ACCESS ALLIANCE OF MICHIGAN REGIONAL PROVIDER MANUAL
Chapter 11
Section 11.1
Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 1
11. Supplement for Residential Care Providers
11.1 Environment of Care Standards and Requirements
Residential care providers under contract with a CMHSP in the Access Alliance
of Michigan (AAM) affiliation are required to comply with the State of Michigan
Licensing Rules for Adult Foster Care (AFC) Small Group Homes, the
Certification Rules for Specialized Programs offered in AFC Homes to Clients
with Mental Illness or Developmental Disabilities, and other federal, state and
local laws as identified in this section of the provider manual. In some cases,
Bay-Arenac Behavioral Health (BABH) Provider Management may require or
recommend additional expectations related to safety and emergency
preparedness. The information in this section is intended to clarify the
expectations and provide interpretive guidelines to assist with implementation of
the requirements.
OBJECTIVE: An Environment of Care (EC) program is established that ensures
a safe and healthy environment for people who live in a Specialized Residential
Adult Foster Care (AFC) home that is operated by a Residential Care Provider
Corporation.
PURPOSE: The EC Program includes activities and processes to:
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Reduce and control hazards and risks to the residents
Prevent accidents and injuries to the residents
Maintain safe conditions for residents, visitors, and staff
Plan and prepare for emergencies that may arise
SCOPE: Specialized Residential AFC homes are managed under contract with
BABH. The Residential Care Provider’s staff are hired and trained to oversee
that residents receive proper care and treatment and that the home environment
is safe and secure. The State of Michigan Department of Human Services is
responsible for licensing specialized residential AFC homes.
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Residential Care Providers are responsible for ensuring that employees are
properly trained as required by federal, state, and local safety and fire
prevention standards, MIOSHA Right to Know information and hazardous
material handling, incident and error event reporting, emergency
preparedness and response, use of fire extinguishers, vehicle safety, etc.
Bay-Arenac Behavioral Health
Access Alliance of Michigan
Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
ACCESS ALLIANCE OF MICHIGAN REGIONAL PROVIDER MANUAL
Chapter 11
Section 11.1

Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 2
The information provided in this document does not replace State of Michigan
public acts or licensing rules, but provides guidance for the development and
implementation of an effective EC Program in the home. The Licensing Rules
for AFC Small Group Homes (12 or less) and the Certification Requirements
for Specialized Programs Offered In AFC Homes to Clients with Mental
Illness or Developmental Disabilities are the main source documents used in
developing the guidelines presented in this document and will be referred to
as the licensing rules throughout the remainder of this document.
PERFORMANCE
1. GENERAL SAFETY
a. Inspections and Evaluations: Initial and recurring inspections and
evaluations are completed as listed here:
Figure 1, Safety and Emergency Preparedness, Fire Safety and Prevention,
and Facility Management and Maintenance Activities
Event
Occurrence
Reference/Notes
Responsibility
Regulatory Services
Inspection
As required
Licensing Rules
MI Dept. of Labor,
Energy and Economic
Growth
Quarterly
1 per shift
Note 1
Home Manager/staff
Annually
1 per shift
Note 1
Home Manager/staff
Fire Extinguisher
Inspection
Monthly
See 5.d.(1)
and Note 2
Home Manager/staff
Fire Extinguisher
Maintenance
Annual
See 5.d.(1)
and Note 2
Annual
See 5.d.(1)
Fire Drill
Tornado Drill
Fire Extinguisher
Training
Bay-Arenac Behavioral Health
Access Alliance of Michigan
Riverhaven Coordinating Agency
Home
Manager/Contractor
Residential Care
Provider
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
ACCESS ALLIANCE OF MICHIGAN REGIONAL PROVIDER MANUAL
Chapter 11
Section 11.1
Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 3
Battery Operated
Smoke Detector Test
Quarterly
Note 3
Home Manager/staff
Integrated Smoke
Detector/Fire Alarm Test
Annual
Note 2
Home
Manager/Contractor
Automatic Sprinkler
System
Annual
Note 2
Home Manager/Contractor
Pull Down Alarm System
Annual
Note 2
Home Manager/Contractor
