DEPARTMENT OF CONSUMER AND INDUSTRY SERVICES

                        BUREAU OF HEALTH SYSTEMS

              DIVISION OF HEALTH FACILITY STANDARDS AND LICENSING

                 NURSING HOMES AND NURSING CARE FACILITIES


(By authority conferred on the department of  public  health  by  sections
2226(d), 2233, 20115, 20145, 20161, 20171, 21741, and 21795 of Act No. 368
of the Public Acts of 1978, as amended, and section 9 of  Act  No. 380  of
the Public Acts  of  1965,  as  amended,  being  SS333.2226(d),  333.2233,
333.20115, 333.20145,  333.20161,  333.20171,  333.21741,  333.21795,  and
16.109 of the Michigan Compiled Laws)

                        PART 1. GENERAL PROVISIONS


R  325.20101   Applicability.
  Rule 101. These rules  provide  for  the  licensure  of  nursing  homes,
including county medical care facilities and child care homes  and  units,
and for the certification of all of the following:
  (a) Intermediate (or basic nursing) care facilities (ICF).
  (b) Skilled nursing facilities (SNF).
  (c) Intermediate care facilities/mentally retarded (ICF/MR).
  (d) Nursing facilities for the care of the mentally ill.
  (e) Nursing facilities for the care of the mentally retarded.
  (f) Nursing facilities for the care of tuberculosis patients pursuant to
the code.

  History:  1981 AACS.


R  325.20102   Definitions; A to H.
  Rule 102. As used in these rules:
  (a) "Applicant" means a person applying to the department for a  nursing
home  or  a  nursing  care  facility  license  or  any  other  permit   or
certification pursuant to state or federal law or these rules.
  (b) "Basic nursing facility" means a nursing care facility, or  distinct
part  thereof,  which  has  been  certified  by  the  department   as   an
intermediate care facility.
  (c) "Change in ownership," for purposes of section 20142(3) of the code,
means a transfer of the property of a nursing care facility from one owner
to another where the new owner  will  use  the  transferred  assets  as  a
nursing care  facility  operated  by  the  new  owner  subsequent  to  the
transfer.
  (d) "Child care home" means a nursing home which is  designed,  staffed,
and equipped exclusively to accommodate patients under 15 years of age who
do not require hospital care, but who are in need of nursing care  because
they cannot be cared for  effectively  in  their  own  homes  or  in  home
substitutes, and which has been licensed by the department as meeting  the
requirements of part 14 of these rules.
  (e) "Child care unit" means a clearly identifiable distinct part  within
a nursing home which is designed, staffed, and equipped to  accommodate  a
specific number of patients under 15 years  of  age  and  which  has  been
licensed by the department as meeting the requirements of part 14 of these
rules.
  (f) "Child" means a person under 15 years of age.
  (g) "Code" means Act No. 368 of the Public Acts  of  1978,  as  amended,
being S333.1101 et seq. of the Michigan Compiled Laws.
  (h) "County medical care facility" means a nursing care facility,  other
than a hospital long-term care unit, which provides organized nursing care
and medical treatment to 7 or more unrelated individuals who are suffering
or recovering from illness, injury, or infirmity and which  is  owned  and
operated by a county or counties.
  (i) "Correction notice" means a notice  to  a  nursing  home  specifying
violations of the code or these rules, corrective action to be taken,  and
the period of time in which the corrective action is to be completed.
  (j) "Department" means the state department of public health.
  (k) "Distinct part" means a clearly identifiable area or section  within
a nursing care facility consisting of  at  least  a  nursing  unit,  wing,
floor, or building containing contiguous rooms providing a  specific  type
or level of care and service. The distinct part may share  services,  such
as management services, building  maintenance,  and  laundry,  with  other
units.
  (l) "Home" means a nursing home.

  History:  1981 AACS.


R  325.20103   Definitions; I to N.
  Rule 103. As used in these rules:
  (a) "Intermediate care facility" or "ICF" means a nursing care facility,
or distinct part thereof, which has been certified by  the  department  as
meeting applicable requirements set forth in part 15 of these rules.
  (b) "Intermediate care facility/mentally retarded" or "ICF/MR"  means  a
nursing care facility, or distinct part thereof, which has been  certified
by the department as meeting the applicable requirements  of  part  15  of
these rules.
  (c) "Licensed bed  capacity"  means  the  authorized  and  licensed  bed
complement of a nursing home or nursing  care  facility  as  shown  on  or
included within its license.
  (d) "Licensee" means a person possessing a currently valid nursing  home
license.
  (e) "Nursing care facility" means a  licensed  nursing  home  or  county
medical care facility or a hospital long-term  care  unit  in  a  licensed
hospital.
  (f) "Nursing care facility for the care of mentally ill patients"  means
a nursing  care  facility,  or  distinct  part  thereof,  which  has  been
certified by the department as meeting the  requirements  of  part  16  of
these rules.
  (g) "Nursing care facility for the care of mentally  retarded  patients"
means a nursing care facility, or distinct part thereof,  which  has  been
certified by the department as meeting the  requirements  of  part  17  of
these rules.
  (h) "Nursing home," for purposes of licensure under the code  and  these
rules, includes a county medical care facility.
  (i) "Nursing home task force" means task  force  4  created  by  section
20127 of the code.

  History:  1981 AACS.


R  325.20104   Definitions; O to W.
  Rule 104. As used in these rules:
  (a) "Ownership interest" means the ownership or control of 5% or more of
the equity in the capital of, or stock in, or interest in the profits  of,
a nursing home.
  (b) "Provisional license" means a limited  license  issued  pursuant  to
section 21757 of the code and R 325.20210.
  (c) "Public place" or  "area  accessible  to  patients,  employees,  and
visitors" means any 1 of the following locations in  a  home  if  open  to
patients, employees, and visitors:
  (i) The main entry or hallway.
  (ii) The reception area or foyer.
  (iii) The patient dining room or multipurpose room.
  (d) "Sale of a nursing home" means a change in ownership by sale.
  (e) "Skilled  nursing  facility"  means  a  nursing  care  facility,  or
distinct part thereof, which has  been  certified  by  the  department  as
meeting the applicable requirements set forth in part 15 of these rules or
which is so certified by the U.S. secretary of health and human  services.
  (f) "Warning  notice"  means  an  advisory  letter  to  a  nursing  home
indicating a problem or  violation  of  the  code  or  these  rules  which
requires prompt correction.

  History:  1981 AACS; 1983 AACS.


R  325.20106   Terms defined in code.
  Rule 106. Terms defined in the code have the same meanings when used  in
these rules.

  History:  1981 AACS.


R  325.20107   Document type size.
  Rule 107. When the statute or these rules require a document or parts of
a document to be printed in 12-point type, the distance between the top of
the ascenders and the bottom of the descenders in all type  used  in  such
document or specified parts of such document shall be not less than 1/6 of
an inch in height.

  History:  1981 AACS.


R  325.20108   Licensure and certification; eligibility requirements.
  Rule 108. (1) To be  eligible  for  licensure  as  a  nursing  home,  an
applicant shall meet the applicable requirements of the code and  parts  2
to 14 of these rules.
  (2) To be eligible for certification as any of the following, a  nursing
care facility shall meet the requirements of the code and  the  applicable
parts of parts 15 to 18 of these rules:
  (a) An intermediate (or basic nursing) care facility.
  (b) A skilled nursing facility.
  (c) An intermediate care facility/mentally retarded.
  (d) A nursing facility for the care of mentally ill patients.
  (e) A nursing facility for the care of mentally retarded patients.
  (f) A nursing facility for the care of tuberculosis patients.

  History:  1981 AACS.


R  325.20109   State,  federal,  and  local  laws,   rules,   codes,   and
  ordinances; compliance.
  Rule 109. A nursing care facility which is licensed or  certified  shall
comply with applicable state and federal laws and rules and shall  furnish
such evidence as the department may require to show compliance  with  such
laws and rules and applicable local rules, codes,  and  ordinances,  as  a
condition of licensure or certification.

  History:  1981 AACS.


R  325.20110   Licensed bed capacity.
  Rule 110. (1) The department shall endorse on the face of  each  nursing
care facility license the number of beds for which the license is  issued.
The number of patients cared for in a nursing care facility and the number
of unoccupied patient beds shall not exceed the number authorized  by  the
license. A nursing care facility issued  a  license  or  certification  is
subject to the standards required for its authorized bed capacity  without
regard to any other licensure.  Any  proposed  change  in  the  number  of
patient beds shall be reported to the department in accordance  with  part
221 of the code. The department, with prior notification,  may  approve  a
temporary reduction for purposes including renovation, maintenance, or new
construction  when  required  for  the  health,  welfare,  and  safety  of
patients. Any other reduction in the number of patient beds available  for
use, whether or not a certificate of need is required, shall automatically
reduce the licensed bed capacity of  the  nursing  care  facility  by  the
amount of such reduction.
  (2) The issuance of a license or certification is not a determination of
the need for a nursing care facility, or  distinct  part  thereof,  or  of
compliance with part 221 of the code.

  History:  1981 AACS.


R  325.20111   Governing   bodies,   administrators,   and    supervisors;
responsibilities.
  Rule 111. (1) The governing body of a nursing  home  shall  assume  full
legal responsibility for the overall conduct and operation of the home. In
the absence of an organized governing body, the owner, operator, or person
legally responsible for the overall conduct  and  operation  of  the  home
shall carry out the functions of the governing body.
  (2)  The  governing  body  shall  appoint  a   licensed   nursing   home
administrator and shall delegate to the administrator  the  responsibility
for operating the home in accordance  with  policies  established  by  the
governing body. An administrator and  all  other  persons  in  supervisory
positions shall be not less than 18 years of age.
  (3) An administrator shall designate, in writing, a competent person who
is not less than 18 years of age to carry  out  the  responsibilities  and
duties of the administrator in the administrator's absence.

  History:  1981 AACS.


R  325.20112   Policy on patient rights and responsibilities.
  Rule 112. (1) A nursing home shall develop,  adopt,  post  in  a  public
place,  distribute,  and  implement   a   policy   on   the   rights   and
responsibilities of  patients  in  accordance  with  the  requirements  of
sections 20201, 20202, and 20203 of the code.
  (2) For purposes of section 20201(2)(a) of the code, denial of  care  on
the basis of source of payment shall  include,  when  a  nursing  home  or
nursing  care  facility   is   certified   for   medicare   or   medicaid,
discrimination in favor of or against a beneficiary of 1 of those programs
by giving unequal or priority preference to patients  with  other  payment
sources.
  (3) For purposes of section 20201(2)(d) of the code, the term  "privacy"
means that private times are assured, including all of the following:
  (a) Toileting.
  (b) Dressing.
  (c) Bathing.
  (d) Medical treatment and consultation.
  (e) Conjugal visits.
  The term also includes the assurance that a patient in  a  private  room
shall be allowed to have his or her door closed, except that  a  physician
or  nursing  personnel  may  enter  when  required  to  provide  necessary
observation, care, or treatment and when the patient is advised in advance
that such entry may be required.
  (4) For purposes of section 20201(2)(i) of the code, the term "available
through the facility"  means  all  sources  of  payment  accepted  by  the
facility, and when the facility is certified for medicare or medicaid, the
information shall include those benefits.
  (5)  For  purposes  of  section  20201(3)(b)  of  the   code,   "special
circumstances" shall include work hours, distance from the home,  and  the
age of the visitor.
  (6) For purposes of section 20201(4) of the code, "harassment"  includes
verbal as well as physical harassment and interference with the  patient's
daily activities.
  (7) The policy prescribed in  section  20201(3)(h)  of  the  code  shall
include an assurance that the  home  will  make  a  reasonable  effort  to
provide access to records for purposes of inspection and  copying  at  the
time of receipt of a written request, if the request is made during normal
office hours.
  (8)  The  patient  rights  and  responsibilities  policy  shall  include
provisions regarding smoking as provided by section 21733 of the code.
  (9) The policy on patient rights and responsibilities shall  be  written
in 12-point type and shall be explained to the patient or  to  the  person
legally responsible for the patient  in  a  manner  that  he  or  she  can
reasonably be expected to understand. Inservice training provided  by  the
home to its staff shall include instruction in the  patient's  rights  and
responsibilities adopted by the home and the manner in which  such  rights
and responsibilities are respected and violations avoided.

  History:  1981 AACS.


R  325.20113   Adoption of written procedures to implement patient  rights
and responsibilities policy.
  Rule 113. (1) A home shall adopt  written  policies  and  procedures  to
implement patient rights and responsibilities as provided by section 21765
of the code. Before and following the patient's admission, such policy and
procedures shall be available, upon request, to all the following:
  (a) The patient.
  (b) Attending physician.
  (c) Next of kin.
  (d) Member of the family.
  (e) Guardian.
  (f) Designated representative.
  (g) Person or agency responsible for placing and maintaining the patient
in the home.
  (h) Employees of the facility.
  (i) Public.
  (2) The  procedures  shall  include  a  procedure  for  the  initiation,
investigation,  and  resolution  of  complaints,  subject  to   department
approval, and, at a minimum, all of the following:
  (a) A statement that a patient may  have  the  alternative  to  complain
either to the home or  the  department  about  any  condition,  event,  or
procedure in the home without citing a specific violation of the  code  or
these rules.
  (b)  A  procedure  for  submitting  written  complaints  to   the   home
identifying potential violations of law or rule, including a procedure  to
assist a complainant in reducing an oral complaint to  writing  when  such
oral complaint is not resolved to the satisfaction of the complainant.  If
a standard form is used for complaints,  a  copy  of  the  form  shall  be
provided to each patient at the time of  admission  and  additional  forms
shall be available on request.
  (c) The name, title, location, and telephone number of the individual in
the home who  is  responsible  for  receiving  complaints  and  conducting
complaint investigations and  a  procedure  for  communicating  with  that
individual.
  (d) A requirement that all complaints be  investigated  within  15  days
following receipt of the complaint by the home, and  a  requirement  that,
within 30 days following receipt of the complaint, the home shall  deliver
to the complainant a written report of the results of the investigation or
a written status report indicating when the report may be expected.
  (e) A mechanism for appealing the matter to  the  administrator  of  the
home if the  complainant  is  not  satisfied  with  the  investigation  or
resolution of the complaint.
  (3) A home shall maintain for 3 years written complaints filed under its
complaint procedure and all complaint investigation reports  delivered  to
each complainant, and such records shall be available  to  the  department
upon request.

  History:  1981 AACS; 1983 AACS.


R  325.20114   Complaints to the department.
  Rule 114. (1) When a person  files  a  written  complaint  against,  and
requests investigation of, a nursing home pursuant to  section  21799a  of
the code, the following provisions apply:
  (a) Such complaint, if alleging a nonrecurring violation, shall be  made
within 12 months of the discovery of the violation or,  if  the  complaint
has been initially filed with the home, within 12 months following a final
determination in the matter by the home.
  (b) Such complaint, if alleging a recurring  violation,  shall  be  made
within 12 months of the last alleged occurrence cited in the complaint  or
within 12 months following a final determination  in  the  matter  by  the
home.
  (2) If a complaint is not filed within the 12-month period specified  in
subrule (1)(a) and (b) of this  rule,  the  department  may  consider  the
complaint based upon information supplied by the  complainant  as  to  the
reasons for the failure to file within the 12-month period.
  (3) Complaints shall be in writing, shall be signed by the  complainant,
and shall indicate the name and address of the home,  the  nature  of  the
complaint, and the complainant's name, address, and telephone number. If a
complaint is oral, the department shall assist the complainant in reducing
the oral complaint to writing within 7 days after the  oral  complaint  is
made.
  (4) Anonymous complaints shall be received and given to the  appropriate
licensing personnel to be evaluated not later than the next visit  to  the
facility.
  (5) A complainant who is dissatisfied with the written determination  or
investigation of the department may request a hearing in  accordance  with
the procedures set forth in R 325.21918 of these rules.
  (6) As used in this rule, "written  determination"  means  a  department
complaint investigation report or a  letter  to  the  complainant  if  the
letter supplants such report.

  History:  1981 AACS.


R  325.20115   Patient trust funds.
  Rule 115. (1) A nursing  home  shall  develop  a  policy  regarding  the
holding of monies in trust for patients. A  representative  payee,  unless
authorized in writing by  the  patient  or  patient  guardian,  shall  not
function as the person designated to handle the personal property  of  the
patient for purposes of this rule. The policy established by  the  nursing
home may provide that the home will not handle monies of any patient which
exceed the sum of $5,000.00. A home may charge a reasonable  fee,  not  to
exceed the actual cost of providing the service, the fee charged to  other
patients, or the  amount  of  interest  which  accrues  all  trust  monies
deposited for such patients for whom the service is provided. In the  case
of patients who are physically or mentally incapable of handling their own
money and who do not have a legal guardian or other person  designated  in
writing to handle the personal property of  the  patients,  the  home  may
charge a fee as specified in this rule.
  (2) At the time of admission, a nursing home shall provide each  patient
and the patient's legal  guardian  or  designated  representative  with  a
written statement which states all of the following:
  (a) That there is no obligation for the patient to deposit  his  or  her
funds with the facility.
  (b) The patient's rights  regarding  personal  funds,  including,  at  a
minimum, all of the following:
  (i) The right to receive, retain, and manage his or her  personal  funds
or to have this done by a legal guardian, if any.
  (ii) The right to apply to the social security administration to have  a
representative payee designated for purposes of federal or state  benefits
to which he or she may be entitled.
  (iii) The right to designate, in writing, another person to act for  the
purpose of managing his or her personal funds.
  (iv) The right to authorize, in  writing,  the  nursing  home  to  hold,
safeguard, and account for the patient's personal funds in accordance with
state law and the nursing home policy.
  (c) The nursing home's policy for handling patient funds  shall  include
the provision that it will provide the service of holding monies in  trust
for persons who are incapable of handling their own funds and who have  no
guardian or designated representative to provide the service.
  (d) In summary form, the home's procedures for handling, accounting for,
and giving access to, monies held in trust for patients.
  (3) A nursing home shall establish written procedures  for  implementing
its policies for handling patient funds in trust. The  written  procedures
shall cover, at a minimum, all of the following items:
  (a) How and where trust fund records will be kept.
  (b) Patient or patient representative access to records,  including  the
times when access is normally permitted.
  (c) Periodic statements of account.
  (d) Interest on account monies.
  (e) Access to funds held within and outside the facility.
  (f) How to get information regarding trust fund services.
These written  procedures  shall  be  made  available  for  inspection  by
patients and patient representatives, upon request, during normal business
hours.
  (4) For each patient whose funds it holds, safeguards, and accounts for,
the facility shall meet all of the following requirements:
  (a) The nursing home shall maintain current, written, individual records
of all financial transactions involving patients' personal funds which the
facility has been given for holding,  safeguarding,  and  accounting.  The
facility  shall  keep  these  records  in  accordance  with  the  American
institute of certified public accountants' generally  accepted  accounting
standards, and the records  shall  include,  at  a  minimum,  all  of  the
following:
  (i) The patient's name.
  (ii) Identification of the patient's representative, if any.
  (iii) Admission date.
  (iv) Date and amount of each deposit and withdrawal.
  (v) The name of the person who accepted withdrawn funds.
  (vi) The balance after each transaction.
  (vii) Receipts indicating the purpose stated by the  person  withdrawing
the funds for which the withdrawn funds were to be spent,  except  that  a
patient may withdraw his or her own funds without stating  a  purpose  for
the withdrawal.
  (viii) The patient's earned interest, if any.
  (b) The home shall provide each patient reasonable access to his or  her
own financial records, including not less than 2 hours each  business  day
during normal business hours.
  (c) The facility shall provide a written statement, at least  quarterly,
to each patient or patient representative. The quarterly  statement  shall
reflect  any  patient  funds  which  the  facility  has  deposited  in  an
interest-bearing account or a non-interest-bearing account, as well as any
patient funds held by the facility in a petty cash account. The  statement
shall include, at a minimum, all of the following:
  (i) The balance at the beginning of the statement period.
  (ii) Total deposits and withdrawals.
  (iii) Interest earned, if any.
  (iv) Identification number and location of  any  account  in  which  the
patient's personal funds have been deposited.
  (v) The ending balance.
  (vi) The sources, disposition, and date of  each  transaction  involving
the patient's funds during the statement period.
  (d) The home shall keep any funds received from a patient  for  holding,
safeguarding, and accounting separate from the facility's funds  and  from
the funds of any person other than patients. Trust funds held by the  home
for patients may be pooled in an interest-bearing account, as provided  in
these rules, if individual records are kept and the other requirements  of
these rules are followed to assure that the  funds  of  each  patient  are
accounted for separately.
  (e) A nursing home may keep up to $200.00 of  a  patient's  money  in  a
non-interest-bearing account or a petty cash fund. The home shall,  within
15 days, deposit in an interest-bearing account any  funds  in  excess  of
$200.00 from an individual patient. The account may be individual  to  the
patient or pooled with other patients. The account shall be in a form that
clearly indicates that the facility does not have an ownership interest in
the funds. The account shall be insured under federal or state law. At the
election  of  the  nursing  home,  the  interest  earned  on  any   pooled
interest-bearing account shall be distributed in either of  the  following
ways:
  (i) Prorated to each patient on an actual interest-earned basis.
  (ii) Prorated to each patient on the basis of his or her  end-of-quarter
balance.
  (f) At a minimum, in the case of patient monies held  in  a  petty  cash
fund by the facility, a patient shall have access  to  his  or  her  funds
during normal business hours. The facility shall, upon request or upon the
patient's  transfer  or  discharge,  return  to  the  patient,  the  legal
guardian, or  the  designated  representative  all  or  any  part  of  the
patient's personal funds which the  facility  has  received  for  holding,
safeguarding, and accounting and which are  maintained  in  a  petty  cash
fund. For a patient's personal fund that the  facility  has  received  and
deposited in an account outside the facility, the facility,  upon  request
or upon the transfer or discharge of the patient, shall, within 3 business
days, return all or  any  part  of  those  funds  to  the  patient,  legal
guardian, or designated representative.
  (5) When a nursing home is serving as a representative payee  under  the
social security act or otherwise receives monthly benefits  to  which  the
patient is entitled, it shall fulfill its duties as a representative payee
in accordance with federal rules. Except for the patient care  portion  of
such monthly benefits, the home shall deposit all such funds in excess  of
$200.00, as provided in subrule (4)(e) of  this  rule,  in  the  patient's
trust account. Payments of amounts due from the  patient  to  the  nursing
home or others shall be made from the patient's trust funds only upon  the
authorization of the patient or the legal representative of  the  patient.
The home shall not interfere with the right  of  a  patient  or  patient's
representative to control all monies or benefits paid to the patient other
than that portion of benefits designated for patient care.
  (6) Upon the sale or other transfer of ownership of  the  nursing  home,
the home shall provide the new owner with a written  accounting,  prepared
in accordance with the American institute of certified public accountants'
generally  accepted  auditing  procedures,  of  all  patient  funds  being
transferred and shall obtain a written receipt for those  funds  from  the
new owner. The facility shall  also  give  each  patient  or  his  or  her
representative a written  accounting  of  a  personal  fund  held  by  the
facility before any transfer of ownership occurs.
  (7) A nursing home shall provide the  executor  or  administrator  of  a
patient's estate with a  written  accounting  of  the  patient's  personal
belongings and funds within 10 business days of a patient's  death.  If  a
deceased patient's estate has no executor or administrator,  the  facility
shall provide the accounting to the patient's next of kin,  the  patient's
representative, and the clerk of the probate court of the county in  which
the patient died.
  (8) A nursing home  shall  purchase  a  surety  bond  to  guarantee  the
security of patients' funds held in trust by the facility, and the  surety
bond shall be in the name of the  individual  facility  as  licensed.  The
surety bond shall meet the requirements of section 21721(1) of  the  code,
but shall not be less than $2,000.00 for any licensed home.
  (9) If a nursing home determines that a patient is incapable of managing
his or her own personal funds and that the patient has no  legal  guardian
or patient representative designated  to  handle  the  patient's  personal
property, the facility shall notify  the  Michigan  department  of  social
services, in writing, of its determination.

