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ADULT FOSTER CARE Family homes small group homes large

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					  ASM 376     1 of 22                        ACP, FACILITIES                          ASB 2010-001
                                                                                          1-1-2010


ADULT FOSTER
CARE                    Family homes, small group homes, large group homes and congregate
                        facilities are licensed by the DHS Bureau of Children and Adult Licens-
                        ing (BCAL) under Act 218 Public Acts of 1979. These facilities provide
                        supervision, protection, and personal care to adults 18 and over who
                        are frail, developmentally disabled, mentally ill, or physically handi-
                        capped that require supervision on an ongoing basis but do not require
                        continuous nursing care.

                        DHS also monitors rule compliance for county infirmaries which were
                        formerly the county poor farms. There are two county infirmaries in the
                        State of Michigan which are located in Midland and Monroe counties.
                        The county infirmaries follow the licensing regulations of congregrate
                        AFC homes, but are not congregrate AFC facilities. However, county
                        infirmaries are coded as an AFC facility for Medicaid purposes.

                        Agencies that arrange for care of residents and maintain ongoing
                        responsibility for them in AFC are defined in Administrative Rules for
                        AFC facilities as responsible agencies. Services Workers carry out
                        placement responsibilities when DHS is the responsible agency. An
                        agreement between the Department of Community Health (DCH) and
                        the DHS is located in ASM 379D and should be utilized to determine
                        the responsible agency as needed.

Overview of             Act 218 of the Public Acts of 1979 as amended is known as the Adult
Licensure               Foster Care Facility Licensing Act. Act 193, Public Acts of 1996, the
                        Michigan Do-Not-Resuscitate Procedure Act and Act 192, Public Acts
                        of 1996 amending the Public Health Code also affect AFC home licens-
                        ing.

                        Among other things, Act 218 states that a regular license is to be valid
                        for 2 years unless revoked or modified.

                        In addition to the Act 218 there are administrative rules that are required
                        to be met prior to the issuance of an adult foster care license. The infor-
                        mation that follows is of a general nature to assure local office staff
                        have a common base of knowledge. Specific interpretations or ques-
                        tions regarding P.A. 218 of 1979, as amended, or the administrative
                        rules should be discussed with the Adult Foster Care Licensing Con-
                        sultant.

Definitions in Act      Act 218 defines both an adult foster care facility and the term adult.
218
                        1.   Adult foster care facility - 400.703 Sec. 3(4)

                             Adult foster care facility means a governmental or nongovernmen-
                             tal establishment that provides foster care to adults. It includes
                             facilities and foster care family homes for adults who are aged,
                             mentally ill, emotionally disturbed, developmentally disabled, or

ADULT SERVICES MANUAL                                                         STATE OF MICHIGAN
                                                               DEPARTMENT OF HUMAN SERVICES
  ASM 376    2 of 22                        ACP, FACILITIES                         ASB 2010-001
                                                                                        1-1-2010


                            physically handicapped who require supervision on an ongoing
                            basis but who do not require continuous nursing care.

                       2.   Adult - 400.703 Sec. 3(1) a and b.

                            Adult means:

                            (a)   A person 18 years of age or older.
                            (b)   A person who is placed in an adult foster care family home or
                                  an adult foster care small group home pursuant to section
                                  5(6) of Act No. 116 of the Public Acts of 1973, as amended,
                                  being section 722.115 of the Michigan Compiled Laws.

                       Four types of facilities are defined in Act 218.

                       •    ADULT FOSTER CARE FAMILY HOME - 400.703 Sec. 3(5).

                            Adult foster care family home means a private residence with the
                            approved capacity to receive not more than 6 adults who shall be
                            provided foster care for 5 or more days a week and for 2 or more
                            consecutive weeks. The adult foster care family home licensee
                            shall be a member of the household and an occupant of the resi-
                            dence.

                       •    ADULT FOSTER CARE SMALL GROUP HOME - 400.703 Sec.
                            3(7).

                            Adult foster care small group home means an adult foster care
                            facility with the approved capacity to receive not more than 12
                            adults who shall be provided foster care.

                            Note: A six bed home can be licensed as either a family or small
                            group home depending on whether or not the licensee is an occu-
                            pant of the residence and a member of the household.

                       •    ADULT FOSTER CARE LARGE GROUP HOME - 400.703 Sec.
                            3(6).

                            Adult foster care large group home means an adult foster care
                            facility with the approved capacity to receive at least 13 but not
                            more than 20 adults who shall be provided foster care.

                            Note: The AFC rules for family and group homes require the lic-
                            ensee to complete a Resident Care Agreement (BCAL-3266 or an
                            approved equivalent) for each resident in the facility. The worker
                            should review and sign agreements for those residents for whom
                            DHS is the responsible agency.

                       •    ADULT FOSTER CARE CONGREGATE FACILITY - 400.703
                            Sec. 3(3).

ADULT SERVICES MANUAL                                                        STATE OF MICHIGAN
                                                              DEPARTMENT OF HUMAN SERVICES
  ASM 376    3 of 22                        ACP, FACILITIES                           ASB 2010-001
                                                                                          1-1-2010


                            Adult foster care congregate facility means an adult foster care
                            facility with the approved capacity to receive more than 20 adults
                            who shall be provided foster care. Section 15 of P.A. 218 prohibits
                            the licensure of new adult foster care congregate facilities.

Adult Foster Care      The DHS-3422 is a written agreement that identifies the responsibilities
Agreement for          of the licensee and the responsible agency. It is required only in congre-
Congregate             gate adult foster care homes. It should be signed by the local office
Facilities (DHS-       manager or designee and the AFC licensee or designee. This form is
3422)                  not required in family homes or group homes; (see RFF 3422).

                       There are several other definitions that are likewise important in under-
                       standing the AFC licensing perspective.

                       1.   Foster Care - 400.704 Sec. 4(6).

                            Foster care means the provision of supervision, personal care,
                            and protection in addition to room and board for 24 hours a day, 5
                            or more days a week, and for 2 or more consecutive weeks, for
                            compensation.

                       2.   Supervision - 400.707 Sec. 7(7).

                            Supervision means guidance of a resident in the activities of daily
                            living including all of the following:

                            (a)   Reminding a resident to maintain his or her medication
                                  schedule, as directed by the resident's physician.

                            (b)   Reminding a resident of important activities to be carried out.

                            (c)   Assisting a resident in keeping appointments.

