reglab/statecodes huggingface dataset:
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart B - POLICIES AND PROCEDURES › Section R. 325.45131 - Discharge; transfer; policy; procedure; planning

Current through Vol. 24-12, July 15, 2024
Rule 131.
(1) A
					 health facility or agency shall have a written discharge policy and procedure
					 that is provided to the patient or any other person or agency responsible for
					 the patient upon request.
(2) A
					 health facility or agency shall have a written transfer policy and procedure
					 that is provided to the patient or any other person or agency responsible for
					 the patient upon request.
(3) In
					 addition to subrule (2) of this rule, a nursing care facility shall have a
					 written involuntary transfer policy and procedure in compliance with R
					 325.45385.
(4) Discharge or
					 transfer planning must be provided for each patient in conjunction with patient
					 care planning.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart C - INFECTION PREVENTION AND CONTROL › Section R. 325.45133 - Infection prevention and control program

Current through Vol. 24-12, July 15, 2024
R 133. An applicant or licensee shall have an infection
						prevention and control program and allocate resources to provide all of the
						following:
(a) A qualified health care
					 professional must be designated in writing to be responsible for the program.
					 The designee shall have completed training in the principles and methods of
					 infection control and maintain qualification through ongoing education and
					 training. Ongoing education and training may be demonstrated by any one of the
					 following:
(i) Certification in infection
					 control (CIC).
(ii) Certification
					 as an ambulatory infection preventionist (CAIP).
(iii) Completion of an infection control
					 course.
(iv) Participation in
					 meetings that include infection control and are organized by recognized
					 professional societies or other associations applicable to the services offered
					 by the health facility or agency.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart C - INFECTION PREVENTION AND CONTROL › Section R. 325.45135 - Infection prevention and control policies and procedures

Current through Vol. 24-12, July 15, 2024
Rule 135.
(1) An
					 applicant or licensee shall maintain written, evidence-based infection
					 prevention and control policies and procedures that are appropriate for the
					 services offered. These policies and procedures must be available in electronic
					 or written format. These policies and procedures must represent the complexity
					 of the healthcare provided and the characteristics of the patient population
					 served.
(2) The policies and
					 procedures for standard precautions must include, but are not limited to, all
					 of the following:
(a) Hand hygiene.
(b) Use of personal protective
					 equipment.
(c) Respiratory hygiene
					 and cough etiquette.
(d) Safe
					 injection practices.
(e) Safe
					 handling of potentially contaminated equipment or surfaces in the patient
					 environment, which for hospice agencies includes a private residence.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart C - INFECTION PREVENTION AND CONTROL › Section R. 325.45137 - Ongoing surveillance and prevention program; communicable disease reporting

Current through Vol. 24-12, July 15, 2024
Rule 137. The applicant or licensee shall provide and
						maintain an ongoing surveillance and prevention program that includes, but is
						not limited to, all of the following:
(a) An active surveillance program for
					 infection detection through ongoing data collection and analysis that includes
					 patients and personnel who have access to or contact with active patient care
					 areas, and other individuals identified by the health facility or agency
					 policies and procedures.
(b)
					 Communicable disease reporting in compliance with section 5111 of the code, MCL
					 333.5111, and the communicable and related diseases rules,
					 R
					 325.171 to
					 R
					 325.199.
(c) An ongoing program to prevent, control,
					 and investigate healthcare associated infections.
(d) Implementation of healthcare associated
					 infections risk mitigation including, but not limited to, all of the following:
(i) Monitoring personnel hand
					 hygiene.
(ii) Monitoring infections
					 caused by organisms that are multidrug-resistant.
(iii) Monitoring device-associated
					 infections.
(iv) Monitoring
					 antibiotic use.
(v) Monitoring safe
					 practices for injecting medication, saline, or other infusates.
(vi) Monitoring use of disinfectants and
					 germicides in accordance with manufacturers instructions.
(vii) Monitoring use of medical equipment,
					 including air filtration equipment, ultra-violet lights, and other equipment
					 used to control the spread of infectious agents in accordance with
					 manufacturers recommendations.
(viii) Monitoring sterilization and
					 disinfection practices and reporting failures.
(ix) Monitoring cleaning procedures used in
					 patient care areas.
(x) Monitoring
					 surgical services in accordance with standards of care for all of the
					 following:
(A) Appropriate use of antibiotic
					 prophylaxis to prevent surgical site infection, such as protocol to assure that
					 antibiotic prophylaxis to prevent surgical site infection for procedures is
					 administered at the appropriate time, done with an appropriate antibiotic, and
					 discontinued appropriately after surgery.
(B) Aseptic technique practices are used in
					 surgery, including sterilization or high-level disinfection of instruments, as
					 appropriate.
(C) Skin antisepsis
					 methods.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart C - INFECTION PREVENTION AND CONTROL › Section R. 325.45139 - Personnel; communicable disease screening; immunization; mitigation