  History:  1981 AACS.


R  325.20116   Involuntary transfers.
  Rule 116. (1) A  patient  shall  not  be  involuntarily  transferred  or
discharged, except as provided by section 21773  of  the  code  and  these
rules.
  (2) For purposes of section 21773 of the  code,  all  of  the  following
provisions apply:
  (a) "Welfare of nursing home employees" means  the  physical  safety  of
nursing home employees.
  (b) The 21-day notice period shall begin  on  the  day  the  patient  or
patient's guardian actually receives the written notice.
  (c) The home shall maintain a record of efforts to collect payment where
nonpayment is the basis for involuntary transfer or discharge and shall be
capable of documenting the nonpayment and efforts to collect payment  upon
request by the department.
  (d) The written summary of the discussion required by  section  21773(8)
of the code shall  be  available  to  each  person  participating  in  the
discussion at the time it is made part of the patient's  clinical  record.
  (e) The home  and  the  department  shall  assure  that  the  counseling
mandated in section 21773(9) of the code is provided.
  (f)  The  department  shall  monitor  counseling  of  patients  who  are
involuntarily transferred or discharged utilizing appropriate  members  of
the department staff. These same members of the department staff, as  part
of the monitoring activity, shall be responsible for approving a  facility
plan to effectuate the  orderly  and  safe  transfer  or  discharge  of  a
patient.
  (g) It shall be the objective of a transfer or discharge plan to  assure
all of the following:
  (i) That the proposed new placement is  appropriate  for  the  patient's
needs and considers the recommendations of the attending physician.
  (ii) That the optimum placement is made, insofar as possible, the  first
time to avoid the necessity for additional transfers at a later date.
  (iii) That  the  patient  or  the  next  of  kin,  guardian,  designated
representative,  agency,  or  organization  responsible  for  placing  and
maintaining the patient in  a  facility  is  involved  in  the  choice  of
facility to which the patient is to be transferred.
  (iv) That at least 1 counseling  session  shall  be  provided  for  each
involuntarily transferred or discharged patient.
  (v) That the patient shall have the opportunity to  visit  the  proposed
new placement at least once. The visit to the new site may only be  waived
if the attending physician documents in the patient's clinical record that
such a visit is medically contraindicated or if the patient, guardian,  or
patient representative determines, in writing,  that  it  is  not  in  the
patient's best interest. In such  instances,  the  patient  shall  receive
appropriate information, such as floor  plans,  brochures,  pictures,  and
other documents, to familiarize the patient with the new facility.
  (vi)  That  the  department  assures  that  a  family  member  or  other
appropriate  person  is  available  to  accompany  the  patient   on   the
involuntary transfer or discharge from the home to a new placement, unless
the patient requests otherwise.
  (h) That the department assures that counseling in the new placement  is
provided following transfer or discharge and that counseling occurs within
72 hours following the transfer or discharge.
  (3) For purposes of section 21774 of the code,  both  of  the  following
provisions apply:
  (a) Submission of a hearing request form  shall  be  prerequisite  to  a
patient's appeal of an involuntary transfer or discharge, and any  written
communication from the patient or  the  patient's  representative  to  the
department shall be accepted as a request for a hearing on the  matter  if
the department has reason to believe  the  communication  is  intended  to
dispute the proposed transfer or discharge.
  (b) Hearings shall be conducted informally by a  representative  of  the
department at the facility in which the patient is  located.  The  patient
and home, or their representative, may state their  position  and  present
documents and other proofs at the  hearing.  Following  the  hearing,  the
department shall issue its decision and reasons therefor in writing, which
decision shall be final and not subject to further administrative  appeal.
  (4) This rule shall not  apply  when  a  facility  discontinues,  or  is
required to discontinue, operations.

  History:  1981 AACS.


R  325.20117   Disaster plans.
  Rule 117. (1) A home shall have  a  written  plan  or  procedure  to  be
followed in case of fire, explosion, or other emergency.
  (2) A disaster plan shall  be  posted  and  shall  specify  all  of  the
following:
  (a) Persons to be notified.
  (b) Locations of alarm signals and fire extinguishers.
  (c) Evacuation routes.
  (d) Procedures for evacuating patients.
  (e) Frequency of fire drills.
  (f) Assignment of specific tasks and responsibilities to  the  personnel
of each shift.
  (3) Personnel shall be trained to perform  assigned  tasks  before  such
assignment.
  (4) A disaster plan shall meet with  the  approval  of  the  state  fire
marshal.
  (5) A disaster plan shall  be  posted  throughout  the  home  in  places
accessible to employees, patients, and visitors.
  (6) A regular simulated drill shall be held for each shift not less than
3 times per year.

  History:  1981 AACS; 1983 AACS.


R  325.20118   Rescission.
  Rule 118. R 325.1901 to R 325.1938, R 325.1941 to R 325.1954, R 325.1959
to  R 325.1962,  R 325.1964,   R 325.1965,   R 325.1968,   R 325.1971   to
R 325.1974, R 325.1981 to R 325.2018, and R 325.2020 to R 325.2097 of  the
Michigan Administrative Code, appearing on pages 1861 to 1892 of the  1979
Administrative Code, are rescinded.

  History:  1981 AACS.

                             PART 2. LICENSURE


R  325.20201   Establishing,  maintaining,  or  operating   nursing   home
  without a license prohibited.
  Rule 201. A person shall not establish, maintain, or operate  a  nursing
home unless licensed by the department in accordance  with  the  code  and
this part.

  History:  1981 AACS.


R  325.20202   Time of application.
  Rule 202. An application for initial licensure may be made at any  time.
An application for renewed licensure shall be submitted to the  department
not less than 90 days before the expiration of the current license.

  History:  1981 AACS.


R  325.20203   Content of application.
  Rule 203. (1) An application for an initial or renewed license shall  be
made on a form authorized and provided by the department, which  shall  be
completed  in  full  in  accordance  with  department  instructions.   The
application form shall be accompanied by the attachments, additional data,
and information required by the department.
  (2) A complete application shall include,  at  a  minimum,  all  of  the
following:
  (a) A completed application form, including the assurances described  in
section 20152 of the code.
  (b) Written evidence of appointment of an authorized  representative  as
required by R 325.20204.
  (c) Identification of owners and of financially  interested  persons  as
required by R 325.20207.
  (d) The applicable license fee.
  (e) Evidence of a currently valid certificate of need if applicable.
  (f) Additional information specified in departmental instructions.

  History:  1981 AACS.


R  325.20204   Authorized representative.
  Rule  204.  An  application  for  an  initial  or  renewed  license   or
certification shall be signed by the owner or an authorized representative
who shall, at a minimum, be authorized to act as agent for  the  owner  or
owners with respect to doing any of the following:
  (a) Submitting the application and making amendments thereto.
  (b) Providing the  department  with  all  information  necessary  for  a
determination with respect to the application.
  (c) Entering into agreements with  the  department  in  connection  with
licensure or certification.
  (d) Receiving notice and service of process on behalf of  the  applicant
in matters relating to licensure or certification.

  History:  1981 AACS.


R  325.20205   Processing the application.
  Rule 205. (1) The department shall review all applications to  determine
whether they are complete and  shall  promptly  notify  the  applicant  in
writing if additional information is required to complete the  application
or determine compliance with the code  and  these  rules.  The  department
shall investigate and consider each completed application.
  (2) By applying for or accepting a license or a permit, an applicant  or
licensee authorizes the department and its representatives to conduct  the
surveys, inspections, and investigations necessary to determine compliance
with applicable licensing standards.

  History:  1981 AACS.


R  325.20206   Surveys and investigations.
  Rule 206. (1) The department shall conduct a survey and investigation of
a nursing home for initial licensure within the 3-month  period  following
receipt of the application or, in the case of renewals, within the 3-month
period before the expiration date of a license. A license  shall  only  be
issued or renewed if the department, after completing such  a  survey  and
investigation, finds the facility to be in substantial compliance with the
requirements of the code and these rules.
  (2)  The  department  may  take  additional  visits,  inspections,   and
investigations for the purpose of  survey,  evaluation,  consultation,  or
enforcement of these rules and the code.
  (3) Surveys and investigations pursuant to this part  may  include,  but
are not limited to, all of the following:
  (a) Inspections of the facility and its operation and maintenance.
  (b) Inspection and copying of books, records, patient clinical  records,
and other documents maintained by the facility.
  (c) The acquisition of other information, including otherwise privileged
or  confidential  information,  from  any  other  person  who   may   have
information bearing on the applicant's or licensee's compliance or ability
to comply with the applicable requirements for licensure.
  (4) When making a survey or investigation, the department representative
or representatives shall present proper identification. For this  purpose,
"proper identification" means a card issued by the  department  certifying
that the holder is an employee of the department.

  History:  1981 AACS; 1983 AACS.


R  325.20207   Disclosure of ownership interests.
  Rule 207. (1)  An  applicant  or  licensee  shall  include  all  of  the
following with its application for an initial or renewed license:
  (a) The name, address, principal occupation, and  official  position  of
all persons who have an ownership interest in the home.
  (b) The name, address, principal occupation, and  official  position  of
each trustee for a voluntary nonprofit corporation.
  (c) The most recent disclosure  of  ownership  and  related  information
prepared pursuant to the federal medicare-medicaid  anti-fraud  and  abuse
amendments of 1977, Public Law 95-142, 42 U.S.C. S1320 a-3 and regulations
promulgated thereunder.
  (d) If a home is located on or in leased real estate, the  name  of  the
lessor and any direct or indirect interest the applicant or  licensee  has
in the lease other than as lessee.
  (2) The department may accept reports  filed  with  the  securities  and
exchange commission as  compliance  with  this  rule,  if  the  department
determines that such reports contain the information required.

  History:  1981 AACS.


R  325.20208   Action on applications for licensure.
  Rule 208. (1) With respect to any  application  for  licensure,  on  the
basis  of  the  information  supplied  by  the  applicant  and  any  other
information available to it,  including  facility  survey  inspection  and
investigation, the department shall take 1 of the following actions:
  (a) Issue or renew the license.
  (b) Issue or renew a provisional license.
  (c) Issue a temporary unrenewable permit.
  (d) Issue or renew a license based upon an approved building program.
  (e) Issue a limited license with such  conditions  or  restrictions,  or
both, as the department determines necessary to carry out the purposes  of
the code.
  (f) Deny an initial or renewed license.
  (g) Take other action consistent with the purposes of the code.
  (2) Action by the department pursuant to subrule (1) (b), (c),  (e),  or
(f) of this  rule  shall  be  preceded  by  a  notice  of  intent  and  an
opportunity for a hearing in accordance with part 19 of  these  rules.  In
all other cases, the determination of the department shall be final.

  History:  1981 AACS.


R  325.20209   Term of license or certification.
  Rule 209. A license or certificate shall expire on the date shown on its
face or 1 year after the date of issuance,  whichever  is  sooner,  unless
renewed or terminated in accordance with the code or these rules.

  History:  1981 AACS.


R  325.20210   Provisional licenses.
  Rule 210. When a provisional license is issued by the  department,  such
license shall expire on the date set  forth  on  its  face  or  the  first
anniversary of  its  issuance,  whichever  is  sooner.  The  holder  of  a
provisional license shall apply for a license not less than 90 days before
the expiration date of the provisional license. The department may renew a
provisional license 1 time only for 1 year or a shorter period if, in  its
discretion, the department determines that the purposes of the  code  will
be served thereby.

  History:  1981 AACS.


R  325.20211   Temporary permits.
  Rule 211. (1)  The  department  may  issue  a  temporary  permit  to  an
applicant  pursuant  to  section  20162(3)  of  the  code  when,  in   the
department's discretion, additional time is needed  for  the  department's
survey, inspection, or investigation of the applicant or  additional  time
is needed for the applicant, including initial applicants  and  applicants
applying because of changes in ownership, to undertake remedial action  as
described in section 20162(2) of the code.
  (2) A temporary permit shall expire on the date set forth on its face or
6 months after the date of its issuance, whichever is sooner.  The  holder
of a temporary permit shall apply for a license  not  less  than  90  days
before the expiration date of the temporary permit. A temporary permit  is
not renewable.

  History:  1981 AACS.


R  325.20212   Notice to department of  change  in  information  required;
transfer of license; posting.
  Rule 212. (1) A license is issued on the basis of information  available
to the department on the date of issuance. An applicant or licensee  shall
give written notice to the department within 5 business days of any change
in information submitted as part of an application for initial or  renewed
licensure.
  (2) A license is not  transferable  between  buildings,  properties,  or
owners, from one location to another, or from one part of  an  institution
to another. A change in ownership shall be reported  pursuant  to  section
20142(3) of the code.
  (3) The current license shall be posted in a conspicuous public place in
the home. For purposes  of  this  rule,  the  term  "license"  includes  a
provisional license, limited license, or a temporary permit.

  History:  1981 AACS.


R  325.20213   Construction and major alterations of nursing homes.
  Rule 213. (1) A home shall not contract for or initiate  either  of  the
following projects without first obtaining a construction permit from  the
department:
  (a) A project for which a construction permit  is  required  by  section
20145 of the code.
  (b) A project to expand or change service areas  for  services  provided
which involves major alterations.
  (2) The owner or governing body of a home or proposed home shall  submit
plans for projects described in subrule (1) of this rule to the department
for review  and  approval  before  contracting  for  and  initiating  such
projects. The department shall approve the plans if it determines that the
project is designed and constructed in accord  with  applicable  statutory
and regulatory requirements.
  (3) A  major  alteration  is  deemed  to  be  any  extensive  structural
alteration of an existing building area involving significant  changes  in
the interior configurations or intended use by the moving of partitions of
a number of rooms and involving an expenditure in an amount in  excess  of
$25,000.00. Removal of a partition between 2  adjacent  rooms  to  provide
additional room space is not deemed to be a major  alteration,  unless  it
exceeds $25,000.00 in cost or unless multiple changes are to be made for a
changed use of an entire wing or area and extensive plumbing or electrical
wiring changes are required.
  (4) The department may waive  the  applicability  of  this  rule  if  it
determines the waiver will not  affect  the  public  health,  safety,  and
welfare.

  History:  1981 AACS.


R  325.20214   Prohibited terms.
  Rule 214. In addition to the terms whose use is limited by the code, the
use of the words "state approved" or words having  a  similar  meaning  is
prohibited unless the home is operated under a current license.

  History:  1981 AACS.


R  325.20215   Public inspection of license records.
  Rule 215. (1) Unless otherwise provided by law,  records  pertaining  to
licensure and  certification  are  available  for  public  inspection  and
copying during business hours on the days when the bureau of  health  care
administration,  Michigan  department  of  public  health,  is  open   for
business.
  (2) The department shall delete from licensing and certification records
made available for inspection any matters or items of  information  exempt
from disclosure under law. Fees related  to  requests  for  inspection  or
copies of  licensing  and  certification  records  shall  be  assessed  in
accordance with applicable law and department procedures.
  (3)  Arrangements  for  the  inspection  or  copying  of  licensing  and
certification records shall  be  made  with  the  bureau  of  health  care
administration in the department.

  History:  1981 AACS.

               PART 3. ACCESS TO NURSING HOMES AND PATIENTS


R  325.20301   Access to nursing home patients by approved  organizations;
application.
  Rule 301. (1) Organizations which are approved pursuant to this part, or
the designated and properly identified representatives, shall have  access
to nursing home patients as provided in section 21763 of the code.
  (2)  An  organization  shall  not  represent  itself  as   an   approved
organization for purposes of section 21763 of the code, unless approved by
the director pursuant to this part.
  (3) An organization desiring to have access to a home and its  patients,
as provided in section 21763 of the code, shall apply to the director  for
approval.
  (4) An application for approval shall include, at a minimum, all of  the
following:
  (a) The name, address, principal occupation, and  official  position  of
all persons who have  an  ownership  interest,  all  directors,  officers,
officials, and trustees.
  (b)  A  copy  of  the  articles  of  incorporation  and  bylaws  of  the
organization, if any.
  (c) The applicant's proposed service area, the services proposed  to  be
delivered, and a statement that the  services  provided  to  nursing  home
patients shall be without charge.
  (d) Evidence that the applicant is a bona fide community organization or
legal aid society with nonprofit status which has  as  1  of  its  primary
purposes the rendering of assistance  to  nursing  home  patients  without
charge.
  (e) Additional information specified in  the  department's  instructions
required to determine compliance with the code and these rules.
  (5) The provisions of this part shall not diminish the right of patients
to receive or refuse to receive visitors pursuant to  section  20201(3)(b)
of the code.

  History:  1981 AACS.


R  325.20302   Patient access application; processing procedure.
  Rule 302. (1) The department shall determine whether an application  for
approval is  complete  and  shall  notify  the  applicant  in  writing  if
additional  information  is  required  to  complete  the  application   or
determine compliance with the code or these rules.
  (2) When an application is deemed complete, the department shall forward
the application and any related information to the nursing home task force
for consideration. The task force, in accord with  its  procedures,  shall
advise the director on the application within 10 working days.
  (3) By applying for or accepting approval pursuant to section  21764  of
the code,  an  organization  authorizes  the  department  to  conduct  the
investigation necessary to determine initial and continued compliance with
the requirements for approval at any time before or  after  the  grant  of
approval.
  (4) On the basis of the information supplied by  the  applicant  or  any
other information available, including the advice of the nursing home task
force, the director shall grant or deny approval to the  applicant,  shall
notify the applicant of the decision, and shall notify  the  nursing  care
facilities in the applicant's service area of any decision of approval.
  (5) An appeal of the director's decision to the nursing home task  force
pursuant to section 21764(4) of the code shall be conducted informally, as
prescribed by the task force, and the decision of the task force is final,
binds the director, and is not subject to further  administrative  appeal.

  History:  1981 AACS; 1983 AACS.


R  325.20303   Patient access approval; change in circumstances; review of
approvals; termination of approvals.
  Rule 303. (1) Patient access under section 21764 of the code  is  issued
on the basis of information available on the  date  of  issuance,  and  an
approved organization shall give written notice to the  department  within
10 business days of any changes in information submitted to the department
in the application. An approval  is  effective  until  terminated  by  the
department at any time for failure to meet the requirements  of  the  code
and these rules. The department's decision to terminate  approval  may  be
appealed as provided in R 325.20302(5).
  (2) The nursing home task force  shall  annually,  in  accord  with  its
procedures, or at the request of the director,  review  approvals  granted
and in force pursuant  to  section  21764  of  the  code  and  shall  make
recommendations to the director as to  whether  such  approvals  shall  be
continued or cancelled.

  History:  1981 AACS; 1983 AACS.


R  325.20304   Patient  access;  adoption  of  a  procedure  to   identify
representatives of approved organizations; complaints.
  Rule 304. (1) A  nursing  home  shall  adopt  a  procedure  by  which  a
representative of an approved organization may be identified to  the  home
and the patient, as provided in section  21763(2)  of  the  code,  without
undue  delay  not  to  exceed  30  minutes.  Representatives  of  approved
organizations  shall  carry  and,  upon  request,  shall   show   official
identification issued by the organization.
  (2) Complaints by nursing homes pursuant to section 21763(4) of the code
shall be made to the nursing home task force in accordance with procedures
established by that body. Complaints shall be reviewed by the  task  force
under procedures established by it, and  a  decision  of  the  task  force
following such review is final, binds the director, and is not subject  to
further administrative appeal.

