within the overall workplace, including administrative and front office operations, to minimize disease transmission:

1. The practice must have access to adequate PPE in order to sustain recommended PPE use for its workforce for two weeks without the need for emergency PPE-conserving measures. If a practice proposes to extend the use of or reuse PPE, it must follow CDC guidance.¹
2. The practice must implement strict infection control policies as recommended by the CDC.²
3. The practice must ensure a minimum of 6 feet of separation between clients and patients, when not directly performing service, and all settings offering services in individuals rooms must comply with the requirements of this Order for each room.
4. The practice must post signage for employees and patients on good hygiene and safety measures being taken.
5. The practice must minimize in-home and in-facility services with remote alternatives whenever possible, such as drive-by services or virtual meetings.
6. Practices must maintain a plan to reduce or stop voluntary and elective surgeries and procedures should a surge/resurgence of COVID-19 cases occur in their region.
   

B. Employers of Limited Healthcare Settings must implement the following measures regarding employees to minimize disease transmission:

1. Services with close, direct personal contact must implement the following:

a. wear medical grade mask and gloves at all times; however, acupuncturists may substitute good hand hygiene by thoroughly washing hands before and after seeing each patient for the gloves if their licensing requirements and standards so allow;
b. change gloves and wash hands between every patient;
c. clean and disinfect all shared equipment and tools between every patient; and
d. maintain a detailed log of patient interactions to enable contact tracing if it becomes necessary. The log should include name, date, details of services performed, and location of contact, as well as the contact’s phone number
e. for services where the client cannot wear a mask, the employee or practitioner must wear a face shield in addition to their mask.

2. Services with low personal contact must implement the following:

a. maintain a minimum of six 6 feet of separation between customers;
b. require face coverings and, if feasible, gloves for any customer interactions; and
c. provide guidance on strict hygiene precautions to employees.

3. The practice must require all administrative personnel to wear a facemask, that can be cloth if necessary, unless the individual cannot medically tolerate a face covering, or is performing one of the enumerated activities in Section II.M of Executive Order D 2020 138, as amended and extended. In order to ensure staff can take off their masks for meals and breaks, scheduling and location for meals and breaks should ensure that at least a 6-foot distance can be maintained between staff when staff needs to remove their mask. It is important for healthcare settings to emphasize that hand hygiene is essential to maintaining employee safety, even if staff are wearing masks. If the facemask is touched, adjusted or removed, hand hygiene should be performed.

C. Limited Healthcare Settings must implement the following measures regarding customers to minimize disease transmission:

1. The practice must provide services by appointment only, do not allow walk-ins or waiting for an appointment;
2. The practice must require patients to wear face coverings; if a patient does not have a mask, a “disposable medical mask” could be provided;
3. The practice must conduct symptom checks for all patients, decline to provide services to anyone who has symptoms, and refer them to their primary care physician. A sample form can be found here; and
4. The practice must provide contactless payment options whenever possible;
5. The practice must follow Distancing protocols of maintaining at least a 6-foot distance between individuals wherever possible such as in waiting rooms and other small spaces, and should use physical barriers within patient care areas when possible.
6. The practice must appropriately schedule patients, so that providers have sufficient time to change PPE and ensure rooms and equipment can be cleaned and disinfected between each patient.
7. The practice should continue to maximize the use of telehealth and virtual office or clinic visits.
8. The practice should use virtual waiting rooms when possible, with patients who are able to wait in their cars not entering the office until they can be moved immediately to an exam room.
9. The practice should implement source control for everyone entering the office or clinic, including requiring all patients and visitors to wear a cloth mask when entering any healthcare building, and if they arrive without a mask, one should be provided.

D. As best practice, it is recommended that if performing voluntary and elective surgeries and procedures, Limited Healthcare Settings reassess their operations every two weeks, in order to ensure:

1. All of the above approaches and criteria are being met;
2. Procedures are prioritized based on whether their continued delay will have an adverse health outcome.
   • Voluntary and elective surgeries and procedures should be prioritized based on indication and urgency3;
3. Strong consideration is given to the balance of risks versus benefits for patients in higher-risk groups such as those over age 65 and those with compromised immune systems or lung and heart function;
4. All patients are pre-screened for COVID-19 risk factors and symptoms prior to delivering care, via telehealth when applicable; and
5. Compliance with the guidance and directives for maintaining a clean and safe work environment issued by the CDPHE and any applicable local health department for critical businesses is maintained, including compliance with Distancing Requirements and all PHOs currently in effect to the greatest extent possible.