                            (d)   Being aware of a resident's general whereabouts even
                                  though the resident may travel independently about the com-
                                  munity.

                       3.   Personal care - 400.706 Sec. 6(1).

                            Personal care means personal assistance provided by the lic-
                            ensee or an agent or employee of the licensee to a resident who
                            requires assistance with dressing, personal hygiene, grooming,
                            maintenance of a medication schedule as directed and supervised
                            by the resident's physician, or the development of those personal
                            and social skills required to live in the least restrictive environment.

                       4.   Protection - 400.706 (4) 26A(2) of Act 194.

                            Protection, subject to section 26a(2), means the continual respon-
                            sibility of the licensee to take reasonable action to insure the

ADULT SERVICES MANUAL                                                         STATE OF MICHIGAN
                                                               DEPARTMENT OF HUMAN SERVICES
  ASM 376    4 of 22                        ACP, FACILITIES                          ASB 2010-001
                                                                                         1-1-2010


                            health, safety, and well-being of a resident, including protection
                            from physical harm, humiliation, intimidation, and social, moral,
                            financial, and personal exploitation while on the premises, while
                            under the supervision of the licensee or an agent or employee of
                            the licensee, or when the resident's assessment plan states that
                            the resident needs continuous supervision.

                            Act 194 defines the following:

                       5.   Licensed hospice program - 400.705(2).

                            Licensed hospice program means a health care program that pro-
                            vides a coordinated set of services rendered at home or in an out-
                            patient or institutional setting for individuals suffering from a
                            disease or condition with a terminal prognosis and that is licensed
                            under article 17 of the public health code, Act No. 368 of the Public
                            Acts of 1978, being sections 333.20101 to 333.22260 of the Michi-
                            gan Compiled Laws.

                       6.   Do-not-resuscitate order - 400.704(5).

                            Do-not-resuscitate order means a document executed pursuant to
                            section 3 of the Michigan do-not-resuscitate procedure act direct-
                            ing that, in the event a resident suffers cessation of both spontane-
                            ous respiration and circulation, no resuscitation will be initiated.

                            In the case of an accident or sudden severe adverse change in a
                            resident’s physical or medical status, such as respiratory or car-
                            diac arrest or life threatening injury, the licensee and/or his/her
                            employees are required to call emergency medical services to the
                            home. The adult foster care licensee and/or his/her employees are
                            not required to resuscitate a resident whose heart and breathing
                            have stopped and who has executed a valid do-not-resuscitate
                            order pursuant to the Michigan Do-Not-Resuscitate Procedure Act,
                            (Act 194).

                            If the resident has a DNR order and emergency medical services
                            are called to the home, the licensee is to provide the written DNR
                            order to the emergency medical services personnel. Under the
                            provisions of the Michigan Do-Not-Resuscitate Procedure Act,
                            emergency medical services personnel are not required to resus-
                            citate a resident if shown a legally valid DNR order.

                            In the event that a resident, who is enrolled in a licensed hospice
                            program (and has a do-not-resuscitate order in his/her assess-
                            ment plan) suffers a cessation of both spontaneous respiration
                            and circulation, the adult foster care facility is allowed to immedi-
                            ately contact the resident’s licensed hospice service provider


ADULT SERVICES MANUAL                                                        STATE OF MICHIGAN
                                                              DEPARTMENT OF HUMAN SERVICES
  ASM 376    5 of 22                         ACP, FACILITIES                            ASB 2010-001
                                                                                            1-1-2010


                            instead of emergency medical services. The licensed hospice pro-
                            vider can then determine the appropriate course of action.

List of Licensed       The Bureau of Children and Adult Licensing, has created a licensed
Facilities             facility locator tool which allows you to search for all licensed adult fos-
                       ter care facilities in the state, by facility name, county, city, zip code,
                       facility type, or license number. The list is available from the Internet at
                       www.michigan.gov/dhs. Once on the DHS website, click on the On Line
                       Lookup at the bottom of the page and then click the Adult Foster Care/
                       Home for the Aged licensed facility locator link to conduct a search for
                       licensed AFC homes or Home for the Aged. The facilities license num-
                       ber begins with a prefix identifying the type of facility such as AF for
                       AFC family home, AS for AFC small home, AL for AFC large home, AG
                       for AFC congregate home, and AH Home for the Aged.

Local Office AFC       Licensing consultants will forward pertinent information to Adult Ser-
Facility Files         vices for each adult foster care facility housing residents for whom DHS
                       is the responsible agency. A local facility file should be established con-
                       taining the initial licensing issuance, updated licensing status reports,
                       special investigation reports, and any notices of Intent to take adverse
                       action (NOI) letters.

                       In addition to the above, the file must contain the DCH-1625A, Adult
                       Foster Care or Home for the Aged Provider Agreement; the DHS-2351,
                       Provider Enrollment; a copy of the DHS-3422, AFC Agreement (Con-
                       gregate Care only).

                       There are other kinds of information that may also be helpful in order to
                       reflect a total picture of the facility. For example, if a list of residents is
                       maintained in this file, it will be available in the worker's absence should
                       questions be raised about vacancies and description of current resi-
                       dents.

                       It may also be helpful to identify unique factors that affect the placement
                       process, for example, whether or not the provider will accept diabetics
                       with their need for special diet and perhaps help with insulin injections.
                       Is there access to public transportation? Is the facility barrier free?

AFC                    Any variance from the AFC administrative rules for family, group or con-
Administrative         gregate facilities is to be requested by the licensee in writing to the AFC
Rule Variances         Licensing Consultant. If approved, the variance is to be noted on the
                       service plan citing the specific rule and circumstances, related to the
                       variance.

                       1.   WORK: (Small Group Home Rule, R400.14305, Large Group
                            Home Rule R400.15305, and Congregate Care Rule
                            R400.2412(3)).



ADULT SERVICES MANUAL                                                           STATE OF MICHIGAN
                                                                DEPARTMENT OF HUMAN SERVICES
  ASM 376    6 of 22                        ACP, FACILITIES                          ASB 2010-001
                                                                                         1-1-2010


                            All work performed by a resident is to be in accordance with the
                            resident's written assessment plan. A plan may allow for work
                            other than expected tidiness of one's personal belongings. The
                            tasks must be goal-oriented, such as participate in meal prepara-
                            tions to aid in resident's ability to become more self-sufficient with
                            a view to independent living.

