DEPARTMENT OF CONSUMER AND INDUSTRY SERVICES

                        BUREAU OF HEALTH SYSTEMS
                              
             DIVISION OF HEALTH FACILITY STANDARDS AND LICENSING

                        LICENSING OF FACILITIES


(By authority conferred on the department of mental health by  sections  1
to 4 of Act No. 80 of the Public Acts of 1905, as amended, section  33  of
Act No. 306 of the Public Acts of 1969, as amended, and sections 114, 130,
136, 157, 206, 244, 498n, 498r, 842, 844, 908, and 1002a of Act No. 258 of
the Public Acts of 1974, as amended,  being  sections  19.141  to  19.144,
24.233,  330.1114,  330.1130,  330.1136,  330.1206,  330.1244,  330.1498n,
330.1498r, 330.1842, 330.1844, 330.1908, and  330.2002a  of  the  Michigan
Compiled Laws)


R  330.1201   Definitions.
  Rule 1201. As used in this subpart:
  (a) "Active treatment" means all of the following:
  (i) Services that are provided under an individualized plan of services.
  (ii) Services that are directed  toward  improving  or  maintaining  the
patient's condition.
  (iii) Services that are provided, or  supervised  and  evaluated,  by  a
mental health professional.
  (b) "Activity area" means a space that is made available to patients for
diversional and social activities.
  (c)  "Hospital"  means  a  mental  hospital,  psychiatric  hospital,  or
psychiatric unit which is not operated by the department of mental  health
or by the federal government.
  (d) "Major construction" means any change or addition to, or  renovation
of, an existing structure which would require an architect or an  engineer
to design a plan or which would cost more than $100,000.00.
  (e) "Mental health professional," within a licensed  hospital,  means  a
psychiatrist, as defined in chapter  4  of  the  act,  a  pediatrician,  a
psychologist, a certified social worker, or a registered nurse.
  (f) "Mental hospital" or "psychiatric  hospital"  means  a  freestanding
establishment  which  offers  inpatient  services  for  the   observation,
diagnosis, active treatment, and overnight care of persons with  a  mental
disease or with a chronic mental condition who require daily direction  or
supervision of physicians and mental health professionals who are licensed
to practice in this state.
  (g) "Psychiatric unit" means a coordinated psychiatric inpatient program
of  a  general  hospital  which  offers  services  for  the   observation,
diagnosis, active treatment, and overnight care of persons with  a  mental
disease or with a chronic mental condition who require the daily direction
or supervision of a physician  or  mental  health  professionals  who  are
licensed or certified to practice in this state.
  (h) "Registered record administrator" or "accredited record  technician"
means a person who met the educational requirements for  taking,  and  who
has successfully passed, the  appropriate  examination  conducted  by  the
American medical record association.

  History:  1979 AC; 1981 AACS; 1983 AACS; 1988 AACS.


R  330.1210   Licenses; application; duration; renewal; qualifications.
  Rule 1210. (1) A hospital shall not be established or maintained in this
state  and  the  terms  "mental  hospital,"  "psychiatric  hospital,"  and
"psychiatric unit" shall not be used without  first  obtaining  a  license
from the department.
  (2) A license as a mental hospital, psychiatric hospital, or psychiatric
unit shall not be issued by the  department  without  first  receiving  an
application for a license which is filed with the department on prescribed
forms.
  (3) A license shall be issued for 1 year and may be renewed on an annual
basis.
  (4) To be considered for licensing, a hospital shall comply with all  of
the following provisions:
  (a) Be in compliance with parts 1, 4, and 7 of these rules.
  (b) Have approval of the state fire marshal.
  (c) Be in continuing compliance with the stipulations contained  in  the
hospital's approved certificate of need application.
  (5) A copy of the applicable standards  shall  be  furnished  with  each
application for license, and the applicant shall  acknowledge  receipt  of
the standards and agree to comply with them by signing a form provided for
that purpose. The form shall be filed with the application for license.

  History:  1979 AC; 1984 AACS.


R  330.1213   Temporary permit.
  Rule 1213. A nonrenewable temporary permit may be issued by the director
for a period of not more than 6 months if a hospital  does  not  meet  the
program requirements  for  licensing.  The  time  period  covered  by  the
temporary permit  shall  be  used  to  conduct  an  investigation  and  to
undertake remedial action. Application shall be filed with the  department
on the prescribed forms and shall be accompanied by the statutory fee.

  History:  1979 AC.


R  330.1214   Provisional licenses.
  Rule 1214. A provisional license may be issued to  a  hospital  that  is
unable to comply with rules relating to physical facilities for any length
of time up to 1 year, but may be renewed for not more  than  1  additional
year. Applications shall be filed with the department on prescribed  forms
and shall be accompanied by the statutory fee.

