This Michigan regulation establishes licensing requirements for psychiatric hospitals, mental hospitals, and psychiatric units (collectively 'hospitals') that are not operated by the state or federal government. Operators must obtain a license from the department before establishing or maintaining such a facility, and must comply with application procedures, physical environment standards, construction requirements, and program standards. The rules cover license issuance, renewal, transfers, temporary and provisional permits, construction permits, inspections, and detailed physical plant requirements for psychiatric nursing units including seclusion rooms, therapy spaces, and safety features.
View official sourcePage 1 Courtesy of www.michigan.gov/orr 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 Publ ic 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 su pervised 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 wh ich 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. Page 2 Courtesy of www.michigan.gov/orr (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 psy chiatric 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 stipulation s 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. App lication 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. Page 3 Courtesy of www.michigan.gov/orr 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 notifi ed 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 sh all 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. Page 4 Courtesy of www.michigan.gov/orr (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 pat ient 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 agreemen t 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 licen sed 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 d esignee 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. Page 5 Courtesy of www.michigan.gov/orr 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 ma de 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 hav e 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 pro vided 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 chartin g nurse or physician may Page 6 Courtesy of www.michigan.gov/orr 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 combine d 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 grou p 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 psychiatri c 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 un it 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 t he patient while maintaining patient privacy. If the in terior 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. Page 7 Courtesy of www.michigan.gov/orr 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, clos ets, 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 wa ter 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 be ds 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 pat ient 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 loca ted 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. Page 8 Courtesy of www.michigan.gov/orr (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 fo r 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 dispen sing 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 Page 9 Courtesy of www.michigan.gov/orr 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 inclu ded 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 sh all h ave 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 sin k 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 findin gs 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. Page 10 Courtesy of www.michigan.gov/orr 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 dec isions 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 per form tasks assigned to them in emergency plans. Page 11 Courtesy of www.michigan.gov/orr 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 sh all 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. Page 12 Courtesy of www.michigan.gov/orr (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. Page 13 Courtesy of www.michigan.gov/orr 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. Page 14 Courtesy of www.michigan.gov/orr (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 a nd 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 psyc hiatric nursing work experience, and a current Michigan license as a registered nurse. Page 15 Courtesy of www.michigan.gov/orr (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. Determ ination 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 sys tem 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 uni t 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, includ ing 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. Page 16 Courtesy of www.michigan.gov/orr 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 s ignificantly 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 suppo rting arguments, shall accompany the original application for license and subsequent annual renewals, when applicable. Page 17 Courtesy of www.michigan.gov/orr (4) A waiver shall only apply to rules between R 330.1210 to R 330.1295 of these rules. History: 1979 AC.