Sprinkler System Flow
Test
Monthly
Note 2
Home Manager/Contractor
Carbon Monoxide
Detector Test
Quarterly
Note 3
Home Manager/staff
Safety & Facility
Inspection
Annual
See 1.h.(1),(2)
BABH EC Office
Emergency Lights
w/battery backup
30 day and
Annual
Note 4
Home Manager/staff
Flashlights
Quarterly
Note 4
Home Manager/staff
Emergency Generator
Maintenance (owned and
maintained by BABH)
Annual
Note 5
BABH Facility
Manager/Contractor
Refrigerator/Freezer
Temperature
Daily
Note 6
Home Manager/staff
Water Faucet
Temperature
Monthly
Note 7
Home Manager/staff
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Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
ACCESS ALLIANCE OF MICHIGAN REGIONAL PROVIDER MANUAL
Chapter 11
Section 11.1
Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 4
Vehicle Safety Inspection
Daily
See 1.k.(3)
Home Manager/staff
GFCI Test
Annual
Note 8
BABH Facility Manager
First Aid Kit
Annual
Note 9
Home Manager/staff
Spill Kit
Annual
Note 10
Home Manager/staff
NOAA Weather Radio
Quarterly
Note 11
Home Manager/staff
Note 1: Fire drills are held per the licensing rules. The licensing rules do not require that a tornado drill be
completed but they do require that a written emergency procedure and evacuation plan for severe weather
emergencies is available. BABH Provider Management requires that providers of specialized residential
services hold 3 tornado drills per year, 1 per shift, over the time period April - September, not to exceed
more than 1 tornado drill in a month or more than 3 tornado drills in a year. Emergency drills are recorded
on the drill report and kept in home files for review by BABH EC staff and Licensing Agent, as requested.
Note 2: The residential manager ensures that a company qualified in servicing fire sprinkler systems, fire
extinguishers, and fire alarm systems has completed necessary repairs, maintenance, tests and inspections
that are required. The home staff completes the monthly sprinkler flow test . Problems are reported to the
Residential Care Provider management. When required, Interim Life Safety Measures (ILSM) are taken as
required by the Life Safety Code.
Note 3: Battery-operated smoke detectors and carbon monoxide detectors are tested at least quarterly by
residential home staff. Batteries are replaced when low and at least annually. Testing and battery
replacement records are kept in the home files.
Note 4: Emergency lights are installed to light up escape routes in the event that the power goes out and/or
the generator fails. A functional test at 30-day intervals for a minimum of 30 seconds and an annual test for
a duration of 60 minutes is required. Record completion of the monthly and annual testing and maintain
records in the home files. Batteries are replaced per the manufacturer's instructions or when no longer
holding an acceptable charge. Some of these light's batteries are sealed and cannot be changed. In these
cases new lights are required. For homes not equipped with emergency lights, flashlights are tested
quarterly, batteries replaced as needed, and documented.
Note 5: Emergency Generators. All generators are owned by BABH and are maintained and serviced by a
service provider contracted by the BABH EC office.
Note 6: Refrigerators and freezers are equipped with a thermometer to monitor that the refrigerator
temperature is maintained between 35 and 40 degrees and freezer temperature is maintained at less than
32 degrees. A daily refrigerator temperature log is maintained.
Note 7: Licensing Rule R 400.14401 - Environmental Health, requires that hot water temperature at the
faucet is maintained between 105 degrees Fahrenheit to 120 degrees Fahrenheit at the faucet. BABH
Provider Management recommends that hot water at the faucet is tested on a monthly basis and recorded
on a log.
Note 8: GFCI outlets are tested at least annually by the BABH Facility Manager.
Bay-Arenac Behavioral Health
Access Alliance of Michigan
Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
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Chapter 11
Section 11.1
Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 5
Note 9: A first aid kit is readily available in the home and in the vehicle(s). The kit is inspected at least
annually and a record of inspection kept in the home files.
Note 10: A blood borne pathogens spill kit is readily available in the home and in the vehicle(s). The kit
needs to be inspected at least annually and a record of inspection kept in the home files.