  History:  1979 AC; 1990 AACS.


R  330.1215   Construction permits.
  Rule 1215. A construction permit shall be obtained from  the  department
before a licensed hospital begins major construction. Application shall be
filed with the department on prescribed forms, shall be accompanied by the
statutory fee, and if also licensed by the department  of  public  health,
shall comply with the provisions of Act No. 256  of  the  Public  Acts  of
1972, being S331.451 et  seq. of  the  Michigan  Compiled  Laws,  covering
certificate of need, and if not, shall comply with provisions  of  section
1122 of amendments of the social security act of 1972, Public Law  92-603,
42 U.S.C. 401 et seq., 1395, 26 U.S.C. 1401, 1402, 3111, 3121,  and  6143.

  History:  1979 AC.


R  330.1220   Transferal of hospital license.
  Rule 1220. (1) A hospital license  is  not  transferable.  A  change  in
location, ownership, or  program  shall  require  a  new  application  for
license.
  (2) The department shall  be  notified  in  advance  of  a  change.  The
existing license shall be void as of the date of the change  and  returned
to the department.
  (3) A change of ownership shall be reported to the department when there
is a sale or transfer of 10% or more of the stock of a corporation  owning
a licensed hospital. The existing license shall be void as of the date  of
this change and returned to the department.

  History:  1979 AC.


R  330.1223   Application for license.
  Rule 1223. Application for a hospital license shall be  filed  on  forms
prescribed by the department and shall contain all of the following:
  (a) The names of the individual stockholders  and  percentage  of  stock
owned by each, and the names of the individuals  composing  the  governing
body.
  (b) An indication of whether the hospital is a member of  any  state  or
national association.
  (c) An indication of whether the hospital is  accredited  by  the  joint
commission  on  accreditation  of  hospitals.  If  it  has   applied   for
accreditation and was disapproved, it shall attach to  the  application  a
copy of the joint commission on accreditation of hospitals notification of
disapproval, including the list  of  recommendations.  If  it  is  already
accredited, it shall attach  to  the  application  a  copy  of  the  joint
commission on accreditation of hospitals  notification  of  accreditation,
including the list of recommendations.
  (d) A description of procedures and practices  followed  to  insure  the
physical health of employees.
  (e) A narrative description of the program plan of the hospital.
  (f) Current staffing patterns and list  of  employees  involved  in  the
professional care and treatment of patients, with their respective license
or certification numbers with the date of expiration.
  (g) Evidence of  conformity  with  standards  and  requirements  of  the
department of public health.
  (h) A floor plan of the space devoted to patient  care  and  activities.
This plan shall illustrate the exact inside  dimensions  of  each  patient
care room, the number of beds in each room, and the dimensions and use  of
other activity areas. Seclusion or quiet rooms and their dimensions  shall
be specifically identified.
  (i) For a mental hospital or psychiatric hospital, a  written  agreement
with a general hospital or group of  physicians  concerning  provision  of
necessary medical care, including  emergency  care  not  provided  in  the
hospital.

  History:  1979 AC.


R  330.1226   Emergency medical certification.
  Rule  1226.  A  licensed  hospital   shall   provide   initial   medical
certification, as defined in chapter 4 of the act, by  a  qualified  staff
person when an individual is presented for examination at a  time  when  a
qualified staff person is on duty.

  History:  1979 AC.


R  330.1228   Probate court hearing.
  Rule 1228. A licensed  hospital  shall  provide  appropriate  space  for
probate court hearings on involuntary  admissions  if  a  court  deems  it
practicable to convene at the hospital.

  History:  1979 AC.


R  330.1232   Inspections.
  Rule 1232. (1) The state fire marshal or  his  designee  may  enter  and
inspect the premises of an applicant or licensee at any  reasonable  time.
  (2) The director of the department of public health or his designee  may
enter the premises of an applicant or licensee at any reasonable time  for
the purpose of determining whether the hospital  meets  the  physical  and
operational standards or other requirements of the  department  of  public
health.
  (3) The director or his designee shall  be  permitted  to  make  on-site
inspections and comprehensive evaluations of the program of a hospital  at
any reasonable time.
  (4) Copies of inspection reports shall  be  sent  to  the  applicant  or
licensee.

  History:  1979 AC.


R  330.1235   Physical environment.
  Rule 1235. A hospital shall be:
  (a) Constructed, equipped,  and  maintained  to  insure  the  safety  of
patients, employees, and the public.
  (b) In compliance with all applicable state and  local  codes  governing
hospital construction.

  History:  1979 AC.