Current through Vol. 24-12, July 15, 2024
Rule 139.
(1) An
					 applicant or licensee shall adopt written policies and procedures to ensure
					 that all of the following communicable disease prevention measures are
					 implemented:
(a) Evaluation of the
					 immunization status of personnel for vaccine preventable diseases as designated
					 in the "Healthcare Personnel Vaccination Recommendations," 2017 edition,
					 published by the Immunization Action Coalition (IAC). These recommendations are
					 adopted by reference and are available for inspection and distribution at cost
					 at the Lansing office of the Department of Licensing and Regulatory Affairs.
					 They are available free of charge at the Immunization Action Coalition, 2550
					 University Avenue West, Suite 415 North, Saint Paul, MN 55114 or
http://www.immunize.org/catg.d/p2017.pdf
.
(b) Identification of the authority and
					 circumstances under which the licensee screens personnel for infections likely
					 to cause spread of communicable disease or other risks to exposed patients and
					 personnel.
(c) Identification of
					 the authority and circumstances under which the licensee restricts personnel
					 who are infectious from providing direct patient care or from entry into the
					 health facility or agency, as recommended by the Centers for Disease Prevention
					 and Control (CDC) in its "Guideline for Infection Control in Health Care
					 Personnel 1998," published in the American Journal of Infection Control, v. 23,
					 no. 3, p. 289-354. This guideline is adopted by reference and is available for
					 inspection and distribution at cost at the Lansing office of the Department of
					 Licensing and Regulatory Affairs. It is available free of charge at
https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html
.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart C - INFECTION PREVENTION AND CONTROL › Section R. 325.45141 - Infection control education and training

Current through Vol. 24-12, July 15, 2024
Rule 141.
(1)
					 The licensee shall maintain an ongoing program of education and training on
					 methods to prevent or reduce the transmission of infectious agents for all
					 personnel upon hire and at ongoing intervals as applicable, including
					 employees, onsite contract workers, medical providers, students, medical
					 residents, and volunteers.
(2) The
					 licensee shall document compliance with initial and ongoing training for
					 personnel in methods of infection prevention and control.
(3) The licensee shall make available
					 information to patients and visitors on methods to prevent or reduce the
					 transmission of infectious agents within the health facility or
					 agency.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart C - INFECTION PREVENTION AND CONTROL › Section R. 325.45143 - Infection prevention and control program; quality assurance and performance improvement

Current through Vol. 24-12, July 15, 2024
Rule 143.
(1)
					 The applicant or licensee shall document how its infection prevention and
					 control program is integrated into its quality assurance and performance
					 improvement program. Documentation must include, but is not limited to, both of
					 the following:
(a) Actions taken in response
					 to data analysis to improve infection control performance and patient
					 outcomes.
(b) Infection prevention
					 activities, including the measures selected for monitoring, data collection,
					 analytical methods, actions taken, and outcomes.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart C - INFECTION PREVENTION AND CONTROL › Section R. 325.45145 - Employee; health; communicable disease

Current through Vol. 24-12, July 15, 2024
Rule 145.
(1)
					 The licensee shall ensure that an employee is free from communicable disease. A
					 health facility or agency shall maintain employee files containing baseline
					 screening for communicable diseases or immunizations, and records of illness
					 and accidents occurring on duty.
(2) Employees, contract personnel, students,
					 volunteers, and other persons who have direct physical contact with patients or
					 food while providing care or services in the facility may participate only when
					 free of signs of infection.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart D - EMERGENCY PREPAREDNESS › Section R. 325.45147 - Emergency preparedness program