  History:  1981 AACS; 1983 AACS.

                PART 4. ADMINISTRATIVE MANAGEMENT OF HOMES


R  325.20401   Administrative policy manual.
  Rule 401. (1) The home shall  make  immediately  available  for  on-site
inspection by the department an administrative policy manual  which  shall
include, at a minimum, all of the following:
  (a) Admission policies, including a copy of the contract  form  used  by
the home when admitting patients.
  (b) Governing body bylaws or equivalent, if any.
  (c) The nursing home departmental policies.
  (d) Personnel policies and job descriptions.
  (e) Patient bill of rights and responsibilities.
  (f) Transfer agreements.
  (g) Contracts with providers of health care and health services.
  (h) Disaster and emergency plans.
  (i) A list of approved abbreviations used  in  recording  administrative
orders.
  (2) The administrative policy manual shall be reviewed annually  by  the
governing body, owner, or operator and shall be  revised  as  appropriate.
Dates of reviews and revisions shall be a matter of record in the home.

  History:  1981 AACS.


R  325.20402   Health of employees and others providing care.
  Rule 402. (1) An employee on duty in the home shall be  in  good  health
and free from communicable disease. Files shall be maintained by the  home
containing evidence of adequate health supervision,  such  as  results  of
preemployment and periodic physical  examinations,  including  intradermal
skin tests for tuberculosis and chest x-rays, and records of  illness  and
accidents occurring on duty.
  (2) An employee shall have an intradermal test for tuberculosis  at  the
beginning of employment and annually thereafter. If at any time  the  skin
test is positive, the local health department shall be  notified  and  the
employee shall have a chest x-ray to determine the  presence  of  disease.
The  facility  shall  develop  and  implement  a  policy  prescribing  the
frequency of subsequent chest x-rays. This policy shall be based upon  the
employee's risk of developing active disease and exposing others. A report
of the results of such tests and any treatment received shall be  included
in the individual employee's personnel file.
  (3) Volunteers, students, and other persons  who  have  direct  physical
contact with patients or food while providing  care  or  services  in  the
facility shall only be permitted to participate  when  free  of  signs  of
infection. The facility shall adopt and implement an  educational  program
to ensure that these care providers are aware of and practicing acceptable
infection control measures.

  History:  1981 AACS.


R  325.20403   Admission policies.
  Rule 403. (1) A home shall have  a  written  admission  policy  that  is
available upon request, before and following the patient's  admission,  to
all of the following:
  (a) The patient.
  (b) Attending physician.
  (c) Next of kin or member of the family.
  (d) Guardian.
  (e) Designated representative.
  (f) Person or agency responsible for placing and maintaining the patient
in the home.
  (g) Employees of the facility.
  (h) The public.
  (2) A patient shall only be admitted to a home on the recommendation and
referral of a physician licensed to practice in Michigan.
  (3) Before but not later than at the time of admission of a patient,  an
attending physician shall be designated to be responsible for the  medical
care and supervision of the patient.
  (4) A home shall not accept a patient for care who is less than 15 years
of age, unless that home is specifically  licensed  and  approved  by  the
director to accept children  as  patients;  however,  the  director,  upon
written  application  by  a  child's  parent  or  guardian   and   written
recommendation by a child's physician, may authorize a  child's  admission
to a home not so licensed when the director determines that  there  is  no
licensed child care home or child care unit in the subareas, as defined by
the department, and the admission is determined to be in the  interest  of
the child's health and welfare.

  History:  1981 AACS.


R  325.20404   Illnesses; accidents; and incidents.
  Rule  404.  (1)  In  case  of  an  accident  or  incident  involving   a
life-threatening change in a patient's condition, the administrator or his
or her designated representative shall immediately  notify  the  attending
physician and the legal guardian, if  any.  In  the  absence  of  a  legal
guardian, or if unable to contact the guardian, the home shall notify  the
next of kin, the person responsible for placing the patient in  the  home,
or the patient's designated representative. A record of the  notification,
including the names and the  time  notified,  shall  be  recorded  in  the
patient's clinical record.
  (2) Immediate investigation of the cause  of  an  accident  or  incident
involving a patient, employee,  or  visitor  shall  be  initiated  by  the
administrator or his or her designated representative, and an  appropriate
accident record or incident report shall be completed.
  (3) The suspected occurrence of  any  reportable  disease  or  condition
shall be reported to the department and to the local health department  in
accordance with published regulations.
  (4) The administrator or his  or  her  designated  representative  shall
furnish all available pertinent information related  to  such  disease  or
poisoning to the department and the  local  health  department  and  shall
cooperate  with  the  department,  local  health  department,  or   others
designated by the department as  appropriate  to  the  resolution  of  the
problem.

  History:  1981 AACS; 1983 AACS.


R  325.20405   Patient deaths.
  Rule 405.  When  a  patient  dies,  the  administrator  or  his  or  her
designated  representative  shall   immediately   notify   the   attending
physician,  the  next  of  kin,   the   legal   guardian   or   designated
representative, and, as soon as possible, the person or agency responsible
for placing and maintaining the patient in the home. A  signed  record  of
this notification, including the names of the  persons  notified  and  the
time notification was made, shall be recorded on  the  patient's  clinical
record.

  History:  1981 AACS.


R  325.20406   Patient bill of rights provisions.
  Rule 406. To protect the rights of patients under section 20201  of  the
code and other relevant provisions of the code, the following requirements
shall be complied with:
  (a) A nursing home  shall  assure  that  information  transmitted  to  a
patient or designated representative  shall  be  communicated  in  such  a
manner that there is reasonable assurance that  the  patient  understands.
Where the patient's condition is such that he or she  cannot  be  made  to
understand,  the  information  shall  be  communicated  to  the  patient's
representative or guardian in such a manner  that  the  representative  or
guardian can understand. Nothing in this rule shall be deemed to limit the
obligation to provide  information  to  the  patient's  representative  or
guardian. Health status information  communicated  to  a  patient  may  be
explained by a physician or registered  nurse  or  other  licensed  health
personnel unless medically contraindicated.
  (b) When a patient refuses treatment, a determination shall be  made  by
the attending physician as to whether or  not  the  patient's  refusal  of
treatment prevents the facility from providing appropriate care  according
to ethical and professional standards. The  physician's  determination  in
this matter shall be in writing and shall be made a part of the  patient's
clinical record. When a relationship between a nursing home and patient is
terminated in conjunction  with  the  physician's  determination  and  the
action results in an involuntary transfer or discharge, such  transfer  or
discharge shall be handled in accordance with the provisions  of  sections
21773 and 21774 of the code.
  (c) A plan  of  care  for  a  patient  that  provides  for  the  patient
performing services for the home shall be authorized  by  the  physician's
written order. The order shall include the specific benefits to be derived
by the patient from such activity, and such  written  order  shall  become
part of the patient's record. The patient shall have the right  to  refuse
to perform such services for the facility, and such refusal shall  not  be
deemed to prevent the facility from providing appropriate care.
  (d) The nursing home shall assure, through the minimum following  steps,
that a patient is provided with information about  health  facility  rules
and regulations affecting patient care and conduct:
  (i) The home  shall  provide  a  written  copy  of  facility  rules  and
regulations to the patient or the patient's representative upon  admission
and when the rules and regulations are changed.
  (ii) The home shall assure that policies,  rules,  and  regulations  are
communicated effectively to  all  patients,  including  patients  who  are
unable to read.
  (iii) The home shall post such rules and regulations in a public  place.
  (e) A home shall provide every reasonable opportunity, at the request of
the patient, the legal guardian, the patient's representative, or the next
of kin, to permit a  limited  number  of  individuals  to  remain  in  the
facility 24 hours a day when the patient is considered terminally ill.

  History:  1981 AACS; 1983 AACS.


R  325.20407   Enforcement of nondiscrimination on the basis of source  of
payment for care.
  Rule 407. (1) When a nursing home is  enrolled  as  a  provider  in  the
medicare and medicaid programs and holds a valid provider  agreement  with
the designated federal or state agency,  discrimination  with  respect  to
source of payment for purposes of sections 21799c(3)  and  20201(2)(a)  of
the code includes action to require a cash payment before  admission  from
any person determined to be eligible to receive medicare or  medicaid,  to
require cash payment instead of medicare or medicaid payment authorized by
the designated federal or state agency for  any  period  of  time,  or  to
require any unauthorized supplemental cash payment in addition to medicare
or medicaid payment for care.
  (2) A home which violates a patient's rights with respect to the matters
described in subrule (1) of this rule shall,  in  addition  to  any  civil
penalties assessed under  the  code,  repay  any  and  all  cash  payments
improperly required of the patient, the patient's  family,  or  designated
representative, with interest, at the prime interest rate on the  day  the
violation is identified, to be added and compounded  for  the  period  the
cash payment has been inappropriately in the home's possession.

  History:  1981 AACS.

                           PART 5. PATIENT CARE

R  325.20501   Care in general.
  Rule 501. The feelings, attitude, sensibility, and comfort of a  patient
shall be fully respected and given meticulous attention at  all  times  by
all personnel.

  History:  1981 AACS.


R  325.20502   Policies and procedures for care.
  Rule 502. (1) The home shall have a written policy governing the nursing
care and other services provided to a patient, which shall be  implemented
through written procedures which are maintained and available to personnel
at all times. All personnel shall be oriented to the  facility  and  their
responsibilities.
  (2) The policy shall be developed by a  patient  care  policy  committee
consisting of at least 1 licensed physician, the director of nursing,  and
the  administrator,  with  such  additional  members  as   the   committee
determines appropriate. When a nursing home owner is responsible for  more
than 1 home, the owner may establish 1 patient care policy committee which
has the  responsibility  for  developing  appropriate  policies  for  each
individual home.
  (3) The policy shall be presented  to  the  governing  body,  owner,  or
operator for review and approval before implementation, and  a  record  of
such approval shall be maintained with the policy.
  (4) The policy shall be reviewed by the patient care policy committee at
least annually and amended as necessary to meet the needs of  patients  in
the home. Revisions shall be approved by the  governing  body,  owner,  or
operator. A record of such approval shall be maintained with  the  policy.
  (5) The policy shall govern, at a minimum, all of the following:
  (a) Admission, discharge, and transfer of patients.
  (b) Categories of patients accepted and not accepted by the home.
  (c) Clinical records.
  (d) Physician services.
  (e) Nursing services.
  (f) Dietary services.
  (g) Rehabilitative services.
  (h) Pharmaceutical services.
  (i) Diagnostic services.
  (j) Consultation services.
  (k) Dental services.
  (l) Podiatry services.
  (m) Social services, including counseling services.
  (n) Mental health services.
  (o) Diversional activities.
  (p) Interdisciplinary patient care planning.
  (q) Discharge planning.
  (r) Care of patients in an  emergency,  during  a  communicable  disease
episode, when critically ill, or when mentally disturbed.

  History:  1981 AACS; 1983 AACS.


R  325.20503   Oxygen administration.
  Rule 503. A written policy shall govern the administration of oxygen  to
a patient in the home. This policy shall  include  the  requirements  that
only personnel who have been trained to administer oxygen shall do so  and
that oxygen shall only be administered on the order of a physician  or  as
authorized in emergency situations.

  History:  1981 AACS.


R  325.20504   Blood and blood substitute administration.
  Rule 504. A written policy shall govern the administration of blood  and
blood substitutes to a patient in the home. This policy  shall  include  a
requirement that blood or blood substitutes administered to a  patient  in
the home shall be started by a physician or registered nurse.

  History:  1981 AACS.


R  325.20505   Parenteral fluid administration.
  Rule 505. A written policy shall govern the administration of parenteral
fluids administered to a patient in the home. Parenteral fluids  shall  be
administered only on the order of a physician, shall be started by  either
a physician or registered nurse, and shall be supervised in the course  of
administration by a physician or licensed nurse.

  History:  1981 AACS.


R  325.20506   Tuberculosis testing.
  Rule  506.  (1)  The  facility  shall  develop  and  implement  policies
governing the periodic  intradermal  tuberculin  testing  of  patients  in
addition to the requirement for a chest x-ray on admission.
  (2) If a patient has a positive skin test or an x-ray  abnormality,  the
local health department  shall  be  notified  and  the  patient  shall  be
evaluated to determine the presence of disease. The  facility  shall  then
develop  and  implement  a  policy  regarding  the   subsequent   periodic
monitoring of these patients, based upon their risk of  developing  active
tuberculosis or exposing others.

  History:  1981 AACS.


R  325.20507   Infection control.
  Rule 507. A written policy shall  govern  the  control  of  communicable
disease  and  infections  in  the  nursing  home  and  shall  require  the
establishment and operation of an infection control committee, which shall
include  at  least  the  director  of  nursing  and   representatives   of
administration,  dietary,  housekeeping,  and  maintenance  services.  The
infection control committee, at  a  minimum,  shall  conduct  all  of  the
following activities and shall submit periodic reports and recommendations
for change to the governing body, owner, or operator:
  (a) Provide surveillance to detect the presence of communicable  disease
or infections.
  (b) Provide for the  immediate  control  of  disease,  when  identified,
through the formulation of policies and procedures.
  (c) Develop and monitor the implementation of procedures for aseptic and
isolation techniques.
  (d)  Periodically  review,  and  revise  as  needed,  all  policies  and
procedures relating to infection control.
  (e) Establish effective communication with the local  health  department
in order to obtain available assistance and to provide for the interchange
of information necessary for the control of disease in  the  nursing  home
and prevent the potential spread of disease to the community.

  History:  1981 AACS.


R  325.20508   Policy availability.
  Rule 508. The written patient care policies shall be made available  for
review on request to all of the following:
  (a) A patient.
  (b) Physician.
  (c) Nursing personnel.
  (d) Next of kin.
  (e) Guardian or designated representative.
  (f) Agency or organization responsible for placing  or  maintaining  the
patient in the home.

  History:  1981 AACS.


R  325.20509   Training for unlicensed nursing personnel.
  Rule 509. For purposes of interpreting section 21795(1) of the code, the
"buddy system" method of  instruction  for  unlicensed  nursing  personnel
shall not be permitted as the only method of such instruction.

  History:  1981 AACS.

                        PART 6. PHYSICIAN SERVICES


R  325.20601   Medical direction of patients.
  Rule 601. (1) The care of a patient admitted to a home  shall  be  under
the continuing direction of a physician licensed to practice in  Michigan.
  (2) The administrator of the home shall be responsible for  assuring  or
promptly arranging for this continuing medical care  and  direction  by  a
licensed physician.
  (3) The name and telephone numbers of the attending  licensed  physician
and the licensed physician to be called in  case  of  emergency  when  the
attending physician is not available  shall  be  posted  at  each  nursing
station. The telephone numbers of the attending physician or  his  or  her
replacement in case  of  emergency  shall  be  provided  to  the  patient,
guardian, or designated representative on request.

  History:  1981 AACS.


R  325.20602   Medical examination of patients.
  Rule 602. (1) Except in the case of a Friday admission, in which case  a
patient shall be examined by a  licensed  physician  within  72  hours,  a
patient admitted to a home shall  be  examined  by  a  licensed  physician
within 48 hours after admission, unless the patient has been examined by a
licensed physician within 5 days before  admission  and  a  copy  of  that
examination is available  in  the  home  at  the  time  of  the  patient's
admission.
  (2) A written record of the clinical history and  physical  examination,
together with  a  diagnosis  and  treatment  plan,  shall  appear  in  the
patient's clinical record.
  (3) The examination shall include a chest x-ray, unless  a  chest  x-ray
has been taken within 90 days of admission and a report of the results  of
that x-ray examination is available  in  the  home  at  the  time  of  the
patient's admission for inclusion in the patient's clinical record.

  History:  1981 AACS.


R  325.20603   Medical visits to patients.
  Rule 603. (1) A patient in a home shall  be  seen  and,  to  the  extent
appropriate, shall be examined by a licensed physician at least once every
60 days, unless  justified  otherwise  and  documented  by  the  attending
physician in the patient's clinical record. At a minimum, a patient  in  a
home shall be seen and, to the extent appropriate, shall  be  examined  by
the attending physician at least once in each 6-month period, and a record
of each physician visit to a patient  shall  be  recorded  with  pertinent
clinical observations in the patient's clinical record by  the  physician.
  (2) Not later than at the time of admission of a patient,  an  attending
physician shall be designated to be responsible for the medical  care  and
supervision of the patient. This shall not preclude a  patient  from  also
receiving  health  services  from  another  provider  of  choice,   unless
medically contraindicated.

  History:  1981 AACS; 1983 AACS.


R  325.20604   Treatment of patients.
  Rule 604. (1) Treatment rendered to a patient  shall  be  in  accordance
with the specific or standing written orders  of  the  attending  licensed
physician. Standing orders shall be reproduced in the  patient's  clinical
record and shall be signed by the attending physician within 48 hours.
  (2) Telephone or other verbal orders from the physician shall be written
on the patient's clinical record by the licensed nurse in charge and shall
be signed by  that  licensed  nurse.  Telephone  or  other  verbal  orders
recorded by the licensed nurse in charge shall  be  countersigned  by  the
physician within 48 hours.

  History:  1981 AACS.


R  325.20605   Physicians' assistants in homes.
  Rule 605. (1) A physician's assistant working under the supervision of a
licensed approved physician, as set forth in parts  170  and  175  of  the
code,  may  carry  out  appropriate  delegated  functions  in  a  home  in
accordance with written policies of  the  home  formally  adopted  by  the
governing body, owner, or operator.
  (2) The written policies governing  the  functions  of  the  physician's
assistant  within  the  home  shall  be  consistent  with  law  and  rules
applicable to the home, the physician's  assistant,  and  the  supervising
physician.
  (3) The physician's assistant shall  not  substitute  for  the  licensed
physician insofar as the overall responsibility for a  patient's  care  is
concerned.
  (4) The physician's assistant shall not be or function as an employee of
the home and shall be limited to providing care for the  patients  of  the
supervising physician.
  (5) The attending physician supervising a physician's assistant shall be
required to visit the patient in a home at intervals prescribed in law and
rule;  shall  check,  renew,  or  amend  physician  orders  at  prescribed
intervals; shall review and participate in the development of patient care
plans following admission and at prescribed intervals; and  shall  review,
approve, and countersign all physician assistant entries in  the  clinical
record. Orders written in the clinical record by the physician's assistant
shall be countersigned by the attending supervising  physician  within  48
hours.

  History:  1981 AACS; 1983 AACS.


R  325.20606   Applicability.
  Rule 606. The provisions of R 325.20601 to R 325.20605  shall  apply  to
all homes, except those subject to the provisions of  section  21707(2)(b)
of the code.

  History:  1981 AACS.



                         PART 7. NURSING SERVICES

R  325.20701   Director of nursing.
  Rule 701. (1) The director of nursing shall be a registered  nurse  with
specialized training or relevant experience in the area of gerontology and
shall be employed full time by only 1 nursing home.
  (2) The director  of  nursing  shall  be  responsible  for  all  of  the
following:
  (a) The development  and  maintenance  of  nursing  service  objectives,
standards of nursing practice, nursing policy and procedure  manuals,  and
written job descriptions for each level of personnel.
  (b) Scheduling of rounds to ensure that all patients are seen daily by a
licensed nurse.
  (c) Methods for coordination of  nursing  services  with  other  patient
services.
  (d) Recommending the number  and  levels  of  nursing  personnel  to  be
employed.
  (e) Nursing staff development.

  History:  1981 AACS; 1983 AACS.


R  325.20702   Charge nurses.
  Rule 702. (1) A licensed nurse shall be the charge nurse on  each  shift
or tour of duty and shall be responsible for the immediate  direction  and
supervision of nursing care provided to patients. In homes with less  than
30 beds, the director of nursing may serve as charge nurse on a shift when
present for a full shift.
  (2) The charge nurse shall be accountable at all times to  the  director
of nursing or her or his designee.
  (3) The charge nurse assigns responsibility to personnel for the  direct
nursing care of specific patients during each tour of duty on the basis of
staff  qualifications,  size  and  physical  layout   of   the   facility,
characteristics of the  patient  load,  and  the  emotional,  social,  and
nursing care needs of patients.

  History:  1981 AACS; 1983 AACS.


R  325.20703   Nursing personnel.
  Rule 703. (1) A licensed nurse shall have immediately available evidence
of a valid and  current  license  or  permit  required  by  the  state  of
Michigan.
  (2) A person employed in the home to give nursing care shall be not less
than  17  years  of  age,  except  that  a   student   in   a   board   of
education-approved cooperative educational  program  may  provide  nursing
care under supervision of a licensed nurse.
  (3) A person employed in the home to give  nursing  care  on  the  night
shift shall be not less than 18 years of age.
  (4) A person shall not be assigned to duty on the night  shift  if  that
person has been on duty either in the home or any other place of  business
during the preceding 8 hours, but may assume temporary duty on  the  night
shift if the facility  has  made  every  reasonable  effort  to  otherwise
eliminate a staffing emergency.
  (5) A member of the nursing staff shall not be  deemed  to  be  on  duty
unless awake, fully dressed, and on the premises.
  (6) The administrator of the home shall not serve  as  the  director  of
nursing in homes of 50 or more beds.
  (7) At all times during each shift, the  home  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 or these rules, a member of the nursing staff who  works  less
than 2 continuous hours shall be counted as part of a full-time equivalent
personnel only if such member was scheduled to work more than 2 continuous
hours.