R  330.1239   Construction and equipment of psychiatric nursing units.
  Rule 1239. (1) Psychiatric nursing units shall be designed for the  care
of ambulatory and nonambulatory inpatients. Provision shall be made in the
design for adapting the area for various types  of  psychiatric  therapies
that will be used and for  providing  a  noninstitutional  atmosphere  for
ambulatory patients.  The  unit  shall  provide  a  safe  environment  for
patients and staff. Details of such facilities shall be  as  described  in
the approved functional program.
  (2) For patient rooms, each psychiatric  nursing  unit  shall  meet  the
standards noted in R 330.1243, except as follows:
  (a) Windows in psychiatric units shall have an operable section or  sash
controlled by keys or tools that are under the control of the  staff.  The
degree of security required shall be determined by  program  requirements,
but operation of the window sash shall be restricted to  inhibit  possible
escape or suicide. Where glass fragments may create a  hazard  because  of
the type  of  patients  expected,  safety  glazing  or  other  appropriate
security features, or both, shall be used.
  (b) A nurses' call system is  not  required,  but  if  it  is  included,
provision shall be made to permit removal of the system  or  for  covering
call button outlets.
  (c) Bedpan flushing devices may be omitted from patient room toilets  in
psychiatric nursing units.
  (3) For service areas, each psychiatric  nursing  unit  shall  meet  the
standards noted in R 330.1243, with modifications as follows:
  (a) The drug  distribution  unit  shall  provide  for  security  against
unauthorized access.
  (b) In place of a nourishment station, kitchen service may  be  provided
within the unit. If  used,  kitchen  service  shall  include  all  of  the
following:
  (i) A sink equipped for handwashing.
  (ii) Storage space.
  (iii) A refrigerator.
  (iv) Facilities for meal preparation.
  (c) Storage space for stretchers and  wheelchairs  may  be  outside  the
psychiatric unit if provision is made for convenient access as needed  for
handicapped patients.
  (d) A bathtub or shower shall be provided for each 6 beds not  otherwise
served by bathing facilities within the patient rooms.
  (4) All  of  the  following  elements  shall  be  provided  within  each
psychiatric nursing unit:
  (a) A separate charting area which provides for  acoustical  privacy.  A
viewing window to permit observation of  patient  areas  by  the  charting
nurse or physician may be used if the arrangement  is  such  that  patient
files cannot be read from outside the charting space.
  (b) Not less than 2 separate social  spaces,  1  appropriate  for  noisy
activities and 1 for quiet activities. The combined area shall be not less
than 3.72 square meters (40 square feet) per patient with  not  less  than
11.1 square meters (120 square feet) for each of the 2  spaces,  whichever
is greater. This space may be shared with dining activities.
  (c) Space for group therapy. This may be combined with the  quiet  space
noted in subdivision (b) of this subrule if an additional area of not less
than 0.7 square meters (8 square feet) per patient is added  to  the  area
and not less than 21 square meters (225 square feet)  of  space,  enclosed
for privacy, is available for group therapy activities.
  (d) Patient laundry facilities with automatic washer and dryer.
  (5) All of the following elements shall be provided, but may  be  either
within the psychiatric unit or immediately accessible to it:
  (a) Rooms for examination and treatment with a minimum area of not  less
than 11.1 square meters (120 square feet). Examination treatment rooms for
medical surgical patients may be shared by the psychiatric unit  patients.
These rooms may be on a different floor if conveniently accessible.
  (b) Separate consultation rooms with a minimum floor space of 9.3 square
meters (100 square  feet)  each  shall  be  provided  at  the  rate  of  1
consultation room for  each  30  psychiatric  beds.  The  rooms  shall  be
designed for acoustical and visual privacy and constructed  to  achieve  a
noise reduction of not less than 45 decibels.
  (c) Each psychiatric unit shall contain 1.39 square  meters  (15  square
feet) of separate space  per  patient  for  occupational  therapy  with  a
minimum total area of not less than 18.6 square meters (200 square  feet),
whichever is greater.  Space  shall  be  provided  for  handwashing,  work
counters, storage, and displays. Occupational therapy areas may serve more
than 1 nursing unit. When psychiatric units contain less than 16 beds, the
occupational  therapy  functions  may  be  performed  within   the   noisy
activities area, if not less than an  additional  0.9  square  meters  (10
square feet) per patient served is included.
  (6) Within the psychiatric nursing unit there shall be a seclusion  room
or rooms for patients requiring security and protection. The  rooms  shall
be located for direct nursing staff supervision. Each room  shall  be  for
only 1 patient. It shall have an area of not less than 9.3  square  meters
(100 square feet) and be constructed to prevent  patient  hiding,  escape,
injury, or suicide. If a facility has  more  than  1  psychiatric  nursing
unit, the number of seclusion rooms shall  be  a  function  of  the  total
number of psychiatric beds in the facility. Seclusion rooms may be grouped
together. The seclusion room is intended for  short-term  occupancy  by  a
patient who has become violent or suicidal.  Therefore,  special  fixtures
and hardware, including ground fault  interrupters  (GFI)  for  electrical
circuits and tamperproof outlets, shall be used. Doors shall open out  and
shall permit staff observation of the patient  while  maintaining  patient
privacy.
  If  the  interior  of  a  seclusion  room  is  padded  with  combustible
materials, the room area, including the floor,  walls,  ceiling,  and  all
openings, shall be protected with not less than 1-hour-rated construction.