                       2.   PROTECTED RESIDENT ACTIVITIES: (Family Home Rule
                            R400.1409, Small Group Home Rule R400.14304, Large Group
                            Home Rule R400.15304, and Congregate Care Rule R400.2418).

                       AFC facilities are intended to simulate an atmosphere of home, family,
                       and community life for the continued growth and enrichment of the resi-
                       dents.

                       The following resident activities are protected unless specifically
                       excluded for stated reasons in the services plan, the resident's written
                       assessment plan, or both:

                       •    Access to mail.
                       •    Access to telephone.
                       •    Access to personal clothing and belongings.
                       •    Private storage space.
                       •    Visitors during reasonable visiting hours.
                       •    Opportunity to shop for personal needs.
                       •    Recreational experiences.
                       •    Freedom of religious practices.
                       •    Freedom to select a home of his or her choice.

                       3.   RESIDENT FUNDS: (Family Home Rule R400.1421, Small Group
                            Home Rule 400.14315, Large Group Home Rule R400.15315, and
                            Congregate Care Rule 400.2421, 2422).

                            Residents shall have access to and use of their personal funds in
                            reasonable amounts. Small and large group home residents must
                            have immediate access to at least $20.00 of their personal funds.
                            (Small Group Home Rule R400.14315 and Large Group Home
                            Rule R400.15315). Congregate care residents must have access
                            to at least $5.00 of their personal funds. (Congregate Care Rule
                            R400.2421). Family home rules do not specifically address the
                            amount of money that must be readily available to a resident
                            (Family Home Rule R400.1421.). In the event that circumstances
                            indicate that some other arrangement is needed, the exclusion is
                            to be identified and noted in the resident's assessment plan.

                            A resident shall receive all of his or her personal funds no later
                            than 5 days after they make the request.



ADULT SERVICES MANUAL                                                         STATE OF MICHIGAN
                                                              DEPARTMENT OF HUMAN SERVICES
  ASM 376     7 of 22                        ACP, FACILITIES                        ASB 2010-001
                                                                                        1-1-2010


Shared                  When DHS is the responsible agency, workers should assist in the
Responsibility for      maintenance of facility records by providing timely and accurate infor-
Maintenance of a        mation. The contents of the record are described in the administrative
Facility Resident       rules for AFC facilities. Copies of the rules may be obtained from the
Record                  AFC Licensing Consultant. Workers should note that family homes
                        have several required forms that are different from those required of
                        group and congregate facilities.

RESIDENT
RECORDS                 Small Group Home Rule 400.14316, Large Group Home Rule
                        400.15316, and Congregate Care Rule 400.2452(2) require the lic-
                        ensee to complete and maintain a separate record for each resident on
                        file in the home. Although Act 218 does not provide for the regulation of
                        responsible agencies, the services worker is expected to assist the pro-
                        vider in collecting the necessary information to establish the record.
                        Services staff should also work with the provider to assure continued
                        maintenance of the information and communicate with the licensing
                        consultant if there are problems. Providers should be encouraged to
                        discuss with the licensing consultant any problems with responsible
                        agencies.

                        According to AFC licensing rules, resident records are to be kept in the
                        facility for a minimum of two years after discharge. The services worker
                        should not remove the records in the event of relocation. Rather, copies
                        should be requested from the licensee by the client or his representa-
                        tive when necessary.

                        A resident record as described in Family Home Rule 400.1422 speci-
                        fies the minimal information to be contained in the record. The following
                        licensing/adult community placement forms contain information
                        required by the licensing rules cited:

                        •    The ASCAP Service Plan. Family Home Rule 400.1407(2) (a, b,
                             c,)(3)(4) specifies that a written assessment is required before
                             accepting or retaining a resident for care except in emergency sit-
                             uations. The ASCAP service plan includes the key elements of the
                             comprehensive assessment and satisfies this requirement. In
                             emergencies, the written assessment must be completed within 15
                             days. The AFC licensee is also required to complete their own
                             assessment of each resident. Generally this is done on a BCAL-
                             3265, Assessment Plan for AFC Residents, which is not a Depart-
                             ment required form.

                        •    BCAL-3483, Resident Information and Identification Record,
                             contains pertinent identifying information as identified in
                             R400.1422(1)(a-j).




ADULT SERVICES MANUAL                                                        STATE OF MICHIGAN
                                                               DEPARTMENT OF HUMAN SERVICES
  ASM 376    8 of 22                        ACP, FACILITIES                         ASB 2010-001
                                                                                        1-1-2010


                       •    BCAL-3947, Health Care Appraisal, or its equivalent in accor-
                            dance with Rule 400.1407(7a, b), (8) and (9), Rule 400.1416(2)
                            specifies health data to be kept on file for not less than two years.

                       •    BCAL-3267, Resident Medication Record, (if appropriate). Rule
                            400.1418(a)(b) details instructions for supervising medication. A
                            written record must be maintained of any adjustments of residents'
                            prescribed medication.

                       •    BCAL-3266, Resident Care Agreement or its equivalent, in
                            accordance with Rule 400.1407(5), requires upon admission that a
                            resident care agreement be established between the resident and
                            provider.

                       •    BCAL-3485, Weight Record. Rule 400.1416(3) states weight is to
                            be recorded upon admission and monthly thereafter. Records are
                            to be kept on file for two years.

                       •    BCAL-4607, Incident/Accident Report. Rules 400.1414, .1415,
                            .1416(4a, b, c), .1417, .1426 require the recording and mainte-
                            nance of incident and accident reports. Reports are to be main-
                            tained for not less than two years.

                       •    BCAL-2318 and BCAL-2319, Resident Funds, Part I and II (as
                            appropriate). Rule 400.1421 specifies the conditions for handling
                            and recording resident funds.

                       In addition to information required by the licensing rules, records for MA
                       recipients for whom the licensee receives monthly personal care/sup-
                       plemental payments will include a copy of the DHS-2353 Invoice or the
                       Provider Log, DHS-721. The Invoices and/or Provider logs are to be
                       retained for six years for Federal Audit purposes.

                       A resident's record as described in Small Group Home Rule
                       400.14316, Large Group Home Rule 400.15316, and Congregate
                       Care Rule 400.2452 specifies the minimal resident information to be
                       contained in the record. The following licensing/adult community place-
                       ment forms contain the required information.