Current through Vol. 24-12, July 15, 2024
Rule 147. The applicant or licensee shall have an
						all-hazard emergency preparedness program to meet the health and safety needs
						of its patient population and personnel. The emergency preparedness program
						must provide guidance on how to respond to emergency situations that could
						impact the operation of the health facility or agency, such as natural or
						man-made disasters. The emergency preparedness program must include all of the
						following components:
(a) A risk
					 assessment.
(b) A written emergency
					 response plan.
(c) Written policies
					 and procedures that support the successful execution of the emergency response
					 plan.
(d) A written communication
					 plan.
(e) A written training and
					 testing plan.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart D - EMERGENCY PREPAREDNESS › Section R. 325.45149 - Risk assessment

Current through Vol. 24-12, July 15, 2024
Rule 149.
(1) An
					 applicant or licensee shall conduct a risk assessment or use a risk assessment
					 conducted by its municipal or county emergency management agency. If an
					 emergency management agencys risk assessment is used, the applicant or licensee
					 shall maintain a copy of it and is required to work with the agency that
					 developed it to ensure that the facilitys emergency response plan is in
					 alignment. The risk assessment must be used to assist the health facility or
					 agency to address the needs of its patient population, identify essential
					 services and vendors to provide support during an actual emergency, and
					 identify alternate service providers and vendors to assure continuity of
					 operations.
(2) The risk assessment
					 must be available to the department upon request.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart D - EMERGENCY PREPAREDNESS › Section R. 325.45151 - Emergency response plan

Current through Vol. 24-12, July 15, 2024
Rule 151.
(1) An
					 applicant or licensee shall have a written emergency response plan. The plan
					 must be based on the risk assessment.
(2) The emergency response plan must address
					 capacities and capabilities critical for a response to and recovery from the
					 types of emergencies likely to impact the health facility or agency that could
					 result in 1 of the following:
(a) Equipment
					 and power failures.
(b)
					 Interruptions in communications that could include cyber-attacks.
(c) Loss of all or a portion of a physical
					 facility.
(d) Extraordinary
					 staffing shortages where the health facility or agency continues to
					 operate.
(e) Interruptions in the
					 normal supply of essentials such as food and water, medications, or medical
					 supplies including medical gases where the health facility or agency continues
					 to operate.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart D - EMERGENCY PREPAREDNESS › Section R. 325.45153 - Policies and procedures for emergency preparedness

Current through Vol. 24-12, July 15, 2024
Rule 153.
(1) An
					 applicant or licensee shall have written policies and procedures for emergency
					 preparedness and recovery that are based on the risk assessment.
(2) The policies and procedures must address,
					 but are not limited to, all of the following subjects:
(a) Subsistence needs of patients receiving
					 inpatient or residential services.
(b) Evacuation.
(c) Shelter in place.
(d) Tracking patients and
					 personnel.
(e) Patient transfers
					 for continuity of care that may include transfer agreements or other
					 arrangements based upon the services offered and needs of the
					 patients.
(f) Preservation and
					 transfer of patient records.
(g)
					 Continuity of operations and recovery.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart D - EMERGENCY PREPAREDNESS › Section R. 325.45155 - Communication plan

Current through Vol. 24-12, July 15, 2024
Rule 155.
(1) As
					 part of its emergency preparedness program, an applicant or licensee shall have
					 a written communication plan. The communication plan must include, but is not
					 limited to, notification of the following as appropriate to the emergent event:
(a) Local emergency response
					 agencies.
(b) Personnel.
(c) Patients.
(d) Patients guardian, family, or other
					 persons designated by the patient.
(e) Patients physician.
(f) Utility maintenance and repair
					 vendors.
(g) Information management
					 support.
(h) Other essential
					 suppliers and vendors.
(i) The
					 department.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart D - EMERGENCY PREPAREDNESS › Section R. 325.45157 - Emergency preparedness training and testing program

Current through Vol. 24-12, July 15, 2024
Rule 157.
(1) An
					 applicant or licensee shall develop and implement an emergency preparedness
					 training and testing program. The training and testing program must include
					 initial emergency response training for new and existing personnel, as well as
					 annual refresher trainings.
(2)
					 Each year the licensee shall exercise its emergency response plan at least
					 twice. This requirement may be fulfilled by participating in 1 or more
					 community-based exercises, facility-based exercises, or by activating its
					 emergency plan in response to one or more actual incidents. One of the two
					 exercises may be a paper-based table-top exercise.
(3) The training and testing program plan,
					 exercise manual, and after-action reports must be retained for a minimum of 4
					 years or according to the licensees records retention schedule, whichever is
					 longer; and they must be available to the department upon request.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart E - MEDICAL AUDIT AND UTILIZATION REVIEW › Section R. 325.45159 - Medical audit; utilization review; document access

