SB-0884, As Passed House, September 27, 2012

HOUSE SUBSTITUTE FOR

SENATE BILL NO. 884

A bill to amend 1978 PA 368, entitled

"Public health code,"

by amending section 20155 (MCL 333.20155), as amended by 2006 PA

195, and by adding section 20155a.

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

Sec. 20155. (1) Except as otherwise provided in this section

and section 20155a, the department 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~~ according 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~~ according

to a complaint are announced or unannounced. Beginning June 20,

2001, the department shall ~~assure~~ ensure 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.

(2) The state shall establish a process that ensures both of

the following:

(a) A newly hired nursing home surveyor shall not make

independent compliance decisions during his or her training period.

(b) A nursing home surveyor shall not be assigned as a member

of a survey team for a nursing home in which he or she received

training for 1 standard survey following the training received in

that nursing home.

(3) Beginning November 1, 2012, the department shall perform a

criminal history check on all nursing home surveyors in the manner

provided for in section 20173a.

(4) 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 3 years.

(5) Representatives from all nursing home provider

organizations and the state long-term care ombudsman or his or her

designee shall be invited to participate in the planning process

for the joint provider and surveyor training sessions. The

department shall include at least 1 representative from nursing

home provider organizations that do not own or operate a nursing

home representing 30 or more nursing homes statewide in internal

surveyor group quality assurance training provided for the purpose

of general clarification and interpretation of existing or new

regulatory requirements and expectations.

(6) The department shall make available online the general

civil service position description related to the required

qualifications for individual surveyors. The department shall use

the required qualifications to hire, educate, develop, and evaluate

surveyors.

(7) The department shall ensure that each annual survey team

is composed of an interdisciplinary group of professionals, 1 of

whom must be a registered nurse. Other members may include social

workers, therapists, dietitians, pharmacists, administrators,

physicians, sanitarians, and others who may have the expertise

necessary to evaluate specific aspects of nursing home operation.

(8) ~~(2) The~~ Except as otherwise provided in this section and

section 20155a, the department 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. The department 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 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.~~ be included in the report required under subsection

(20). Except as otherwise provided in this subsection, beginning

with his or her first full relicensure period after June 20, 2000,

each member of a department 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.

(9) ~~(3)~~ The department shall make a biennial visit to each

hospital for survey and evaluation for the purpose of licensure.

Subject to subsection ~~(6)~~ (12), 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)~~ (11) 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 of

title XVIII of the social security act, 42 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.

(10) ~~(4)~~ Except as provided in subsection ~~(8)~~ (14),

accreditation information provided to the department under

subsection ~~(3)~~ (9) 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.

(11) ~~(5)~~ The department shall grant a waiver under subsection

~~(3)~~ (9) if the accreditation report submitted under subsection

~~(3)(b)~~ (9)(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).~~(9)(a).

(b) Grant a waiver under subsection ~~(3)~~ (9) 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.

under subsection ~~(3).~~(9).

(12) ~~(6)~~ This section does not prohibit the department from

citing a violation of this part during a survey, conducting

investigations or inspections ~~pursuant~~ according 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 bureau of fire services created in

section 1b of the fire prevention code, 1941 PA 207, MCL 29.1b,

from conducting annual surveys of hospitals, nursing homes, and

county medical care facilities.

(13) ~~(7)~~ At the request of a health facility or agency, the

department 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).

(14) ~~(8)~~ If the department 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~~

under subsection ~~(3)(b)~~ (9)(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.

(15) ~~(9)~~ The department or a local health department shall

conduct investigations or inspections, other than inspections 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 not for the purpose of annual or follow-up inspection or

survey may be announced.

(16) ~~(10)~~ The department shall maintain a record indicating

whether a visit and inspection is announced or unannounced.

~~Information~~ Survey findings gathered at each health facility or

agency during each visit and inspection, whether announced or

unannounced, shall be taken into account in licensure decisions.

(17) ~~(11)~~ The department 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 patient's clinical 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.

Surveyors shall use electronic resident information, whenever

available, as a source of survey-related data and shall request

facility assistance to access the system to maximize data export.

(18) ~~(12)~~ The department 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.

(19) ~~(13)~~ If, upon investigation, the department 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.

(20) ~~(14)~~ The department may consolidate all information

provided for any report required under this section and section

20155a into a single report. The department 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.~~

the most recent calendar year.

(d) ~~(e)~~ The number of night and weekend complaints filed.

(e) ~~(f)~~ The number of night and weekend responses to

complaints conducted by the department.

(f) ~~(g)~~ The average length of time for the department to

respond to a complaint filed against a nursing home.

(g) ~~(h)~~ The number and percentage of citations ~~appealed.~~

disputed through informal dispute resolution and independent

informal dispute resolution.