                       •    The ASCAP Service Plan contains the components of the
                            assessment plan as specified in Small Group Home Rule
                            400.14301(2), Large Group Home Rule 400.15301(2), and Con-
                            gregate Care Rule 400.2417. The AFC licensee is also required to
                            complete their own assessment of each resident. Generally, this is
                            done on a BCAL-3265, Assessment Plan for AFC Residents,
                            which is not an Agency required form.

                       •    BCAL-3483, Resident Information and Identification Record,
                            contains pertinent resident information; next of kin or legal guard-

ADULT SERVICES MANUAL                                                        STATE OF MICHIGAN
                                                              DEPARTMENT OF HUMAN SERVICES
  ASM 376    9 of 22                        ACP, FACILITIES                          ASB 2010-001
                                                                                         1-1-2010


                            ian data, person or placing agency data, date of admission/dis-
                            charge, preferred physician and hospital with instructions for
                            emergency care, information regarding insurance policies, and
                            prearranged funeral arrangements, and other vital information.

                       •    BCAL-3947, Health Care Appraisal, plus statements and instruc-
                            tions for administering prescribed medication will provide the nec-
                            essary information.

                       Information found on the following forms also located in the facility resi-
                       dent record meets the rules cited:

                       •    BCAL-3485, Weight Record, Small Group Home Rule
                            400.14310, Large Group Home Rule 400.15310, and Congregate
                            Care Rule 400.2415 state weight is to be recorded upon admis-
                            sion and monthly thereafter.

                       •    BCAL-2318 and BCAL-2319, Resident Funds and Valuables,
                            Small Group Home Rule 400.14315 and Large Group Home Rule
                            400.15315 specify information and procedures to be used in
                            recording resident transactions and the handling of resident funds
                            and valuables. Congregate Care Rule 400.2457 states the resi-
                            dent's funds must be accounted for, but the use of the BCAL-2318
                            and BCAL-2319 is not mandatory.

                       •    BCAL-3266, Resident Care Agreement or its equivalent, Small
                            Group Home Rule 400.14301, Large Group Home Rule 400.-
                            15301, and Congregate Care Rule 400.2417 requires upon admis-
                            sion that a resident care agreement be established between the
                            resident and provider.

                       •    Small Group Home Rule R400.14303, Large Group Home Rule
                            400.15303, and Congregate Care Rule 400.2456 provide a resi-
                            dent the right to voice grievances.

                       •    BCAL The Bureau of Children and Adult Licensing-4607, Inci-
                            dent/ Accident Report. Small Group Home Rule 400.14311,
                            Large Group Home Rule 400.15311, and Congregate Care Rule
                            400.2454 require the reporting of incidents or accidents involving a
                            resident. Copies of these reports are to be kept in the facility
                            records.

                       In addition to information required by the licensing rules, records for MA
                       recipients for whom the licensee receives monthly personal care/sup-
                       plemental payments will include the DHS-721, Provider Log. Provider
                       logs are to be retained for six years for Federal Audit purposes.




ADULT SERVICES MANUAL                                                        STATE OF MICHIGAN
                                                              DEPARTMENT OF HUMAN SERVICES
  ASM 376   10 of 22                        ACP, FACILITIES                           ASB 2010-001
                                                                                          1-1-2010


Monitoring             Incident and accident reports are submitted by the licensee or designee
Incident and           to the responsible agency and the licensing consultant. Workers are to
Accident Reports       review these reports and take appropriate action. Incident and acci-
                       dents that require 48 hour notification are:

                       •    The death of a resident.
                       •    Any accident or illness that requires hospitalization.
                       •    Incidents that involve any of the following:
                            ••   Displays of serious hostility.
                            ••   Attempts at self-inflicted harm or harm to others.
                            ••   Instances of destruction of property.
                            ••   The arrest or conviction of a resident.
                            ••   Medication error by staff or pharmacy.

                       If incidents and accidents are not reported timely, workers are to notify
                       the appropriate licensing consultant.

                       On receipt of these reports, Adult Protective Services procedures
                       should be followed if the worker has a reasonable belief the incident or
                       accident resulted from abuse, neglect or exploitation.

                       It is important to consider what preceded the event to determine
                       whether or not it could have been prevented and if so how. For
                       instance, violent behavior on the part of residents may occur because
                       of failure to take medication. Thus corrective action might take the form
                       of a conference with CMH staff to discuss the problem of medical man-
                       agement. This information should then be shared with the provider and
                       client to help prevent the problem.

                       Not all incidents or accidents are preventable, but it is important to min-
                       imize them.

Monitoring Death       Death reports must be submitted by the licensee or designee to the
Reports                responsible agency and the licensing consultant within 48 hours of a
                       death. Workers are to review reports and monitor for unnatural causes.
                       If a death appears suspicious, the licensing consultant should be con-
                       tacted.

Unnatural Deaths       As with incident or accident reports, it is important to determine what
                       preceded the event so that preventive action may be taken with other
                       residents. Was there evidence of unusual behavior such as depres-
                       sion? Were appropriate referrals made? Was extra supervision pro-
                       vided?

                       Contact should be made with the licensing consultant who will share
                       investigative responsibilities per Adult Foster Care Licensing Manual
                       Item 330 - Agency Coordination/Information Sharing and Referrals.



ADULT SERVICES MANUAL                                                        STATE OF MICHIGAN
                                                              DEPARTMENT OF HUMAN SERVICES
  ASM 376   11 of 22                        ACP, FACILITIES                         ASB 2010-001
                                                                                        1-1-2010


                       Adult Protective Services procedures should be followed if the worker
                       has reasonable belief that the death resulted from abuse, neglect or
                       exploitation.

SSI Recipients         Adverse actions by AFC licensing staff may include license revocation,
Notification of        refusal to renew or denial of the license. When notice of adverse action
Adverse Action by      is received from Licensing, workers are to notify all SSI recipients in
Licensing              writing of the areas of noncompliance and offer to assist in relocation.
                       This notification is a requirement of the Keys Amendment.

Involuntary        Resident admission and discharge policy and Resident rights; lic-
Transfer/Discharge ensee responsibilities; Specific areas to be aware of are:

                       •    A licensee shall provide a resident and his or her designated rep-
                            resentative with a 30-day written notice before discharge from the
                            home. See AFC Licensing Rules 400.1407, 400.14302, and
                            400.15302.