Current through Vol. 24-12, July 15, 2024
Rule 159.
(1) A
					 health facility or agency shall establish a process for medical audits of
					 individual patient cases. Medical audits shall be conducted on a representative
					 sample of patient cases. A medical audit is to ensure proper documentation of
					 clinical information, continuity and coordination of patient care, and the
					 quality and safety of medical and other health care services
					 provided.
(2) A health facility or
					 agency shall establish a process for utilization review of care and services on
					 a systemic and aggregated basis. A utilization review is to ensure the
					 provision and utilization of health care services provided in terms of cost,
					 effectiveness, efficiency, and quality.
(3) Medical audit and utilization review
					 documents may be accessed by the department during a survey or complaint
					 investigation when necessary to determine compliance with the code and these
					 rules. The department shall maintain and protect these documents in accordance
					 with state and federal laws, including privacy laws.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart F - QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM › Section R. 325.45161 - Quality assessment and performance improvement program

Current through Vol. 24-12, July 15, 2024
Rule 161. The governing body shall ensure the health
						facility or agency has a quality assessment and performance improvement program
						that is defined, implemented, maintained, and includes all of the
						following:
(a) Addresses identified
					 priorities.
(b) Evaluates
					 improvements for effectiveness.
(c)
					 Specifies data collection methods, frequency, and detail.
(d) Establishes an expectation for patient
					 safety and quality health care services.
(e) Allocates staff, time, information
					 systems, and training to implement the quality assessment and performance
					 improvement program.
(f) Is
					 evaluated and revised on a periodic basis in accordance with the applicable
					 subject matter.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart F - QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM › Section R. 325.45163 - Quality assessment and performance improvement program; monitor quality; ongoing program; measurable improvements

Current through Vol. 24-12, July 15, 2024
Rule 163.
(1)
					 The quality assessment and performance improvement program must monitor quality
					 in all areas of operations that may adversely affect patient care or core
					 services, demonstrate measurable improvements in patient health or palliative
					 outcomes, and improve patient safety.
(2) A quality assessment and performance
					 improvement program must:
(a) Be data
					 driven.
(b) Identify
					 problems.
(c) Reduce medical
					 errors.
(d) Improve patient
					 safety.
(e) Evaluate systems and
					 processes.
(f) Be
					 ongoing.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart F - QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM › Section R. 325.45165 - Performance improvement initiatives; indicators

Current through Vol. 24-12, July 15, 2024
Rule 165. The quality assessment and performance
						improvement program must establish performance improvement initiatives that
						focus on high risk, high volume, and problem-prone areas. If no performance
						improvement projects are conducted in a calendar year, justification explaining
						why no performance improvement projects were conducted must be
						documented.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart F - QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM › Section R. 325.45167 - Documentation; evidence; program activities; data usage

Current through Vol. 24-12, July 15, 2024
Rule 167. A health facility or agency shall maintain
						documentation and demonstrate evidence of an ongoing quality assessment and
						performance improvement program that includes both of the following:
(a) Methods and reports demonstrating
					 systematic identification, reporting, investigation, analysis, and prevention
					 of adverse events.
(b)
					 Documentation demonstrating the development, implementation, and evaluation of
					 corrective actions resulting from quality assessment and performance
					 improvement activities.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 3 - ADMINISTRATION › Subpart G - CLOSURE › Section R. 325.45169 - Proposed closure of a health facility or agency; notification; closure plan; patient referral package

Current through Vol. 24-12, July 15, 2024
Rule 169.
(1) At
					 least 30 days prior to the proposed closure date, a licensee shall notify the
					 department in writing and identify all of the following:
(a) The name and address of the health
					 facility or agency.
(b) The
					 proposed closure date.
(c) The
					 patient census at the time of notification.
(d) The name, title, telephone number, and
					 email address of the individual who is designated by the governing body to
					 serve as the contact person for the closure process.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 4 - HUMAN RESOURCES › Section R. 325.45171 - Administrator

Current through Vol. 24-12, July 15, 2024
Rule 171.
(1) The
				  governing body shall appoint one individual who is responsible for managing the
				  health facility or agency, including but not limited to the following duties:
(a) Directing all day-to-day
				  activities.
(b) Ensuring the
				  implementation of all policies and procedures.
(c) Ensuring regulatory compliance.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 4 - HUMAN RESOURCES › Section R. 325.45173 - Medical Staff