Note 11: The NOAA Weather Radio is checked monthly to ensure that it is working properly. Batteries are
replaced as needed or at least annually.
b. Residential Care Providers will assist BABH with its performance
improvement processes by providing safety and environment of care
related data and information, as requested.
c. The Residential Care Provider will ensure that its administration and staff
receive the appropriate training and have the minimum qualifications as
required by the licensing rules and other federal, state and local laws.
BABH Policy and Procedure, C07-S03-T04 Group Home Curriculum
(Attachment 1) provides information on additional training that is required.
d. The Residential Care Provider designates an employee to develop,
implement and oversee the EC program in the home to include safety, and
emergency preparedness and planning.
e. Evacuation Difficulty Score Calculation (E-Score): The Residential Care
Provider will ensure that the capability of the residents to evacuate a
facility in the event of a fire is assessed using methods described in the
NFPA 101® 1985 Life Safety Code (Attachment #2) and Appendix F of the
1985 Life Safety Code (Attachment #3) as required by the licensing rules
(R 330.1803 - Facility environment; fire safety). The worksheets are
available as part of attachment #3 to this manual.
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BABH policy and procedure C05-S05-T06 (Evacuation Difficulty Score,
Destination Training and Waiver Process) provides information
regarding completion of the Evacuation Difficulty Score, Destination
Training and Waiver Process (Attachment #4).
See Attachment #5, E-Score Clarification of Requirements (revised
September 16, 2009), for additional guidance on calculating the Escore.
f. Medications are stored and administered per the Licensing Rules (R
400.14312) and BABH Policy and Procedure C06-S01-T06 (Medications:
Storage, Samples, Injectables, Disposal, Expirations and Recalls)
(Attachment #6).
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Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
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Chapter 11
Section 11.1
Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 6
g. Per the licensing rules and BABH requirements, Environment of Care
records consist of the following:
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Accident records and incident reports
Policies and procedures related to safety and emergency management
Fire drill records
E-Score Worksheets (Evacuation Difficulty Score)
Smoke/Fire Incident Reports (Reports of fire, smoke, or severe
property damage) (See Attachments #7 and #8)
Records of other emergency drills, as applicable
Records of licensing rule variances that have been granted
Heating, ventilation and air conditioning (HVAC) equipment inspection
and approval records
Fire detection and sprinkler equipment inspection and approval
records, if applicable
Fire extinguisher safety checks and annual maintenance records
Refrigerator and freezer temperature log
Hot water temperature log
Record of battery powered/battery backup emergency equipment
inspection, testing and battery replacement (emergency lights,
flashlights, smoke detectors, carbon monoxide detectors, NOAA
radios, etc.)
Electrical inspection records, if applicable
Fire Safety reports from the department or state fire marshal, as
required by law
Environmental inspection reports, as required by law
Product manuals and service agreements for appliances, HVAC
equipment, alarm and sprinkler systems, generator, etc.
Record of maintenance and repair contractors for emergency repairs of
heating, cooling, plumbing, and electrical equipment, etc.
h. The BABH EC staff conduct an annual inspection of specialized residential
AFC homes to assess compliance with applicable safety and environment
of care standards and maintenance and upkeep of the building(s) and
grounds. Follow-up visits are made as needed to assure that any serious
discrepancies are addressed within a reasonable timeframe.
(1) Inspection Report: The home manager/staff are informed of the
findings at the end of the inspection. An inspection report which
includes deficiencies and discrepancies, requirements and
recommendations, and responsibilities is sent to the Residential Care
Provider Management and copies are provided to the BABH Provider
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Tuscola Behavioral Health Systems
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Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Chapter 11
Section 11.1
Page 7
Management and Contract Management Departments. See the
Annual Safety and Facility Assessment form (Attachment 9).
(2) Hazardous Conditions: If during an inspection, a hazardous condition
is identified (broken equipment, trip hazard, fire hazard), BABH EC
staff will attempt to correct the situation immediately. If unable to
correct an issue, the appropriate service provider will be contacted.
Any affected items will be removed from service or the area blocked to
protect residents and staff from injury.
i.