                       •    A licensee may discharge a resident before 30-day notice when
                            the licensee has determined and documented that any of the fol-
                            lowing exists: substantial risk or an occurrence of self destructive
                            behavior, serious physical assault, or destruction of property. See
                            AFC Licensing Rules 400.1407, 400.14302, and 400.15302.

                       •    The licensee shall confer with the responsible agency, or if the res-
                            ident does not have a responsible agency, with adult protective
                            services and the local community mental health response service
                            regarding the proposed discharged. If the responsible agency or if
                            the resident does not have a responsible agency, adult protective
                            services does not agree with the licensee that emergency dis-
                            charge is justified, the resident shall not be discharged from the
                            home; see AFC Licensing Rules 400.1407, 400.14302, and
                            400.15302.

                       •    The licensee shall not change the residency of a resident from one
                            home to another without the written approval of the resident or the
                            resident’s designated representative or responsible agency; see
                            AFC Licensing Rules 400.1407, 400.14302, and 400.15302.

                       •    A resident has a right to request and receive assistance from the
                            responsible agency in relocating to another living situation; see
                            AFC Licensing Rules 400.1409, 400.14304, 400.15304.

ADVERSE ACTION
AND KEYS
AMENDMENT              The Keys Amendment amends Title XVI (Supplemental Security
                       Income) of the Social Security Act with the goal of ensuring quality of
                       care for SSI recipients by requiring adherence to state care standards.
                       In Michigan the standards are the AFC rules, adult foster care licensing

ADULT SERVICES MANUAL                                                       STATE OF MICHIGAN
                                                              DEPARTMENT OF HUMAN SERVICES
  ASM 376   12 of 22                        ACP, FACILITIES                          ASB 2010-001
                                                                                         1-1-2010


                       law, children's foster care family/family group home rules, child caring
                       institution rules, the Child Care Organization law, homes for the aged
                       rules, and the Public Health Code. If the department suspends, revokes
                       or refuses to renew an adult foster care license, relocation services
                       shall be provided to all residents of the facility if such assistance is
                       needed. The responsible agency shall provide the relocation services,
                       or, if a resident has no agency designated as responsible, by the
                       department. An individual in need of adult foster care services may not
                       remain in a facility that is no longer licensed under Act 218.

                       The local office will receive copies of all letters which the Department of
                       Human Services, Bureau of Children and Adult Licensing will send to
                       licensees in conjunction with the adverse action.

                       The intent to revoke or refusal to renew letter is sent to the licensee
                       specifying the areas of noncompliance. This is an intent letter signed by
                       the Director of the Bureau of Children and Adult Licensing and which
                       transmits the licensing study report. The intent letter allows the licensee
                       30 days to appeal the decision.

                       If the licensee has not appealed the Department's decision after the 30-
                       day appeal period, a revocation or refusal to renew letter is sent to the
                       licensee stating the date on which the license is no longer valid. This
                       letter is also signed by the Director of Children and Adult Licensing.

                       When the adverse action is a summary suspension the license is sus-
                       pended upon receipt of the letter by the licensee or by an established
                       date that is stated in the letter. The letter sets an appeal deadline date
                       and informs the licensee to immediately cease providing adult foster
                       care. Upon receipt of this letter, the responsible agency must begin
                       immediate action to ensure the relocation of any adult foster care resi-
                       dents.

                       In cases where the licensee unsuccessfully appeals the revocation or
                       refusal to renew decision and the department director signs the final
                       decision and order, another letter is sent to the licensee indicating the
                       effective date of the adverse action.

                       In either situation, unappealed or appealed, the worker must notify each
                       resident in writing after the adverse action letter is received stating the
                       effective date. The letter of notification must include the “intent” letter,
                       information on the provision of services to relocate, and a reminder that
                       the licensee is prohibited from keeping residents in the facility. Individu-
                       als who require adult foster care services may not continue residing in
                       an unlicensed home. If the former licensee continues to serve residents
                       in need of foster care, the Adult Foster Care Licensing Division will
                       request assistance from the Attorney General in taking legal action to
                       immediately enjoin further operation of the facility.


ADULT SERVICES MANUAL                                                         STATE OF MICHIGAN
                                                              DEPARTMENT OF HUMAN SERVICES
  ASM 376   13 of 22                        ACP, FACILITIES                          ASB 2010-001
                                                                                         1-1-2010


Adverse Action         Act 149 of 1994 amends the Penal Code by adding Chapter XXA
Relocation             which:

                       •    Establishes penalties for harm caused to a vulnerable adult as the
                            result of the actions or failure to act by a caregiver or other person
                            with authority over a vulnerable adult.

                       •    Establishes penalties for an operator of an unlicensed facility, an
                            employee or an individual acting on behalf of an unlicensed facility
                            who violates the licensing act and whose violation is the proximate
                            cause of the death of a vulnerable adult.

                       •    Establishes penalties for a caregiver, person with authority over a
                            vulnerable adult or a licensee who comingles, borrows, or pledges
                            resident funds, interferes with or obstructs a licensing investiga-
                            tion, or files false or misleading information required under the
                            licensing act.

                       •    Establishes penalties for a caregiver, licensee or other person with
                            authority over a vulnerable adult for retaliation against a resident
                            or employee because they make certain disclosures.

                       •    Establishes second or subsequent violation penalties.

                       •    Authorizes community service in addition to or as an alternative to
                            imprisonment within defined parameters.

                       Act 262, P.A. of 1990 amends Public Act 218 by adding two new sub-
                       sections (3) and (4) to Section 22 that describe action to be taken when
                       a provider's license is revoked, suspended or renewal is refused. Act
                       150 of 1994 further amended subsection (4).

                       The amendments provide that:

                       1.   The provider shall not keep the current residents or receive new
                            residents that need foster care.

                       2.   Providers who violate the law are guilty of a felony, punishable by
                            imprisonment for up to five years or a fine of up to $75,000.00 or
                            both.

                       3.   The department shall determine for each of the residents whether
                            they will be able to relocate with assistance from their designated
                            representative.

                       4.   The department shall provide immediate relocation services for all
                            DHS clients as well as those who do not have a responsible
                            agency and will need assistance to relocate.



ADULT SERVICES MANUAL                                                        STATE OF MICHIGAN
                                                              DEPARTMENT OF HUMAN SERVICES
  ASM 376    14 of 22                        ACP, FACILITIES                          ASB 2010-001
                                                                                          1-1-2010


                        Once the adverse action steps for revocation or refusal to renew are
                        finalized, as described in Adverse Action and Keys Amendment, resi-
                        dents can be formally notified of the need for relocation. If the adverse
                        action is a summary suspension, the responsible agency must assure
                        prompt action for the relocation of any residents. If there is no responsi-
                        ble agency, the department is responsible to provide relocation ser-
                        vices.