Current through Vol. 24-12, July 15, 2024
Rule 173.
(1) The
				  governing body shall ensure that medical staff requirements are met and that
				  the medical staff is accountable to the governing body.
(2) A physician must be designated as the
				  leader of the medical staff and be assigned the responsibility for the
				  organization and conduct of the medical staff.
(3) The leader of the medical staff may
				  delegate this role in writing to another qualified physician as needed to
				  ensure continuous medical direction and in accordance with the health facility
				  or agencys policy.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 4 - HUMAN RESOURCES › Section R. 325.45175 - Director of nursing

Current through Vol. 24-12, July 15, 2024
Rule 175.
(1) A
				  health facility or agency shall designate a registered professional nurse to
				  serve as the director of nursing.
(2) The director of nursing shall direct all
				  nursing services.
(3) A health
				  facility or agency may assign a different title to this position.
(4) The director of nursing may delegate this
				  role in writing to another qualified registered professional nurse as needed to
				  ensure continuous nursing services and in accordance with the health facility
				  or agencys policy.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 4 - HUMAN RESOURCES › Section R. 325.45177 - Nursing personnel

Current through Vol. 24-12, July 15, 2024
Rule 177. At all times during each shift, a health facility
					 or agency shall meet the minimum staffing requirements specified in the code.
					 For the purposes of determining compliance with nursing personnel-to-patient
					 ratios specified in the code, a member of the nursing staff who works less than
					 2 continuous hours may be counted as part of full-time equivalent personnel
					 only if such member was scheduled to work more than 2 continuous
					 hours.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 4 - HUMAN RESOURCES › Section R. 325.45179 - Independently licensed health professional

Current through Vol. 24-12, July 15, 2024
Rule 179. A health facility or agency may employ, contract,
					 or grant privileges to a qualified individual who is independently licensed to
					 practice a health profession pursuant to article 15 of the
					 code.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 4 - HUMAN RESOURCES › Section R. 325.45181 - Ancillary personnel

Current through Vol. 24-12, July 15, 2024
Rule 181. A health facility or agency may employ or
					 contract ancillary personnel to assist in patient care within the areas of
					 their competence if the individual is adequately trained and working under
					 appropriate supervision.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 4 - HUMAN RESOURCES › Section R. 325.45183 - Employee records

Current through Vol. 24-12, July 15, 2024
Rule 183. A health facility or agency shall maintain a
					 record for each employee that includes all of the following:
(a) Relevant professional license or
				  registration number.
(b) Relevant
				  credentialing and education.
(c)
				  Beginning date of employment and position for which employed.
(d) Results of baseline screening for
				  communicable disease as set forth in R 325.45139.
(e) For former employees, the date employment
				  is severed.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 4 - HUMAN RESOURCES › Section R. 325.45185 - Credentialing; clinical privileges; policy; procedure; record

Current through Vol. 24-12, July 15, 2024
Rule 185. A health facility or agency shall maintain
					 policies and procedures for the credentialing and granting of clinical
					 privileges to medical and allied health professionals. Records must be
					 maintained and include the individuals education, training, and
					 experience.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 5 - PATIENT AND ADMINISTRATIVE RECORDS › Section R. 325.45191 - Patient record; required information

Current through Vol. 24-12, July 15, 2024
Rule 191.
(1) A
				  health facility or agency shall keep and maintain a record for each patient in
				  compliance with sections 20175 and 20175a of the code, MCL 333.20175 and
				  333.20175a.
(2) The patient record
				  must include, as a minimum, all of the following:
(a) Patient identification, including name,
				  address, and birthdate.
(b)
				  Admission date or date services are initiated.
(c) Information submitted by a referral
				  source, if any.
(d) Admitting
				  diagnosis.
(e) Medical history and
				  physical examination.
(f) Clinical
				  diagnostic tests and findings.
(g)
				  Physician and other health professional orders.
(h) Health professional progress
				  notes.
(i) Medication and treatment
				  records.
(j) Notes and observations
				  by other personnel providing care.
(k) Final diagnosis, including pathological
				  findings if any.
(l) Record of
				  discharge, transfer, or death.
(m)
				  Patient designated representative for care, if applicable, and emergency
				  contact information.
(n) Consent
				  forms as required and appropriate.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 5 - PATIENT AND ADMINISTRATIVE RECORDS › Section R. 325.45193 - Surgical patient record; required information; informed consent