  History:  1981 AACS; 1983 AACS; 1986 AACS.


R  325.20704   Reporting and enforcement of nurse  staffing  requirements.
  Rule 704. (1) A home shall maintain, for a period of  not  less  than  2
years, employee time records, including time cards or their equivalent and
payroll records.
  (2) A home shall submit nurse staffing  reports  to  the  department  at
least quarterly. The department may require more frequent reports  when  a
quarterly report on annual or other  survey  and  evaluation  visit  or  a
complaint investigation indicates  that  deficiencies  in  nurse  staffing
requirements may exist.
  (3) Nurse staffing reports shall cover the employed nursing staff of the
home, including registered nurses, licensed practical nurses, nurse aides,
and orderlies. Only those nursing personnel listed  in  this  subrule  who
actually provide direct patient care shall be  counted  in  meeting  nurse
staff requirements. Ward clerks shall not be included as  members  of  the
nursing staff.
  (4) Nurse staffing reports shall be submitted on forms provided  by  the
department and shall, at a minimum, cover a 7-day period specified by  the
department, including a Saturday and  Sunday,  but  need  not  necessarily
include 7 consecutive days.
  (5) The administrator of record, or  the  acting  administrator  in  the
absence of the administrator, in the home shall certify to the accuracy of
the nurse staffing reports submitted to the department.

  History:  1981 AACS; 1986 AACS.


R  325.20705   Enforcement.
  Rule 705. If the department believes  there  has  been  a  violation  of
section 21720a of the code, it shall take any of the following actions:
  (a) Issue a facility evaluation report pursuant to R 325.20706.
  (b) Issue a correction notice pursuant to section 21799b of the code and
R 325.21903(1).
  (c) Initiate an action for denial, limitation, suspension, or revocation
of a license by issuing a notice pursuant to R 325.21903(2).
  (d) Take any other action authorized by law to  assure  compliance  with
the law and these rules.

  History:  1981 AACS.


R  325.20706   Facility evaluation reports.
  Rule 706. When the department issues a facility evaluation report  which
cites 1 or more violations of section 21720a of the code or these rules, a
copy of the facility evaluation report shall  be  sent  to  the  licensee,
together with a request to respond within 14 days. The licensee's response
shall state that the violations cited in the  facility  evaluation  report
have been eliminated or corrected or shall state why the  violations  have
not been eliminated or corrected. Failure to respond within 14 days  shall
be deemed to be an acknowledgement of the violations.

  History:  1981 AACS.


R  325.20707   Nursing care and services.
  Rule 707. (1) A patient in a home shall receive preventive,  supportive,
maintenance, habilitative, and rehabilitative nursing care directed to the
physiologic and psychosocial needs and well-being of that patient.
  (2) Patient  observations  by  nursing  personnel  shall  be  accurately
recorded in the clinical record in accordance with established and written
procedures.
  (3) Treatments administered to a patient shall be modified according  to
the patient response consistent with the orders of the attending physician
and nursing assessment. All  modifications  shall  be  documented  in  the
patient's clinical record.
  (4) Nursing care and services shall include, at a minimum,  all  of  the
following:
  (a) Care of the skin, mouth, teeth, hands, and feet and  shampooing  and
grooming of the hair.
  (b) Oral hygiene shall be provided at least  daily  and  more  often  as
required. Special mouth care shall be regularly provided  to  the  acutely
ill patient in accordance with  individual  need  or  as  ordered  by  the
physician.
  (c) A patient's hair shall be combed or brushed daily. A patient's  hair
shall be shampooed on a routine basis at least weekly and  more  often  as
required, unless the attending physician writes an order to the  contrary.
  (d) A patient shall be offered the opportunity and facilities  for,  and
assistance with, shaving, if  necessary,  as  often  as  is  required  for
comfort and appearance, unless  the  patient  requests  otherwise  or  the
physician writes an order to the contrary. Daily  shaving  shall  be  made
available on request or for comfort and appearance as needed.
  (e)  A  complete  tub  or  shower  bath  shall  be  taken,  under  staff
supervision, by, or administered to, an ambulatory patient at least once a
week, unless the physician writes an order to the contrary.
  (f)  A  bedfast  patient  shall  be  assisted  with  bathing  or  bathed
completely at least twice a week and shall be partially bathed  daily  and
as required due to secretions, excretions, or odors.
  (g) A patient shall be provided the opportunity for, and, as  necessary,
assisted with, personal  care,  including  toileting,  oral  hygiene,  and
washing of hands and face before the breakfast  meal.  A  patient's  hands
shall be washed before and, as required, after all meals and snacks.
  (h) A patient's clothing or bedding shall be changed  promptly  when  it
becomes wet or soiled.
  (i) A patient shall receive skin care as required according  to  written
procedures to prevent dryness, irritation, itching, or decubitus.
  (j) A patient shall  receive  care  as  required  according  to  written
procedures to prevent complications of inactivity or prolonged periods  of
being bedfast.
  (k) An inactive or bedfast patient  shall  be  positioned  according  to
written procedures so that major body parts are in natural alignment. Such
position  shall  be  changed  appropriately  at  regular   and   specified
intervals. Supportive devices shall be employed as indicated  to  maintain
posture, support weakened body parts, or relieve undue pressure.
  (l) A patient shall have, during each  day,  planned  periods  of  rest,
exercise, and diversional activities consistent with the patient's  health
status and desires.
  (m) A patient shall be weighed and have his or her  temperature,  pulse,
respirations, and blood pressure taken and recorded on  admission  and  at
least monthly thereafter or more frequently if ordered by a physician. The
patient's measured or estimated height shall be recorded on admission.
  (n) Provisions shall be made for the marking, laundering,  ironing,  and
mending of the clothing of each patient.  The  clothing  of  each  patient
shall be stored individually. A system of inventory for  patient  clothing
shall be implemented and maintained to prevent and control loss  or  theft
insofar as possible.
  (o) A patient who is out of bed in  the  daytime  shall  be  dressed  in
comfortable clothing, unless  contraindicated  by  the  patient's  medical
condition or preference and justification thereof  is  documented  in  the
patient's clinical record.  Ambulatory  patients  shall  wear  appropriate
footwear.  Nonambulatory  patients  shall  at   least   wear   appropriate
protective foot coverings.

  History:  1981 AACS; 1983 AACS.


R  325.20708   Rehabilitative nursing care.
  Rule 708. (1) Rehabilitative nursing care shall be provided as  part  of
the home's nursing care program for patients. Such care shall be  directed
to restoring and maintaining a patient's optimum  level  of  independence,
particularly in terms of activities of daily living.
  (2) A patient's care plan for purposes of  rehabilitative  nursing  care
shall include, at a minimum, all of the following:
  (a) An evaluation of a patient's disabilities and care needs.
  (b) An estimation of rehabilitation potential.
  (c) A program for relearning activities of daily living.
  (d)  A  program  of  assistance   in   adjusting   physiologically   and
psychosocially to impairments, disabilities, and utilization of prosthetic
appliances and devices.
  (3) Nursing personnel in a home shall be competent  and  experienced  in
providing, at a minimum, all of the following:
  (a) A range of motion exercises.
  (b) Positioning and body alignment.
  (c) Preventive skin care.
  (d) Transfer and ambulation training.
  (e) Bowel and bladder training.
  (f) Training in activities of daily living, including eating,  dressing,
personal hygiene, and toilet activities.
  (4) Rehabilitative nursing procedures and techniques shall be available,
provided, and recorded in  the  patient's  clinical  record  on  a  weekly
summary basis or in accordance  with  a  physician's  orders  and  nursing
assessment.
  (5)  Necessary  equipment  utilized  in  application  of  rehabilitative
nursing techniques and procedures shall be available in adequate supply to
meet  the  needs  of  all  patients.  Such  equipment  shall  include  the
following:
  (a) Bedboards, footboards, footstools.
  (b) Trochanter rolls, positioning pillows, bed cradles.
  (c) Wheelchairs, geriatric chairs, canes, crutches, slings, splints, and
lifts.
  (d) Trapeze equipment.
  (6) Rehabilitative nursing policies, procedures, and techniques shall be
an integral part of inservice education for nursing personnel in the home.

  History:  1981 AACS.


R  325.20709   Patient care planning.
  Rule 709. (1) Nursing care provided to each patient in  a  nursing  home
shall be based on all of the following:
  (a) Written assessment of the patient.
  (b) Identification of health problems.
  (c) A written plan of care or intervention.
  (d) Implementation of the care plan.
  (e) Evaluation of the results of the planned care or intervention.
  (2) An assessment of a patient shall be initiated  by  licensed  nursing
personnel within 24 hours of admission, and the results of the  assessment
shall be documented in the patient's clinical record.
  (3) The written plan of care  shall  be  available  to  all  individuals
involved in the care  of  the  patient  and  shall  document  all  of  the
following:
  (a) The patient's problems and needs.
  (b) Goals and objectives of care.
  (c) Methods of approach to care.
  (d) Treatment and orders.
The disciplines responsible for each element of care shall  be  identified
in the plan. The written plan of care for a patient shall be considered to
be part of the patient's clinical record and shall be  included  with  the
record at the time of discharge.
  (4) The patient care plan shall  be  reviewed  and  the  care  shall  be
evaluated periodically, as required,  to  reflect  the  patient's  current
condition.
  (5) The nursing home  shall  make  reasonable  efforts  to  discuss  the
patient care plan with the patient, next of kin, guardian,  or  designated
representative  so  that  such  parties  can  contribute  to  the   plan's
development and implementation.
  (6) A patient care conference shall be held periodically, but  not  less
than once every 90 days, to evaluate a patient's needs and to provide  for
the  appropriate  revision  of  the  patient  care  plan  while  promoting
continuity  of  care.  The   patient   care   conference   shall   include
representatives from the professional disciplines  providing  services  to
the  patient,  and  observations  and  recommendations   of   the   health
professionals participating in  the  patient  care  conferences  shall  be
summarized in the patient's clinical record or plan of care.

  History:  1981 AACS; 1983 AACS; 1984 AACS.


R  325.20710   Discharge planning.
  Rule 710. Discharge planning shall  be  provided  for  each  patient  in
conjunction with patient care planning.

  History:  1981 AACS.


R  325.20711   Equipment and supplies.
  Rule 711. (1) Each patient shall be provided with all of the  following:
  (a) An individual bed not less than 36 inches wide and 72  inches  long,
or longer when necessary, with springs in good condition, and  a  mattress
not less than 5 inches thick in good condition, with a nonabsorbent cover.
  (b) A bedside stand which is designed to hold  small  personal  articles
and necessary bedside equipment.
  (c) A flameproof cubicle curtain or its equivalent which shall  be  used
to ensure privacy.
  (d) A reading light.
  (e) A comfortable cushioned chair.
  (2) A cot or rollaway cot shall not be used as a patient bed.
  (3) Each bed shall be maintained as follows:
  (a) Covered with a mattress pad.
  (b) Made daily with clean linen in good repair.
  (c) Changed immediately when  soiled  and  at  least  twice  weekly  for
bedfast patients and once weekly for ambulatory patients.
  (4) Each patient shall be provided linen sufficient to meet his  or  her
needs for comfort and privacy, and the following minimum amounts of  linen
shall be available for each patient:
  (a) At least 1 pillow, l bedspread, and 1 blanket.
  (b) Not less than 2 mattress pads, 2  pillow  cases,  2  towels,  and  2
washcloths.
  (c) Not less than 4 sheets.
  (d) At least 1 bath blanket for each bedfast  patient,  which  shall  be
changed at each bed bath.
  (e) A bib or protective cover for each patient requiring such protection
during eating or feeding.
  (f) A clean individual towel and washcloth which  shall  be  changed  at
least every other day and more often if they become soiled.
  (5) The following items of equipment shall be  available  in  sufficient
quantities so that patients who require them may have  them  assigned  for
personal use:
  (a) Washbasins.
  (b) Mouthwash cups.
  (c) Denture cups.
  (d) Emesis basins.
  (e) Bedpans and urinals.
  (f) Water carafes and drinking glasses or cups.
  (g) Oral and rectal clinical thermometers.
  (h) Bedside safety rails.
  (6) Equipment and supplies shall be  stored,  handled,  dispensed  in  a
sanitary manner.
  (a) Bedpans, urinals, and emesis basins shall  be  emptied  and  cleaned
immediately after use.
  (b) Mouthwash cups, denture cups, water carafes,  and  bedside  drinking
cups and glasses shall be cleaned daily.
  (c) Single service equipment shall be used  only  once,  and  disposable
equipment shall be used only by the patient  to  whom  it  was  originally
dispensed.
  (d) Individual personal equipment shall  not  be  transferred  from  one
patient to another without being thoroughly disinfected.
  (7) Each patient shall be provided with clean clothing in  good  repair,
as needed.

  History:  1981 AACS; 1983 AACS.


R  325.20712   Diversional activities.
  Rule 712. (1) A home shall provide  an  ongoing  diversional  activities
program that stimulates and promotes  social  interaction,  communication,
and constructive living.
  (2) There shall be a qualified staff member and such additional staff as
necessary to plan, conduct, and evaluate individual and group  activities.
Individual and group activities shall be available 7 days a week.
  (3)  There  shall  be  adequate  recreational  and  therapeutic   areas,
equipment, and supplies to conduct ongoing  recreational  and  therapeutic
activities.
  (4) Adequate storage space shall be provided for equipment close to  the
space utilized for such activities.
  (5) A patient shall be provided diversional  activities  suited  to  the
patient's needs, capabilities, and interests as an adjunct to treatment to
encourage the patient, insofar as possible, to resume self-care and normal
activities.

  History:  1981 AACS; 1983 AACS.


R  325.20713   Patient evaluation by mental health worker; therapy.
  Rule 713. All patients in need of mental health services  shall  receive
an evaluation by a professional mental health worker and, when ordered  by
the physician, shall receive indicated therapy through arrangements with a
community mental health center or comparable agency or provider.

  History:  1981 AACS.


R  325.20714   Patient councils.
  Rule 714. (1) The home shall permit the formation of a  patient  council
by interested patients and, at the time of admission to  the  home,  shall
inform patients and their representatives of either the right to establish
a patient council  if  one  does  not  exist  or  to  participate  in  the
activities of an operating patient council in the home.
  (2) The patient council shall be entitled to meet privately or to invite
members of the home's staff,  members  of  patients'  families,  patients'
friends, and members of community organizations to participate in meetings
of the patient council.
  (3) The home shall designate a staff person to serve as liaison  to  the
patient council, to attend council meetings  as  requested,  and  to  make
available support services and assistance to  the  council,  such  as  the
typing of minutes and correspondence; provision of  policies,  procedures,
and other documents related to the operation of the home; and  such  other
assistance as may be reasonably requested. The home  shall  provide  space
for meetings and necessary assistance to patients requiring assistance  to
attend meetings.

  History:  1981 AACS; 1983 AACS.

                         PART 8. DIETARY SERVICES


R  325.20801   Supervisor of dietary or food services; qualifications.
  Rule 801. (1) Dietary or food services in a home shall be supervised  by
an individual who meets any of the following qualifications:
  (a) Is registered by the commission  on  dietetic  registration  of  the
American dietetic association.
  (b) Has completed all nutrition and related coursework necessary to take
the registration examination required to become a registered dietitian.
  (c) Is a graduate of a dietetic technician training program approved  by
the American dietetic association.
  (d) Is a graduate of an approved correspondence  or  classroom  dietetic
assistant training program which qualified such person  for  certification
by the hospital, institution, and educational food service society.
  (e) Is a graduate of  a  dietetic  assistant  training  program  granted
approved status by the Michigan department of public health before July 6,
1979.
  (2) When the dietary  or  food  services  supervisor  is  other  than  a
registered dietitian, the supervisor shall  receive  routine  consultation
and technical assistance from a registered dietitian (R.D.).  Consultation
time shall not be less than 4 hours every 60 days. Additional consultation
time may be needed based on the total number  of  patients,  incidence  of
nutrition-related health problems, and food service  management  needs  of
the facility.

  History:  1981 AACS; 1983 AACS.


R  325.20802   Policies and procedures.
  Rule 802. There shall  be  written  policies  and  procedures  for  food
storage, preparation, and service; written job  descriptions  for  dietary
personnel; and in-service training for dietary personnel.

  History:  1981 AACS.


R  325.20803   Nutritional needs of patients.
  Rule 803. (1) Food and nutritional needs of a patient shall  be  met  in
accordance with the physician's orders in keeping with accepted  standards
of  practice  which  includes  most  recent  recommended   daily   dietary
allowances of the food  and  nutrition  board  of  the  national  research
council adjusted for age, sex, and activity.
  (2) Not less than 3 meals or their equivalent shall be served daily,  at
regular times, with not more than a 14-hour  span  between  a  substantial
evening meal and breakfast, except that when a substantial snack is served
after the evening meal, this time span may be increased to  14-3/4  hours.
  (3)  Therapeutic  or  special  diets  shall  be  provided  upon  written
prescription or order of the physician.
  (4) Supplementary fluids and special nourishments, as required, shall be
provided.
  (5) A meal shall be prepared and served in an  appetizing  and  sanitary
manner.
  (6) A table or individual freestanding tray of  table  height  shall  be
provided for a patient who is able to be out of bed to eat, but  who  does
not go to a dining room.

  History:  1981 AACS.


R  325.20804   Menus; posting; filing.
  Rule 804. The menu for regular and therapeutic or special diets for  the
current week shall be posted in the dietary department and either  in  the
patient dining room or a public place as defined in  R 325.20104.  Changes
shall be written on the planned menu to show the menu as actually  served.
The menu as actually served to patients for the preceding 3  months  shall
be kept on file in the home.

  History:  1981 AACS; 1983 AACS.



R  325.20805   Meal census; food record.
  Rule 805. A meal census, to include patients, personnel, and guests, and
a record of the kind and amount of food used for the  preceding  3  months
shall be kept on file in the home.

  History:  1981 AACS.


R  325.20806   Food acceptance record.
  Rule 806. (1) The food acceptance of a  patient  shall  be  recorded  as
follows:
  (a) For a period of 14 days immediately following admission.
  (b) For a period of 14 days immediately following initiation of a change
in diet, unless otherwise ordered by a physician.
  (c) Under any other circumstances, such as abnormal weight loss,  for  a
period ordered by a physician.
  (2) Food acceptance records shall be retained in the facility.

  History:  1981 AACS; 1983 AACS.

                      PART 9. PHARMACEUTICAL SERVICES

R  325.20901   Medication kits.
  Rule 901. (1) A medication kit  for  medical  emergency  use,  which  is
accessed only on the direct order of a physician and which  is  maintained
in a locked cabinet, shall be accessible only to  the  licensed  nurse  in
charge.
  (2) The emergency kit shall be obtained only on the order of a  licensed
physician and shall be prepared and sealed by a pharmacist.
  (3) The kit shall contain a list of its contents and expiration date  on
the outside surface of the  lid,  and  a  complete  record  of  usage  and
disposal shall be available.

  History:  1981 AACS; 1983 AACS.


R  325.20902   Medications; dispensing and storage.
  Rule 902. (1)  A  legend  drug  shall  not  be  dispensed  except  by  a
pharmacist according to established pharmacy policies and  procedures.  It
shall be contained in properly labeled individual containers,  kept  in  a
locked cabinet, and shall be accessible  only  to  the  nurse  in  charge.
Labeling and relabeling of all drugs shall only be done by  a  pharmacist.
  (2) A controlled substance shall be kept in a separate locked box within
the locked medication cabinet, except that under a  unit  dose  system,  a
single dose or limited number of doses shall be stored separately for each
patient as indicated in subrule (1) of this rule.
  (3) A medication requiring refrigeration shall be  kept  in  a  separate
locked  box  within  a  refrigerator.  Drugs  and  biologicals   requiring
refrigeration  shall  be  stored  at  a  temperature  recommended  by  the
manufacturer.
  (4) A medication for external use only shall be kept in a locked cabinet
separate from other medications.

  History:  1981 AACS.


R  325.20903   Medications; administration.
  Rule 903. (1) Medications shall  be  administered  only  by  medical  or
nursing personnel in accordance with the written or verbal  order  of  the
attending physician.
  (2) A dose of medication administered shall be properly recorded in  the
patient's clinical record and, when applicable,  in  special  records  for
controlled substances as required by law. Abbreviations used in  recording
medication orders and administration shall be  standardized  in  the  home
according to a written source document.
  (3) A medication shall be listed on an approved medication card  or  its
equivalent and shall be checked  against  the  physician's  orders  before
being administered.
  (4) A medication prescribed for a patient shall not be  administered  to
another patient.
  (5) A medication prescribed for a patient shall be administered promptly
after the appropriate dose is prepared for administration.
  (6)  Self-administration  of  medication  by  a  patient  shall  not  be
permitted, except when special circumstances exist and when supported by a
physician's written order and justification.
  (7) An unused portion of  a  previously  prepared  medication  dose  not
administered to a patient shall not be returned to its original container,
but shall be disposed of appropriately.

  History:  1981 AACS.


R  325.20904   Medications; errors; reactions.
  Rule 904.  Medication  error  or  drug  reaction  shall  be  immediately
reported to the charge nurse, physician, and the  pharmacist  as  soon  as
possible and shall be recorded in the patient's clinical record as well as
on an incident report form which shall be forwarded to  the  administrator
and kept on file. Corrective action shall be  initiated  promptly  by  the
physician,  administrator,  director  of   nursing,   or   pharmacist   as
appropriate.