                        The Adult Foster Care licensing consultant is to be kept informed of the
                        status of relocation efforts.

16 and 17 Year-         In 1981, Public Act 116 of 1973, as amended, was amended to accom-
Olds in AFC             modate placement of 16 and 17-year-olds in certain AFC homes. P.A.
                        116 of 1973, as amended, is the Child Care Organizations Act. This act
                        allows DHS to authorize a licensed child placing agency or approved
                        governmental unit to place 16 or 17-year-old children in an AFC family
                        or small group home, if specific conditions have been met.

                        The definition of an adult as defined in Section 3 of Act 218, Public Acts
                        of 1979 was modified to include such persons within its scope.

                        In order to place a 16 or 17-year-old person in an AFC facility, the fol-
                        lowing conditions must be met:

                        •    The licensed child placing agency must provide ongoing supervi-
                             sion and prepare certification letters containing the following docu-
                             mentation:

                             1.   That placement is in the best interest of the child.

                             2.   That a specifically selected AFC home can meet the particu-
                                  lar needs of the child.

                             3.   That the child will be compatible with the other residents of
                                  the AFC home.

                        •    The letter is to be sent to the assigned child welfare and AFC
                             licensing consultants with a copy going to the appropriate AFC
                             family or small group licensee.

                        •    The child placing agency will periodically reevaluate the placement
                             to determine that placement criteria continues to be satisfied.

                        Special Note: Local office ACP staff have no responsibility for these
                        children in terms of SSI level of care determination, AFC agreements,
                        service plans or personal care payments. All questions in this area from
                        providers should be directed to the appropriate children's services
                        placement worker. ACP, when contacted by licensed child placing staff,
                        should provide information about appropriate vacancies, compatibility
                        with other residents, and any other pertinent, helpful information.

ADULT SERVICES MANUAL                                                         STATE OF MICHIGAN
                                                               DEPARTMENT OF HUMAN SERVICES
  ASM 376    15 of 22                          ACP, FACILITIES                            ASB 2010-001
                                                                                              1-1-2010


                        Before the actual placement occurs, the question of whether Adult Ser-
                        vices or Community Mental Health is to become the responsible agency
                        for the resident when they turn 18, or MCI status is ended, must be
                        determined. If the facility can meet the resident’s needs with the Title
                        XIX supplement in addition to the basic SDA or SSI money, Adult Ser-
                        vices may become the responsible agency. If the facility cannot con-
                        tinue to meet the now adult resident’s care needs for the Adult
                        Community Placement (ACP) supplement, then Community Mental
                        Health must be approached to meet this need.

HOMES FOR THE
AGED (HA)               Homes for the Aged are licensed facilities that provide room, board, and
                        supervised personal care to individuals 60 years of age or older. Resi-
                        dents receive assistance with Activities of Daily Living (ADL’s) and
                        medication administration similar to an adult foster care home. They are
                        licensed by the Michigan Department of Human Services, Bureau of
                        Children and Adult Licensing under Act 368 Public Acts of 1978 as
                        amended.

                        Licensure as a home for the aged is restricted to freestanding facilities
                        of 21 or more beds or facilities of any size attached to a nursing care
                        facility. Some homes have specialized dementia care programs.

                        Prior to accepting an individuals for admission, the home must assure
                        that they are able to care for them. The home cannot admit someone
                        who has a mental condition that may be disturbing to other residents or
                        personnel of that facility.

                        Before persons can be admitted to a HA, the following must be com-
                        pleted:

                        •    A chest X-ray.

                        •    Physical examination report with diagnosis and special needs
                             defined.

                        •    Doctor certification indicating that the individual has no communi-
                             cable diseases.

                        AS workers complete an assessment and develop a service plan for the
                        HA resident following the same guidelines as those completed for AFC
                        residents. HA providers receive the personal care supplement for resi-
                        dents on Medicaid.

Age Waiver              The Public Health Code allows for an age waiver when requested by a
                        facility. If it is in the best interest of an individual under the age of 60 and
                        of an individual in the facility, a waiver can be granted. Three docu-
                        ments need to be submitted to DHS/ BCAL for consideration:


ADULT SERVICES MANUAL                                                             STATE OF MICHIGAN
                                                                  DEPARTMENT OF HUMAN SERVICES
  ASM 376        16 of 22                          ACP, FACILITIES                         ASB 2010-001
                                                                                               1-1-2010


                            •    A letter from the facility administrator explaining the situation and
                                 making the request.

                            •    A physician's statement that the proposed residents' needs can be
                                 served at that facility.

                            •    A letter of explanation from the proposed resident, his guardian or
                                 concerned family member detailing why the waiver should be
                                 granted.

                            Generally, decisions are made within one week of submitting all
                            required documentation.

                            Send Information to:

                            DHS Bureau of Children and Adult Licensing (BCAL)
                            Home for the Aged 2nd Floor
                            7109 W. Saginaw
                            Lansing, MI 48917

NURSING CARE
FACILITIES                  A nursing care facility is a licensed nursing home, county medical care
                            facility or a long-term care unit in a licensed hospital. They provide
                            organized nursing care and medical treatment to 7 or more unrelated
                            individuals who are suffering or recovering from illness, injury, or infir-
                            mity. These persons must be 15 years of age or older except in child
                            caring homes and units. Nursing care facilities may also be certified for
                            the purpose of becoming eligible for payment from federal or state
                            health programs. Licenses are usually valid for not more than 1 year
                            after date of issuance. Workers may assist MA recipients in locating
                            available vacancies in appropriate nursing care facilities.

                            1978 P.A. 368, as amended, commonly known as the Public Health
                            Code, Article 17, Facilities and Agencies, contains information in two
                            parts specifically related to nursing care facilities. Part 201 is entitled
                            General Provisions and Part 217 is entitled Nursing Homes. In addition
                            there are administrative rules that provide for licensure and certification.
                            The Rules contain detailed information necessary to implement the Act.
                            Copies of the Public Health Code and the rules may be obtained from
                            the Department of Community Health (DCH), Division of Health Facili-
                            ties Licensure and Certification.

