1. DIVISION OF LICENSING & CERTIFICATION, BUREAU OF HEALTH SYSTEMS (BHS) - MDCH (517) 241-4160 Fax (517) 241-3354

2. 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.

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Number of Facilities We Oversee 177 Licensed hospitals 7100 Clinical Laboratories of which 350 are surveyed biennial 1361 Licensed Substance Abuse Facilities

11. 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.

12. 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.