Product Recalls: The BABH EC staff may send product recall notifications
to home managers who are responsible for ensuring that any faulty
product or equipment is handled according to the information provided in
the recall notification.
j.
A potentially hazardous condition* that does not result in injury but may
cause damage to the facility, grounds, or equipment are reported
immediately to the Residential Care Provider’s management staff. Action
is taken to eliminate the hazard and protect property from further damage.
If unable to safely eliminate the hazard, staff should contact the
appropriate public service (police or fire department), utility company, or
contractor for assistance. The BABH Environment of Care office may be
contacted to provide assistance, as necessary.
*A hazardous condition is any set of circumstances that significantly
increases the likelihood of a serious adverse outcome.
k. Vehicle Safety is the responsibility of all staff members who transport
residents.
(1) BABH Provider Management requires that the driving record of staff
who will be transporting residents are checked upon hire and on a
random basis thereafter. See the Michigan Vehicle Code MCL
257.207a for more information.
(2) Vehicle accidents involving residents are reported according to the
incident reporting process and as required by the State of Michigan
Vehicle Code.
(3) Per Licensing Rule R400.14319 - Resident Transportation, Residential
Service Providers ensure the following:
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Vehicle is in good operating condition
Bay-Arenac Behavioral Health
Access Alliance of Michigan
Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
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Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Chapter 11
Section 11.1
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Page 8
Vehicle has a basic first aid kit
Residents who are transported by truck ride only in the cab
Vehicle operators have a valid driver's license
In addition, BABH Provider Management recommends the following:
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A vehicle safety inspection process is in place
Periodic maintenance is completed and documentation maintained
Van lifts are checked before use for proper operation
The lifts are equipped with a safety strap and stopping device
Staff are trained on the use of the lifts and safety straps prior to use
Vehicles are equipped with an Emergency Supply Kit
Residents are not transported during severe weather
2. SECURITY
Security measures are taken for purposes of controlling access to the home
and preventing elopement by residents. The following measures are
recommended by BABH Provider Management:
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Keep all exit doors locked
Verify the identification of all visitors
Prohibit unauthorized persons from entering the home
Closely supervise residents who are prone to elopement
Educate staff regarding security measures and the reporting of security
incidents
3. HAZARDOUS MATERIAL AND WASTE
In accordance with the following MIOSHA and OSHA rules, hazardous
material and waste must be handled appropriately:
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MIOSHA Part 92 - Hazard Communications
MIOSHA Part 430 - Hazard Communications
MIOSHA Part 554 - Bloodborne Infectious Disease
OSHA 29CFR 1910.1200 - Hazard Communication
The above standards require that employers have a written policy and
procedure that addresses hazardous material and waste and that staff are
Bay-Arenac Behavioral Health
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Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
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Chapter 11
Section 11.1
Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 9
trained in the selection, handling, storage and disposal of hazardous material
and waste.
Please refer to the BABH memo dated November 12, 2009 for guidelines
regarding sharps disposal (Attachment #10).
4. EMERGENCY MANAGEMENT
Licensing Rule R 400.14318 Emergency preparedness; evacuation plan;
emergency transportation, requires that Residential Care Providers plan and
prepare for emergency response.
