August 3, 2005, Introduced by Reps. Williams, Phillips, Gonzales and Alma Smith and referred to the Committee on Senior Health, Security, and Retirement.
A bill to amend 1978 PA 368, entitled
"Public health code,"
by amending section 20155 (MCL 333.20155), as amended by 2001 PA
218.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 20155. (1) Except as otherwise provided in this section,
the
department of consumer and industry services shall
make
annual and other visits to each health facility or agency licensed
under this article for the purposes of survey, evaluation, and
consultation. A visit made pursuant to a complaint shall be
unannounced. Except for a county medical care facility, a home for
the aged, a nursing home, or a hospice residence, the department
shall determine whether the visits that are not made pursuant to a
complaint are announced or unannounced. In addition to visits made
pursuant to a complaint investigation, the department shall
annually make at least 2 unannounced visits to each county medical
care facility and hospice residence. Beginning June 20, 2001, the
department shall assure that each newly hired nursing home
surveyor, as part of his or her basic training, is assigned full-
time to a licensed nursing home for at least 10 days within a 14-
day period to observe actual operations outside of the survey
process before the trainee begins oversight responsibilities. A
member of a survey team shall not be employed by a licensed nursing
home or a nursing home management company doing business in this
state at the time of conducting a survey under this section. The
department shall not assign an individual to be a member of a
survey team for purposes of a survey, evaluation, or consultation
visit at a nursing home in which he or she was an employee within
the preceding 5 years.
(2)
The department of consumer and industry services shall
make
at least a biennial visit to each licensed clinical laboratory
,
each nursing home, and each
hospice residence for the purposes
of survey, evaluation, and consultation. In addition to visits made
pursuant to complaint investigations, the department shall annually
make at least 2 unannounced visits and inspect each nursing home
licensed under this article, regardless of whether the nursing home
is
certified under title XVIII or title XIX.
The department of
consumer
and industry services shall semiannually provide for
joint training with nursing home surveyors and providers on at
least 1 of the 10 most frequently issued federal citations in this
state
during the past calendar year. The department of consumer
and
industry services shall develop a protocol for the review of
citation patterns compared to regional outcomes and standards and
complaints regarding the nursing home survey process. The review
will result in a report provided to the legislature. Except as
otherwise provided in this subsection, beginning with his or her
first
full relicensure period after June 20, 2000 2001,
each
member
of a department of consumer and industry services nursing
home survey team who is a health professional licensee under
article 15 shall earn not less than 50% of his or her required
continuing education credits, if any, in geriatric care. If a
member of a nursing home survey team is a pharmacist licensed under
article 15, he or she shall earn not less than 30% of his or her
required continuing education credits in geriatric care.
(3)
The department of consumer and industry services shall
make a biennial visit to each hospital for survey and evaluation
for the purpose of licensure. Subject to subsection (6), the
department may waive the biennial visit required by this subsection
if a hospital, as part of a timely application for license renewal,
requests a waiver and submits both of the following and if all of
the requirements of subsection (5) are met:
(a) Evidence that it is currently fully accredited by a body
with expertise in hospital accreditation whose hospital
accreditations are accepted by the United States department of
health
and human services for purposes of section 1865 of part C
D of title XVIII of the social security act, 42 U.S.C.
USC
1395bb.
(b) A copy of the most recent accreditation report for the
hospital issued by a body described in subdivision (a), and the
hospital's responses to the accreditation report.
(4) Except as provided in subsection (8), accreditation
information
provided to the department of consumer and industry
services
under subsection (3) is confidential, is not a
public
record, and is not subject to court subpoena. The department shall
use the accreditation information only as provided in this section
and shall return the accreditation information to the hospital
within a reasonable time after a decision on the waiver request is
made.
(5)
The department of consumer and industry services shall
grant a waiver under subsection (3) if the accreditation report
submitted under subsection (3)(b) is less than 2 years old and
there is no indication of substantial noncompliance with licensure
standards or of deficiencies that represent a threat to public
safety or patient care in the report, in complaints involving the
hospital, or in any other information available to the department.
If the accreditation report is 2 or more years old, the department
may do 1 of the following:
(a) Grant an extension of the hospital's current license until
the next accreditation survey is completed by the body described in
subsection (3)(a).
