Who surveys a PASA in Colorado?

CDPHE, through its Health Facilities and Emergency Medical Services Division, surveys the agency and recommends whether to certify it. HCPF, the Medicaid agency, enrolls the agency and makes the final decision.

What happens if a PASA is cited with deficiencies?

The agency submits a Plan of Correction, and CDPHE does a desk revisit to confirm the deficiencies are corrected before it recommends certification. The PASA pages do not state a deadline. For facilities CDPHE licenses, the plan is due within 10 calendar days of the written notice and carries a completion date no more than 30 calendar days out unless CDPHE approves otherwise.

How often is a PASA surveyed?

We found no published interval for an agency that is certified but holds no facility license, so ask CDPHE. For licensed group homes and intermediate care facilities, CDPHE may extend the survey cycle up to three years for a licensee with a clean three-year record, or use a lighter tiered inspection.

What do CDPHE surveyors review?

CDPHE's readiness materials point to written policies and procedures, personnel files with background and CAPS checks, a training program, secure individual records, a system of regular onsite monitoring, and fire, health and medication-training requirements at program sites.

Is it still called a PASA?

CDPHE still uses the name. The current Medicaid rule, 10 CCR 2505-10 Section 8.7000 and following, calls the same kind of agency a Provider Agency. Search and conversation still use PASA.

Colorado PASA Survey Readiness: What CDPHE Looks At

Short answer: In Colorado, the survey of a Program Approved Service Agency (PASA) is done by the state health department, CDPHE, through its Health Facilities and Emergency Medical Services Division. For a new agency it comes in two steps, a readiness call and an onsite (or virtual) initial survey. The surveyors work from your written policies, your personnel files, your individual records, your monitoring system and, for residential and day sites, the safety basics. If they cite deficiencies, you send a plan of correction and CDPHE checks the fix before it recommends certification to HCPF, which makes the final decision. What is not published is how often an agency that holds no facility license is resurveyed. Ask CDPHE for that, and do not rely on a number from a forum.

This article is written against the Medicaid rule in effect since August 14, 2026, and the CDPHE chapters named below. Rules and CDPHE guidance change, so check the current version before you rely on any checklist, including this one. If you are still working out how to become a PASA and what the rule requires you to document, start with our guide to PASA requirements in Colorado. This piece picks up at the survey itself.

A note on the name

"PASA" is what providers search for, and it is what CDPHE still calls its program. The current Medicaid rule, 10 CCR 2505-10 Section 8.7000 and following, uses the term Provider Agency instead. If a checklist you are using cites sections in the 8.500 or 8.600 range, it was written for the old rule. CDPHE's own survey-readiness handout is one example: it still cites those older sections, although its categories are still the ones surveyors work through.

Who surveys, and who decides

Two state agencies are involved, and they do different jobs.

CDPHE verifies qualifications and surveys the agency. Its guidance for applicants is written by the division and describes "the information the HFEMSD survey staff look for when completing initial on-site surveys." The Medicaid rule refers to "the state survey Agency."
HCPF, the Department of Health Care Policy and Financing, enrolls the agency in Medicaid and decides. Under the rule, certification is "a determination made by the Department, after considering a recommendation from the state survey Agency." HCPF has the final say, and it issues the final approval only after both the CDPHE process and Medicaid enrollment are complete.

If you also run a group home, that site is licensed by CDPHE, as either a Group Home or an Intermediate Care Facility (6 CCR 1011-1, Chapter 8). A licensed home is inspected under CDPHE's general licensing rules (Chapter 2) in addition to the PASA process.

How the initial survey runs

CDPHE's PASA site says every applicant must "complete and pass a Readiness Call and an Onsite Initial Survey" before CDPHE recommends certification.

Documents first. The survey team contacts you and asks for documents to be sent in for review before the readiness call.
Readiness call. The survey team assesses whether you are prepared for the survey.
Initial survey. CDPHE's guidance refers to the survey as "on-site or virtual."
Result. With no deficiencies, CDPHE sends its recommendation to HCPF. With deficiencies, you submit a plan of correction and CDPHE does a desk revisit to confirm the fixes before it recommends certification.

CDPHE's pages do not describe survey day itself, such as whether staff or members are interviewed, so we will not either. Ask your CDPHE contact on the readiness call.

What surveyors look at

CDPHE publishes two readiness documents for applicants, a policies and procedures guidance document (dated August 2024) and a "You are ready for an initial survey when" list. Together they point to six areas.

Policies and procedures. CDPHE says that for it to recommend certification each required element must appear in your submitted policies. The list follows the rule's policy section (8.7408) and includes staffing and employment, medication administration, protected health information, mistreatment, abuse, neglect and exploitation, protection of individual rights, non-discrimination, dispute resolution, grievances and complaints, independent contractors, contingency planning, telehealth, incident reporting, rights modifications and personnel training. CDPHE is specific about quality: policies "must reflect the agency's organizational structure, methods of operation, and values and not simply be a copy and paste of rules and regulations," and you "must be able to show on an on-going basis the date(s) the policies and procedures were developed and updated." If you will not offer a service such as medication administration, you still need a policy that says so.

Personnel files. Every employee and contractor needs a file showing qualifications, training, supervision and evaluation, proof they were told the policies, a job description or signed contract, and a criminal background check and a Colorado Adult Protection Services (CAPS) check. CDPHE's readiness list extends this to owners and operators who have direct contact with members. Individual licenses and certifications belong in the file too.