  History:  1990 AACS.


R  330.1243   Construction and equipment of nursing units generally.
  Rule 1243. (1) Each patient room in a nursing unit shall meet all of the
following standards:
  (a) Maximum room capacity shall be 4 patients.
  (b) Patient room areas, exclusive of  toilet  rooms,  closets,  lockers,
wardrobes, alcoves, or vestibules, shall be  not  less  than  9.29  square
meters (100 square feet) for single-bed rooms and 7.43 square  meters  (80
square  feet)  per  bed  for  multiple-bed  rooms.  Minor   encroachments,
including columns and lavatories, that do not interfere with functions may
be ignored when determining  space  requirements  for  patient  rooms.  In
multiple-bed rooms, a clearance of 1.12 meters (3 feet 8 inches) shall  be
available at the foot of each bed to permit the passage of  equipment  and
beds. The areas noted in  this  subdivision  are  intended  as  recognized
minimums and do not prohibit the use of larger rooms  where  required  for
needs and functions.
  (c) Patient rooms intended for 24-hour  occupancy  or  more  shall  have
operable windows. Special tools for window operation may be used if  these
are available at all times for staff use.
  (d) Hand-washing facilities shall be provided in each patient room.  The
lavatory may be omitted from a bedroom if a water closet and lavatory  are
provided in a toilet room designed to serve 1 single-bed room or  1  2-bed
room.
  (e) Each patient shall have access to a toilet room without entering the
general corridor area. One toilet room shall serve not more  than  4  beds
and not more than 2 patient rooms. The toilet room shall contain  a  water
closet and a lavatory. The lavatory may be omitted from a toilet  room  if
each  patient  room  served  by  that  toilet  contains  a  lavatory   for
hand-washing.
  (f) Each patient shall have within his or her room a separate  wardrobe,
locker, or closet  suitable  for  hanging  full-length  garments  and  for
storing personal effects.
  (g) In multiple-bed rooms, visual privacy shall  be  provided  for  each
patient. The design for privacy shall not restrict patient access  to  the
entrance, lavatory, or toilet.
  (h) Ceilings shall be monolithic from wall to wall without fissures.
  (2) Provisions for the services noted in this subrule shall  be  located
in, or be readily available to, each nursing unit. The size  and  location
of each service area will depend  upon  the  numbers  and  types  of  beds
served. Identifiable  spaces  are  required  for  each  of  the  indicated
functions. Each service area may be arranged and  located  to  serve  more
than 1 nursing unit, but, unless noted otherwise, at least 1 such  service
area shall be provided on each nursing floor. Where  the  word  "room"  or
"office" is used, a separate, enclosed space for the 1 named  function  is
intended; otherwise, the described area may be a specific space in another
room or common area. Service areas shall include all of the following:
  (a) Administrative center or nurses' station.
  (b) Nurses' office for floor staff.
  (c) Administrative supplies storage.
  (d) Lavatories for hand-washing, conveniently accessible to the  nurses'
station, drug distribution station, and nourishment center.  One  lavatory
may serve several areas if convenient to each area.
  (e) Charting facilities.
  (f) Toilet rooms for staff.
  (g) Staff lounge facilities. These facilities may be  centrally  located
on another floor.
  (h) Securable closets or cabinet compartments for the  personal  effects
of nursing personnel, conveniently located  to  the  duty  station.  At  a
minimum, the closets or cabinets shall be  large  enough  for  purses  and
billfolds. Coats may be stored in closets or cabinets on each floor  in  a
central staff locker area.
  (i) Multipurpose rooms for staff  and  patient  conferences,  education,
demonstrations,  and  consultation.  These  rooms  shall  be  conveniently
accessible to each nursing unit. The rooms  may  be  on  other  floors  if
convenient for regular use. One such room may serve several nursing  units
or departments, or both.
  (j) Examination and treatment rooms. These rooms may be omitted  if  all
beds in the facility are single-bed patient  rooms.  The  examination  and
treatment rooms may serve several nursing units and may be on a  different
floor if conveniently located for routine  use.  Examination  rooms  shall