(b) Grant a waiver under subsection (3) based on the
accreditation report that is 2 or more years old, on condition that
the hospital promptly submit the next accreditation report to the
department.
(c) Deny the waiver request and conduct the visits required
under subsection (3).
(6) This section does not prohibit the department from citing
a violation of this part during a survey, conducting investigations
or inspections pursuant to section 20156, or conducting surveys of
health facilities or agencies for the purpose of complaint
investigations or federal certification. This section does not
prohibit the state fire marshal from conducting annual surveys of
hospitals, nursing homes, and county medical care facilities.
(7) At the request of a health facility or agency, the
department of
consumer and industry services may conduct a
consultation engineering survey of a health facility and provide
professional advice and consultation regarding health facility
construction and design. A health facility or agency may request a
voluntary consultation survey under this subsection at any time
between licensure surveys. The fees for a consultation engineering
survey are the same as the fees established for waivers under
section 20161(10).
(8)
If the department of consumer and industry services
determines that substantial noncompliance with licensure standards
exists or that deficiencies that represent a threat to public
safety or patient care exist based on a review of an accreditation
report submitted pursuant to subsection (3)(b), the department
shall prepare a written summary of the substantial noncompliance or
deficiencies and the hospital's response to the department's
determination. The department's written summary and the hospital's
response are public documents.
(9)
The department of consumer and industry services or a
local health department shall conduct investigations or
inspections,
other than inspections an
inspection of financial
records, of a county medical care facility, home for the aged,
nursing home, or hospice residence without prior notice to the
health facility or agency. An employee of a state agency charged
with investigating or inspecting the health facility or agency or
an employee of a local health department who directly or indirectly
gives prior notice regarding an investigation or an inspection,
other than an inspection of the financial records, to the health
facility or agency or to an employee of the health facility or
agency,
is guilty of a misdemeanor. Consultation visits that are
A consultation visit that is not for the purpose of annual or
follow-up inspection or survey may be announced.
(10)
The department of consumer and industry services shall
maintain a record indicating whether a visit and inspection is
announced or unannounced. Information gathered at each visit and
inspection, whether announced or unannounced, shall be taken into
account in licensure decisions.
(11)
The department of consumer and industry services shall
require periodic reports and a health facility or agency shall give
the department access to books, records, and other documents
maintained by a health facility or agency to the extent necessary
to carry out the purpose of this article and the rules promulgated
under this article. The department shall respect the
confidentiality of a patient's clinical record and shall not
divulge or disclose the contents of the records in a manner that
identifies an individual except under court order. The department
may copy health facility or agency records as required to document
findings.
(12)
The department of consumer and industry services may
delegate survey, evaluation, or consultation functions to another
state agency or to a local health department qualified to perform
those functions. However, the department shall not delegate survey,
evaluation, or consultation functions to a local health department
that owns or operates a hospice or hospice residence licensed under
this article. The delegation shall be by cost reimbursement
contract between the department and the state agency or local
health department. Survey, evaluation, or consultation functions
shall not be delegated to nongovernmental agencies, except as
provided in this section. The department may accept voluntary
inspections performed by an accrediting body with expertise in
clinical laboratory accreditation under part 205 if the accrediting
body utilizes forms acceptable to the department, applies the same
licensing standards as applied to other clinical laboratories and
provides the same information and data usually filed by the
department's own employees when engaged in similar inspections or
surveys. The voluntary inspection described in this subsection
shall be agreed upon by both the licensee and the department.
(13)
If, upon investigation, the department
of consumer and
industry
services or a state agency determines that an individual
licensed to practice a profession in this state has violated the
applicable licensure statute or the rules promulgated under that
statute, the department, state agency, or local health department
shall forward the evidence it has to the appropriate licensing
agency.
(14)
The department of consumer and industry services shall
report to the appropriations subcommittees, the senate and house of
representatives standing committees having jurisdiction over issues
involving senior citizens, and the fiscal agencies on March 1 of
each year on the initial and follow-up surveys conducted on all
nursing homes in this state. The report shall include all of the
following information:
(a) The number of surveys conducted.
(b) The number requiring follow-up surveys.
(c) The number referred to the Michigan public health
institute for remediation.
(d) The number of citations per nursing home.
(e) The number of night and weekend complaints filed.
(f) The number of night and weekend responses to complaints
conducted by the department.