Current through Vol. 24-12, July 15, 2024
Rule 193.
(1) In
				  addition to R 325.45191, a freestanding surgical outpatient facility and a
				  hospital shall keep and maintain in the surgical patient record all of the
				  following:
(a) Name of the surgeon.
(b) Name of the anesthesiologist or
				  anesthetist, if other than the surgeon, if applicable.
(c) Preoperative study and diagnosis details
				  if medically necessary.
(d)
				  Provider notes including preoperative and postoperative vital signs and other
				  relevant observations to document the patient's stabilized condition at the
				  time of discharge.
(e) Product name
				  and dosage of any sedative and anesthetic used.
(f) Method of anesthesia and any pertinent
				  information concerning results or reactions.
(g) Operation and treatment notes and
				  consultations.
(h) The
				  postoperative diagnosis, including pathological findings.
(i) Social or social service information
				  relevant to the case.
(j) Surgeon's
				  operative note including all of the following:
(i) Name of each procedure
				  performed.
(ii) Duration of
				  procedure and any unusual problems or occurrences encountered.
(iii) Surgeon's description of gross
				  appearance of any tissues removed.
(k) Summary of instructions given for
				  follow-up observation and care.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 5 - PATIENT AND ADMINISTRATIVE RECORDS › Section R. 325.45195 - Hospice patient record; additional requirement

Current through Vol. 24-12, July 15, 2024
Rule 195. In addition to R 325.45191, a hospice agency or
					 residence shall keep and maintain in the patient record the individuals
					 terminal prognosis in compliance with section 21417 of the code, MCL
					 333.21417.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 5 - PATIENT AND ADMINISTRATIVE RECORDS › Section R. 325.45197 - Nursing care facility patient record; additional requirements

Current through Vol. 24-12, July 15, 2024
Rule 197. In addition to R 325.45191, a nursing care
					 facility shall document in the patient record that a clinical history and
					 physical examination was performed by a physician within 5 days before or on
					 admission, including a physicians treatment plan. The patients record must be
					 completed within 30 days following discharge.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 5 - PATIENT AND ADMINISTRATIVE RECORDS › Section R. 325.45199 - Standing order; written order; verbal order; telephone order

Current through Vol. 24-12, July 15, 2024
Rule 199.
(1)
				  Treatment rendered to a patient must be in accordance with the specific
				  standing, written, verbal, or telephone order of a physician or other licensed
				  health professional ordering within their scope of practice and clinical
				  privileges.
(2) Standing and
				  written orders must be recorded in the patient record and be signed by the
				  licensed health professional who issued the order in accordance with the policy
				  of the health facility or agency.
(3) When verbal or telephone orders are used,
				  they must only be accepted by persons who are authorized to do so by the health
				  facility or agencys policy and procedures consistent with federal and state
				  law. Orders must be recorded in the patient record, restated back to the
				  ordering licensed health professional, and then signed by the person who
				  recorded the order. The licensed health professional who issued the order shall
				  subsequently sign the order in accordance with the health facility or agencys
				  policy and procedures.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 5 - PATIENT AND ADMINISTRATIVE RECORDS › Section R. 325.45201 - Administrative record

Current through Vol. 24-12, July 15, 2024
Rule 201.
(1) A
				  health facility or agency shall maintain administrative records that include
				  all of the following:
(a) Daily census
				  records.
(b) Staffing
				  records.
(c) Incident and accident
				  reports.
(d) Transfer of patient to
				  hospital records.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 5 - PATIENT AND ADMINISTRATIVE RECORDS › Section R. 325.45203 - Patient and administrative records; storage

Current through Vol. 24-12, July 15, 2024
Rule 203.
(1)
				  Patient and administrative records must be preserved and readily available to
				  assure necessary access by appropriate health care professionals and staff to
				  deliver needed care.
(2) Records
				  must be secured to assure confidentiality and protect them from access by
				  unauthorized persons and maintained in accordance with section 20175 of the
				  code, MCL 333.20175.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 5 - PATIENT AND ADMINISTRATIVE RECORDS › Section R. 325.45205 - Patient and administrative records; survey and review by department; confidentiality

