Approval Procedures for ICFs/IID

2138 - Approval Procedures for ICFs/IID (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 2138A - Initial Certification of ICF/IID (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) Initial certification of ICFs/IID may be granted by the SA only as a result of a complete survey which has found the agency to comply with all of the CoPs specified in 42 CFR 483, Subpart I. A facility must be operational prior to scheduling an initial survey. Even though a facility may be part of a larger corporation, the fact that it is separately certified means that it is an independent institution and must be capable of providing all of the services necessary to meet the client’s needs. Therefore, the survey of each separately certified ICF/IID must ensure that any evidence used in the determination of compliance for the requirements stands on its own. A facility may request that the SA review relevant aspects of its existing immediate track record as part of the initial survey process if the following is true. A facility must have been fully operational as a licensed group home or a distinct part that was never certified because of physical plant limitations yet it provided treatment comparable to that required by a certified ICF/IID. For example, if the entity claims that it has provided active treatment to the same clients who will be certified, with the same staff, and consistent with the components of active treatment described in the Federal regulations, then an initial survey may be scheduled immediately. To the extent that a survey determines that the agency’s current and immediate past practices comply with the ICF/IID requirements, the SA surveyor may utilize this information in making a compliance determination, as part of the survey, but not as a substitution for the survey. There is no specific number of days that an ICF/IID must be operational prior to its initial survey, but in most cases approximately 30-35 days (except as described above) would be a general safety measure. This timeframe, however, is only a recommendation since 42 CFR Part 483.440(c)(4) only requires that the client’s initial individual program plan (IPP) must be developed within 30 days after admission. 42 CFR Part 483.440(d)(1) requires that as soon as the IPP is developed, each client receives a continuous active treatment program. Therefore, should the facility wish to have its initial survey prior to being operational for 30-35 days, it should identify the date by which it will be able to demonstrate its compliance with 42 CFR Part 483.440(a) for each of its clients. Additionally, for an initial survey, a facility may not demonstrate its “compliance” with active treatment based primarily on its policies and procedures. Policies and procedures are designed to describe how a facility intends to provide active treatment. This is inconsistent with §1905(d)(2) of the Act, which requires that each individual with intellectual disabilities for whom a request for payment is made is receiving active treatment. For purposes of the initial survey of an agency in which clients have just moved to the agency, the following key components of the active treatment process that are most relevant to the survey methodology for the CoP, Active Treatment Services (data tag W 195; Appendix J) are: • The comprehensive functional assessment (42 CFR Part 483.440(c)(3)); • The IPP (42 CFR Part 483.440(c)(4)); • Program implementation (42 CFR Part 483.440(d)); and • Program documentation (42 CFR Part 483.440(e)). It would not be necessary to measure the component of active treatment dealing with program monitoring and change (42 CFR Part 483.440(f)) unless it is determined through the survey that the initial program clearly does not meet the client’s needs and there is no evidence of appropriate oversight and attention. 2138B - Multiple Certification of Dispersed Locations (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) When surveying ICFs/IID with more than one unit at dispersed locations, either for an initial certification or recertification, the SA surveys each unit. Even if a group of small ICFs/IID is centrally administered, the SA prepares a certification package for each unit. 2138C - Minimum Size of ICF/IID (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) An ICF/IID is defined as a facility that furnishes food, shelter, treatment, or services to 4 or more individuals unrelated to the proprietor. ICFs/IID vary in size from very large multi-unit, multi-level facilities with sophisticated programs to very small, home-like settings with required services provided through an arrangement with community organizations. “Satellite” facilities off the main grounds of an institution are certified as separate ICFs/IID. Each must meet the 4-individual minimum. Not withstanding common ownership or unified administration, a “cluster” of separate facilities in the community cannot be considered as one establishment meeting the definition of “institution.” Separate cluster facilities in the community must be viewed as separate establishments. Each must meet the 4-individual minimum to qualify as an “institution.” An individual living unit that is part of an overall ICF/IID may be separately certified under its own provider number if the living unit meets the criteria for a freestanding ICF/IID. Each separately certified facility, at any point in time, must be able to independently meet all standards and CoPs. This includes, among other things, maintaining independent staffing and management. Any services which are not provided directly by the separately certified facility would have to be provided through a written agreement with outside sources as required by 42 CFR Part 483.410(d). It is unlikely that, for example, a facility with several units housed within one building sharing common corridors and utilizing a common kitchen/dining area could meet the requirements for maintaining independent staffing and management to meet the criteria for a freestanding ICF/IID. There is no minimum number of individuals who must be in residence at the time of the initial survey. The facility must have enough individuals in residence to demonstrate that it is able to, and does in fact, provide services to the total number of individuals it proposes to serve. For example, a facility established to serve 4 individuals would need to show capacity to serve 4 people, even though not all 4 people would be required to have actually moved in at the time of the initial survey. (42 CFR Part 435.1009(b)(2) requires that a facility serve a minimum of 4 persons in order to meet the definition of an institution.) 2138D - Interpretive Guidelines for ICFs/IID (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) Guidelines for surveying ICFs/IID are located in Appendix J. They provide an interpretation of the ICF/IID regulations that are applicable to all sizes of facilities that provide services. They focus on individual and staff performance rather than on compliance with process and paper requirements and reflect current philosophies and practices in training individuals with intellectual disabilities and related conditions. 2138E - Survey Report (Form CMS-3070G-I) (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) To survey ICFs/IID, the SA must use the Interpretive Guidelines and Survey Procedures (see Appendix J) in conjunction with Forms CMS-3070G-I. The forms and optional work sheet permit the SA to summarize pertinent facility, individual, and survey data, record observations about active treatment provided for individuals by staff, and summarize deficiency-related data on the standards and CoPs. In an effort to monitor the number of allegations of abuse and neglect investigated and the number of deaths related to restraints and unusual incidents, CMS revised Form CMS- 3070G, the ICF/IID survey report form, to now include an item “M” - Allegations of Abuse and Neglect, to capture this information. All surveys, including initials, recertifications, complaints, and follow-ups, occurring after January 2, 2002, must be entered into the Online Survey and Certification System (OSCAR). 2138F - Application of LSC to ICFs/IID of 16 Beds or Less (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) When conducting a LSC survey, the SA applies the appropriate occupancy chapter (see Appendix I) of the LSC of the National Fire Protection Association (NFPA), 2000 edition. 2138G - Schedule for Recertification (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) The SA completes a recertification survey an average of every 12 months and at least once every 15 months (see §2141).