(g) The average length of time for the department to respond
to a complaint filed against a nursing home.
(h) The number and percentage of citations appealed.
(i) The number and percentage of citations overturned or
modified, or both.
(15)
The department of consumer and industry services shall
report annually to the standing committees on appropriations and
the standing committees having jurisdiction over issues involving
senior citizens in the senate and the house of representatives on
the percentage of nursing home citations that are appealed and the
percentage of nursing home citations that are appealed and amended
through the informal deficiency dispute resolution process.
(16) Subject to subsection (17), a clarification work group
comprised
of the department of consumer and industry services in
consultation with a nursing home resident or a member of a nursing
home resident's family, nursing home provider groups, the American
medical directors association, the department of community health,
the state long-term care ombudsman, and the federal centers for
medicare and medicaid services shall clarify the following terms as
those terms are used in title XVIII and title XIX and applied by
the department to provide more consistent regulation of nursing
homes in Michigan:
(a) Immediate jeopardy.
(b) Harm.
(c) Potential harm.
(d) Avoidable.
(e) Unavoidable.
(17) All of the following clarifications developed under
subsection (16) apply for purposes of subsection (16):
(a)
Specifically, the term "immediate jeopardy" means "
a
situation in which immediate corrective action is necessary because
the nursing home's noncompliance with 1 or more requirements of
participation has caused or is likely to cause serious injury,
harm, impairment, or death to a resident receiving care in a
nursing
home. ".
(b) The likelihood of immediate jeopardy is reasonably higher
if there is evidence of a flagrant failure by the nursing home to
comply with a clinical process guideline adopted under subsection
(18) than if the nursing home has substantially and continuously
complied with those guidelines. If federal regulations and
guidelines are not clear, and if the clinical process guidelines
have been recognized, a process failure giving rise to an immediate
jeopardy may involve an egregious widespread or repeated process
failure and the absence of reasonable efforts to detect and prevent
the process failure.
(c) In determining whether or not there is immediate jeopardy,
the survey agency should consider at least all of the following:
(i) Whether the nursing home could reasonably have been
expected to know about the deficient practice and to stop it, but
did not stop the deficient practice.
(ii) Whether the nursing home could reasonably have been
expected to identify the deficient practice and to correct it, but
did not correct the deficient practice.
(iii) Whether the nursing home could reasonably have been
expected to anticipate that serious injury, serious harm,
impairment, or death might result from continuing the deficient
practice, but did not so anticipate.
(iv) Whether the nursing home could reasonably have been
expected to know that a widely accepted high-risk practice is or
could be problematic, but did not know.
(v) Whether the nursing home could reasonably have been
expected to detect the process problem in a more timely fashion,
but did not so detect.
(d) The existence of 1 or more of the factors described in
subdivision (c), and especially the existence of 3 or more of those
factors simultaneously, may lead to a conclusion that the situation
is one in which the nursing home's practice makes adverse events
likely to occur if immediate intervention is not undertaken, and
therefore constitutes immediate jeopardy. If none of the factors
described in subdivision (c) is present, the situation may involve
harm or potential harm that is not immediate jeopardy.
(e)
Specifically, "actual harm" means " a
negative outcome
to a resident that has compromised the resident's ability to
maintain or reach, or both, his or her highest practicable
physical, mental, and psychosocial well-being as defined by an
accurate and comprehensive resident assessment, plan of care, and
provision
of services. ". Harm does not include a
deficient
practice that only may cause or has caused limited consequences to
the resident.
(f) For purposes of subdivision (e), in determining whether a
negative outcome is of limited consequence, if the "state
operations manual" or "the guidance to surveyors" published by the
federal centers for medicare and medicaid services does not provide
specific guidance, the department may consider whether most people
in similar circumstances would feel that the damage was of such
short duration or impact as to be inconsequential or trivial. In
such a case, the consequence of a negative outcome may be
considered more limited if it occurs in the context of overall
procedural consistency with an accepted clinical process guideline
adopted pursuant to subsection (18), as compared to a substantial
inconsistency with or variance from the guideline.
(g) For purposes of subdivision (e), if the publications
described in subdivision (f) do not provide specific guidance, the
department may consider the degree of a nursing home's adherence to
a clinical process guideline adopted pursuant to subsection (18) in
considering whether the degree of compromise and future risk to the
resident constitutes actual harm. The risk of significant
compromise to the resident may be considered greater in the context
of substantial deviation from the guidelines than in the case of
overall adherence.
