Assessment of ICFs/IID Based on CoPs for Active Treatment

2139 - Assessment of ICFs/IID Based on CoPs for Active Treatment (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) To be certified as a Medicaid provider of ICF/IID services, a facility is required by §1905(d) of the Act to provide active treatment services for each individual for whom payment is claimed. Federal regulations in 42 CFR Part 435.1009 and 483, Subpart I outline the requirements for active treatment in ICFs/IID. While a facility must comply with the CoPs to be certified, the SA must place particular emphasis on an assessment of whether active treatment is in fact received by individuals for whom payment is claimed. Appendix J contains a basic methodology for surveying these requirements. The definition of “active treatment” in intermediate care facilities for individuals with intellectual disabilities in 42 CFR Part 435.1009 refers to treatment that meets the requirements specified in the CoPs for active treatment in 42 CFR Part 483.440(a). The components of the active treatment process most relevant to this survey methodology are: 2139A - Comprehensive Functional Assessment (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) Within 30 days of admission, the individual’s interdisciplinary team must produce accurate comprehensive functional assessment data that identifies all her/his present problems and disabilities. Also, when possible, their causes; specific developmental strengths and needs; behavioral management needs; and the need for services without regard to the availability of those services. 1. Money Management Program • Citing Deficiencies: Surveyors currently cite a deficiency during the ICF/IID survey process if every client in the facility does not have a formal money management program in place. • Regulatory Provisions: The regulations at 42 CFR 483.420(a)(4) state that clients in the ICF/IID must be allowed to manage their financial affairs and be taught to do so to the extent of their capabilities. • Determination of Compliance: The determination as to the appropriateness of a formal money management program for an ICF/IID client is based upon the results of a comprehensive functional assessment and a consensus by the interdisciplinary team. The need for a formal money management program must be addressed in every client’s IPP by the IDT on an annual basis. The determination of the appropriateness of a formal money management program is made by the IDT and must be based upon a CFA. The IDT discussions resulting in that determination must be established through documentation in the client’s IPP. Surveyors will question and cite any IDT team decision that a formal money management program is not appropriate when the client clearly exhibits and the CFA supports the skills needed to implement such a program. 2. Self-Administration of Medications It has been the expectation of ICF/IID surveyors pursuant to previous Centers for Medicare & Medicaid Services interpretations of §483.460(k)(4), that every client residing in an ICF/IID must participate at some level in a formal, self- administration program for medications. • Regulatory Requirement for Self Administration Programs: There is no regulation that requires every client to have a formal, self-administration program for medications. The appropriateness of such a program for a client is determined by the interdisciplinary team in consideration of the comprehensive functional assessment data. • Regulatory Requirement for Those Clients Not in Self-Administration Programs: The concept of continuous active treatment at §483.440(d)(1) requires that the facility utilize the time during medication administration by staff as a teaching opportunity for clients who have formal training programs for the development of skills that are transferrable to the drug administration process. Self administration of medication refers to the intentional, independent application or ingestion of over the counter or prescribed medications by an individual without assistance, instruction or direction. The regulation at §483.460(k)(4) requires the interdisciplinary team to develop and implement training objectives for individuals, “determined” to be appropriate for self administration of medications unless the client’s physician specifies otherwise. The interdisciplinary team must determine, based on comprehensive assessment, whether an individual possesses, or has the potential to develop, the requisite skill set needed to safely self administer medications and individually tailor training objectives to advance the individual toward the goal of self administration. §483.460(k)(4) does not require that all individuals in an ICF/IID be engaged in self administration training programs. The interdisciplinary team decision that a self administration program is appropriate, as is the case for all formal training objectives, must be based upon accurate, current, valid assessment of the individual’s skills and potential. The determination as to the appropriateness of a self administration program must never be made singularly on the individual’s diagnosis or current functional abilities. For individuals assessed to be inappropriate for a self administration program, but determined by the interdisciplinary team to possess the capacity to functionally, cognitively, emotionally or developmentally benefit from participation in the drug administration process, it is expected that the facility will provide opportunities for the client to participate in the medication administration process under direct supervision. This participation can include but is not limited to identifying the medication taken, reaching/grasping a cup of water during the process and placing oral medications in the mouth, etc. During drug passes observe whether clients are offered the opportunity to participate consistent with their functional skill level and verify that the programs are being carried out consistently and in accordance with the written objective. For individuals not in need of formal self-administration programs who are not provided opportunities to participate in administration process, cite a deficiency at §483.440(c)(6)(vi). If, as a result of observations and interviews, there are any concerns as to why a client is not on a formal program, the surveyor should review the associated assessments and interdisciplinary discussions. During this review look for evidence that the interdisciplinary team documented a justification as to why the client was not appropriate for a formal self-administration program and that the justification provided was based on an evaluation of the assessment results. Deficiencies for a failure by the facility to properly assess, to develop written self administration objectives or to carry out the self- administration programs consistently should be cited at §483.460(k)(4). 2139B - Individual Program Plan (IPP) (Rev. 1, 05-21-04) The individual’s interdisciplinary team must prepare an IPP which identifies the discrete, measurable, criterion-based objectives the individual is to achieve; the timetables for expected mastery; and the specific individualized program of specialized and generic strategies and techniques to be employed. The IPP must be directed toward the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible and the prevention or deceleration of regression, or loss of current optimal functional status. 2139C - Program Implementation (Rev. 1, 05-21-04) Each individual must receive continuous active treatment consisting of needed interventions and services in sufficient number and frequency to achieve the IPP objectives. Each individual’s IPP must be implemented by all staff working with the individual, except where only licensed personnel may implement certain areas of the program. 2139D - Program Documentation (Rev. 1, 05-21-04) Accurate, systematic, behaviorally-stated data about an individual’s performance toward meeting the criteria in the IPP objectives must be documented and serve as the basis for changes and revisions, whenever necessary. 2139E - Program Monitoring and Review (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) At least annually, the comprehensive functional assessment of each individual is reviewed by the interdisciplinary team for relevancy and updated as needed. The IPP is revised, as appropriate. The IPP must also be reviewed by a qualified intellectual disabilities professional and revised as necessary. Approximately one-third of the ICF/IID CoPs (42 CFR Part 483, Subpart I) deals with the sufficiency and adequacy of staff to deliver each service. The regulations provide guidance about what constitutes active treatment and enable the SA to assess these standards from the standpoint of whether active treatment is being provided in a consistent and aggressive manner. SA entries on both Form CMS-3070G-I and Form CMS-2567 should reflect this approach. Of greatest importance in determining if active treatment is being provided is whether the facility provides competently trained staff of all types and at all levels who, in fact, do implement individually identified objectives established for each individual. A correct certification addresses these objectives in terms of whether the services are being delivered to each individual whose IPP indicates that they are needed and whether adequate staff and facilities are engaged in furnishing them. A certification which affirms no more than that the services, staff, and facilities are available is incorrect and unacceptable. A provider agreement may be held invalid under 42 CFR Part 483.440(a) of the CoPs if the regulation is not correctly applied. If a facility has the necessary resources available but does not actually provide active treatment to individuals in accordance with identified needs or does not conduct the comprehensive functional assessment evaluations to identify individuals’ needs, the SA denial, nonrenewal, cancellation, or termination of the agreement is supportable. The SA carefully explains the deficiency in the SA notice of determination.