have a minimum floor  area  of  11.2  square  meters  (120  square  feet),
excluding space for vestibules,  toilets,  and  closets.  The  room  shall
contain a lavatory or sink equipped for hand-washing, storage  facilities,
and a desk, counter, or shelf space for writing.
  (k) Clean workroom or clean holding  room.  If  the  room  is  used  for
preparing patient care items, it shall contain a counter and  hand-washing
and storage facilities. If the room is used only for storage  and  holding
as part of a system for the  distribution  of  clean  and  sterile  supply
materials, the work counter and hand-washing facilities may be omitted.
  (l) Soiled material  workroom.  This  room  shall  contain  all  of  the
following:
  (i) A clinical sink or equivalent flushing rim fixture.
  (ii) A sink equipped for hand-washing.
  (iii) A work counter.
  (iv) Waste receptacles.
  (v) A linen receptacle.
Rooms used only for the temporary holding  of  soiled  material  need  not
contain hand-washing sinks or work counters. However, if  a  flushing  rim
sink is omitted, other provisions for the disposal of liquid waste at each
unit shall be made if the program requirements so dictate.
  (m) Drug distribution station. Provision shall be made for  the  24-hour
distribution of medications. This may be from a medicine preparation  room
or unit, from a self-contained medicine dispensing  unit,  or  by  another
approved system. If used, a medicine preparation room  or  unit  shall  be
under the visual control of nursing  staff.  A  medical  preparation  room
shall contain a work counter, sink, refrigerator, and locked  storage  for
controlled drugs and shall have a minimum area of 4.65 square  meters  (50
square feet). A self-contained medicine dispensing unit may be located  at
the nurses' station, in the clean workroom, or in an alcove.  As  standard
cup-sinks provided in many  self-contained  units  are  not  adequate  for
hand-washing,  provision  shall  be  made   for   convenient   access   to
hand-washing facilities.
  (n) Clean linen storage. Each nursing unit shall  contain  a  designated
area for clean linen storage. This may be within  the  clean  workroom,  a
separate closet, or an approved distribution system on each  floor.  If  a
closed cart system is used, storage may be in an alcove.  Carts  shall  be
out of the path of normal traffic.
  (o)  Nourishment  station.  This  station  shall  contain  all  of   the
following:
  (i) A sink.
  (ii) A work counter.
  (iii) A refrigerator.
  (iv) Storage cabinets.
  (v) Equipment for serving nourishment between scheduled meals.
Provisions and space shall be included for the separate temporary  storage
of unused and soiled dietary trays which are not picked up at mealtime. In
place of a nourishment station, kitchen service may be provided within the
unit. If kitchen service is used, this shall include a sink  equipped  for
hand-washing, storage space,  a  refrigerator,  and  facilities  for  meal
preparation.
  (p) Ice machine. Each nursing unit shall have equipment to  provide  ice
for treatments and nourishment. Ice-making equipment may be in  the  clean
workroom or at the nourishment station under staff control.  Ice  intended
for human consumption shall be from self-dispensing ice makers.
  (q) Equipment storage room. Storage space for stretchers and wheelchairs
may be outside the psychiatric unit if provisions are made for  convenient
access as needed for handicapped patients.
  (r) Bathing facilities. A bathtub or shower shall be provided for each 6
beds not otherwise served by bathing facilities within the patient  rooms.
  (s) Emergency equipment storage. Space shall be provided  for  emergency
equipment, such as a cardiopulmonary resuscitation (CPR)  cart,  which  is
under direct control of the nursing  staff,  in  close  proximity  to  the
nurses' station, but out of normal traffic.
  (t) Direct access to a janitor's closet for each nursing  unit  and  not
less than 1 janitor's closet for each floor. Each janitor's  closet  shall
contain a service sink or receptor  and  provisions  for  the  storage  of
supplies. This provision is in addition to separate janitor's closets that
may otherwise be required for the exclusive use of specific services.
  (u) An electrical receptacle shall be a  safety-type  receptacle  or  be
protected by 5 milliampere ground fault interrupters (GFI).