BABH Provider Management provides the Residential Care Providers with a
"Home Managers Emergency Preparedness Handbook" which includes tools to
assist Residential Care Providers in their response planning for emergencies in
the home and community. The handbook includes planning templates that may
be used to assist in preparedness and planning efforts. They include:
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Business Preparedness Planning Guide from F.A.C.E.S of Michigan
Emergency Preparedness Planning Checklist for Group Homes
Fire Response Planning Checklist
Severe Weather/Tornado Planning Checklist
Pandemic Emergency Planning Checklist
Toxic Gas and Fumes Emergency Planning Checklist
Bomb Threat or Explosion Emergency Planning Checklist
Terrorism Emergency Planning Checklist
Workplace Violence Emergency Planning Checklist
Emergency Utility & Shutdown Planning Checklist
Evacuation to an Alternate Site or Temporary Community Shelter Planning
Checklist
Shelter In-Place Planning Checklist
Additional information included in the Handbook:
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BABH Environment of Care Office Contact Information
Emergency Supply Kit Requirements
Information on NOAA Weather Radios
Bay-Arenac Behavioral Health
Access Alliance of Michigan
Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
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Chapter 11
Section 11.1
Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 10
Emergency Evacuation Supply Kits:
The Michigan Department of Community Health requires the following minimum
requirements for the Emergency Evacuation Supply Kits:
Battery operated radio
Depends (if necessary)
Keys for van and home
Diabetic snacks (if necessary)
Staff phone numbers
Extra batteries
Resident profiles
Gloves (latex/non-latex)
Blankets
Wet wipes
Guardian phone numbers
First aid kit
Flashlight
Rain coats
Bottled water
Snacks
In addition to the required items above, BABH Provider Management has
developed a list of recommended emergency supplies to have available in case
of a long-term evacuation or mandatory sheltering in place. Please see the
Emergency Supply Kits document included in the Home Managers Emergency
Preparedness Handbook for additional information (Attachment #11).
Emergency Drills (other than fire):
(1) Residential Care Providers are required by BABH Provider Management to
hold three (3) tornado drills annually one (1) per shift, over the time period
April - September, not to exceed more than one (1) tornado drill in a month
and three (3) per year). The drill needs to be recorded on the Tornado Drill
report and kept in home files for review by BABH EC staff and Licensing
Agent, as requested.
(2) BABH Provider Management recommends that Residential Care Providers
hold at least one (1) carbon monoxide drill per year, preferably before the
heating season begins. It is at the discretion of the Residential Care Provider
whether they implement this recommendation. The drill needs to be recorded
on an emergency drill report form and kept in home files for review by BABH
EC staff and Licensing Agent, as requested.
Emergency Generators:
BABH Provider Management has provided and installed emergency generators
in some group homes. These generators are sized to allow for normal operation
during power outages, are fueled by natural gas, and operate automatically upon
power failure (the unit will sense a power failure and start up automatically with
10 seconds). The generators have a self-test feature which will start
automatically once per week. BABH is responsible for maintenance and repairs
of the generators and has entered into a service contract with a local electrical
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Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
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Chapter 11
Section 11.1
Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 11
contractor to provide the service. Questions or concerns may be directed to the
BABH Environment of Care office.
5. FIRE PREVENTION AND LIFE SAFETY
a. Fire Drills: Per the Licensing Rule R 400.14318, fire drills are held during
daytime, evening, and sleeping hours at least once per quarter (one per
quarter per shift). The drills need to be recorded on a fire drill report form
and kept in home files for review by BABH EC staff and Licensing Agent,
as requested. Fire drill reports may be requested by BABH Provider
Management on a random basis.
b. Smoke/Fire Incident Report: The Smoke/Fire Incident Report is used to
report smoke or fire incidents or severe property damage (required by
Licensing Rule R 400.14209 - Home records generally). This report
needs to be submitted to the BABH EC office (Attachment #8)
Per Licensing Rule R 400.14403 - Maintenance of Premises, a written
report shall be made to the AFC Licensing Division of the department, the
resident’s designated representative, and the responsible agency within
48 hours, excluding holidays and weekends, of the occurrence of any fire
and property damage of more than $5,000.00.
c. Smoking Policy: BABH Provider Management recommends that smoking
by residents is restricted to a designated smoking area, away from other
residents, oxygen tanks, and under the direct observation of direct support
professionals. Smoking by staff is restricted to a designated smoking area
away from residents and oxygen tanks. A fireproof container (butt can) is
available for disposal of matches and smoking material and is located at
least 4 feet away from the home. The contents of the butt can are emptied
on a routine basis.
