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.  
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(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.  
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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.  
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(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.  
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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  
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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.  
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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.  
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(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  
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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.  
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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.  
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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.  
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(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.  
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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.  
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(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.  
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(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.  
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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.  
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(4) A waiver shall only apply to rules between R 330.1210 to R 330.1295 of these  
rules.  
History: 1979 AC.  
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;