Pursuant to Michigan Public Acts 27, 28, and 29 of 2006 (MCL 330. 1134a, MCL 333. 20173a and MCL 400. 734b), it is required that as a condition of continued employment in a health facility or agency (hereinafter defined as a nursing home, county medical care facility, hospice, hospital that provides bed services, home for the aged, or home health agency, psychiatric hospital, or ICF/MR) or adult foster care facility, each employee, independent contractor, or individual granted clinical privileges shall agree in writing that he or she will report to the health /adult foster care facility or agency immediately upon being arraigned on a felony charge and upon being convicted of one or more of the criminal offenses listed below. Reporting of an arraignment is not cause for termination or denial of employment.
i.) A felony that involves the intent to cause death or serious impairment of a body function, that result in death or serious impairment of the body function that involves the use of force or violence, or that involves the threat or the use of force or violence.
ii.) A felony involving cruelty or torture.
iii.) A felony under chapter XXA of the Michigan Penal Code, 1931 PA 328, MCL 750. 145m to 750.145r. These statutory citations refer to crimes committed against “vulnerable adults,” i.e., individuals aged 18 and over who , because of age, developmental disability, mental illness, or physical disability, require supervision or personal care or lack the personal and social skills required to live independently.
iv.) A felony involving criminal sexual conduct.
v.) A felony involving abuse or neglect.
vi.) A felony involving the use of a fire arm or dangerous weapon.
vii.) A felony involving the diversion of adulteration of a prescription drug or other medications.
viii.) Any other felony.
i) A misdemeanor involving the use of a firearm or dangerous weapon with the intent to injure, the use of a firearm or dangerous weapon that results in a personal injury, or a misdemeanor involving the use of force or violence or the threat of the use force or violence.
ii) A misdemeanor that involves vulnerable adult abuse under chapter XXA of the Michigan Penal Code, 1931 PA 328, MCL 750. 145m to 750.145r.
iii) A misdemeanor involving criminal sexual conduct.
iv) A misdemeanor involving cruelty or torture.
v) A misdemeanor involving abuse or neglect.
vi) A misdemeanor involving cruelty if committed by an individual who is less than 16 years of age.
DCH - 1373 (Revised 1/24/2007)
ivii) A misdemeanor involving home invasion.
viii) A misdemeanor involving embezzlement.
ix) A misdemeanor involving negligent homicide.
x) A misdemeanor involving larceny.
xi) A misdemeanor of retail fraud in the second degree.
xii) Any other misdemeanor involving assault, fraud, theft, or the possession or delivery or a controlled substance.
xiii) A misdemeanor for assault if there was no use a firearm or dangerous weapon and no intent to commit murder or inflict great bodily injury.
xiv) A misdemeanor of retail fraud in the third degree.
xv) A misdemeanor under part 74 of the Public health Code, 1978 PA 366, MCL 333. 7401 to 333.7461 involving the creation, delivery, or possession with intent to manufacture or deliver a controlled substance.
xvi) A misdemeanor under part 74 of the Public Health Code, 1978 PA 336, MCL 333. 7401 to 333.7461 involving the creation, delivery, or possession with intent to manufacture or deliver a controlled substance, if the individual, at the time of conviction, is under the age of 18.
xvii) A misdemeanor for larceny or retail fraud in the second or third degree if the individual , at the time of conviction, is under the age of 16.
I agree to report to the health/ adult foster care facility or agency immediately upon being arraigned on a felony charge and upon being convicted of one or more of the criminal offenses listed above.
I agree to immediately report If I become the subject of an order or disposition finding of not guilty by reason of insanity under Section 16b of Chapter IX of the Code of Criminal Procedures, 1927 PA 175, MCL 769.16b.
I also agree to immediately report upon becoming the subject of a substantiated finding of neglect, abuse, or misappropriation of property by a state or federal agency pursuant to an investigation conducted in accordance with 42 USC 1395i-3 or 1396r. This statutory citation refers to violations of those provisions of the federal Social Security Act that set forth requirements for skilled nursing facilities and nursing facilities, respectively.
Further, I understand that the new background check requirements stipulate that within 24 months after the effective date of April 1,2006, all current employees, independent contractors, or individuals granted clinical privilege's shall provide the Michigan State police with a set of fingerprints for input into the automated fingerprint identification system database that would provide for an automatic notification if and when subsequent criminal arrest fingerprints matches a set of fingerprints previously submitted. I agree to provide same when requested by the employer.
MCL 333.20173a, MCL 333.1134a, and MCL 440.734b require that a heath facility/agency that is a:
- psychiatric facility
- hospital that provides swing bed services
- ICF/MR
- home for the aged
- nursing home
- home health agency
- country medical care facility
- hospice
- adult foster care facility (AFC)
Shall not employ, independendtly contract with, or grant clinical privileges to an individual who regularly has Direct access to or provides direct services to patients or residents in the health facility/agency or AFC until The health facility/agency or ACF conducts a fingerprint-based criminal history check.
An individual who applics for employment either as an employee or an independent Contractor or for Clinical privileges with a health care facility / agency or AFC and has received a good faith offer of Employment, an independent contract, or clinical privileges shall give written consent at the time of Application for the health vare facility/agency or AFC to conduct a criminal history check, including a state And federal Bureau of Invertigation (FBI) fingerprint-based cheak, and shall give a written statement Disclosing that he or she has not been convicted of a crime that would prohibit employment.
NOTE: Throughout this form:
- "Employmente" includes persons independenty contracted with and/or those granted clinical privilegeas
- Clinical privileges do not apply to adult foster care facilities.
Health Facility or Agency
The health facility /agency or AFC:
a. May not Knowingly employ a worker, having direvt access to patients or resdents, who has been Convicted of a disqualifying crime or has been of a state or federal agency substantiated Finding of patient or resident neglect, abuse, or misappropriation of property.*"Direct access means regular access to a patient or resident, or to a patient's or resident's property, financial information,medical records, treatment information,or any other identifying information.
b. May terminate the background check or decide not to hire the individual at any stage of the proess.
c. Must ensure that any background check information provided will only be used the purpose of determining an individual's suitability for employment in a long - term vare setting.Must retain verification of compliance with background check requirments.
d. Will make the employment decision.
* This does not include a finding of abure, neglect, or misappropriation (financial exploitation) substantiated Under the Michigan Mental Health Code or Adult P rotective Servies Act.