Current through Vol. 24-12, July 15, 2024
Rule 205.
(1)
				  Relevant patient and administrative records must be available for survey and
				  complaint investigation by an employee assigned by the department as a
				  surveyor.
(2) Records must be
				  maintained as confidential documents with the following exceptions:
(a) Information required under these
				  rules.
(b) Information required by
				  law.
(c) Information authorized for
				  disclosure by written release of the patient or the patients designated
				  representative.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 5 - PATIENT AND ADMINISTRATIVE RECORDS › Section R. 325.45207 - Data collection; informal advisory group

Current through Vol. 24-12, July 15, 2024
Rule 207.
(1) In
				  addition to the collection of information and documents necessary to determine
				  compliance during a licensure survey or complaint investigation, the department
				  may also collect non-personally identifiable patient information and aggregated
				  data from licensees including, but not limited to, all of the following:
(a) Availability of services.
(b) Hours of operation.
(c) Demographic data.
(d) Morbidity and mortality data.
(e) Volume of care provided to
				  patients.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 6 - ANCILLARY CARE AND SERVICES › Section R. 325.45211 - Laboratory services

Current through Vol. 24-12, July 15, 2024
Rule 211. Where medically necessary, a health facility or
					 agency shall provide, directly or through contract, laboratory services. These
					 laboratory services must be in compliance with the Clinical Laboratory
					 Improvement Amendments (CLIA) regulations, 42 CFR part 493
					 (2017).
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 6 - ANCILLARY CARE AND SERVICES › Section R. 325.45213 - Radiological and imaging services

Current through Vol. 24-12, July 15, 2024
Rule 213.
(1)
				  Where medically necessary, a health facility or agency shall provide, directly
				  or through contract, radiological and imaging services.
(2) These services must be offered on a
				  regular schedule based on the health facilitys or agencys hours of
				  operation.
(3) The staff
				  responsible shall be trained, qualified, and competent for the services being
				  offered. The health facility or agency shall maintain documentation
				  demonstrating the staffs training, qualifications, and competencies.
(4) A health facility or agency shall have
				  written policies and procedures for the maintenance of equipment related to
				  this service that consider applicable manufacturers guidelines.
(5) The health facility or agency shall
				  immediately document any adverse testing or machine error that may cause an
				  adverse patient reaction. Investigation and corrective action must be initiated
				  promptly. Any investigation and corrective action taken in response to an
				  adverse patient reaction must be reported to the appropriate licensed health
				  care professional and recorded in the patients record.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 6 - ANCILLARY CARE AND SERVICES › Section R. 325.45215 - Pharmacy services

Current through Vol. 24-12, July 15, 2024
Rule 215.
(1)
				  Medical supplies and appliances, durable medical equipment, drugs and
				  biologicals related to patient care and treatment, as identified in the
				  patients plan of care, must be provided by the health facility or agency while
				  the patient is under its care.
(2)
				  Where medically necessary, a health facility or agency shall provide, directly
				  or through contract, pharmacy services.
(3) Pharmacy services offered directly within
				  a health facility or agency must be licensed. A health facility or agency
				  contracting pharmacy services shall ensure these services are
				  licensed.
(4) These services must
				  be offered on a regular schedule based on the health facilitys or agencys hours
				  of operation.
(5) The staff
				  responsible must be trained, qualified, and competent for the services being
				  offered. A health facility or agency shall maintain documentation demonstrating
				  the staffs training, qualifications, and competencies.
(6) A health facility or agency shall have
				  written policies and procedures for both of the following:
(a) Drug control.
(b) Maintenance of equipment related to this
				  service that consider applicable manufacturers guidelines.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 6 - ANCILLARY CARE AND SERVICES › Section R. 325.45217 - Dietary services

Current through Vol. 24-12, July 15, 2024
Rule 217. A health facility or agency that offers dietary
					 services shall do all of the following:
(a) Meet all the dietary and nutritional
				  needs of the patient in accordance with the patient assessment and treatment
				  plan.
(b) Obtain a diet order for
				  each patient upon admission, written by a physician or other qualified health
				  professional, based on patient condition, diagnosis, food restrictions,
				  preferences, and nutritional assessment. After the diet order is obtained,
				  information must be provided to the patient regarding their diet order and how
				  the patient can make food choices from the offerings on the facility
				  menu.
(c) Offer nutrition
				  counseling and interventions to patients regarding appropriate nutritional
				  intake in accordance with their condition and treatment plan. Nutrition
				  counseling must be provided by a qualified individual.
(d) Develop and adopt policies and procedures
				  including a diet manual that outlines facility diet orders.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 6 - ANCILLARY CARE AND SERVICES › Section R. 325.45219 - Communication services