(h) ~~(i)~~ The number and percentage of citations overturned or

modified, or both.

(i) The review of citation patterns developed under subsection

(8).

(j) Implementation of the clinical process guidelines and the

impact of the guidelines on resident care.

(k) Information regarding the progress made on implementing

the administrative and electronic support structure to efficiently

coordinate all nursing home licensing and certification functions.

(l) The number of annual standard surveys of nursing homes that

were conducted during a period of open survey or enforcement cycle.

(m) The number of abbreviated complaint surveys that were not

conducted on consecutive surveyor workdays.

(n) The percent of all form CMS-2567 reports of findings that

were released to the nursing home within the 10-working-day

requirement.

(o) The percent of provider notifications of acceptance or

rejection of a plan of correction that were released to the nursing

home within the 10-working-day requirement.

(p) The percent of first revisits that were completed within

60 days from the date of survey completion.

(q) The percent of second revisits that were completed within

85 days from the date of survey completion.

(r) The percent of letters of compliance notification to the

nursing home that were released within 10 working days of the date

of the completion of the revisit.

(s) A summary of the discussions from the meetings required in

subsection (24).

(t) The number of nursing homes that participated in a

recognized quality improvement program as described under section

20155a(3).

(21) ~~(15)~~ The department shall report ~~annually~~ March 1 of each

year 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~~ all

of the following:

(a) The percentage of nursing home citations that are appealed

~~and the~~ through the informal dispute resolution process.

(b) The number and percentage of nursing home citations that

are appealed and supported, amended, or deleted through the

informal ~~deficiency~~ dispute resolution process.

citations and related survey retraining efforts to improve

consistency among surveyors and across the survey administrative

unit that occurred in the year being reported.

(22) ~~(16)~~ Subject to subsection ~~(17),~~ (23), a clarification

work group comprised of the department 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 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:~~this state:

(a) Immediate jeopardy.

(b) Harm.

(d) Avoidable.

(e) Unavoidable.

(23) ~~(17)~~ All of the following clarifications developed under

subsection ~~(16)~~ (22) apply for purposes of subsection ~~(16):~~(22):

(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)~~ (25) 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.

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~~ under subsection ~~(18),~~ (25), 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~~ under subsection

~~(18)~~ (25) 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~~ under subsection ~~(18)~~

(25) is relevant information in considering whether a negative

outcome was avoidable or unavoidable and may be considered in the

application of that term.

(24) The department shall conduct a quarterly meeting and

invite appropriate stakeholders. Appropriate stakeholders shall

include at least 1 representative from each nursing home provider

organization that does not own or operate a nursing home

representing 30 or more nursing homes statewide, the state long-

term care ombudsman or his or her designee, and any other clinical

experts. Individuals who participate in these quarterly meetings,

in conjunction with the department, may designate advisory

workgroups to develop recommendations on the discussion topics that

should include, at a minimum, all of the following:

(a) Opportunities for enhanced promotion of nursing home

performance, including, but not limited to, programs that encourage

and reward providers that strive for excellence.

(b) Seeking quality improvement to the survey and enforcement

process, including clarifications to process-related policies and

protocols that include, but are not limited to, all of the

following:

(i) Improving the surveyors' quality and preparedness.

(ii) Enhanced communication between regulators, surveyors,

providers, and consumers.

(iii) Ensuring fair enforcement and dispute resolution by

identifying methods or strategies that may resolve identified

problems or concerns.

communities, including, but not limited to, all of the following:

(i) Applying regulations in a consistent manner and evaluating

changes that have been implemented to resolve identified problems

and concerns.

(ii) Providing consumers with information regarding changes in

policy and interpretation.

(iii) Identifying positive and negative trends and factors

contributing to those trends in the areas of resident care,

deficient practices, and enforcement.

(d) Clinical process guidelines.

(25) ~~(18)~~ Subject to subsection ~~(19)~~ (27), 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.

(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.

(n) Culture–change principles, person-centered caring, and

self-directed care.

(26) The department shall biennially review and update all

clinical process guidelines as needed and shall continue to develop

and implement clinical process guidelines for topics that have not

been developed from the list in subsection (25) and other topics

identified as a result of the meetings required in subsection (24).

The department shall consider recommendations from an advisory

workgroup created under subsection (24) on clinical process

guidelines. The department shall include training on new and

revised clinical process guidelines in the joint provider and

surveyor training sessions as those clinical process guidelines are

developed and revised.

(27) ~~(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.~~Beginning November 1, 2012,

representatives from each nursing home provider organization that

does not own or operate a nursing home representing 30 or more

nursing homes statewide and the state long-term care ombudsman or

his or her designee shall be permanent members of any clinical

advisory workgroup created under subsection (24). The department

shall issue survey certification memorandums to providers to

announce or clarify changes in the interpretation of regulations.