Nursing Care                Local offices should establish an individual file on each licensed nursing
Facility Files              care facility in their county used as a placement resource. Maintenance
                            of such files provides staff with centralized current information neces-
                            sary to carry out their responsibilities.

                            The following information should be available in the nursing care facility
                            facility file:

ADULT SERVICES MANUAL                                                              STATE OF MICHIGAN
                                                                     DEPARTMENT OF HUMAN SERVICES
  ASM 376   17 of 22                         ACP, FACILITIES                           ASB 2010-001
                                                                                           1-1-2010


                       1.   Certification Notices

                            MSA will issue certification notices to local offices based upon
                            information received from the DCH. These notices include the
                            name and address of the facility, the number of certified beds and
                            type of program (Medicaid and/or Medicare), whether or not there
                            are some beds for which there is no certification, and whether or
                            not there is concurrent certification of the skilled unit of a facility.

                            In addition to the certification notices for nursing care facilities,
                            MSA will also issue certification notices for other specialized facili-
                            ties such as hospital long term care units, regional psychiatric hos-
                            pitals and centers for developmental disabilities. These notices
                            may or may not be retained since local offices do not use these
                            resources in assisting individuals to locate appropriate living
                            arrangements.

                       2.   Complaints

                            ASM 210, ASM 250 and ASM 255 describe in detail the proce-
                            dures for handling adult protective services (APS) complaints.
                            Copies of APS complaint material regarding residents in a particu-
                            lar nursing care facility are to be sent to DCH, Division of Health
                            Facilities Licensure and Certification. In addition, copies should be
                            filed in the client's record and in the facility file. See ASM 210 for
                            explanation of materials required. Materials relating to any non-
                            APS complaints referred to the MDCH.

Pre-Placement          Local office staff may provide information and referral or, where appro-
Activities             priate, open a services case. Staff who carry out this responsibility
                       should have visited each facility so that they are somewhat familiar with
                       it. In addition, the local office facility file will provide current data. If
                       financial assistance is needed, referral should be made to Eligibility
                       Specialist (ES) staff.

                       There may be times when local office staff become more directly
                       involved with individuals seeking placement in a nursing care facility. If
                       a case is opened, staff must have a face-to-face contact and complete
                       the assessment to determine the extent of the services needs. If the
                       assessment indicates that the client cannot be cared for in a less
                       restrictive setting (own home with supportive services) AFC, or HA,
                       placement in a nursing care facility should be pursued. If care is to be
                       paid for under Medicaid, a level of care determination must be submit-
                       ted by the facility to DCH before payment can be authorization.

                       Families should be encouraged to visit the facilities with vacancies, and
                       the client should be involved as much as possible in the decision mak-
                       ing. If a facility has appealed a negative licensing action, families should


ADULT SERVICES MANUAL                                                          STATE OF MICHIGAN
                                                               DEPARTMENT OF HUMAN SERVICES
  ASM 376       18 of 22                        ACP, FACILITIES                          ASB 2010-001
                                                                                             1-1-2010


                           be made aware of this and be encouraged to contact DCH licensing
                           staff if there are questions about quality of care.

Post-Placement             Service goals include assessing:
Activities
                           •    Client needs.
                           •    Whether client is safe and stable/secure.
                           •    If plan of service is in place.
                           •    Whether placement is appropriate.

                           When the service goals have been achieved the case may be closed.

Level of Care              When a person applies for Medicaid for the purpose of reimbursement
Determination              to a skilled nursing or intermediate care facility for nursing care and ser-
Process                    vices, both financial and medical eligibility must be determined prior to
                           any payment for care. Medical eligibility is determined by Department of
                           Community Health (DCH) staff.

Referrals from     Referrals will be made to local office adult services staff for action
MSA Exception      whenever the level of care change affects MA recipients in the following
Operations Section two situations:

                           1.   Patient's level of care is evaluated as nursing and they are resid-
                                ing in a facility certified for non-nursing care;

                           2.   Patient's level of care is evaluated as non-nursing and they are
                                residing in a nursing facility.

                           Note: See the procedures contained in ASM 379E for details on appro-
                           priate local office response to the MSA referrals.

                           In both cases described above, when the client has been a resident of
                           the nursing home on a continuous basis for one year or more, or has
                           been involuntarily transferred within the past year, the special provi-
                           sions of the Borton v Califano consent judgment apply. In this federal
                           court action, state and federal authorities agreed certain nursing care
                           residents could not be transferred involuntarily because of a level of
                           care change unless the possibility of transfer trauma had been consid-
                           ered and ruled out. The MSA Exceptions Operation Section will pursue
                           this option on behalf of the client if they are unwilling to move from the
                           nursing care facility as determined by the client's response on the form
                           included in the referral packet.

Referrals for              If NH patients are unable to manage their own funds or other personal
Money                      property and have no one else to provide this management for them,
Management                 the facilities may refer the situation to local offices.

                           Before making the referral to DHS the nursing care facilities are to
                           exhaust the following possible alternative arrangements in behalf of the
                           patient:

ADULT SERVICES MANUAL                                                             STATE OF MICHIGAN
                                                                  DEPARTMENT OF HUMAN SERVICES
  ASM 376   19 of 22                        ACP, FACILITIES                          ASB 2010-001
                                                                                         1-1-2010


                       1.   If the patient is willing and mentally competent to give consent,
                            they may authorize in writing that the nursing home or nursing care
                            facility may hold their personal funds in trust for a reasonable fee
                            and under the direction of the patient.

                       2.   If the patient is unable to manage social security benefits they are
                            receiving, the nursing home or nursing care facility should contact
                            the Social Security Administration (SSA) for their designation of a
                            representative payee.

                       3.   If the patient is unable to manage funds other than social security
                            benefits or other personal property and has a representative
                            payee, then the possibility of the patient authorizing the represen-
                            tative payee, or another person if the patient has no representative
                            payee, to handle their other personal property should be consid-
                            ered and arranged if the patient is willing and mentally competent.

                       4.   If there is a willing and capable third person to assume the respon-
                            sibility of managing the patient's personal funds, other than social
                            security benefits, or other personal property, then the patient, if
                            willing and mentally competent, may designate in writing that the
                            person has the authority to manage these personal funds or prop-
                            erty. The availability of friends or relatives who might be suitable to
                            perform this function should be explored and inquiry made regard-
                            ing their acceptance of this responsibility.