  History:  1990 AACS.


R  330.1250   Refusal to issue or renew and suspension  or  revocation  of
license.
  Rule 1250. If an  inspection  and  evaluation  results  in  findings  of
demonstrable deficiencies in the program, operating practices, or physical
conditions of a hospital, as specified in the act or  these  rules,  those
findings shall be grounds for refusal to issue or renew a license  or  for
suspension or revocation of a license:
  (a) The department shall list and describe deficiencies  upon  which  it
bases refusal to issue or renew or  for  suspension  or  revocation  of  a
license.
  (b) This list  and  description  shall  be  sent  to  the  applicant  or
licensee, stating proposed action and date for hearing.

  History:  1979 AC.


R  330.1252   Public inspection of license application records.
  Rule 1252. The department shall make  available  for  public  inspection
records pertaining  to  the  application  for  continued  licensure  of  a
hospital.
  (a) Records shall be available for public inspection in the department's
office in Lansing, Michigan, during regular office hours.
  (b) A report of department inspections shall be available 30 days  after
the department mails or otherwise delivers a copy of an inspection  report
to the applicant or licensee.
  (c) Records shall include all of the following:
  (i) A copy of the application for license.
  (ii) A copy of the license if one has been issued, or a  record  of  its
contents and date of issue if a copy has not been retained.
  (iii) Copies of reports of inspections made by  the  department  to  the
applicant or licensee and responses, if any, of the applicant or licensee.
  (iv) Copies of final orders or decisions  in  contested  cases  and  the
records on which they were based.
  (d) The department may delete  from  records  to  be  inspected  matters
described in section 13 of Act No. 442 of the Public Acts of  1976,  being
S15.243 of the Michigan Compiled Laws.
  (e) Copies of records pertaining to licenses processed by the department
will be available to the public by application to the  department  and  at
the expense of the applicant.

  History:  1979 AC.


R  330.1255   Disaster plan and emergency procedures.
  Rule 1255. (1) A hospital shall have written procedures to  be  followed
in case of fire, explosion, or  other  emergency,  including  all  of  the
following:
  (a) Persons to be notified.
  (b) Location of alarm signals and fire extinguishers.
  (c) Evacuation routes.
  (d) Procedures for evacuation of helpless patients.
  (e) Assignment of specific tasks and responsibilities  to  personnel  on
each shift.
  (2) Frequency of, and procedures for, fire drills and simulated disaster
drills shall be included in the written policy of a hospital.
  (3) A hospital shall conduct a simulated drill to test the effectiveness
of the disaster plan not less than 4 times a year.
  (4) The disaster  plan  and  frequency  of  simulated  drills  shall  be
prominently posted and made available to all employees.
  (5) A hospital shall have written procedures by which  patients  can  be
speedily removed from restraint or seclusion in the case of emergency.
  (6) A hospital shall assure that personnel are trained to perform  tasks
assigned to them in emergency plans.

  History:  1979 AC; 1986 AACS.


R  330.1260   Rights of recipients.
  Rule 1260. A hospital shall insure, in written policy and  in  practice,
that individuals receiving  services  shall  be  entitled  to  the  rights
guaranteed by the act and the rules promulgated thereunder.

  History:  1979 AC.


R  330.1265   Governing body.
  Rule 1265. (1) A hospital that is licensed by the department shall  have
a governing body which shall be responsible for all of the following:
  (a) Administration and management of the hospital.
  (b) Selection of medical staff and the quality of care rendered  by  the
hospital.
  (c) Assuring that physicians  and  other  personnel  for  whom  a  state
license,  certification,  or  registration  is  required   are   currently
licensed, certified, or registered.
  (2) The governing body of a licensed hospital shall adopt  bylaws  which
are in accordance with legal requirements.
  (3) The governing body of a  licensed  hospital  shall  certify  to  the
department that the hospital does not discriminate against any  person  on
the basis of race, color, nationality, religious or political belief, sex,
age, or handicap in any area of its operation. This includes  all  of  the
following areas:
  (a) Employment, unless a requirement of sex or age is based  on  a  bona
fide occupational qualification.
  (b) Patient admission and care.
  (c) Professional and nonprofessional training programs.
  (4) The governing body shall direct the administration of  the  hospital
to take action to assure that the hospital  adheres  to  nondiscriminatory
practices.

  History:  1979 AC; 1981 AACS.


R  330.1267   Administrator and chief of service.
  Rule 1267. (1) The governing body of a licensed hospital  other  than  a
psychiatric unit shall appoint  a  person,  responsible  to  them,  as  an
administrator, whose primary duties shall be to:
  (a) Organize and oversee daily administrative functions of the hospital.
  (b) Maintain effective liaison between the  staff,  departments  of  the
hospital, and the governing body.
  (2) The administrator, acting in behalf of  the  governing  body,  shall
appoint a psychiatrist with a current license in the state of Michigan  as
the chief of service responsible for:
  (a) The general character of professional diagnostic and treatment  care
provided.
  (b) Recommendations to the administration concerning equipment,  routine
procedures, and other matters concerning patient care.

  History:  1979 AC.


R  330.1269   Available services.
  Rule 1269. (1) A hospital shall provide for the services of a sufficient
number  of  appropriately  qualified  mental  health   professionals   and
supporting staff to develop and carry out the program  plan.  These  shall
include all of the following:
  (a) Educators.
  (b) Occupational, music, recreational, or physical therapists.
  (c) Registered nurses.
  (d) Psychiatrists and other physicians.
  (e) Psychologists.
  (f) Social workers.
  (g) Vocational counselors.
  (h) Mental health counselors.
  (2) The administrator of a hospital which has a separate, formal program
for adolescents or children, or both, shall insure  that  the  fundamental
needs of the patients are met and shall provide  for  the  services  of  a
sufficient number of appropriately qualified mental  health  professionals
and support staff as necessary to develop and carry out the program  plan.
These shall include all of the following:
  (a) Child care workers.
  (b) Educators.
  (c) Mental health counselors.
  (d) Occupational, music, recreational, or physical therapists.
  (e) Psychiatrists and other physicians.
  (f) Psychologists.
  (g) Registered nurses.
  (h) Social workers.
  (i) Speech, hearing, and language specialists.
  (j) Vocational counselors.