(h) To improve consistency and to avoid disputes over
"avoidable" and "unavoidable" negative outcomes, nursing homes and
survey agencies must have a common understanding of accepted
process guidelines and of the circumstances under which it can
reasonably be said that certain actions or inactions will lead to
avoidable negative outcomes. If the "state operations manual" or
"the guidance to surveyors" published by the federal centers for
medicare and medicaid services is not specific, a nursing home's
overall documentation of adherence to a clinical process guideline
with a process indicator adopted pursuant to subsection (18) is
relevant information in considering whether a negative outcome was
"avoidable" or "unavoidable" and may be considered in the
application of that term.
(18) Subject to subsection (19), the department, in
consultation with the clarification work group appointed under
subsection (16), shall develop and adopt clinical process
guidelines that shall be used in applying the terms set forth in
subsection (16). The department shall establish and adopt clinical
process guidelines and compliance protocols with outcome measures
for all of the following areas and for other topics where the
department determines that clarification will benefit providers and
consumers of long-term care:
(a) Bed rails.
(b) Adverse drug effects.
(c) Falls.
(d) Pressure sores.
(e) Nutrition and hydration including, but not limited to,
heat-related stress.
(f) Pain management.
(g) Depression and depression pharmacotherapy.
(h) Heart failure.
(i) Urinary incontinence.
(j) Dementia.
(k) Osteoporosis.
(l) Altered mental states.
(m) Physical and chemical restraints.
(19) The department shall create a clinical advisory committee
to review and make recommendations regarding the clinical process
guidelines with outcome measures adopted under subsection (18). The
department shall appoint physicians, registered professional
nurses, and licensed practical nurses to the clinical advisory
committee, along with professionals who have expertise in long-term
care services, some of whom may be employed by long-term care
facilities. The clarification work group created under subsection
(16) shall review the clinical process guidelines and outcome
measures after the clinical advisory committee and shall make the
final recommendations to the department before the clinical process
guidelines are adopted.
(20) The department shall create a process by which the
director of the division of nursing home monitoring or his or her
designee or the director of the division of operations or his or
her designee reviews and authorizes the issuance of a citation for
immediate jeopardy or substandard quality of care before the
statement of deficiencies is made final. The review shall be to
assure that the applicable concepts, clinical process guidelines,
and other tools contained in subsections (17) to (19) are being
used consistently, accurately, and effectively. As used in this
subsection, "immediate jeopardy" and "substandard quality of care"
mean those terms as defined by the federal centers for medicare and
medicaid services.
(21) The department may give grants, awards, or other
recognition to nursing homes to encourage the rapid implementation
of the clinical process guidelines adopted under subsection (18).
(22) The department shall assess the effectiveness of the
amendatory act that added this subsection. The department shall
file an annual report on the implementation of the clinical process
guidelines and the impact of the guidelines on resident care with
the standing committee in the legislature with jurisdiction over
matters pertaining to nursing homes. The first report shall be
filed
on July 1, 2002. of the year following the year in which the
amendatory
act that added this subsection takes effect.
(23)
The department of consumer and industry services shall
instruct and train the surveyors in the use of the clarifications
described in subsection (17) and the clinical process guidelines
adopted under subsection (18) in citing deficiencies.
(24) A nursing home shall post the nursing home's survey
report in a conspicuous place within the nursing home for public
review.
(25) Nothing in this amendatory act shall be construed to
limit the requirements of related state and federal law.
(26) As used in this section:
(a) "Title XVIII" means title XVIII of the social security
act, chapter
531, 49 Stat. 620, 42 U.S.C. 1395 to 1395b, 1395b-2,
1395b-6
to 1395b-7, 1395c to 1395i, 1395i-2 to 1395i-5, 1395j to
1395t,
1395u to 1395w, 1395w-2 to 1395w-4, 1395w-21 to 1395w-28,
1395x
to 1395yy, and 1395bbb to 1395ggg 42
USC 1395 to 1395hhh.
(b)
"Title XIX" means title XIX of the social security act,
chapter
531, 49 Stat. 620, 42 U.S.C. 1396 to 1396f, 1396g-1 to
1396r-6,
and 1396r-8 42 USC 1396 to 1396v.