DIVISION OF LICENSING & CERTIFICATION, BUREAU OF

HEALTH SYSTEMS(BHS) - MDCH

(517) 241-4160

Fax (517) 241-3354

Background of the Division

• The Licensing and Certification Division (L&C) was established to protect the health and safety of individuals receiving care in non-long term care health facilities.

• L&C assists in the protection of the health and safety of individuals by scheduling inspections and complaint investigations of various non long-term care health facilities.

Inspections of Facilities - Objectives

• Are facilities compliant with state and federal statutes?

• Determine if applicable complaint allegations are supported.

• Help to protect and promote the public’s health.

State & Federal Statutes Providing Authority

• Public Health Code (PHC), Act 368 of 1978• Mental Health Code (MHC) Act 258 of 1974,

as amended• Code of Federal Regulation (CFR), Part / Title

42, Subchapter E – Standards & Certification• The Federal Clinical Laboratory Improvement

Amendments of 1988 (CLIA), at 42 CFR 493 • Substance Abuse Administrative Rules

MAJOR TYPES OF NON-LONG TERM FACILITIES

• Hospitals, Psychiatric Hospitals and Psychiatric Units in Hospitals, Freestanding Surgical Outpatient Facilities, End Stage Renal Disease Facilities, Home Health Care Agencies, Hospices & Hospice Residences, Ambulatory Surgical Care, Outpatient Physical Therapy, Laboratories, and Substance Abuse Facilities

SOME DEFINITIONS

• Hospitals: staffed to provide 24 hour care• Psychiatric Hospital: offers inpatient services

for the observation, diagnosis, active treatment, and overnight care of persons with a mental disease or with a chronic mental condition

• Psychiatric Unit: A unit of a general hospital that provides inpatient services for individuals with serious mental illness

Definitions (cont…….)

• Freestanding Surgical Outpatient Facility: surgical procedures not requiring overnight stay

• End Stage Renal Disease (ESRD) Facility: certified to provide ESRD services such as dialysis

• Home Health Care Agency: provides skilled nursing services to patients in homes

• Hospices: alternative way of caring for the terminally ill individuals; stresses palliative care

Definitions (cont……)

• Clinical Labs: any facility that examines human specimens for the diagnosis, prevention, or treatment of any disease or impairment of human beings

• Substance Abuse Programs: public or private firm, association, organization, or group offering substance use disorder treatment

Type of Facilities We Don’t Inspect

• Physician offices

• Health clinics

• Urgent care facilities

• Labs where examinations are performed personally

• Adult Foster Care

• Assisted Living

Number of Facilities We Oversee

• 177 Licensed hospitals

• 7100 Clinical Laboratories of which 350 are surveyed biennial

• 1361 Licensed Substance Abuse Facilities

ACCOMPLISHMENTS – FISCAL YEAR 06

• Conducted 71 acute care complaint investigations, surveyed 24 high-risk End Stage Renal Dialysis facilities.

• Conducted 165 on-site surveys for Substance Abuse facilities, with an emphasis on high-risk facilities such as Methadone Clinics.

Most Frequent Cited Deficiencies

• Hospitals: Physical Environment such as building not clean; Medical orders not dated and signed.

• Home Health Agencies (HHA): Inadequate Plan of Care such as the scope of services not specified or no needs assessment done.