Psychiatric Hospitals/Units & PPS-Exempt Units

State Licensing

  • State licensing is required for psychiatric hospitals/units under the Michigan Mental Health Code.

     

    State licensure application (BCHS-HFD-100) with required licensure fee to:

     

    State licensure application with no required licensure fee to:

    • Change in the hospital name
    • Change in the hospital location
    • Change in bed designations - Include Appendix E
    • Decrease in bed capacity - Include Appendix E

     

    LICENSURE

    • Application Fee (new facility): $2,000 - Include Invoice
    • Initial and Renewal Licensure Fee: $500, plus $10 per bed
    • Annual renewal invoices sent in June of each year
    • License renewals must be paid online no later than July 31st
  • Other state agencies may require approval prior to licensing actions. Contact the following state agencies to determine whether their approval is required.

    Certificate of Need
    Michigan Department of Health & Human Services (MDHHS)
    Lewis Cass Building, 3rd Floor
    320 S. Walnut Street
    Lansing, MI 48913
    Phone: 517-241-3344

    Health Facilities Engineering Section
    Michigan Department of Licensing and Regulatory Affairs (LARA)
    PO Box 30664
    Lansing, MI 48909
    Phone: 517-241-3408

    Bureau of Fire Services
    Michigan Department of Licensing and Regulatory Affairs (LARA)
    3101 Technology Boulevard, Suite H
    PO Box 30700
    Lansing, MI 48909
    Phone: 517-335-5804

Federal Certification

  • Psychiatric hospitals may apply for certification to participate in the Medicare/Medicaid programs. The Centers for Medicare and Medicaid Services (CMS) contracts with LARA to evaluate compliance with the federal regulations. Hospitals must be licensed with the State of Michigan before Medicare certification is approved.

     

    For initial certification, relocations, or change of ownership:

    • Complete Provider Enrollment Application (CMS-855A) and submit to Medicare Administrative Contractor (MAC)
    • Contact CMS approved accrediting organization (AO) to schedule initial certification survey
    • Complete and submit to BCHS:
      • An e-mail confirming a successful electronic submission of your Civil Rights Clearance for Medicare Provider Certification from the Office for Civil Rights (OCR)
      • A signed Health Insurance Benefit Agreement (CMS-1561)
      • A signed Hospital/CAH Medicare Database Worksheet (Exhibit 286)

Federal PPS-Exempt Units

  • This information is to assist with Prospective Payment System (PPS) exemption.

     

    Information for PPS-excluded psychiatric units only:

    • Medical record protocols to permit verification that each patient receives a psychiatric evaluation within 60 hours of admission.
    • Documentation that each patient has a comprehensive treatment plan.
    • Documentation progress notes are routinely recorded.
    • Documentation each patient has discharge planning and discharge summary.
    • Description of the type and number of clinical staff, including a qualified medical director of inpatient psychiatric and a qualified director of psychiatric nursing services, registered nurses, licensed practical nurses, and mental health workers to provide care necessary under their patients' active treatment plans.

     

    Note: An annual attestation is required for compliance with federal regulations.

State and Federal Reporting Requirements

  • Psychiatric Notification of Death - Effective March 24, 2021, MCL 330.1720 and 330.1721 require state licensed psychiatric hospitals and units to report to the Department of Health and Human Services (DHHS) all deaths of mental health care recipients occurring in a psychiatric hospital or psychiatric unit and within 48 hours of discharge, as well as the cause of death, if known. DHHS must investigate the deaths of mental health care recipients that resulted from suicide or unknown causes. Please use the new reporting form (MDHHS-5949) that providers will be responsible to complete and email directly to DHHS-ORR at MDHHS-recipientrights@michigan.gov or by FAX to 248-348-9963.  Should you have questions and/or need additional information, please contact: Andrew Silver, MDHHS-ORR Director of Education, Training and Compliance at silvera@michigan.gov or (248) 756-6610 or visit the MDHHS-ORR website at michigan.gov/recipientrights.

  •  

    Hospital Restraint/Seclusion Deaths - CMS requires all hospitals to report deaths associated with restraint and/or seclusion on the electronic CMS-10455 form.  The only reporting requirement exceptions are deaths associated with 2-point soft wrist restraints. See QSOG-20-04-Hospital-CAH-DPU.

     

    Hospitals must report the following information to CMS no later than the close of business on the next business day following the acknowledgment of the restraint and/or seclusion associated patient death:

    • Death that occurs while a patient is in restraint or seclusion.
    • Death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
    • Death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to a patient's death.

     

    2-Point Soft Wrist Restraint Exception - When the patient was not in seclusion and when the only restraints used on the patient were those applied exclusively to the patient's wrist(s), the death could be considered a 2-point soft wrist restraint situation. To be a soft wrist restraint, the restraint on the patient's wrist must be composed solely of soft, non-rigid, cloth-like materials. In these cases, the hospital staff must record the death in an internal log or other system. The hospital must record no later than seven (7) days after the date of death, the following information:

    • Death that occurs while a patient is in such restraints.
    • Death that occurs within 24 hours after a patient has been removed from such restraints.
    • Death entry must document the patient's name, date of birth, date of death, name of attending physician or other licensed practitioner who is responsible for the care of the patient, medical record number and primary diagnoses.

     

    Questions regarding reporting of hospital restraint or seclusion deaths may be directed to the CMS Chicago Regional Office at ChicagoNLTCPOC@cms.hhs.gov.

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    Change in Administrator - If your facility or agency is state licensed or federally certified, we request that you update the bureau when there is a change in administrator.  The information requested below will allow us to keep both the state licensing and federally certification data bases current.  Thank you for your assistance in self-reporting this information.

    • Facility or agency name, address, and federal (CCN) provider # (23-xxxx) or state facility ID (xx-xxxx)
    • New administrator full name
    • Effective start date of administrator
    • Best contact number for our office to reach this facility or agency
    • Best email address for our office to reach this facility or agency

     

    Email change of information to: BCHS_FedDivision@michigan.gov.

Contact Information

  • Michigan Department of Licensing & Regulatory Affairs
    Bureau of Community and Health Systems
    611 W. Ottawa Street
    PO Box 30664
    Lansing, MI 48909
    Main Line: 517-335-1980

     

    State Licensing
    Phone: 517-241-1970
    FAX: 517-241-3354

    Email: bchs-statelicensing@michigan.gov

     

    Federal Certification
    Phone: 517-284-8953
    FAX: 517-241-3354

    Email: BCHS-CMSCertification@michigan.gov