d. Fire prevention, detection, and protection equipment is available in
accordance with the licensing rules R 400.14505 - Smoke detection
equipment and R330.1803 Facility Environment; fire safety, and R
400.14506 - Fire extinguishers. The above referenced Licensing Rules
include information on the following:
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Required smoke detection equipment
Location of smoke detection equipment
Battery replacement
Testing, examination and maintenance of smoke detection equipment
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Access Alliance of Michigan
Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
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Chapter 11
Section 11.1
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Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 12
Installation requirements of smoke detection equipment
Fire extinguisher requirements
Location of fire extinguishers
Examination and maintenance of fire extinguishers
Fire drill requirements
Assessment of evacuation capability of residents
(1) Fire Extinguishers: In accordance with MIOSHA General Industry
Standards, Part 8 - Portable Fire Extinguishers, R 408.10835, fire
extinguishers are serviced and maintained by a qualified service
provider at least annually. Additionally, fire extinguishers are checked
monthly by home staff, and recorded on an inspection log or on the fire
extinguisher tag. Staff are trained in the use of fire extinguishers in
accordance with OSHA Standard 1910.157(g)(2) - Training and
Education.
e. Evacuation Procedures, Evacuation Plan, Floor Plan: In accordance with
Licensing Rule R 400.14318 - Emergency Preparedness, a specialized
residential adult foster care home is required to have a written emergency
procedure and evacuation plan. In accordance with the Michigan Fire
Prevention Code, the floor plans must include the location of the
"designated smoking area", whether that location is inside or outside. In
addition to the requirements of these rules, BABH Provider Management
recommends that the floor plan include the location of the tornado shelter,
location of the external assembly location and a "you are here" indicator
such as a star, an asterisk, etc. to show a person's present location on the
floor plan.
f. Emergency Contact/Communication: In accordance with licensing rule R
400.14318, specialized residential AFC homes must post near the phone,
a listing of emergency telephone numbers that, at a minimum, include fire,
police, and medical emergency services. BABH Provider Management
also recommends that the list of emergency telephone numbers include a
heating and cooling contractor, an electrical contractor, plumbing
contractor, utility service providers, Poison Control, hospital, pharmacy,
after-hours emergency pharmacy, on-call hotel, snow removal contractor,
BABH Provider Management contacts, etc. and any others that the
provider deems important and necessary.
g. Interim Life Safety Measures (ILSM*): In accordance with the NFPA 101®
Life Safety Code, ILSMs must be implemented to ensure adequate life
safety protection:
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Chapter 11
Section 11.1
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Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 13
whenever Life Safety Code deficiencies cannot be immediately corrected;
during periods of construction and renovation; and
when the fire alarm, detection, or suppression system is out of service
or impaired for more than 4 hours in a 24 hour period.
*Interim Life Safety Measures – A series of thirteen administrative actions
intended to temporarily compensate for significant hazards posed by
existing National Fire Protection Association (NFPA 101®) 2000 Life
Safety Code (LSC) deficiencies or construction activities.
Refer to the National Fire Protection Association (NFPA 101®) Life Safety
Code for more information or contact the local Fire Marshall for
assistance. The BABH Environment of Care office is also available to
assist with implementation of ILSMs when necessary.
6. MEDICAL EQUIPMENT
BABH Provider Management recommends the following regarding medical
equipment:
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Wheelchairs (manual and battery powered) are inspected and maintained
according to the manufacturer's instructions. Maintenance and service
records are maintained in the home.
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Oxygen tanks and regulators are handled and stored in accordance with
the MIOSHA General Industry Standards, Part 69 - Compressed Gases.
The equipment is serviced and maintained according to the
manufacturer's instructions by a qualified service technician. Records of
periodic maintenance are kept in the home files. An "Oxygen in Use" sign
is posted at the front and back doors to alert the fire department that
oxygen is in the house.

Lifts: BABH Provider Management requires that lifts are operated only by
trained staff. Home Managers are responsible for training new staff
initially (training is documented). New staff will receive extensive training
on the use of the lifts and slings during BABH Group Home Curriculum
training. See the April 2010 letter that was sent to all Residential Care
Provider CEOs for specifics on the training requirements and
responsibilities (Attachment 12). Lifts are inspected and tested according
to the manufacturer's instructions. Records of periodic maintenance are
kept in the home files.