Training. A training program, with the trainings planned for the current or next year. Staff who help with medications need to have passed an approved QMAP course.

Individual records. Each person served has a record that is kept in a safe and secure location. The service documentation the rule asks for is covered in our PASA requirements guide.

Monitoring. CDPHE's list asks for "a system of regular on-site monitoring for all services and supports being provided." Having the policy is not the same as being able to show the monitoring happened.

Sites and safety. Residential and day program sites must meet local fire authority code and health regulations. The rule adds fire drills at least quarterly at each physical facility, working smoke detectors, unexpired fire extinguishers and first aid supplies. CDPHE also says new providers must fully comply with the federal HCBS Settings Rule before certification is recommended.

Survey readiness at a glance

Area	What CDPHE materials point to	What to have on hand
Policies	A written policy for each required topic, reflecting how your agency really works	Dated versions and a revision history
Personnel	Qualifications, training, supervision, background and CAPS checks	A complete file per person, including owners with direct contact
Training	A training program and a plan for the year	The plan, and records of who completed what
Records	One secure individual record per person served	Notes, plans and incident reports in one retrievable place
Monitoring	A regular system of onsite monitoring	Dated monitoring entries and what was done about findings
Sites and medications	Fire, health and QMAP requirements	Drill logs, inspection papers, QMAP completion records

Deficiencies and plans of correction

For a PASA initial survey, CDPHE's FAQ says that if you are cited, you must submit a Plan of Correction (POC) and a desk revisit is done "to ensure the deficiencies have been corrected." The PASA pages do not state a deadline for that plan.

For facilities that CDPHE licenses, the deadlines are in writing. Under 6 CCR 1011-1, Chapter 2 (effective September 14, 2025), a plan of correction must:

describe how each deficiency will be corrected, and how recurrence is prevented for the people affected and for others who could be;
describe how you will monitor the correction;
carry a completion date no more than 30 calendar days after the deficiency list, unless CDPHE requires or approves otherwise;
be signed by the director, administrator or manager and submitted within 10 calendar days of CDPHE's written notice, with any extension requested in writing before the due date.

CDPHE can approve, modify or reject a plan. If a plan is rejected you resubmit by the date CDPHE sets, and failing to carry out an approved plan can bring sanctions. For licensed group homes and ICFs, an agency that has not corrected a harmful or potentially harmful deficiency by the first revisit can see its renewal fee rise, and a second and later revisits for the same deficiency carry a revisit fee (Chapter 8).

We do not know whether those same 10-day and 30-day clocks apply to a PASA that holds no license. Read the notice CDPHE sends you, because it sets your dates.

One more point from the Medicaid rule: HCPF may decertify an agency that fails to comply with law or rule, fails to give timely access to records on lawful request, or poses a threat to members' health, safety or welfare. A written dispute must reach HCPF within 30 calendar days of the notice (10 CCR 2505-10 § 8.7403).

How often, and what is public

Frequency is the part with the least published detail. For licensed group homes and ICFs, a license runs one year, and CDPHE may extend the survey cycle up to three years or use a lighter tiered inspection for a licensee that has been licensed at least three years with no enforcement activity, no pattern of deficient practice and no substantiated complaint with significant deficiencies in that time. CDPHE may expand a tiered inspection to a full survey if it finds deficient practice. CDPHE may also review a licensed site without notice, including after a complaint, and routine unannounced inspections are limited to the hours between 7 a.m. and 7 p.m.

For an agency that is certified but not licensed, we found no published resurvey interval. Ask CDPHE.

Inspection results can be public. CDPHE's Find and Compare Facilities tool shows results from the previous three years for providers licensed by CDPHE, state-certified by HCPF or federally certified, including citations and the plan of correction the provider submitted. If your agency or a site you run appears there, a family or a referral partner can read it.

What to do before CDPHE calls

Read your own policies against the 8.7408 list and date every revision.
Open a personnel file at random and check it against the list above, including the CAPS check and the dates of expiring credentials.
Pull one individual record and see whether a stranger could follow the plan, the notes and the incident reports.
Find your last three monitoring entries, and what you did about what they found.
Walk each site with the fire, medication and first-aid items in hand.
Decide who answers CDPHE's document request, and how fast.

Where OutcomeGrid fits

Software does not pass a survey. A clear system makes the evidence easy to find. OutcomeGrid keeps service notes against the member's goals, structured incident reports with notification tracking, credential tracking with expiration alerts, and an audit trail of every change. Our I/DD HCBS waiver software page shows how that works end to end.

What we could not confirm

How often CDPHE resurveys a PASA that holds no facility license.
What surveyors do onsite for a PASA, such as interviews or an exit meeting.
The plan of correction deadline for a PASA that holds no license.

Sources: CDPHE Program Approved Service Agency pages and the CDPHE PASA information site; CDPHE/HFEMSD PASA Policies and Procedures Guidance Document (August 2024); 10 CCR 2505-10, Section 8.7000 (current version effective August 14, 2026); 6 CCR 1011-1, Chapter 2 (effective September 14, 2025) and Chapter 8 (effective July 1, 2025); CDPHE Find and Compare Facilities. This article is general information, not legal advice.

Colorado PASA Survey Readiness: What CDPHE Surveyors Look At