Hospitals

  • This page is designed to assist providers through the state licensure and federal certification processes, as well as provide additional resources to maintain compliance.

State Licensing

  • State licensing is required for hospitals.

    A state licensure application (BCHS-HFD-100) is required to (Licensure fee required):

    • Begin operation of a new hospital ($2,000 application fee/invoice required) - Include Appendix E
    • Change of ownership (CHOW) for an existing hospital
    • Change in bed capacity (adding beds) at a hospital - Include Appendix E
       

    A state licensure application is also required to (No fee required):

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

    LICENSURE FEES

    • 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

  • Important Note: The Centers of Medicare and Medicaid Services (CMS) has suspended some survey activities in order to prepare for the protentional threat of the 2019 Novel Coronavirus (COVID-19). CMS issued Quality, Safety & Oversight (QSO) Memos with details and guidance for infection control and prevention: QSO-20-13-Hospitals, QSO-20-14-NH, QSO-20-15 Hospital/CAH/EMTALA, QSO-20-16-Hospice, QSO-20-17-All, QSO-20-18-HHA, QSO-20-19-ESRD, QSO-20-20-All, QSO-20-22-ASC,CORF,OPT,RHC/FQHCs, QSO-20-24-ASC, QSO-20-28-NH

  • 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 by conducting certification surveys and complaint investigations. 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)/Federal Fiscal Intermediary (FI)
    • Complete and submit to BHCS:
      • An e-mail confirming a successful electronic submission of your Civil Rights Clearance for Medicare Provider Certification from the Office for Civil Rights (OCR)
      • Two (2) signed originals Health Insurance Benefit Agreement (CMS-1561)
      • One (1) signed original Hospital/CAH Medicare Database Worksheet (Exhibit 286) - Needed for Initial and relocation only.

    Note: For hospitals with PPS-exempt psychiatric or rehabilitation units, see the Psychiatric Hospitals/Units provider page.

    For a change in administrator, please email BCHS_FedDivision@michigan.gov the following:

    • Facility name, address, and provider # or state facility ID
    • New administrator full name
    • Effective start date of administrator

Federal Reporting Requirement

  • Hospital Restraint/Seclusion Deaths

    Hospital Restraint/Seclusion Deaths - Centers for Medicare and Medicaid Services (CMS) requires (QSOG-20-04-Hospital-CAH-DPU) 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.

    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.

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: 517-241-2635