Current through Vol. 24-12, July 15, 2024
Rule 219. A health facility or agency shall assure the
					 availability of appropriate methods and tools to communicate with patients who
					 are non-English speaking or have communication impairments. While a patient is
					 receiving services, a health facility or agency shall safeguard any patient
					 sensory items such as eye glasses, dentures, and hearing
					 aids.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 6 - ANCILLARY CARE AND SERVICES › Section R. 325.45221 - Transportation services

Current through Vol. 24-12, July 15, 2024
Rule 221.
(1) A
				  health facility offering inpatient or residential services shall arrange and
				  provide for appropriate transportation services if diagnostic, medical, or
				  other services are necessary and not available onsite.
(2) Excluding a hospital with an emergency
				  department, a health facility or agency shall have protocols for obtaining
				  emergency transportation services for patients requiring emergency medical
				  treatment. When indicated, a qualified health professional from the health
				  facility or agency shall accompany a patient requiring transfer to a facility
				  for emergency medical treatment.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 7 - PATIENT RIGHTS AND RESPONSIBILITIES › Section R. 325.45231 - Patient rights and responsibilities; policies and procedures

Current through Vol. 24-12, July 15, 2024
Rule 231.
(1) A
				  health facility or agency shall develop, adopt, implement, post, and distribute
				  written policies and procedures to protect the rights and responsibilities of
				  patients as provided in sections 20201, 20202, and 20203 of the code, MCL
				  333.20201, 333.20202, and 333.20203.
(2) Before a patients admission, and if
				  requested after admission, policies and procedures related to rights and
				  responsibilities must be made available to all of the following:
(a) The patient.
(b) The patients guardian.
(c) The patients representative.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 8 - COMPLAINTS, INVESTIGATIONS, AND HEARINGS › Subpart A - COMPLAINTS AND INVESTIGATIONS › Section R. 325.45241 - Complaint filed with health facility or agency; procedure

Current through Vol. 24-12, July 15, 2024
Rule 241.
(1) A
					 health facility or agency shall adopt written policies and procedures for the
					 initiation, investigation, and resolution of complaints filed by a patient, or
					 the patients legal guardian or designated representative when that person has
					 standing. The procedure to file a complaint must be made available to the
					 patient at the time of admission and upon request. The procedure must contain,
					 at a minimum, all of the following:
(a) A
					 notice that an individual may file a complaint, orally or in writing, with the
					 health facility or agency, the department, or both.
(b) The name, title, and contact information
					 of the health facility or agency staff member who is responsible for receiving
					 complaints.
(c) The contact
					 information necessary to file a complaint with the department.
(d) Resources to assist the individual with
					 writing a complaint if needed.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 8 - COMPLAINTS, INVESTIGATIONS, AND HEARINGS › Subpart A - COMPLAINTS AND INVESTIGATIONS › Section R. 325.45245 - Investigation by department

Current through Vol. 24-12, July 15, 2024
Rule 245.
(1)
					 The department shall assign a qualified employee to investigate a health
					 facility or agency for a complaint that alleges violation of state law or
					 rule.
(2) An investigation may
					 include, but is not limited to, all of the following:
(a) Inspection of the health facility or
					 agency, observation of its operations, and interviews with the complainant,
					 staff, and relevant patients with their consent.
(b) Inspection of relevant administrative
					 records, patient records, and other documents and media maintained by the
					 health facility or agency.
Michigan Administrative Code › Department - Licensing and Regulatory Affairs › Bureau of Community and Health Systems › Licensing Health Facilities Or Agencies › Part 8 - COMPLAINTS, INVESTIGATIONS, AND HEARINGS › Subpart B - HEARINGS › Section R. 325.45247 - Applicability

Current through Vol. 24-12, July 15, 2024
Rule 247.
(1)
					 The procedures set forth in this subpart apply to the hearings and penalties
					 related to violations under sections 20165, 20166, 20168, 21799b(2), and 21799c
					 of the code, MCL 333.20165, 333.20166, 333.20168, 333.21799b, and
					 333.21799c.
(2) Unless otherwise
					 provided by article 17 or these rules, the procedures for a hearing must comply
					 with sections 71 to 92 of the administrative procedures act, 1969 PA 306, MCL
					 24.271 to 24.292, and part 1 of the Michigan administrative hearing system
					 administrative hearing rules,
					 R
					 792.10101 to
					 R
					 792.10137.