  History:  1981 AACS.


R  325.20905   Stop orders and policies.
  Rule 905. An automatic stop order and policy governing the use of  drugs
shall be formulated and shall be made a part of the written  patient  care
policy implemented and in effect in the home.

  History:  1981 AACS.


R  325.20906   Medications; disposal and release.
  Rule 906. (1) A medication  no  longer  in  use  or  outdated  shall  be
disposed of immediately and in accordance with federal or state  laws  and
regulations.
  (2) A medication shall not be released  or  sent  with  a  patient  upon
discharge, except on the written order of the physician.

  History:  1981 AACS.


                          PART 10. OTHER SERVICES


R  325.21001   Diagnostic service.
  Rule 1001. (1) An arrangement shall be made  by  the  administrator  for
obtaining promptly and conveniently a clinical laboratory, x-ray, or other
diagnostic service ordered by the physician.
  (2) A diagnostic test or service shall be provided  only  on  a  written
order of the physician.
  (3) An arrangement for transporting a patient to and from  a  source  of
services outside the home shall be made by the administrator or designated
representative.
  (4) A written report of  each  diagnostic  test  and  service  shall  be
included in the patient's clinical record  within  1  week.  When  written
reports are not received within 1 week, the home shall  continue  to  take
action to obtain a report at the earliest possible time. A record of  this
action shall be maintained in the patient's clinical record.

  History:  1981 AACS.


R  325.21002   Dental services.
  Rule 1002.  A  patient  shall  be  assisted  in  obtaining  regular  and
emergency dental care.

  History:  1981 AACS.


R  325.21003   Social services.
  Rule 1003. Social services shall be provided for as follows:
  (a) A designated member of the staff shall be responsible for  assisting
the patient and the patient's family in securing help with  the  patient's
social service needs.
  (b) In providing the assistance specified in  subdivision  (a)  of  this
rule, the designated member of the staff shall be aware of the public  and
private resources available in the community.

  History:  1981 AACS; 1983 AACS; 1986 AACS.


                             PART 11. RECORDS


R  325.21101   Required records.
  Rule 1101. All of the following records shall be kept in  the  home  and
shall be available to the director or his or her authorized representative
for review and copying if necessary:
  (a) A current patient register.
  (b) Contracts between the home and patients.
  (c) Patient clinical records.
  (d) Accident records and incident reports.
  (e) Employee records and work schedules.

  History:  1981 AACS; 1983 AACS.


R  325.21102   Patient clinical records.
  Rule 1102. (1) A clinical record shall be provided for each  patient  in
the home. The clinical record shall be current and entries shall be  dated
and signed.
  (2) The clinical  record  shall  include,  at  a  minimum,  all  of  the
following:
  (a) The identification and summary sheet, which shall include all of the
following patient information:
  (i) Name.
  (ii) Social security number.
  (iii) Veteran status and number.
  (iv) Marital status.
  (v) Age, sex, and home address.
  (b) Name, address, and telephone number of next of kin, legal  guardian,
or designated representative.
  (c) Name, address, and telephone number of person or agency  responsible
for patient's maintenance and care in the home.
  (d) Date of admission.
  (e) Clinical history and physical examination performed by the physician
within 5 days before or on admission, including a report of chest  x  rays
performed within 90 days of admission and a physician's treatment plan.
  (f) Admission diagnosis and amendments thereto during the course of  the
patient's stay in the home.
  (g) Consent forms as required and appropriate.
  (h) Physician's orders for medications, diet, rehabilitative procedures,
and other treatment or procedures to be provided to the patient.
  (i) Physician's progress  notes  written  at  the  time  of  each  visit
describing  the  patient's  condition   and   other   pertinent   clinical
observations.
  (j) Nurse's notes and observations by other personnel providing care.
  (k) Medication and treatment records.
  (l) Laboratory and x-ray reports.
  (m) Consultation reports.
  (n) Time and date of discharge,  final  diagnosis  and  place  to  which
patient was discharged, condition on discharge, and  name  of  person,  if
any, accompanying patient.
  (3)  Copies  of  clinical  history  and  physical  examination   report,
discharge summary, transfer form, and other pertinent information arriving
at the home with the patient upon transfer from  another  health  facility
shall be maintained in the facility.
  (4) Clinical records of discharged patients shall be completed within 30
days following discharge.
  (5) Clinical records shall be  under  the  supervision  of  a  full-time
employee of the home.
  (6) Clinical records are retained for a minimum of 6 years from the date
of discharge or, in the case of a minor,  3  years  after  the  individual
comes of age under state law, whichever is longer.
  (7) If a facility ceases to  operate,  the  clinical  records  shall  be
transferred with the individual to another health care facility. It is the
responsibility of the owner or corporate body to maintain clinical records
of discharged patients for the length of retention as  stated  in  subrule
(6) of this rule.
  (8) If the department believes that patient  clinical  records  are  not
being properly maintained or completed, the department may order a home to
secure  from  a  registered  record  administrator  or  accredited  record
technician on-site consultation of up to 4 hours  per  quarter  until  the
problem is corrected.

  History:  1981 AACS; 1983 AACS.


R  325.21103   Patient registers.
  Rule 1103. A current register or file of patients  shall  be  maintained
and shall include all of the following information for each patient:
  (a) Name, social security number, veteran  status  and  number,  marital
status, age, sex, and home address.
  (b) Name, address,  and  telephone  number  of  next  of  kin  or  legal
guardian.
  (c) Name, address, and telephone number of person or agency  responsible
for patient's maintenance and care in the home.
  (d) Date of admission.
  (e) Date of discharge and place to  which  patient  was  discharged,  if
applicable.

  History:  1981 AACS.


R  325.21104   Accident records and incident reports.
  Rule 1104. An accident record or incident report shall be  prepared  for
each accident or incident involving a patient, personnel, or  visitor  and
shall include all of the following information:
  (a) Name of person involved in accident or incident.
  (b) Date, hour, place, and cause of accident or incident.
  (c) A description of the accident or incident by any observer who  shall
be identified and a statement of the effect of the accident or incident on
the patient and any other individual involved.
  (d)  Name  of  physician  notified  and  time   of   notification   when
appropriate.
  (e)  Physician's  statement  regarding  extent  of  injuries,  treatment
ordered, and disposition of person involved.
  (f) Corrective  measures  taken  to  avoid  repetition  of  accident  or
incident.
  (g) Record of notification of  the  person  or  agency  responsible  for
placing and maintaining the patient in the home, the legal guardian,  and,
in a case where there is no legal guardian, the designated  representative
or next of kin.

  History:  1981 AACS.


R  325.21105   Employee records and work schedules.
  Rule 1105. (1) A record shall be maintained for  each  employee  in  the
home and shall include all of the following:
  (a) Name, address, telephone number, and social security number.
  (b) License or registration number, if applicable.
  (c) Results of any preemployment or periodic physical examination.
  (d) Summary of experience and education.
  (e) Beginning date of employment and position for which employed.
  (f) References, if obtained.
  (g) Results  of  annual  chest  x  ray  or  intradermal  skin  test  for
tuberculosis.
  (h) For former employees, the date employment  ceased  and  the  reasons
therefor.
  (2) A daily work schedule for employees shall be prepared in writing and
shall be maintained to show the number and type of personnel  on  duty  in
the home for the previous 3 months.
  (3) A time record for each employee shall be  maintained  for  not  less
than 2 years.

  History:  1981 AACS; 1983 AACS.

      PART 12. MEDICAL AUDIT, UTILIZATION REVIEW, AND QUALITY CONTROL


R  325.21201   Definitions.
  Rule 1201. As used in this part:
  (a) "Medical audit" means the  retrospective  examination,  review,  and
evaluation of the clinical application of medical  knowledge  utilized  in
the diagnosis and treatment of  patients  as  revealed  in  the  patient's
clinical record and carried out for purposes of education, accountability,
and quality control.
  (b)  "Quality  control"  means  the  planned  and   systematic   medical
management actions which  assure  the  consistent  acceptable  quality  of
health care and services rendered to patients including the use of various
monitoring techniques.
  (c)  "Utilization   review"   means   retrospective,   concurrent,   and
prospective review  of  the  provision  and  utilization  of  health  care
services by providers and recipients  in  terms  of  cost,  effectiveness,
efficiency, and quality.

  History:  1981 AACS.


R  325.21203   Medical audits.
  Rule 1203. (1) The home, through its medical  director,  if  applicable,
and the participation of 1 or more attending physicians, shall complete at
least 1 medical audit annually for the following purposes:
  (a) To assure the adequacy of documentation, clinical  information,  and
data in the patient's clinical record.
  (b) To evaluate continuity and coordination of patient care and identify
problems requiring corrective action.
  (c) To assess the quality of medical and other health care and  services
provided.
  (2) Audit results and specific recommendation for corrective  action  or
improvements, if indicated, shall  be  reported  to  the  governing  body,
owner, or operator through  the  administrator.  Audit  reports  shall  be
retained on file in the home for 1 year.

  History:  1981 AACS.


R  325.21204   Utilization review; quality control.
  Rule 1204. For purposes of certification, the home shall carry out  such
utilization review and quality control programs and activities as  may  be
required by the federal certification standards for  skilled  nursing  and
intermediate care facilities.

  History:  1981 AACS.


                      PART 13. BUILDINGS AND GROUNDS


R  325.21301   Definitions.
  Rule 1301. As used in this part:
  (a) "Bed" or "licensed bed" means  a  patient  bed  in  a  nursing  home
authorized by the department, included within the licensed  capacity,  and
available for use at a location designated by the home and  acceptable  to
the department.
  (b) "Construction project" means an addition to, or major change in,  an
existing nursing home, construction of a new home,  or  conversion  of  an
existing structure for use as a home.

  History:  1981 AACS.


R  325.21302   Floor plans.
  Rule 1302. A floor plan of the nursing home as licensed, with designated
rooms showing size, use, door locations, window area, and number of  beds,
shall be on file in the home and in the department.

  History:  1981 AACS.


R  325.21303   Narrative program; architectural plans and  specifications;
construction permit.
  Rule  1303.  (1)  A  nursing   home,   through   its   governing   body,
administrator, designated representative, or architect under  contract  to
the home, shall provide a narrative program for each construction  project
before submitting architectural plans and specifications to the department
for review and  approval  or  disapproval.  The  narrative  program  shall
include, at a minimum, a description of all of the following:
  (a) Each function to be performed in the home.
  (b) Functional space requirements.
  (c) Number of staff or  other  occupants  anticipated  for  the  various
functional units.
  (d) Type of equipment to be required and utilized.
  (e) Interrelationship of functional spaces.
  (f) Services and equipment to be brought into the home from outside  the
home and not requiring duplication in the home.  A  copy  of  a  narrative
program prepared for submission in conjunction with a certificate of  need
application or for some other purpose may  be  accepted  for  purposes  of
compliance with this rule to the extent it provides the required data  and
information as determined by the department.
  (2) Construction projects involving alterations of,  and  additions  to,
existing nursing homes remaining  in  operation  during  the  construction
shall be planned, programmed, and  phased  so  that  on-site  construction
permits the continued operation of the home without significant disruption
or effect on patient care.
  (3) Complete architectural plans  and  specifications  for  construction
projects shall be submitted to the department for review and  approval  or
disapproval  to  assure  compliance  with  the  code  and   these   rules.
Construction  projects  shall  not  be  initiated  until  the  plans   and
specifications have been approved by the department and a permit has  been
issued for the initiation of such construction.
  (4) Changes in architectural plans and specifications  proposed  in  the
course of construction shall be brought to the attention of the department
for review and approval or  disapproval  before  altering  the  course  of
construction.
  (5) Architectural and engineering  plans  and  specifications  shall  be
prepared and sealed by architects and professional engineers  licensed  to
practice in Michigan.
  (6) Projects involving normal building maintenance, repair, upkeep,  and
equipment replacement not requiring a certificate of  need  shall  not  be
submitted for review.
  (7) A permit for construction shall not be issued until such time as  an
acceptable valid certificate of need has been issued if required  for  the
construction project and if the project conforms with the code  and  these
rules as determined by the department.
  (8) A construction project requiring a  permit  shall  not  be  occupied
until all of the following occur:
  (a) An architect or professional  engineer  has  evaluated  the  project
on-site and has forwarded findings and appropriate  documentation  to  the
department to indicate that the  project  is  substantially  complete  and
constructed in accordance with approved plans and specifications.
  (b) The department has determined and so notified the project sponsor of
its determination that the project component is acceptable for  occupancy.
  (c) The fire marshal division, department of state police, has certified
the project or project component for use and occupancy.

  History:  1981 AACS; 1983 AACS.


R  325.21304   Home location; exterior.
  Rule 1304. (1) The home shall be located in an area free from hazards to
the health and safety of patients, personnel, and visitors.
  (2) The premises shall be maintained in a safe  and  sanitary  condition
and in a manner consistent with the public health and welfare.
  (3) Sufficient light for an exterior ramp,  step,  and  porch  shall  be
provided for the safety of persons using the facilities.
  (4) An exterior step or ramp shall have a  handrail  on  both  sides.  A
porch shall have a railing on open sides.

  History:  1981 AACS.


R  325.21305   Home entrances for physically handicapped.
  Rule 1305. In a new construction, addition, major change, or  conversion
after August 22, 1969, at least 1 entrance to the home shall provide  easy
access for the physically handicapped.

  History:  1981 AACS; 1983 AACS.


R  325.21306   Interior construction.
  Rule 1306. (1) A building shall be of safe  construction  and  shall  be
free from hazards to patients, personnel, and visitors.
  (2) A part of a building in use as a home shall  not  be  used  for  any
purpose  which  interferes  with  the  care,  well-being,  and  safety  of
patients, personnel, and visitors.
  (3) Each area of the home shall be provided with  lighting  commensurate
with the use made of each area and in  accord  with  generally  recognized
standards acceptable to the director.
  (4) A stairway or ramp shall have a handrail on both sides.
  (5) A room used for living or sleeping purposes  shall  have  a  minimum
total window glass area on outside walls equal to 10% of the floor area of
the room. Forty-five percent of this window glass area shall be  openable,
unless the room is artificially ventilated.
  (6) Each area of the home shall be provided with a type  and  amount  of
ventilation commensurate with  its  use  to  minimize  the  occurrence  of
transmissible disease, control odors, and contribute to comfort.
  (7) A patient room shall open to a corridor, lobby, or dayroom.  Traffic
to and from any room shall  not  be  through  a  sleeping  room,  kitchen,
bathroom, utility room, toilet room,  or  service  room,  except  where  a
utility room, toilet room, or bathroom opens  directly  off  the  room  or
rooms which it serves.
  (8) A doorway, passageway, corridor, hallway, or stairwell shall be kept
free from obstructions at all times.
  (9) A floor, wall, or ceiling shall be covered and finished in a  manner
that will permit maintenance of a sanitary environment.
  (10) A basement shall be of such construction that it can be  maintained
in a dry and sanitary condition.
  (11) A minimum of 20 square feet of floor space per patient bed shall be
provided for dayroom, dining, recreation, and activity purposes.
  (12) All occupied rooms shall have a minimum ceiling height of 7 feet, 6
inches. Floor area under a part of a drop or slant ceiling which  is  less
than 7 feet, 6 inches from the floor shall not be used  in  computing  the
dayroom, dining, recreation, and activity space per patient bed.
  (13) A basement or cellar shall not  be  used  for  sleeping  or  living
facilities, except that recreation and activity space may be provided in a
basement in addition to dayroom, dining, recreation,  and  activity  space
required in subrule (11) of this rule.
  (14) A handrail shall be provided in a corridor used by patients.
  (15) A room or compartment housing a water closet shall have  a  minimum
width of 3 feet.
  (16)  Emergency  electrical  service,  at  a  minimum,   shall   provide
battery-operated lighting units sufficient to light corridors, exits,  and
nursing stations.
  (17) Functionally separate living,  sleeping,  dining,  lavatory,  water
closet, and bathing accommodations shall be  provided  for  personnel  and
members of their families who live on the premises.
  (18) A new construction, addition, major  change,  or  conversion  after
August 22, 1969, shall provide all of the following:
  (a) A sleeping, day, dining, recreation, or activity room with a minimum
ceiling height of 8 feet.
  (b) Twenty feet of unobstructed vision space outside of any window in  a
room requiring windows. One additional foot shall be added to the  minimum
distance of 20 feet for each 2-foot rise above the first  story  up  to  a
maximum of 40 feet of required unobstructed space.
  (c) A minimum of 30 square feet of floor space per bed in any room  used
for dayroom, dining, recreation, and activity purposes.
  (d) A handrail with ends returned  to  the  wall  on  both  sides  of  a
corridor, ramp, or stairway used by patients.

  History:  1981 AACS; 1983 AACS.


R  325.21307   Elevators and emergency electrical service.
  Rule 1307. A new construction, addition,  major  change,  or  conversion
after August 22, 1969, shall provide the following:
  (a) An elevator, if patient bedrooms are situated on more than  1  floor
level. An elevator shall have a cab size of not less  than  5  feet  by  7
feet, 6 inches.
  (b) Emergency electrical service capable of providing not  less  than  4
hours of service at full load.  It  shall  serve  lights  at  all  of  the
following locations:
  (i) Nursing stations.
  (ii) Telephone switchboard.
  (iii) Night lights.
  (iv) Exit and corridor lights.
  (v) Heating plant controls.
  (vi) Other critical mechanical equipment essential  to  the  safety  and
welfare of patients, personnel, and visitors in the home.

  History:  1981 AACS; 1983 AACS.


R  325.21308   Public and personnel areas.
  Rule  1308.  (1)  A  lobby  or  waiting  area  for  visitors  shall   be
functionally separate from patient care units.
  (2) A public lavatory and water closet which is convenient to the  lobby
or waiting area shall be provided.
  (3) Office space shall be provided for the administrator.
  (4) Office space shall be provided for the director of nursing.
  (5) Separate dressing rooms  shall  be  provided  for  male  and  female
employees. A lavatory and water closet shall be convenient to the dressing
rooms.

  History:  1981 AACS.


R  325.21309   Patient rooms.
  Rule 1309. (1) A patient bedroom shall have  the  floor  surface  at  or
above grade level along exterior walls with windows.
  (2) A single patient room shall have not less than  80  square  feet  of
usable floor space.
  (3) A multibed patient room shall have not less than 70 square  feet  of
usable floor space per bed.
  (4) Floor area under any part of a drop or slant ceiling which  is  less
than 7 feet, 6 inches shall not be used in computing  usable  floor  space
per patient bed.
  (5) A toilet room or closet shall not be included in usable floor space.
  (6) A patient room shall provide a minimum of 5  square  feet  of  floor
space per bed for wardrobe and closet, in addition to  other  requirements
for usable floor space per bed.
  (7) A bedroom shall permit the functional  placement  of  furniture  and
equipment essential to patient care, comfort, and safety.
  (8) A multibed patient room shall have a 3-foot clearance between  beds.
  (9) A patient room, toilet room, or  corridor  shall  be  provided  with
night lighting.
  (10) A bed in a multibed patient  room  shall  have  flameproof  cubicle
curtains or their equivalent.
  (11) A patient room  shall  have  not  less  than  2  duplex  electrical
receptacles, at least 1 of which shall be near the head of each bed.

  History:  1981 AACS.


R  325.21310   Skilled homes; patient room requirements.
  Rule 1310. (1) A multibed patient room in a skilled home shall have  not
less than 70 square feet of usable floor space per bed.
  (2) A patient shall be provided with a nurse call signal which registers
at the nursing station.

  History:  1981 AACS.


R  325.21311   Patient   room   requirements;   requirements    for    new
construction, addition, major changes, or conversions.
  Rule 1311. In a new construction, addition, major change, or  conversion
after August 22, 1969, all of the following shall be required:
  (a) A patient room shall have not more than 4 beds.
  (b) A patient room shall have not less than a 3-foot clearance available
on both sides and at the foot of each bed.
  (c) An isolation room shall be  a  single  patient  room  with  attached
lavatory, water closet, and bathing facility reserved for the use  of  the
occupants of the isolation room only.
  (d) A door to a patient water closet compartment shall be not less  than
2 feet, 10 inches in width, and shall be equipped with  suitable  hardware
to assure the safety of the patient.
  (e) A single patient room shall have not less than 100  square  feet  of
usable floor space.
  (f) A multi-bed patient room shall have not less than 80 square feet  of
usable floor space per bed.
  (g) Usable floor space shall not  include  a  toilet  room,  closet,  or
vestibule.
  (h) A patient room shall be provided with a  lavatory  and  toilet  room
opening into the room.

  History:  1981 AACS; 1983 AACS.


R  325.21312   Isolation rooms.
  Rule 1312. (1) A room shall be available for the isolation  of  patients
with, or suspected of having, transmissible infections.
  (2) An isolation room shall be  a  single  patient  room  with  attached
lavatory and water closet  reserved  for  use  of  the  occupants  of  the
isolation room only.

  History:  1979 ACS 7, Eff. Aug. 4, 1981.


R  325.21313   Nursing stations.
  Rule 1313. (1) A nursing station shall be provided for  a  nursing  care
unit not more than 120 feet from any patient room which it serves.
  (2) A nursing station shall have all of the following:
  (a) A telephone connected to an outside service line.
  (b) Space for charting on patient clinical records and space  for  other
recordkeeping related only to patient care.
  (c) A nurse call system from each patient bed, patient toilet room,  and
bathtub and shower room which registers at the nursing station.
  (3) A room with lavatory and  water  closet  located  near  the  nursing
station shall be provided for the nursing staff.