                       5.   If the patient is incapable of managing his or her own funds or per-
                            sonal property due to age or physical infirmity but is mentally com-
                            petent, the patient may petition the court for appointment of a
                            suitable and willing person to serve as a conservator. DHS, the
                            nursing home or nursing care facility or its employees may not
                            serve as a conservator but family members, friends or a public
                            guardian should be considered.

                       6.   If the patient is incapable of managing his or her own funds or per-
                            sonal property due to reasons such a mental illness, mental
                            incompetency, or physical illness or disability, then the nursing
                            home or nursing care facility, the patient or some interested per-
                            son or relative or a public guardian may petition the court for
                            appointment of a suitable and willing person to serve as conserva-
                            tor. DHS, the nursing home or nursing care facility or its employ-
                            ees may not serve as a conservator but family members, friends or
                            a public guardian should be considered.

                       If the facility is unable to resolve the problem by use of one of the above
                       alternatives or some other arrangement, then it is appropriate for the
                       facility to make a referral to the Adult Services Unit.

                       Information that needs to be included in the written referral is:

ADULT SERVICES MANUAL                                                         STATE OF MICHIGAN
                                                              DEPARTMENT OF HUMAN SERVICES
  ASM 376     20 of 22                         ACP, FACILITIES                            ASB 2010-001
                                                                                              1-1-2010


                         1.   Name, age, gender and address of the patient.

                         2.   A DHS case number if the patient is currently receiving assistance
                              or services from DHS.

                         3.   Whether or not the patient has ever been determined to have a
                              developmental disability.

                         4.   The reasons for referral.

                         5.   A description of the personal funds or property that needs man-
                              agement.

                         6.   The name of the person to call for more information about the situ-
                              ation.

                         Upon acceptance of a referral, an adult services worker will be asked to
                         do an assessment of the patient and the situation to determine the level
                         of management that may be needed. This might be a power of attorney,
                         a conservator, a guardian or a partial guardian. If the worker determines
                         that no formal type of substitute management is needed for the patient's
                         funds or personal property, then the worker will assist the patient to
                         make some informal arrangements regarding the management of their
                         funds or personal property or in some other way try to resolve the prob-
                         lem. Neither DHS nor its employees can serve as guardian, conserva-
                         tor, representative payee or power of attorney. The only exception to
                         this would be a situation involving a member of an employee's family.
                         The Adult Protective Services Manual, ASM 215 and ASM 253, may be
                         helpful in explaining how to assess the level of management needed,
                         the process of arranging for a court appointed conservator or guardian
                         and the limitations on the DHS worker's ability to assume a manage-
                         ment role for a DHS client's fund or personal property.

                         The local office will notify the referring nursing care facility of the results
                         of the assessment and the resolution of the referral.

Involuntary              Section 21773 of the Public Health Code and Rule 325.20116 discuss
Transfers                in detail the following conditions under which an individual may be invol-
                         untarily transferred out of a nursing home.

                         1.   For medical reasons.

                         2.   For the patient's welfare or that of other patients or facility employ-
                              ees.

                         3.   For nonpayment of patient stay.

                              The decision to involuntarily transfer or discharge an individual
                              requires that there be a minimum written notice of 21 days except
                              in the following instances:

ADULT SERVICES MANUAL                                                             STATE OF MICHIGAN
                                                                  DEPARTMENT OF HUMAN SERVICES
  ASM 376    21 of 22                        ACP, FACILITIES                          ASB 2010-001
                                                                                          1-1-2010


                             •    If an emergency transfer or discharge is mandated by the
                                  patient's health care needs and is in accord with a written
                                  order of medical justification by the attending physician.

                             •    If transfer or discharge, mandated by the physical safety of
                                  other patients and facility employees, is documented in the
                                  clinical record.

                             •    If transfer or discharge is subsequently agreed to by the
                                  patient or the patient's legal guardian. Notification must be
                                  given to next of kin and the person or the agency responsible
                                  for patient's placement, maintenance and care in the facility.

                        Section 21774 of the Public Health Code allows the patient the right to
                        file a request for a hearing with the Department of Community Health,
                        within 10 days following receipt of the written notice of the involuntary
                        transfer.

Nursing Care            Sections 21785 and 21786 of the Public Health Code outline the
Facility Closures       responsibilities of a nursing home, and the Department of Community
                        Health and the Department of Human Services (DHS) in those situa-
                        tions where a facility is closing.

                        1.   Section 21875 discusses the procedures to be followed when a
                             facility voluntarily proposes to discontinue operation.

                             The facility is to notify both the Department of Community Health
                             and DHS, in addition to notifying all patients and their next of kin,
                             as well as any patient representatives. These notices shall be
                             given not less than 30 days before the facility proposes to close.

                             The facility and DHS are responsible for securing a suitable relo-
                             cation of a patient who does not have a relative or legal represen-
                             tative to assist in his or her relocation. The facility and DHS are to
                             keep the Department of Community Health informed of the
                             progress in relocating the individuals. The code specifically states
                             that “the Department of Human Services shall make available to
                             the licensee (facility) and the Department of Community Health
                             assistance necessary to assure the effectiveness of efforts to
                             secure a suitable relocation.”

                        2.   Section 21786 deals with those situations in which an emergency
                             closing of a home has been ordered or where it is determined by
                             the health department that a facility is “suddenly no longer able to
                             provide adequate patient care.”

                             It is the responsibility of the Department of Community Health to
                             notify the local DHS office to make arrangements for the orderly
                             and safe discharge and transfer of the patients to another facility.

ADULT SERVICES MANUAL                                                         STATE OF MICHIGAN
                                                               DEPARTMENT OF HUMAN SERVICES
  ASM 376   22 of 22                         ACP, FACILITIES                          ASB 2010-001
                                                                                          1-1-2010


                            The Department of Community Health will have representatives in
                            the facility on a daily basis to:

                            •    Monitor the discharge to other facilities or locations.
                            •    Insure the rights of the patients are protected, and
                            •    Discuss the discharge and relocation with each patient and
                                 next of kin or legal guardian, person, or agency responsible
                                 for the patient's placement, maintenance and care in the facil-
                                 ity. Local office staff should assist in every way possible.

                       ASM 379H which contains the Interagency Agreement for Nursing
                       Facility Closures. Local office responsibilities are further defined in this
                       document.




ADULT SERVICES MANUAL                                                          STATE OF MICHIGAN
                                                               DEPARTMENT OF HUMAN SERVICES

				
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