Bay-Arenac Behavioral Health
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Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
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ACCESS ALLIANCE OF MICHIGAN REGIONAL PROVIDER MANUAL
Chapter 11
Section 11.1

Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 14
Slings and Clips that are used in conjunction with the lifts are inspected
before each use. The sling material should be durable with no rips or
tears. The sling clips need to be inspected for wear and tear - they need
to clip/snap into place snugly when connected to the lift.
7. UTILITY SYSTEMS
a. The staff is trained in how to do an emergency turn-off for various utility
systems like electrical, gas, and water. These are clearly identified in the
home.
b. Seasonal preventative maintenance is completed by qualified technicians
on the furnace and air conditioning units.
8. PHYSICAL ENVIRONMENT
a. The requirements regarding environmental health, food service,
maintenance of premises, laundry, living space, room temperature,
bathrooms, bedrooms, bedroom space, bedroom furnishings, and linens
are addressed in the licensing rules.
b. The residential staff needs to be aware of conditions in the home
environment. Situations that have the potential to cause damage to the
structure, appliances, HVAC, or grounds need to be monitored, reported,
and repaired. If a process is causing damage to the walls, doors, floors,
counters, utility systems, or appliances then the process needs to be
evaluated and corrective action taken.
c. Residential Care Providers consult and work with the BABH EC office
regarding repair and maintenance of premises.
Attachments:
1.
2.
3.
4.
5.
C07-S03-T04 Group Home Curriculum Policy and Procedure
National Fire Protection Association (NFPA 101®) 1985 Life Safety Code
Appendix F of 1985 Life Safety Code - A Procedure for Determining
Evacuation Capability
C05-S05-T06 Evacuation Difficulty Score, Destination Training and Waiver
Process Policy and Procedure
E-Score Clarification of Requirements (revised September 16, 2009)
Bay-Arenac Behavioral Health
Access Alliance of Michigan
Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems
ACCESS ALLIANCE OF MICHIGAN REGIONAL PROVIDER MANUAL
Chapter 11
Section 11.1
Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan
Supplement for Residential Care Providers
Environment of Care Standards and Requirements
Page 15
6.
C06-S01-T06 Medications: Storage, Samples, Injectables, Disposal,
Expiration and Recalls Policy and Procedure
7. Reporting/Retention Guidelines for Fire and Smoke Related Events in
Specialized Residential Group Homes
8. Smoke/Fire Incident Report
9. BABH Annual Safety and Facility Assessment Form
10. November 12, 2009 Memo regarding disposal of sharps
11. Emergency Supply Kits Requirements
12. April 2010 Letter regarding training on the use of lifts and slings
References/Legal Authority:
1. Licensing Rules for Adult Foster Care (AFC) Small Group Homes (12 or less)
2. Certification Requirements for Specialized Programs Offered in AFC Homes
to Clients with Mental Illness or Developmental Disabilities
3. Michigan Department of Licensing and Regulatory Affairs, Occupational
Health and Safety Standards
a. MIOSHA Part 8 - Portable Fire Extinguishers
b. MIOSHA Part 69 - Compressed Gases
c. MIOSHA Part 92 - Hazard Communications
d. MIOSHA Part 430 - Hazard Communications
e. MIOSHA Part 554 - Bloodborne Infectious Disease
4. United State Department of Labor, Occupational Health and Safety Standards
a. OSHA 29CFR 1910.1200 - Hazard Communication
b. OSHA 1910.157 (g)(2) - Portable Fire Extinguishers - Training and
Education
5. State of Michigan Vehicle Code, MCL 257.207a
6. National Fire Protection Association (NFPA 101®) 1985 Life Safety Code
(See attachments)
7. Appendix F to NFPA 101® 1985 Life Safety Code - A Procedure for
Determining Evacuation Capability (See attachments)
8. NFPA 101® 2000 Life Safety Code (Proprietary)
9. Michigan Fire Prevention Code (1941 PA 207, as Amended July 2002)
Bay-Arenac Behavioral Health
Access Alliance of Michigan
Riverhaven Coordinating Agency
Huron Behavioral Health
Montcalm Center for Behavioral Health
Shiawassee County Community Mental Health
Tuscola Behavioral Health Systems