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DIVISION OF LICENSING & CERTIFICATION, BUREAU OF HEALTH SYSTEMS (BHS) - MDCH

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

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DIVISION OF LICENSING & CERTIFICATION, BUREAU OF HEALTH SYSTEMS (BHS) - MDCH

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  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.

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