  History:  1981 AACS.


R  325.21314   Nursing care units.
  Rule 1314. A nursing care unit shall have all of the following:
  (a) A medication storage  and  preparation  area  which  shall  be  well
lighted and equipped with a sink with a  gooseneck  inlet,  hot  and  cold
water, and locked storage for medications.
  (b) Space for storage of clean linen, equipment, and supplies.
  (c) A toilet utility room.
  (d) A janitor's closet.

  History:  1981 AACS.


R  325.21315   Toilet and bathing facilities.
  Rule 1315. (1) A patient toilet facility shall be located in a  separate
room or stall and shall be provided on each patient floor at least in  the
ratio of 1 lavatory and water closet for every  8  patient  beds  on  that
floor.
  (2) A bathing facility shall be provided at least for every  20  patient
beds on that floor.
  (3) At least 1 of each 5 bathing  facilities  shall  provide  sufficient
clearance to accommodate a wheelchair and attendant, except that at  least
1 bathing facility per floor shall meet this requirement on  floors  where
wheelchairs are used.
  (4) A water closet or bathing facility shall have substantially  secured
grab bars at least 1 foot long.
  (5) A patient toilet room or bathroom shall not be used for  storage  or
housekeeping functions.

  History:  1981 AACS.


R  325.21316   Lavatories  and  nursing  stations;  requirements  for  new
construction, additions, major changes, or conversions.
  Rule 1316. A new construction, addition,  major  change,  or  conversion
after August 22, 1969, shall provide for both of the following:
  (a) A patient room with a lavatory in the room or in an attached  toilet
room.
  (b) At least 1 nursing station on each floor of the home.

  History:  1981 AACS; 1983 AACS.


R  325.21317   Water supply systems.
  Rule 1317. (1) A home located in an area served by a public water system
shall connect to and use that system.
  (2) When a public water  system  is  not  available,  the  location  and
construction of a well or wells and all other portions of the water system
shall comply with applicable statutes, rules, and regulations.
  (3) A home using a private water system shall  take  at  least  1  water
sample for bacteriologic testing each 3 months and shall submit the sample
to  the  department  laboratory,  or  to  a  laboratory  approved  by  the
department,  for  examination.  The   administrator   shall   report   all
unsatisfactory examination results to the department within  72  hours  of
receipt of the report.
  (4) A home with 30 beds or more served by a private water  system  shall
provide a secondary well or other reserve source of water.
  (5) A physical cross-connection shall not exist  between  water  systems
that are safe for human consumption and those that are, or may at any time
become, unsafe for human consumption.
  (6) The minimum water pressure available to each plumbing fixture  shall
exceed 20 pounds per square inch.
  (7) The plumbing system shall be designed and  maintained  so  that  the
possibility of backflow or back siphonage is eliminated.
  (8) The plumbing system shall supply an adequate amount of hot water  at
all times to meet the needs of each patient and  the  functioning  of  the
various service areas.
  (9) The temperature of hot water at plumbing fixtures used  by  patients
shall be regulated to provide tempered water not less than 105 degrees  or
more than 120 degrees Fahrenheit.

  History:  1981 AACS; 1983 AACS.


R  325.21318   Liquid wastes.
  Rule 1318. (1) Liquid wastes shall be discharged into a public  sanitary
sewage system when such a system is available.
  (2) When a public sanitary sewage system is not available and a  private
liquid wastewater disposal system is used, the type,  size,  construction,
and alteration of, or major repairs to, the system shall  be  approved  by
the department and shall comply with all applicable laws.
  (3) The wastewater disposal system shall be  maintained  in  a  sanitary
manner.

  History:  1981 AACS.


R  325.21319   Solid wastes.
  Rule 1319. (1) The collection, storage, and disposal  of  solid  wastes,
including garbage, refuse, and  dressings,  shall  be  accomplished  in  a
manner which will minimize the danger of disease  transmission  and  avoid
creating a public nuisance or a breeding place for insects and rodents.
  (2) Suitable containers for garbage, refuse, dressings, and other  solid
wastes shall be provided, emptied at frequent intervals, and maintained in
a clean and sanitary condition.
  (3) Dressings, bandages, and similar materials shall be disposed  of  in
an incinerator provided with  auxiliary  fuel  or  in  some  other  manner
approved by the department.

  History:  1981 AACS.


R  325.21320   Heating.
  Rule 1320. (1) A home shall provide a safe heating system in  accordance
with applicable law.
  (2) A room in a home used for patients shall be maintained at a  regular
daytime temperature of not less than 72 degrees Fahrenheit measured 3 feet
above the floor.

  History:  1981 AACS.


R  325.21321   Laundry and linens.
  Rule 1321. (1) The collection, storage, and transfer of clean and soiled
linen shall be accomplished in a manner which will minimize the danger  of
disease transmission.
  (2) A home that processes its own linen shall provide a  well-ventilated
laundry of sufficient size which shall include all of the following:
  (a) Commercial laundry equipment with the capacity to meet the needs  of
the home.
  (b) A separate soiled linen room.
  (c) A separate laundry processing room.
  (d) A separate clean linen storage area.
  (e) A lavatory for handwashing in the laundry processing area.
  (3) A home that uses a commercial  or  other  outside  laundry  facility
shall have a soiled linen storage room and a separate clean linen  storage
room.

  History:  1981 AACS.


R  325.21322   Kitchen and dietary area.
  Rule 1322. (1) A home shall have a kitchen and dietary area of  adequate
size to meet food service needs of patients.  It  shall  be  arranged  and
equipped for the refrigeration, storage, preparation, and serving of food,
dish and utensil cleaning, and refuse storage and removal.
  (2) The kitchen and dietary area shall be equipped with a  lavatory  for
handwashing. A lavatory shall have a gooseneck inlet and wrist,  knee,  or
foot control. Soap and single service towels shall be available for use at
each lavatory.
  (3) The kitchen and dietary area shall  be  restricted  to  kitchen  and
dietary activities.
  (4) Separate personnel dining space shall be provided.
  (5) The kitchen and dietary area, as well  as  all  food  being  stored,
prepared, served, or transported, shall  be  protected  against  potential
contamination from dust, flies, insects, vermin, overhead sewer lines, and
other sources.
  (6) Food and drink used in the home shall be  clean  and  wholesome  and
shall be manufactured, handled, stored, prepared, transported, and  served
so as to be safe for human consumption.
  (7) Perishable food shall be stored at temperatures which  will  protect
against spoilage.
  (8) A reliable thermometer shall be provided for each  refrigerator  and
freezer.
  (9) An individual portion of food which is served and not eaten shall be
destroyed.
  (10) A separate storage area for poisonous material  shall  be  provided
away from food service and food storage areas. Poisonous material shall be
identified as such and shall be used only  in  a  manner  and  under  such
conditions that it will not contaminate food or  constitute  a  hazard  to
patients, personnel, or visitors.
  (11) Food service equipment and multi-use  utensils  shall  be  of  such
design and material as to be smooth, easily cleanable, and durable.
  (12) Food service equipment and work surfaces shall be installed in such
a manner as to facilitate cleaning and shall be maintained in a clean  and
sanitary condition and in good repair.
  (13) A multi-use utensil used in food storage,  preparation,  transport,
or serving shall be thoroughly cleaned and sanitized after  each  use  and
shall be handled and stored  in  a  manner  which  will  protect  it  from
contamination.
  (14) A single service  eating  or  drinking  article  shall  be  stored,
handled, and dispensed in a sanitary manner and shall be used  only  once.
  (15) Ice used in the home for any purpose shall be manufactured, stored,
transported, and handled in a sanitary manner.
  (16) A storage area for housekeeping items and a janitor's closet  shall
be provided with convenient access to the kitchen and dietary area.

  History:  1981 AACS.


R  325.21323   Kitchen and dietary area ventilation.
  Rule 1323. In a new construction, addition, major change, or  conversion
after August 22, 1969, the design and operation of the filtered makeup air
and exhaust air systems in the kitchen and dietary area shall be  adequate
for the comfort of employees and control of odors and shall  minimize  the
danger of disease transmission.

  History:  1981 AACS; 1983 AACS.


R  325.21324   Insect and vermin control.
  Rule 1324. (1) A home shall be kept free from insects and vermin.
  (2) Breeding places for insects and vermin shall be  eliminated  from  a
home.
  (3)  Insect  and  vermin  control  procedures  involving  the   use   of
insecticides or pesticides shall be carried out  in  a  manner  consistent
with the health and safety of patients, personnel, and visitors.

  History:  1981 AACS.


R  325.21325   Maintenance and storage generally.
  Rule 1325. (1) The building, equipment,  and  furniture  shall  be  kept
clean and in good repair.
  (2) A room shall be  provided  in  the  home  or  on  the  premises  for
equipment and furniture maintenance and repair and storage of  maintenance
equipment and supplies.
  (3) Hazardous  and  toxic  materials  shall  be  stored  safely  and  in
accordance with applicable law.

  History:  1981 AACS.


R  325.21326   General storage space in new construction, additions, major
changes, or conversions.
  Rule 1326. In a new construction, addition, major change, or  conversion
after August 22, 1969, 10 square feet of general storage  space  shall  be
provided per bed in the home.

  History:  1981 AACS; 1983 AACS.


R  325.21327   Examination  and  treatment  rooms  in  new   construction,
additions, major changes, or conversions.
  Rule 1327. In a new construction, addition, major change, or  conversion
after August 22, 1969, an examination and treatment room equipped  with  a
treatment table, instrument table, and lavatory with gooseneck  inlet  and
wrist, knee, or foot controls shall be provided.

  History:  1981 AACS; 1983 AACS.


R  325.21328   Autoclaves; personal cleanliness of personnel; water closet
room accommodation of wheelchair and  attendant;  soap  and  towels  for
employees and visitors.
  Rule 1328. (1) An autoclave shall  be  provided  in  all  homes  reusing
medical supplies which require sterilization between uses.
  (2) Personnel shall wear clean  garments,  maintain  a  high  degree  of
personal cleanliness, and conform to hygienic practices while on duty.
  (3) At least 1 patient water  closet  room  on  a  patient  floor  where
wheelchair patients are located shall be of sufficient size to accommodate
wheelchair, patient, and attendant.
  (4) Soap and single use  towels  shall  be  available  for  the  use  of
employees and visitors at all times. Use of a common towel is  prohibited.


  History:  1981 AACS.


              PART 14. CHILD CARE HOMES AND CHILD CARE UNITS


R  325.21401   Compliance with skilled nursing home requirements.
  Rule 1401. A child care home or a child care unit shall comply with  all
requirements for a skilled nursing home.

  History:  1981 AACS.


R  325.21402   Admission policies.
  Rule 1402. (1) A child shall not be admitted to a  home  or  child  care
unit unless the home is licensed and approved by the director as  a  child
care home or a child care unit.
  (2) A person 15 years of age or older shall not be admitted to  a  child
care home or a child care unit.
  (3) A patient shall be admitted to a child care home  or  a  child  care
unit only on recommendation of a licensed physician and concurrence of the
home's consulting pediatrician and administrator.
  (4) The name, address, and telephone  number  of  the  parent  or  legal
guardian and the person or agency responsible for placing and  maintaining
the child in the home shall be on file in the administrator's  office  and
on the patient's clinical record.

  History:  1981 AACS.


R  325.21403   Physician services.
  Rule 1403. (1) A child care  home  or  child  care  unit  shall  have  a
consulting physician who is a board-certified pediatrician on  its  staff.
  (2) The consulting pediatrician shall provide pediatric consultation and
recommend policies concerning the management of children who are  patients
in the home with regard to their total welfare and their physical, mental,
and social health. When the attending physician does not comply with rules
governing the frequency of visits to patients or fails to record physician
orders  and  other  medical  information  as  required,   the   consulting
pediatrician and the administrator  together  shall  undertake  corrective
measures.
  (3) The consulting pediatrician may serve as attending physician  for  1
or more of the individual patients or may serve as  a  staff  pediatrician
for the home.
  (4) The consulting pediatrician may serve as 1 of the physicians  to  be
called in case of emergency.
  (5) The initial  examination  of  the  patient  shall  be  completed  on
admission and shall include an evaluation of physical  and  mental  health
and diagnosis.
  (6) A written plan for continuing care and eventual discharge  shall  be
prepared at the time of the admission examination and shall be  placed  in
the patient's clinical record.
  (7) A hematocrit, hemoglobin, and a urine analysis shall be included  in
a  patient's  initial  examination  and  shall  be   repeated   at   least
semiannually thereafter.
  (8) An intradermal tuberculin skin test shall be included in a patient's
initial examination and shall be repeated at least  annually.  If  at  any
time this test is positive, the patient  shall  be  studied  to  determine
whether or not disease is present and shall be given appropriate treatment
if indicated. Annual repetition of the skin test shall not be made if  the
skin test is positive, but the patient shall have appropriate followup  as
ordered by the attending physician consistent with  written  patient  care
policies.
  (9) A patient is not required to have a routine admission  chest  x-ray,
unless the patient's tuberculin test is positive or unless  the  physician
considers it necessary.
  (10) Medical service shall include physician visits at  least  every  30
days,  recommended  medical  treatment,  and   consultation   by   medical
specialists as ordered by the physician.
  (11)  A  patient  who  has  been  immunized  for  diphtheria,   tetanus,
pertussis,  measles,  rubella,  mumps,  and  poliomyelitis  shall  receive
booster inoculations as ordered by the physician.
  (12) A patient who has  not  been  immunized  for  diphtheria,  tetanus,
pertussis, measles, rubella, mumps, and poliomyelitis shall  be  immunized
as  ordered  by  the  physician,  unless  it  is  against  the   religious
convictions of the patient as stated in writing by the parent or guardian.

  History:  1981 AACS.


R  325.21404   Nursing services.
  Rule 1404. (1) In addition to all licensure requirements for  a  skilled
nursing facility, a child care home or a  child  care  unit  shall  employ
sufficient nursing personnel to provide continuous 24-hour nursing care to
meet the needs of each patient in the nursing home.
  (2) The director of nursing in a child care home or the charge nurse  on
duty in the daytime in a child care unit shall be a registered nurse  who,
in the opinion of  the  director,  is  qualified  to  supervise  pediatric
nursing care.
  (3) A charge nurse who is  either  a  registered  nurse  or  a  licensed
practical nurse shall be on duty at all times during a shift  in  a  child
care home or  unit.  She  shall  receive  regular  inservice  training  in
pediatric nursing care.
  (4) Nursing personnel assigned to  provide  care  to  children  who  are
patients in the home shall not  be  assigned  to  provide  care  to  adult
patients in the home on the same shift.
  (5) A patient shall not be physically punished.
  (6) A restraint shall not be used unless ordered by the physician for  a
specified and limited time or as necessitated by emergency.
  (7) A patient's identity shall be displayed on his or her person by 1 or
more commonly used methods of patient identification.

  History:  1981 AACS.


R  325.21405   Patient care policies.
  Rule 1405. (1) A child care home and the child care unit  shall  have  a
written patient care policy governing the nursing care and other  services
provided to patients.
  (2) The professional patient care policy  group  which  advises  in  the
development of a written patient care policy, as required by these  rules,
shall include at least 1 board-certified pediatrician, the  administrator,
director of nursing, and such other persons as may be required.
  (3) The patient care policy shall cover  those  items  of  patient  care
required in these rules and shall be applicable to children and consistent
with the age and condition of the patients.

  History:  1981 AACS.


R  325.21406   Food services; formula room.
  Rule 1406. (1) Food and liquid served to children who  are  patients  in
the home shall be appropriate for the child's age, level of maturity,  and
physical condition.
  (2) A separate room shall be provided  for  the  preparation  of  infant
formulas and water solutions and shall be reserved for this purpose  only.
  (3) The formula room shall contain a  handwash  lavatory  with  tempered
running water, soap, and individual towels in a towel dispenser.
  (4) The formula room shall have a double compartment sink with  hot  and
cold running water for use in preparation of  infant  formulas  and  water
solutions.
  (5) The formula room shall contain enclosed cabinets for the storage  of
supplies used in the preparation of infant formulas and  water  solutions.
  (6) Cleaning supplies used in the formula room  shall  be  stored  in  a
separate cabinet clearly identified for this purpose only.
  (7) A refrigerator shall be available exclusively  for  the  storage  of
infant formulas and water solutions requiring refrigeration.
  (8) After nippling and capping each individual unit of infant formula or
water solution prepared in the formula room, the unit shall  be  subjected
to a terminal sterilizing process at a minimum of 230  degrees  Fahrenheit
at 7 pounds pressure for 10 minutes.
  (9) Nipples shall not be  changed  following  sterilization.  Provisions
shall be made to protect the sterility of the units in transportation from
the formula room to the infant.
  (10) The sterility of  infant  formulas  and  water  solutions  and  the
attached nipples  prepared  in  the  formula  room  shall  be  checked  by
bacteriologic methods at least once a month.
  (11) Records of the bacteriologic check of  infant  formulas  and  water
solutions and the attached nipples prepared in the formula room  shall  be
available for inspection. Records shall be maintained for 1 year from  the
date of bacteriologic check.
  (12) The home shall develop and have available written policies for  the
preparation, storage, distribution, and use of infant formulas  and  water
solutions prepared in the formula room.

  History:  1981 AACS.


R  325.21407   Commercial infant formulas and water solutions.
  Rule 1407. (1) The director shall approve each type of package  unit  of
commercially prepared and prepackaged infant formula  and  water  solution
before it is used for infant feeding.
  (2) A disposable component  of  commercially  prepared  and  prepackaged
infant formula and water solution units shall not be reused.
  (3) An enclosed cabinet shall be provided for the short-term storage  of
commercially prepared and prepackaged infant formulas and water  solutions
removed  from  their  original   shipping   carton   and   not   requiring
refrigeration.
  (4) A nipple shall not be changed  following  assembly  of  commercially
prepared and prepackaged infant formula and water solution units.
  (5) A refrigerator shall be available exclusively for storage of  infant
formulas and water solutions requiring refrigeration.
  (6) Provision shall be made to protect the sterility of the commercially
prepared  and  prepackaged   formula   and   water   solution   units   in
transportation from the point of unit assembly to the infant.
  (7) A home shall develop and have available a  written  policy  for  the
storage, assembly, distribution, and  use  of  commercially  prepared  and
prepackaged units of infant formula and water  solution  used  for  infant
feeding.

  History:  1981 AACS.


R  325.21408   Patient activities and rehabilitation.
  Rule 1408. (1) Recreational and social activity  shall  be  provided  in
sufficient amount and variety to meet the needs and interests of a patient
and shall be consistent with the patient's  age,  maturity,  and  physical
condition.
  (2) An individual shall be designated as  being  in  charge  of  patient
recreation and activities and shall be  responsible  for  supervising  and
directing these activities.
  (3) A bed patient shall be taken out of bed at least twice daily, unless
there are written physician orders to the contrary.
  (4) The physician and  the  administrator  are  responsible  for  making
necessary arrangements to obtain physical therapy,  occupational  therapy,
and such other special forms of therapy as may be required in the care  of
a patient.

  History:  1981 AACS.


R  325.21409   Educational activities.
  Rule 1409. (1) The administrator shall notify  the  board  of  education
having jurisdiction that the administrator is operating a child care  home
or a child care unit and that there are children  of  school  age  in  the
home.
  (2) The  administrator  shall  request  assistance  from  the  board  of
education having jurisdiction in providing for the  educational  needs  of
children of school age.

  History:  1981 AACS.


R  325.21410   Physical environment.
  Rule 1410. (1) Not more than 4 beds or 4 bassinets shall be in a patient
room.
  (2) A room used for the care of small infants shall be used  exclusively
for that purpose.
  (3) A minimum of 40 square feet of usable floor space per bassinet shall
be provided in a room used for the care of small infants.
  (4) A minimum of 30 square feet of floor space per bed shall be provided
for dayroom, dining, recreation, and activity purposes.
  (5) A minimum of 75 square feet of outdoor play space per bed  shall  be
provided, shall be safely enclosed, and shall be supervised when  in  use.
  (6) A choice of toys, games, books, and recreational equipment shall  be
available for children who can use them. A radio and a television shall be
available for the use of the children.

  History:  1981 AACS.


R  325.21411   Transfer agreements.
  Rule 1411. A written, signed  transfer  agreement  shall  be  in  effect
between the child care home or a home with a child care unit and at  least
1 hospital that has a pediatric department certified by the department  to
provide care services to children. The transfer  agreement  shall  provide
reasonable assurance that transfer of patients will  be  effected  between
the home and the hospital when such transfer is  medically  indicated,  as
determined by the physician. The transfer agreement shall also provide for
the interchange of necessary medical and other information.

  History:  1981 AACS.


                          PART 15. CERTIFICATION


R  325.21501   Certification; effect.
  Rule 1501. A nursing home or nursing care  facility,  or  distinct  part
thereof, shall not be eligible to participate in a federal or state health
program requiring certification as an intermediate  (basic  nursing)  care
facility (ICF), intermediate  care  facility/mentally  retarded  (ICF/MR),
skilled nursing facility (SNF), nursing  facility  for  care  of  mentally
retarded patients, nursing facility for care of mentally ill patients,  or
nursing facility for care of tuberculosis  patients  unless  certified  as
such by the department in accordance with  this  code,  these  rules,  and
applicable federal and state law and regulations or  unless  certified  by
the U.S. secretary of health and human services.

  History:  1981 AACS.