  History:  1979 AC; 1983 AACS.


R  330.1274   Notification of deaths.
  Rule  1274.  The  administrator  or  his  designee  shall   inform   the
department, as soon as administratively possible, of all deaths.

  History:  1979 AC.


R  330.1275   Summary of patient movement.
  Rule 1275. A monthly summary of patient movement shall  be  compiled  by
each psychiatric hospital and psychiatric unit. This monthly summary shall
be filed with the department on the prescribed form.

  History:  1990 AACS.


R  330.1276   Records.
  Rule 1276. (1) All of the following records shall  be  maintained  by  a
licensee and shall be made available for examination by the department:
  (a) Policies and procedures followed by  the  hospital  to  ensure  that
employees are in good physical and mental health.
  (b) Documentation which substantiates that the policies  and  procedures
specified in subdivision (a) have been uniformly implemented.
  (c) Records of periodic inspection by local and state fire marshals.
  (d) Records of execution of fire and simulated disaster plan drills.
  (e) Records of health inspections, including both of the following:
  (i) Inspections by state or local health authorities.
  (ii) Documentation of actions taken to comply with department of  public
health recommendations.
  (f) Reports of the  joint  commission  on  accreditation  of  hospitals,
including both of the following:
  (i) Notification of accreditation and a list of recommendations.
  (ii) Notification of disapproval and a list of recommendations.
  (2) All of the following administrative records shall be maintained by a
licensee and shall be made available for examination by the department:
  (a) Admissions, discharges, transfers, and deaths.
  (b) All of the following complete and accurately written records:
  (i) Personnel policies and procedures.
  (ii) Job descriptions.
  (iii) Personnel assignments.
  (c) Written policies and procedures  relating  to  the  notification  of
responsible persons in the event of a significant change in  the  physical
or mental condition of a patient.
  (d) Records of all of the following:
  (i) Unusual deaths of patients.
  (ii) Unusual behavior of, or incidents regarding, patients.
  (iii) Accidents or injuries.
  (e) Patient movement in and out of the hospital.
  (3) A licensee shall maintain  an  adequate  medical  record  for  every
patient in  the  hospital,  which  shall  include  all  of  the  following
information:
  (a) Identification data and consent forms.
  (b) History of the patient.
  (c) All of the following reports:
  (i) Psychiatric evaluations.
  (ii) Neurological and physical examinations.
  (iii) Other diagnostic procedures and examinations.
  (d) Individualized plan of services.
  (e) Medical orders.
  (f) Observations.
  (g) Reports of actions, findings, and conclusions.
  (h) Discharge summary.
  (4) Medical records shall be confidential, as required by section 748 of
the act, and shall be current and accurate.
  (5) A registered record administrator or an accredited record technician
shall be employed on a full-time or part-time basis to facilitate accurate
processing, checking, indexing, and filing of medical records.
  (6)  The  medical  record  services   shall   maintain   a   system   of
identification and filing to facilitate prompt  location  of  a  patient's
medical records.

  History:  1979 AC; 1986 AACS; 1988 AACS.


R  330.1279   Coordinated plan of service.
  Rule  1279.  Mental  health  professionals  involved  in  the  care  and
treatment of a patient shall work together to provide an  integrated  plan
of service.

  History:  1979 AC.


R  330.1281   Physician responsibility.
  Rule 1281. (1) Health care of every patient in a psychiatric hospital or
a psychiatric unit shall be under the supervision of a physician from  the
time of admission to discharge.
  (2) The type, duration, and amount of medications and medical  treatment
shall be ordered by a patient's physician or  by  a  psychiatric  hospital
physician if the patient's physician is not available.

  History:  1979 AC; 1986 AACS.