(28) ~~(20)~~ The department shall ~~create a~~ maintain the 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)~~

(25) to (27) 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.

(29) ~~(21) The~~ Upon availability of funds, the department ~~may~~

shall give grants, awards, or other recognition to nursing homes to

encourage the rapid implementation or maintenance of the clinical

process guidelines adopted under subsection ~~(18).~~(25).

~~(22) The department shall assess the effectiveness of 2001 PA~~

~~218. 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.~~

(30) ~~(23)~~ The department 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)~~ (25) in citing deficiencies.

(31) ~~(24)~~ A nursing home shall post the nursing home's survey

report in a conspicuous place within the nursing home for public

review.

(32) ~~(25)~~ Nothing in this amendatory act shall be construed to

limit the requirements of related state and federal law.

(33) ~~(26)~~ As used in this section:

(a) "Consecutive days" means calendar days, but does not

include Saturday, Sunday, or state- or federally-recognized

holidays.

(b) "Form CMS-2567" means the federal centers for medicare and

medicaid services' form for the statement of deficiencies and plan

of correction or a successor form serving the same purpose.

act, 42 USC 1395 to ~~1395hhh.~~1395kkk.

(d) ~~(b)~~ "Title XIX" means title XIX of the social security

act, ~~chapter 531,~~ 42 USC 1396 to ~~1396v.~~1396w-5.

Sec. 20155a. (1) Nursing home health survey tasks shall be

facilitated by the licensing and regulatory affairs bureau of

health systems to ensure consistent and efficient coordination of

the nursing home licensing and certification functions for standard

and abbreviated surveys. The department shall develop an electronic

system to support the coordination of these activities and shall

submit a report on the development of an electronic system,

including a proposed budget for implementation, to the senate and

house appropriations subcommittees for the department, the senate

and house of representatives standing committees having

jurisdiction over issues involving senior citizens, and the senate

and house fiscal agencies by November 1, 2012. If funds are

appropriated for the system, the department shall implement the

system within 120 days of that appropriation.

(2) When preparing to conduct an annual standard survey, the

department shall determine if there is an open survey cycle and

make every reasonable effort to confirm that substantial compliance

has been achieved by implementation of the nursing home's accepted

plan of correction before initiating the annual standard survey

while maintaining the federal requirement for standard annual

survey interval and state survey average of 12 months.

(3) The department shall seek approval from the centers for

medicare and medicaid services to develop a program to provide

grants to nursing homes that have achieved a 5-star quality rating

from the centers for medicare and medicaid services. The department

shall seek approval from the centers for medicare and medicaid

services for nursing homes to be eligible to receive a grant, up to

$5,000.00 per nursing home from the civil monetary fund for nursing

homes that meet the centers for medicare and medicaid services

standards for the 5-star quality rating. Grants to nursing homes

shall be used to implement evidence-based quality improvement

programs within the nursing home. Each nursing home that receives a

grant shall submit a report to the department that describes the

final outcome from implementing the program.

(4) All abbreviated complaint surveys shall be conducted on

consecutive days until complete. All form CMS-2567 reports of

survey findings shall be released to the nursing home within 10

consecutive days after completion of the survey.

(5) Departmental notifications of acceptance or rejection of a

nursing home's plan of correction shall be reviewed and released to

the nursing home within 10 consecutive days of receipt of that plan

of correction.

(6) A nursing-home-submitted plan of correction in response to

any survey must have a completion date not to exceed 40 days from

the exit date of survey. If a nursing home has not received

additional citations before a revisit occurs, the department shall

conduct the first revisit not more than 60 days from the exit date

of the survey.

(7) Letters of compliance notification to nursing homes shall

be released to the nursing home within 10 consecutive days of all

survey revisit completion dates.

(8) The department may accept a nursing home's evidence of

substantial compliance instead of requiring a post survey on-site

first or second revisit as the department considers appropriate in

accordance with the centers for medicare and medicaid services

survey protocols. A nursing home requesting consideration of

evidence of substantial compliance in lieu of an on-site revisit

must include an affidavit that asserts the nursing home is in

substantial compliance as shown by the submitted evidence for that

specific survey event. There may be no deficiencies with a scope

and severity originating higher than level D. If there is no

enforcement action, the nursing home's evidence of substantial

compliance may be reviewed administratively and accepted as

evidence of deficiency correction.

(9) Informal dispute resolution conducted by the Michigan peer

review organization shall be given strong consideration upon final

review by the department. In the annual report to the legislature,

the department shall include the number of Michigan peer review

organization-referred reviews and, of those reviews, the number of

citations that were overturned by the department.

(10) Citation levels used in this section mean citation levels

as defined by the centers for medicare and medicaid services'

survey protocol grid defining scope and severity assessment of

deficiency.