R  325.21502   Time of application.
  Rule 1502. Applications for initial certification may  be  made  at  any
time by a currently licensed nursing care facility. If  the  applicant  is
not  currently  licensed,  the  application  for  certification  shall  be
accompanied by  an  application  for  initial  license.  Applications  for
renewed certification shall be made at the same time  as  application  for
renewed licensure.

  History:  1981 AACS.


R  325.21503   Content of application.
  Rule 1503. (1) An application for initial or renewed certification shall
be made on a form authorized and provided by the department which shall be
completed  in  full  in  accordance  with  department  instructions.   The
application form shall be accompanied by the attachments, additional data,
and information required by the department.
  (2) A complete application form shall include, at a minimum, all of  the
following:
  (a) A completed application form indicating the  type  of  certification
requested and, if the  certification  is  not  requested  for  the  entire
facility, the distinct part thereof for which certification is  requested.
  (b)  Evidence  that  the  person  submitting  the  application  is   the
authorized representative as defined by R 325.20204.
  (c) Additional  information  specified  in  department  instructions  to
determine compliance with the code or these rules.

  History:  1981 AACS.


R  325.21504   Processing the application.
  Rule 1504. (1) The department shall determine whether an application for
initial  or  renewed  certification  is  complete  and  shall  notify  the
applicant in writing if additional information is required to complete the
application or determine  compliance  with  the  code,  these  rules,  and
applicable federal law and regulations. The department shall consider each
completed application and make a determination in the matter.
  (2) By applying for or accepting certification,  a  facility  authorizes
the  department  and  its  representatives   to   conduct   the   surveys,
inspections, and investigations necessary  to  determine  compliance  with
applicable certification standards.
  (3) On the basis of the information supplied to it by the applicant  and
any other information available to it, including the facility  survey  and
evaluation, the department may take any  of  the  following  actions  with
respect to the application for certification:
  (a) Issue or renew the certification, except as provided in  subdivision
(c) of this subrule.
  (b) Deny or limit the certification, except as provided  in  subdivision
(c) of this subrule.
  (c) In the case of a skilled nursing  facility  which  has  applied  for
certification for purposes of  participating  in  both  the  medicare  and
medicaid programs, recommend to the U.S. secretary  of  health  and  human
services that certification be issued, renewed, limited, or denied.
  (4) Except as otherwise provided by federal law and  regulation,  action
by the department pursuant  to  subrule  (3)(b)  of  this  rule  shall  be
preceded by a notice of intent to deny,  suspend,  limit,  or  revoke  the
certification and opportunity for a hearing in accordance with part 19  of
these  rules.  The  department's  final  decisions  with  respect  to  the
granting, suspension, limitation, or revocation of a  certification  shall
be sent simultaneously to the facility and to the department of health and
human services and to the department of social services as required.

  History:  1981 AACS.


R  325.21505   Term of certification.
  Rule 1505. (1) The term of a certification shall be concurrent with  the
term of the facility's license and shall expire on the date shown  on  the
face of the license, unless  renewed  or  terminated  in  accordance  with
applicable law and rule.
  (2) A  complete  application  for  renewal  of  certification  shall  be
submitted  annually  in  accordance  with  the  code,  these  rules,   the
instructions of the department at the time of application, and  applicable
federal law and regulations.

  History:  1981 AACS.


R  325.21506   Surveys and investigations.
  Rule 1506. (1) The department shall conduct a survey  and  investigation
of a facility applying for initial or  renewed  certification  within  the
3-month period following receipt of the application and, in  the  case  of
renewals, within the 3-month period before  the  expiration  date  of  the
current  certification.  The  department  shall  not  issue  or  renew   a
certification until the completion of such a survey and investigation.
  (2) Surveys and investigations pursuant to these rules may be a part  of
the  facility's  licensure  survey  and  investigation  and  may   include
inspections of the facility; inspection and  copying  of  books,  records,
patient clinical records, and other documents maintained by the  facility;
and the acquisition of other information, including  otherwise  privileged
or  confidential  information,  from  any  other  persons  who  may   have
information bearing on the facility's compliance or ability to comply with
the applicable requirements for certification.
  (3) A representative  of  the  department  or  the  state  fire  marshal
division of the department of state police shall be  granted  entrance  to
the premises of a certified facility or  an  applicant  for  certification
upon presenting proper identification which shall include a card issued by
the department or the department  of  state  police  certifying  that  the
holder is an employee of that department.

  History:  1981 AACS.


R  325.21507   Notice   of   change   in   circumstances;   transfer    of
certification; posting.
  Rule 1507. (1) A certification is issued on  the  basis  of  information
available to the department on the date of issue. A  facility  shall  give
written notice to the department within 5 business days of any  change  in
information submitted as part of an application  for  initial  or  renewed
certification.
  (2) A certification may not be transferred from one  owner  to  another,
from one location to another, or  from  one  part  of  an  institution  to
another. Changes in  ownership  shall  be  reported  pursuant  to  section
20142(3) of the code.
  (3) The current certification shall be posted in a facility in the  same
place as the facility's license.

  History:  1981 AACS.


R  325.21508   Requirements for certification as  an  intermediate  (basic
nursing) care facility (ICF).
  Rule 1508. A licensed nursing care facility  shall,  at  the  facility's
request, be certified by the department as an intermediate  care  facility
when it is determined by the department, on the basis of facility  survey,
inspection, investigation, and evaluation that the facility complies  with
applicable state and federal statutes,  rules,  and  other  standards  for
intermediate care  facilities.  Such  federal  regulations  are  generally
available from the Health Care Financing  Administration,  U.S. Department
of Health and Human Services, Washington, D.C. 20024, and  the  Bureau  of
Health Care Administration, Michigan Department of Public Health, Lansing,
MI 48909.

  History:  1981 AACS.


R  325.21509   Requirements for  certification  as  an  intermediate  care
facility/mentally retarded (ICF/MR).
  Rule 1509. A licensed nursing care facility  shall,  at  the  facility's
request, be certified by the director of the department as an intermediate
care facility/mentally retarded when it is determined by the  director  of
the  department,  on   the   basis   of   facility   survey,   inspection,
investigation, and evaluation, that the facility complies with  applicable
state and federal statutes, rules, and other  standards  for  intermediate
care facilities/mentally retarded. Such federal regulations are  generally
available from the Health Care Financing  Administration,  U.S. Department
of Health and Human Services, Washington, D.C. 20024, and  the  Bureau  of
Health Care Administration, Michigan Department of Public Health, Lansing,
MI 48909.

  History:  1981 AACS.


R  325.21510   Requirements  for  certification  as  a   skilled   nursing
  facility (SNF).
  Rule 1510. (1) A licensed nursing care facility shall, at the facility's
request, be  certified  by  the  department  or,  when  required,  by  the
U.S. secretary of the department of health and human services as a skilled
nursing facility when it is determined by the director of  the  department
or the secretary of the department of health and human  services,  on  the
basis of facility survey, inspection, investigation, and evaluation,  that
the facility complies with applicable state and federal  statutes,  rules,
and  other  standards  for  skilled  nursing  facilities.   Such   federal
regulations  are  generally  available  from  the  Health  Care  Financing
Administration, U.S. Department of Health and Human Services,  Washington,
D.C. 20024,  and  the  Bureau  of  Health  Care  Administration,  Michigan
Department of Public Health, Lansing, MI 48909.
  (2) A licensed nursing care facility  certified  as  a  skilled  nursing
facility shall comply with the following provisions:
  (a) There shall be at least  1  licensed  nurse  on  duty  for  each  64
patients, or fraction thereof, on the day shift, at least 1 licensed nurse
on duty for each 96 patients, or fraction thereof, on the afternoon shift,
and at least 1 licensed nurse on duty for each 120 patients,  or  fraction
thereof, on the night shift.
  (b) Additional licensed nurses shall be employed and on duty  when  such
additional licensed nursing personnel are required to meet minimum nursing
care needs because of any of the following:
  (i) The physical layout or size of the facility or nursing unit.
  (ii) The complexity of patient care needs.
  (iii) The qualifications of the nursing staff in terms of  training  and
experience.
  (iv) The number of therapeutic treatments to be provided.
  (v) The number of medications to be administered.

  History:  1981 AACS.


R  325.21511   Requirements for certification as a  nursing  facility  for
the care of mentally retarded patients.
  Rule 1511. An applicant for certification as a nursing facility for  the
care of mentally retarded  patients  shall  be  a  licensed  nursing  care
facility and shall meet the requirements of part 16 of these rules.

  History:  1981 AACS.


R  325.21512   Requirements for certification as a  nursing  facility  for
the care of mentally ill patients.
  Rule 1512. An applicant for certification as a nursing facility for  the
care of mentally ill patients shall be a licensed  nursing  care  facility
and, in addition, shall meet the requirements of part 17 of  these  rules.

  History:  1981 AACS.


R  325.21513   Requirements for certification as a  nursing  facility  for
the care of tuberculin patients.
  Rule 1513. Requirements for certification as a nursing facility for  the
care of tuberculosis patients shall be that the nursing care  facility  be
licensed and, in addition, that the facility meet the requirements of part
18 of these rules.

  History:  1981 AACS.


R  325.21514   Denial,   limitation,   suspension,   or   revocation    of
certification.
  Rule 1514. (1) The department may deny,  limit,  suspend,  or  revoke  a
certification for failure  to  comply  with  the  code,  these  rules,  or
applicable provisions of federal law and regulation.
  (2) Except when the department of health and human services has  denied,
limited, suspended, or revoked  certification,  the  procedures  to  deny,
limit, suspend, or revoke a certification shall be the same as those  used
to deny, limit, suspend, or revoke a license.
  (3) The department's  action  to  deny,  limit,  suspend,  or  revoke  a
certification may be taken in the same proceeding  and  concurrently  with
action to deny, limit, suspend, or revoke a license.
  (4) The issuance of  a  certification  shall  be  considered  an  action
independent of the issuance of a license, and  the  certification  may  be
reviewed,  renewed,   denied,   limited,   suspended,   or   revoked   for
noncompliance with the code or these rules without  initiating  a  similar
action with respect to the nursing care facility's license.

  History:  1981 AACS.


R  325.21515   Issuance of certification.
  Rule 1515. When the department issues a certification  pursuant  to  the
code and these rules, it shall cause a separate certificate to  be  issued
which indicates any distinct parts of  the  nursing  care  facility  being
certified and the type of certification  granted  to  each  such  distinct
part.

  History:  1981 AACS.


       PART 16. NURSING FACILITIES FOR CARE OF MENTALLY ILL PATIENTS


R  325.21601   Applicability.
  Rule 1601.  A  nursing  home  or  nursing  facility  requesting  special
certification to the  department  of  social  services  for  the  care  of
mentally ill patients under the medicaid program, in addition to all other
applicable  requirements  for  licensure  and  skilled  nursing   facility
certification under these rules, shall comply with this part.

  History:  1981 AACS.


R  325.21602   Patient capacity and admission.
  Rule 1602. A special mental illness nursing  home  or  nursing  facility
shall comply with both of the following provisions:
  (a) Be an entire facility or a distinct part of a facility of  not  more
than 150 nor less than 16 patient beds and be able to care for a  mentally
ill patient of any age in need of nursing care.
  (b) Have a written agreement in effect with  the  department  of  mental
health and admit only mentally ill individuals as defined  and  authorized
by the department of mental health under that agreement.

  History:  1981 AACS.


R  325.21603   Specialized physician services.
  Rule 1603. A special mental illness nursing  home  or  nursing  facility
shall have on its staff a physician who is a specialist in the  diagnosis,
treatment, and care of the mentally  ill.  The  physician  specialist,  in
accordance with written policy of the facility, shall comply with  all  of
the following provisions:
  (a) Have special training and experience in  the  diagnosis,  treatment,
and care of the mentally ill.
  (b) Serve as a consultant  to  the  administrator  of  the  facility  in
planning and implementing  a  continuing  program  designed  to  meet  the
special needs of patients in the facility.
  (c) Serve as consultant to other physicians attending  patients  in  the
facility.
  (d) Care for mentally ill  patients,  as  may  be  appropriate,  at  the
request of the patient or his or her  guardian,  the  patient's  attending
physician, and the facility.
  (e) Assist the facility in  the  development  of,  and  approve  written
patient care policies for, the diagnosis, treatment, and care of  patients
in the facility.
  (f) Assist the facility in the writing of individual patient care  plans
and approve such plans.
  (g) Assure that  patients  are  seen  and  evaluated  by  the  attending
physician not less than every 30 days and more often as may be required to
adequately care for patients.

  History:  1981 AACS.


R  325.21604   Specialized nursing services.
  Rule 1604. Specialized nursing services in a mental illness nursing home
or nursing facility shall comply with all of the following provisions:
  (a) Be directed by a registered nurse who has at least 1  year  of  work
experience in the care of mentally ill patients or who, in the opinion  of
the physician specialist on the staff of the  facility,  is  qualified  to
supervise the nursing care and other specialized  services  necessary  for
the care of  mentally  ill  patients,  particularly  those  with  aberrant
behavior.
  (b) Provide that nursing care for patients on all shifts in the facility
shall be in the charge of a registered nurse or licensed  practical  nurse
experienced in the care of mentally ill patients.
  (c) Provide that the nursing staff  shall  receive  orientation  of  the
provision of nursing care and other specialized services necessary to  the
care of mentally ill patients. Nursing personnel shall receive specialized
inservice training on a regular and continuing basis.
  (d) Provide, in addition to personnel required for compliance with nurse
staffing  requirements  for  licensure  and  skilled  nursing   facilities
certification, additional licensed and unlicensed  personnel  required  to
meet the needs of individual patients, but not less  than  an  average  of
3.35 hours of nursing care per patient per day.

  History:  1981 AACS.


R  325.21605   Other specialized services.
  Rule 1605. A mental illness  nursing  home  or  nursing  facility  shall
comply with all of the following:
  (a) Provide an organized program of diversional activities and  training
services required to meet the needs of individual mentally  ill  patients,
particularly those  who  exhibit  aberrant  behavior.  Such  programs,  in
accordance with the needs of individual patients, shall be consistent with
the  patient's  physical  condition,  level  of  functioning,  and  mental
capacity.
  (b)  Provide  necessary  arrangements  to   obtain   other   specialized
diagnostic services and forms  of  therapy  as  may  be  required  by  the
individual patient.
  (c) Keep the state hospital, which is designated by  the  department  of
mental health, in the home's or  facility's  area  advised  on  a  monthly
basis, by mail, of the availability of beds for the care of  patients  and
the name of the physician specialist on its staff.

  History:  1981 AACS.


    PART 17. NURSING FACILITIES FOR CARE OF MENTALLY RETARDED PATIENTS


R  325.21701   Applicability.
  Rule 1701. A nursing home or nursing care  facility  requesting  special
certification to the  department  of  social  services  for  the  care  of
mentally retarded patients under the medicaid program, in addition to  all
other applicable requirements for licensure and skilled  nursing  facility
certification under these rules, shall comply with this part.

  History:  1981 AACS.


R  325.21702   Patient capacity and admissions.
  Rule 1702. A special mental retardation nursing home or nursing facility
shall comply with both of the following provisions:
  (a) Be an entire facility or a distinct part of a facility of  not  more
than 150 nor less than 16 patient beds and be able to care for a  mentally
retarded patient of any age in need of nursing care.
  (b) Have a written agreement in effect with  the  department  of  mental
health and  admit  only  mentally  retarded  individuals  as  defined  and
authorized by the department of mental health under that agreement.

  History:  1981 AACS.


R  325.21703   Specialized physician services.
  Rule 1703. A special mental retardation nursing home or nursing facility
shall have on its staff a physician who is a specialist in the  diagnosis,
treatment, and care of the mentally retarded. The physician specialist, in
accordance with written policy of the facility, shall comply with  all  of
the following provisions:
  (a) Have special training and experience in  the  diagnosis,  treatment,
and care of the mentally retarded.
  (b) Serve as a consultant  to  the  administrator  of  the  facility  in
planning and implementing  a  continuing  program  designed  to  meet  the
special needs of patients in the facility.
  (c) Serve as a consultant to other physicians attending patients in  the
facility.
  (d) Care for mentally retarded patients, as may be appropriate,  at  the
request of the patient or his or her  guardian,  the  patient's  attending
physician, and the facility.
  (e) Assist the facility in development of, and approve  written  patient
care policies for, the diagnosis, treatment, and care of patients  in  the
facility.
  (f) Assist the facility in the writing of individual patient care  plans
and approve such plans.
  (g) Assure that  patients  are  seen  and  evaluated  by  the  attending
physician not less than every 30 days and more often as may be required to
care adequately for patients.

  History:  1981 AACS.


R  325.21704   Specialized nursing services.
  Rule 1704. Specialized nursing services in a mental retardation  nursing
home  or  nursing  facility  shall  comply  with  all  of  the   following
provisions:
  (a) Be directed by a registered nurse who has at least 1  year  of  work
experience in the care of  mentally  retarded  patients  or  who,  in  the
opinion of the physician specialist on  the  staff  of  the  facility,  is
qualified to supervise the nursing care and habilitative and developmental
training services for mentally retarded patients.
  (b) Provide that nursing care for patients on all shifts in the facility
shall be in the charge of a registered nurse or licensed  practical  nurse
experienced in the care of mentally retarded patients.
  (c) Provide that the nursing staff  shall  receive  orientation  in  the
provision of habilitative and developmental training services necessary to
the care of mentally retarded patients. Nursing  personnel  shall  receive
specialized inservice training on a regular and continuing basis.
  (d) Provide, in addition to personnel required for compliance with nurse
staffing  requirements  for  licensure  and   skilled   nursing   facility
certification, additional licensed and unlicensed  personnel  required  to
meet the needs of individual patients, but not less  than  4.35  hours  of
nursing care per patient per 24  hours  of  residence.  In  addition,  the
following provisions shall be complied with:
  (i) The ratio of patients present to nursing  care  personnel  from  the
hours of 6 a.m. to 8 p.m. shall not exceed 4 patients to  1  nursing  care
personnel.
  (ii) For the hours of 8 p.m. to 6 a.m., the ratio of patients to nursing
care personnel shall not exceed 12 patients to 1 nursing  care  personnel.
  (iii) In addition to the provisions of paragraphs (i) and (ii)  of  this
subdivision, there shall be sufficient nursing care personnel available on
duty to assure coverage for patients at all times during each shift.

  History:  1981 AACS.


R  325.21705   Other specialized services.
  Rule 1705. A mental retardation nursing home or nursing  facility  shall
comply with all of the following provisions:
  (a) Provide an organized program of diversional activities and  training
services required to  meet  the  needs  of  individual  mentally  retarded
patients. Such programs,  in  accordance  with  the  needs  of  individual
patients, shall be consistent with the patient's physical condition, level
of functioning, and mental capacity.
  (b)  Provide  necessary  arrangements  to   obtain   other   specialized
diagnostic services and forms  of  therapy  as  may  be  required  by  the
individual patients.
  (c) Keep the state mental retardation facility, which is  designated  by
the department of mental health, in the home's or facility's area  advised
on a monthly basis, by mail, of the availability of beds for the  care  of
patients and the name of the physician specialist on its staff.

  History:  1981 AACS.


       PART 18. NURSING FACILITIES FOR CARE OF TUBERCULOSIS PATIENTS


R  325.21801   Applicability.
  Rule 1801. (1) A nursing home or nursing facility, when  not  prohibited
by law or rule, may  request  authorization  and  certification  from  the
department to establish and maintain the nursing facility  or  a  distinct
part of the facility as a tuberculosis nursing home or facility.
  (2) In the interest of protecting the health and welfare  of  the  large
number of elderly patients in nursing facilities  from  tuberculosis,  the
department  shall  issue  the  authorization  and  certification  when  it
determines, on the basis of available information and surveys, all of  the
following:
  (a) That a  tuberculosis  nursing  home  or  facility  is  needed  in  a
particular health facility planning region.
  (b) That an applicant is licensed or  complies  with  the  standards  of
licensing.
  (c) That an applicant can safely establish and  maintain  a  program  of
care for tuberculosis patients in compliance with this part.

  History:  1981 AACS.


R  325.21802   Patient capacities and admissions.
  Rule 1802. A tuberculosis nursing facility shall comply with both of the
following provisions:
  (a) Be an entire facility or distinct part of a  facility  of  not  more
than 30, nor less than  4,  patient  beds  and  be  able  to  care  for  a
tuberculosis patient of any age in single or  multiple  patient  rooms  as
ordered by the physician in charge.  The  physician  in  charge  shall  be
approved by the department to direct or supervise the care.
  (b) Have  a  written  agreement  with  the  department  and  admit  only
tuberculosis patients as defined and authorized by the department  in  the
agreement.

  History:  1981 AACS.


R  325.21803   Specialized physician services.
  Rule 1803. A tuberculosis nursing facility shall  have  a  physician  in
charge approved by the department to render medical care to  patients  and
to direct or supervise care provided to  patients  in  the  facility.  The
physician in charge, in accordance with written policies of the  facility,
shall comply with all of the following provisions:
  (a) Be the attending physician to patients in the facility.
  (b) Have special training and experience in  the  diagnosis,  treatment,
and care of patients with tuberculosis.
  (c) Serve as a consultant  to  the  administrator  of  the  facility  in
planning and implementing  a  continuing  program  designed  to  meet  the
special needs of tuberculosis patients in the facility.
  (d) Assist the facility in  the  development  of,  and  approve  written
patient care policies for, the treatment  and  care  of  patients  in  the
facility.
  (e) Assist the facility in the writing of individual patient care  plans
and approve such plans.

  History:  1981 AACS.