R  330.1285   Nursing.
  Rule 1285. (1) A psychiatric hospital or psychiatric unit shall have  an
organized nursing service adequate to care for the patients.
  (2) A nursing service shall have a  written  plan  that  delineates  its
functional structure  and  its  mechanism  for  cooperative  planning  and
decision making, including periodic review and evaluation of the plan.
  (3) A nursing  service  shall  have  written  policies  and  procedures,
including a system of annual review  and  update,  for  the  provision  of
nursing services and  for  the  direction  of  nursing  personnel  in  the
performance of their duties.
  (4) A nursing service shall be under the direction of a registered nurse
who shall have, at a minimum, a bachelor's degree, 3 years of  psychiatric
nursing work experience, and a current Michigan license  as  a  registered
nurse.
  (5) Administrative and clinical consultation shall be available  to  the
director of nursing from a qualified psychiatric nursing specialist with a
master's degree, unless the director of nursing is so qualified.
  (6) In addition to the requirements of subrule (7) of this  rule,  there
shall be at least 1 licensed registered nurse with 1 year  of  psychiatric
nursing experience on  duty  on  each  work  shift  within  a  psychiatric
hospital or psychiatric unit.
  (7) A psychiatric hospital or psychiatric unit shall provide  ratios  of
clinical nursing personnel to number of patients 24 hours a day  to  carry
out the individual service plan for each  patient.  Determination  of  the
ratio shall be made in accordance with the  nursing  program  requirements
for each nursing unit of the psychiatric  hospital  or  psychiatric  unit.
Once determined it shall be stated in the nursing  organization  plan  and
program staffing shall be maintained at not less  than  the  stated  level
until there is a change in the type of patient care required.
  (8) Orientation and staff development programs  in  psychiatric  nursing
shall be provided for all psychiatric nursing personnel.

  History:  1979 AC; 1986 AACS.


R  330.1287   Social service staff requirements.
  Rule 1287. (1) A psychiatric hospital or psychiatric unit shall have  an
organized social services program and staff adequate to  meet  the  social
service needs of the patients.
  (2) A social service  program  shall  have  a  written  plan  describing
arrangements for the provisions of the services.
  (3) A social services program shall have written policies and procedures
for provision of social services, including a system of review and  annual
update, to guide social service personnel  in  the  performance  of  their
duties.
  (4) A social services program  shall  be  under  the  supervision  of  a
certified social worker on a full-time or part-time basis.
  (5) Staff shall be social workers.
  (6) Orientation and staff development programs  shall  be  provided  for
social service personnel.

  History:  1979 AC; 1986 AACS.


R  330.1289   Psychological services.
  Rule 1289. (1) A psychiatric hospital or psychiatric unit shall  have  a
psychological services program which has a written  plan  arrangement  for
the provision of services.
  (2) A psychological services program shall  have  written  policies  and
procedures for the provision of psychological services, including a system
of review and annual update, to guide psychological services personnel  in
the performance of their duties.
  (3) A psychological services program shall be under the supervision of a
fully licensed psychologist on a full-time or part-time basis.
  (4) When the psychiatric hospital or psychiatric unit has  psychological
staff in its employ, orientation and staff development programs  shall  be
provided.

  History:  1979 AC; 1986 AACS.


R  330.1291   Activity therapy service staff requirements.
  Rule 1291. (1) A psychiatric hospital or psychiatric unit shall have  an
organized activity therapy services program and staff adequate to meet the
therapeutic activity needs of the patients.
  (2) An activity therapy services  program  shall  have  a  written  plan
describing arrangements for the provision of services.
  (3) An activity therapy services program shall have written policies and
procedures for the provision of activity services, including a  system  of
review and annual update, to guide  activity  services  personnel  in  the
performance of their duties.
  (4) An activity therapy services program shall be under the  supervision
of a registered  occupational,  music,  or  recreational  therapist  on  a
full-time or part-time basis. The program may  be  directed  by  a  mental
health professional.
  (5) Orientation and staff development programs  shall  be  provided  for
activity therapy services personnel.

  History:  1979 AC; 1986 AACS.


R  330.1295   Posting of license and fire regulations.
  Rule 1295. (1) A current  license  shall  be  prominently  posted  in  a
conspicuous place in the hospital.
  (2) Fire regulations shall be prominently posted and carefully observed.

  History:  1979 AC.



R  330.1299   Waiver of licensure requirements.
  Rule  1299.  (1)  The  director  may  issue  a  temporary  waiver  of  a
requirement for licensure when:
  (a) There is a justifiable and documented  reason  why  the  requirement
cannot be met.
  (b) Temporary waiver of the requirement would not  significantly  reduce
effective treatment, nor adversely affect the health of patients.
  (c) All other requirements are met.
  (d) The provisions of the mental health code are not violated.
  (2) A waiver of a requirement shall be for 1 year and may be renewed if:
  (a) The applicant shows evidence that significant attempts were made  to
meet the requirement.
  (b) Services to residents were not significantly  affected  because  the
licensee has not met the requirement.
  (3) A request for waiver, and supporting arguments, shall accompany  the
original application for license  and  subsequent  annual  renewals,  when
applicable.
  (4) A waiver shall only apply to rules between R 330.1210 to  R 330.1295
of these rules.

  History:  1979 AC.