R  325.21804   Specialized nursing services.
  Rule 1804.  Specialized  nursing  services  in  a  tuberculosis  nursing
facility shall comply with both of the following provisions:
  (a) Be directed by a registered nurse who has at least 1  year  of  work
experience in the care of tuberculosis patients or who, in the opinion  of
the physician in charge, is qualified to supervise the  nursing  care  and
other  specialized  services  necessary  for  the  care  of   tuberculosis
patients.
  (b) Provide that nursing personnel  receive  orientation  and  inservice
training in the provision of nursing care and other  specialized  services
necessary to the care of tuberculosis patients.

  History:  1981 AACS.


R  325.21805   Other specialized services.
  Rule 1805. A tuberculosis nursing facility shall comply with both of the
following:
  (a) Provide an organized program of diversional activities  designed  to
meet the needs of the patients.
  (b) Provide organized programs  of  physical  and  occupational  therapy
designed to meet the needs of individual patients requiring such services.

  History:  1981 AACS.


R  325.21806   Visitation.
  Rule 1806. In accordance with written facility policies and  the  orders
of the physician in charge, patients in a  tuberculosis  nursing  facility
shall be permitted to visit other patients  in  the  tuberculosis  nursing
facility and receive visitors.

  History:  1981 AACS.


R  325.21807   Record requirements.
  Rule 1807. A tuberculosis nursing facility shall submit  such  forms  as
may be required by the department to provide information on the status  of
patients entering and leaving the facility.

  History:  1981 AACS.


                        PART 19. HEARING PROCEDURE


R  325.21901   Applicability.
  Rule 1901. (1) The procedures set  forth  in  this  part  apply  to  the
hearings required by sections 20165, 20166, 20168,  21799a(9),  21799b(2),
and 21799c of the code.
  (2) This article shall apply  to  certification  and  other  proceedings
under federal statutes where required by federal law or regulation.
  (3) Unless otherwise provided by the code or these rules, the procedures
for a hearing shall comply with sections 71 to 92 of Act  No. 306  of  the
Public Acts of 1969, as amended, being SS24.271 to 24.292 of the  Michigan
Compiled Laws.

  History:  1981 AACS.


R  325.21902   Definitions.
  Rule 1902. In addition to the definitions of the code,  Act  No. 306  of
the Public Acts of 1969, as amended, being S24.201 et seq. of the Michigan
Compiled Laws, and these rules, the following definition applies  to  this
part: "Authorized  representative"  means  the  representative  designated
pursuant to R 325.20204.

  History:  1981 AACS.


R  325.21903   Correction notice; opportunity to show compliance.
  Rule 1903. (1) When the department issues a correction notice under  the
provisions of section 21799b of the code, the correction notice shall  set
forth all findings mandated  by  section  21799b  of  the  code,  and  the
department shall inform the licensee that he or  she  has  a  right  to  a
hearing within 72 hours and that, if he or she wishes  to  be  heard,  the
department will have a hearing officer  present  at  the  time  and  place
specified in the correction notice. The time of hearing shall be within 72
hours of the time of service. Upon request, an adjournment, for  a  period
not to exceed 10 days, may be granted by a  hearing  officer.  Failure  to
raise a defense on or before the hearing, or to  appear  at  the  hearing,
shall be deemed an admission of the matters  asserted  in  the  correction
notice. If the respondent fails to make an appearance or  to  contest  the
notice,  the  correction  notice  shall  be  final  without  any   further
proceeding whatsoever.
  (2)  Before  commencing  the   proceedings   for   denial,   limitation,
suspension, or revocation of a license  pursuant  to  sections  20165  and
20166 of the code, the department shall give notice to  the  applicant  or
licensee, personally or by registered or certified mail, of the  facts  or
conduct which warrants the intended action and shall provide the applicant
or licensee with an opportunity to show compliance with the code and these
rules at a compliance conference. The notice shall state the  date,  time,
and location of compliance  conference.  If  the  licensee  is  unable  to
demonstrate, to the satisfaction  of  the  department  at  the  compliance
conference, compliance with all lawful requirements for retention  of  its
license, the department may proceed with a hearing.  This  rule  does  not
apply to notices issued under section 20162, 20168, 21799a(9),  21799b(2),
or 21799c of the code or section 63 of Act No. 306 of the Public  Acts  of
1969, as amended, being S24.263 of the Michigan Compiled Laws.

  History:  1981 AACS.


R  325.21904   Initiation of hearings.
  Rule 1904. (1) A hearing is initiated by the department by giving notice
thereof personally or by registered or certified mail.  The  notice  shall
include all of the following:
  (a) The time, date, place, and nature of the hearing.
  (b) The action intended by the department, and a brief statement of  the
facts involved.
  (c) The legal authority and jurisdiction under which the hearing  is  to
be held.
  (d) A reference to the applicable sections of the code and rules.
  (2) The hearing shall be conducted by the director or 1 or more  hearing
officers designated by the director.

  History:  1981 AACS.


R  325.21905   Service.
  Rule 1905. Unless otherwise specified, service of a  document  upon  any
party shall be  made  by  personal  delivery  or  mailing  by  registered,
certified, or first-class mail to the last known address of the  party  or
the authorized representative of a party as indicated on  the  records  of
the department, and proof of service shall be filed with  the  department.

  History:  1981 AACS.


R  325.21906   Appearances.
  Rule  1906.  A  party  may  appear   in   person,   by   an   authorized
representative, or by legal counsel.

  History:  1981 AACS.


R  325.21907   Form of pleadings.
  Rule 1907. (1) All pleadings shall contain the department's caption  and
docket number, if assigned, and shall include a clear and plain  statement
of facts alleged and the relief sought.
  (2) A pleading, other than an  exhibit,  shall  be  typewritten,  double
spaced, and on letter-size opaque paper, approximately 8 1/2 inches by  11
inches. The left margin shall be 1 1/2 inches and the right margin 1 inch.
A pleading and other documents shall be fastened in the upper left corner.

  History:  1981 AACS.


R  325.21908   Pleading captions.
  Rule 1908. (1) A hearing shall be titled "In  the  matter  of  (name  of
respondent)." This caption shall appear at the  upper  left  side  of  the
first page of each filed pleading or document other than an exhibit.
  (2) The first page of a pleading or document,  other  than  an  exhibit,
shall show at its upper right  side,  opposite  the  caption,  the  docket
number assigned by the department, if known.

  History:  1981 AACS.


R  325.21909   Extensions of time.
  Rule 1909. A request for an extension  of  time  for  the  filing  of  a
pleading or document shall be made in writing and served on the  presiding
officer and all parties 5 days before the date on which  the  pleading  or
document is due to be filed.

  History:  1981 AACS.


R  325.21910   Answers.
  Rule 1910. Within 15 days after  service  of  a  notice  of  hearing,  a
respondent shall file a written answer with  the  department.  The  answer
shall respond to all allegations in the notice of hearing which the  party
plans to contest, and a respondent shall raise  any  affirmative  defenses
not later than 10 days prior to the hearing. All allegations not denied by
written  answer  are  deemed  admitted.  This  rule  shall  not  apply  to
proceedings under R 325.21903(1).

  History:  1981 AACS.


R  325.21911   Consolidation and severance of cases.
  Rule 1911. (1) Cases may be consolidated, for good cause, on the  motion
of any party or the hearing officer's own motion,  when  justice  and  the
administration of the code and these  rules  require.  A  motion  for  the
consolidation of cases shall be filed within 20 days after service of  the
notice of hearing on each party to the cases which would be  consolidated.
Within 10 days after service of the motion, the other parties may  file  a
response thereto. Unless a request for oral argument is made and  granted,
the determination on the motion shall be made on the pleadings.
  (2) Upon his or her own motion, or upon motion of any party, the hearing
officer, for good cause, may order any case severed  as  to  some  or  all
issues or parties.

  History:  1981 AACS.


R  325.21912   Presiding officer; powers and duties.
  Rule 1912. (1) A presiding officer shall have all  powers  necessary  or
appropriate to conduct a fair, full, and impartial hearing, including  the
power to do all of the following:
  (a) Administer oaths and affirmations.
  (b) Rule upon offers of proof and receive relevant evidence.
  (c) Provide for the taking of testimony by deposition.
  (d) Regulate the course of the hearings, set  the  time  and  place  for
continued hearings, fix the time  for  the  filing  of  briefs  and  other
documents, and issue subpoenas.
  (e) Consider and rule upon procedural requests.
  (f) Hold conferences for the settlement or simplification of the  issues
by consent of the parties.
  (g) Prepare proposed decisions, if required.
  (2) When a hearing officer believes that he or she  is  disqualified  to
preside over a particular hearing, he or she shall withdraw  therefrom  by
notice on the record directed to the director. A party who claims  that  a
hearing officer should be disqualified  to  preside,  or  to  continue  to
preside, over a particular hearing may timely file  with  the  director  a
motion to disqualify. The motion shall be supported by affidavits  setting
forth the alleged grounds for disqualification. The  director  shall  rule
upon the motion, and the decision shall be determinative for  purposes  of
the hearing.

  History:  1981 AACS.


R  325.21913   Prehearing conference.
  Rule 1913. (1) The presiding officer, upon request of any  party  or  on
his or her own motion, may order a prehearing conference for  the  purpose
of facilitating the disposition of a contested case.
  (2) The following are the purposes of the prehearing conference:
  (a) To state and simplify the factual and legal issues to be  litigated.
  (b) To admit matters of fact and the authenticity of  documents  and  to
resolve other evidentiary matters to avoid unnecessary proof.
  (c) To exchange lists of witnesses and the nature of their testimony.
  (d) To estimate the time required for the hearing.
  (e) To resolve other matters which may aid in  the  disposition  of  the
case.
  (3) At the prehearing conference, the presiding officer may make rulings
on  motions  pertaining  to  evidence,  law,  and   the   procedure   when
practicable. A record shall be made of all motions and rulings  and  other
matters deemed appropriate at the presiding officer's discretion and shall
become a part of the hearing record.
  (4) The parties to a hearing are encouraged to  voluntarily  confer  for
the purpose of facilitating the disposition of a case.

  History:  1981 AACS.


R  325.21914   Adjournment.
  Rule 1914. A party may request an adjournment of a scheduled hearing  by
motion to the presiding officer  assigned  to  conduct  the  hearing.  The
presiding officer shall not rule on the  request  until  opposing  parties
have had an opportunity to be  heard  on  the  request.  However,  if  all
parties agree to the adjournment, then the presiding officer may  rule  on
the request immediately.

  History:  1981 AACS.


R  325.21915   Consent findings and orders.
  Rule 1915. (1) At any time before a final order is issued,  the  parties
may negotiate an  agreement  containing  consent  findings  and  an  order
disposing of the whole or a part of the  case.  This  agreement  shall  be
submitted  to  the  presiding  officer  who  shall  rule  upon  it   after
considering the nature of  the  proceeding,  the  representatives  of  the
parties, and the probability of an agreement which would result in a  just
disposition of the issues involved.
  (2) The agreement containing consent findings and an order disposing  of
a proceeding shall contain all of the following provisions:
  (a) That the consent finding and order shall have  the  same  force  and
effect as if made after a full hearing.
  (b) That the record on which an order may be based shall consist  solely
of the pleadings and the agreement.
  (c) A waiver of any further proceedings before the hearing  officer  and
the director.
  (d) A waiver of any right to challenge or contest,  in  any  forum,  the
validity of the consent findings and order made  in  accordance  with  the
agreement.

  History:  1981 AACS.


R  325.21916   Discovery and depositions.
  Rule 1916. (1) The same rights to discovery and depositions provided  in
the general court rules of this state  applicable  to  civil  cases  shall
apply to all hearings commenced and conducted under  the  code  and  these
rules. The presiding  officer  shall  rule  on  all  motions  relative  to
depositions and discovery.
  (2) Discovery depositions and motions for discovery shall not be allowed
by the presiding  officer  if  they  are  likely  to  interfere  with  the
efficient conduct of  the  hearing,  unless  substantial  prejudice  would
result therefrom.

  History:  1981 AACS.


R  325.21917   Complaints.
  Rule 1917. Any person who believes that a provision of the code relating
to nursing homes, any other law administered by the department relating to
nursing homes, or these rules has been violated may file a complaint  with
the department. The complaint shall include  a  statement  of  the  facts,
without repetition, upon which the complainant relies to fully note his or
her complaint and may include a statement of the relief requested.

  History:  1981 AACS.


R  325.21918   Investigation of complaints and hearings.
  Rule 1918. (1) The department  shall  review  the  complaint  and  shall
investigate the same. The substance of the complaint shall be provided  to
the  licensee  not  earlier  than  at  the  commencement  of  the  on-site
inspection  of  the  nursing  home  which  takes  place  pursuant  to  the
complaint.  At  the  conclusion  of  its  review  on  investigation,   the
department  shall  inform  the  complainant  of  its  disposition  of  the
complaint. If the complainant is dissatisfied with the disposition of  the
complaint made by the department, and if  the  code  or  other  applicable
statute gives the complainant  the  right  and  standing  to  do  so,  the
complainant may demand a hearing on the  complaint  under  R 325.21917  by
filing written request therefor.
  (2) A hearing on a complaint shall be noticed in the same  manner  as  a
hearing initiated by the department,  except  that  the  notice  need  not
comply with the provisions of R 325.21904(b).  If  the  person  complained
against is a licensee, a copy of the complaint shall be  appended  to  the
notice.
  (3) When the person complained against is a licensee, the licensee shall
be the respondent, but the department may, if it chooses, intervene as  of
right in the proceedings, in which case, the department shall have all the
rights of a party.

  History:  1981 AACS.


R  325.21919   Motion practice.
  Rule 1919. (1) Not less than 5 days before the date set for  hearing  in
the notice, all preliminary motions shall be filed, unless  the  presiding
officer, for good cause shown, permits the filing of  such  motions  at  a
later date. These motions include all of the following:
  (a) Motions for a more definite statement.
  (b) Motions to strike pleadings.
  (c) Motions to amend pleadings.
  (d) Motions for accelerated judgment.
  (e) Motions for summary judgment.
  (f) Discovery motions.
  (g) Motions relative to depositions.
  (2) On the date set for hearing in the  notice,  the  presiding  officer
shall first hear all pending preliminary motions. He or she  shall  decide
them in the same manner as provided for in the general court rules of this
state for civil cases. Thereafter, all motions are to be made, heard,  and
decided at the discretion of the presiding officer.
  (3) After hearing all pending preliminary motions, if any, the presiding
officer may hold a prehearing conference as provided for in  these  rules.

  History:  1981 AACS.


R  325.21920   Direct testimony and exhibits.
  Rule 1920. When in any  case  it  is  deemed  necessary,  the  presiding
officer may direct that the direct testimony of any witness  or  witnesses
be submitted in written form, together with any exhibits to  be  sponsored
by the witness, before hearing. Such direct testimony shall  be  submitted
in typewritten form on 8 1/2  inch  by  11-inch  paper  and  shall  be  in
question and  answer  form.  The  direct  testimony  of  each  witness  so
submitted shall be made a separate exhibit, and the name  and  address  of
the witness, together with the caption of the  case,  shall  appear  on  a
cover sheet. Each witness is required to be  present  at  the  hearing  to
introduce  his  or  her  written  testimony  as   an   exhibit   and   for
cross-examination at such  date,  time,  and  place  as  directed  by  the
presiding officer. In any case, and upon request therefor, a  party  shall
have the right, notwithstanding any provision of this rule,  to  have  any
witness on his or her behalf present his or her  direct  testimony  orally
before the hearing officer.

  History:  1981 AACS.


R  325.21921   Transcripts.
  Rule 1921. Hearings shall be recorded,  but  need  not  be  transcribed,
unless requested by a party. The party requesting the transcript shall pay
for the transcription.

  History:  1981 AACS.


R  325.21922   Proposal for decision and final order.
  Rule 1922. (1) Following  the  conclusion  of  a  hearing,  the  hearing
officer, if other than the director, shall deliver to the  department  the
official case file and his or her proposal for  decision.  The  department
shall serve the proposal for decision upon the parties  by  registered  or
certified mail or personal service, and each party shall have 10 days from
the date of service of the proposal for decision  to  file  exceptions  or
present written arguments to the department.
  (2) Following review of the record or  the  proposal  for  decision  and
exceptions thereto, if any, the department shall issue  an  order  stating
the findings of fact, conclusions of law, and the final order or an  order
for further proceedings. The department shall serve copies  of  the  order
upon all parties.
  (3) If no exceptions are filed, the proposal for decision  shall  become
the final order of the department, unless the director issues his  or  her
order within 90 days  from  the  date  of  service  of  the  proposal  for
decision.

  History:  1981 AACS.


      PART 20. EDUCATION AND TRAINING OF UNLICENSED NURSING PERSONNEL


R  325.22001   Minimum criteria for education and training  of  unlicensed
nursing personnel.
  Rule 22001. (1) Each facility shall adopt and implement an education and
training program that  shall  specify  minimum  competencies,  performance
objectives, and methods of evaluation which cover  at  least  the  content
listed in subrule (2) of this rule. If the facility, by policy,  does  not
permit unlicensed  nursing  personnel  to  perform  a  specific  procedure
covered in subrule (2) of this rule, training in that  specific  procedure
may be excluded.
  (2) The following content shall be presented, except as noted in subrule
(1) of this rule:
  (a) Personnel policies, including the facility's personnel policies, job
responsibilities, legal and ethical responsibilities, and  the  importance
of the individual's position as a member of the health care team.
  (b) Concepts of care, including physical, psychological,  cultural,  and
social components of care; the impact  on  the  patient  of  physical  and
psychological changes that occur  with  trauma,  the  aging  process,  and
developmental disabilities; the legal rights and privileges  of  patients;
and communication techniques necessary to provide care.
  (c) Environment, including  what  constitutes  a  safe  and  comfortable
environment  for  giving  care;  safety  and  fire  prevention;  emergency
procedures,  including   cardiopulmonary   resuscitation,   the   Heimlich
maneuver, and fire and disaster procedures; bed-making and when bed  linen
should be changed; restraint procedures, including protecting  the  safety
and dignity of the patient; prevention  and  control  of  infections;  and
information necessary to assist the new patient to  become  aware  of  the
facility's routines and available services.
  (d) Collecting and sharing information,  including  observation  of  the
individual patient and how to recognize changes from normal; vital  signs;
reporting  and   documenting   observations;   and   medical   terms   and
abbreviations necessary for the tasks performed.
  (e) Personal care, including bathing a patient in a safe  and  dignified
manner while encouraging independence; skin care, including preventive and
supportive care; routine morning and evening mouth  care,  hair  and  nail
care; shaving; dressing and undressing, with emphasis on  encouraging  and
maintainiing independence; and prosthetic devices used in providing  care.
  (f) Nutrition, including the importance of a balanced diet  and  how  to
help bring this about; the importance of  making  meal  times  a  pleasant
experience; measuring and recording the patient's food and  fluid  intake;
how to carry out orders to increase or reduce fluid intake, and techniques
to assist a patient to eat, with emphasis on encouraging  and  maintaining
independence and dignity.
  (g) Elimination, including encouraging and maintaining  independence  in
toileting; the use of the bed pan and urinal;  catheter  care;  preventing
incontinence; prevention  of  constipation;  observation,  reporting,  and
recording of significant information about a patient's  urine  and  stool;
perineal care; measuring and recording output; urine  testing;  and  bowel
and bladder training.
  (h)   Rehabilitation,   including    principles    of    rehabilitation;
complications of immobility and their prevention; techniques of turning  a
patient; maintaining proper body alignment; range of motion exercises; the
use  of  ambulation  aids,  including  wheelchairs,  walkers,  canes,  and
crutches; transfer techniques; proper body mechanics involved  in  lifting
patients or objects; and use of bed  boards,  foot  boards,  foot  stools,
trochanter rolls, pillows for positioning, bed cradles,  slings,  splints,
lifting equipment, and trapezes.

  History:  1981 AACS.


R  325.22002   Verification of competency.
  Rule 2002. (1) The director of nursing, or a registered nurse  designee,
shall verify that each  unlicensed  employee  providing  nursing  care  is
competent to perform all assigned tasks prior to the time the employee  is
assigned to perform them, unless the employee  is  under  supervision,  as
defined in section 16109 of the code, for training purposes.
  (2) Verification of competency shall  be  indicated  by  an  appropriate
entry in the employee's personnel record which is signed by  the  director
of nursing or other registered nurse and  which  specifies  the  date  and
method by which each competency was verified. This  information  shall  be
maintained in each employee's personnel file for the duration  of  his  or
her employment in the facility.
  (3) Personnel files shall also include the number of classroom hours and
the hours of planned clinical experience supervised by a  licensed  nurse.

  History:  1981 AACS.


R  325.22003   Class outline and lesson plans.
  Rule 2003. Class outlines and lesson plans  shall  be  retained  in  the
facility for not less than 2 years.

  History:  1981 AACS.


R  325.22003a   Testing for competency.
  Rule 2003a. The department  shall  test  the  competency  of  unlicensed
nursing  personnel  by  observation  of  care  given  and  may   interview
unlicensed nursing personnel to evaluate  the  adequacy  of  the  training
program.

  History:  1984 AACS.


R  325.22004   Plan of correction.
  Rule 2004. If a violation of R 325.22001 to R 325.22003 is cited, within
30 days the facility shall submit a written plan to assess and revise  the
training program to correct the deficiency. Staff of the department  shall
assist with this process and shall reevaluate the program within 120  days
of the date of the citation of the violation to assure compliance.

  History:  1983 AACS.