Use of Survey Protocol in the Survey Process

2712 - Use of Survey Protocol in the Survey Process (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) Survey protocols are established to provide surveyors with guidance in conducting surveys to assess the compliance of providers and suppliers participating in the Medicare and Medicaid programs with certain regulatory requirements. Survey protocols appear in the various appendices to this manual. The purpose of the protocols is to provide instructions, check lists, and other tools for use both in preparation for the survey and when performing the survey. Survey protocols are to be used by all surveyors to measure compliance with Federal requirements. They are the authorized interpretations of mandatory requirements set forth in provisions of the Act, the Public Health Service Act (for laboratories), and the regulations. Survey protocols identify relevant areas and issues to be surveyed as specified in each regulation, and, in some cases, the methods to be used to survey those areas and issues. These protocols promote consistency in the survey process. They also assure that a facility’s compliance with the regulations is reviewed in a thorough, efficient, and consistent manner. At the completion of the survey, the SA should have sufficient information to make compliance decisions. Included in the survey protocols are interpretive guidelines that serve to interpret and clarify the CoPs, conditions for coverage, and requirements of participation for specific types of entities. The interpretive guidelines contain authoritative interpretations and clarifications of statutory and regulatory requirements and are to be used to make determinations about a provider’s compliance with requirements. These interpretive guidelines define or explain the relevant statutes and regulations and do not impose any requirements that are not otherwise set forth in the statute or regulations. The SA conducts the surveys in accordance with the appropriate protocols, and looks to the substantive requirements in the statute and regulations to determine whether a citation of noncompliance is appropriate. The SA bases any deficiency on a violation of the statute or the regulations. The decision of whether there is a violation of the statute or the regulations must be based upon observations of the facility’s performance, practices, or conditions in the facility. Where the surveyor sees conditions or practices that are in conflict with a particular interpretive guideline, these observations are indications that the applicable provisions of the statute or regulation are not met. To make a determination whether the requirement is met, the SA should evaluate the observation in terms of frequency and/or severity of the condition or practice. Moreover, the SA may find that a facility’s deficiencies in meeting statutory or regulatory requirements may be based on observations other than those mentioned in the guidelines because the guidelines cannot provide an exhaustive, all-inclusive listing of all circumstances which might indicate violations of the requirements. The following is an example of how an interpretive guideline may be used to support a deficiency citation: EXAMPLE • Requirement: The comprehensive functional assessment of the client must identify his/her specific developmental and behavioral management needs. • Interpretive Guideline: Findings are reported in terms that facilitate clear communication. Diagnoses or imprecise terms and phrases (including, but not limited to, “developmental level,”) in the absence of specific terms are not acceptable. • Statement of deficiency: 42 CFR 483.440(c)(3)(iii): The comprehensive functional assessment must identify the client’s specific developmental and behavioral management needs. This Standard was NOT MET as evidenced by the following: • For 2 of the 4 clients reviewed (clients #2 and 3), it was determined by record review and staff interview that the facility’s functional assessment process required staff merely to identify the clients’ diagnoses or overall level of functioning without identifying the clients’ specific developmental needs. The findings include: • The record of client #3 included 11 evaluations conducted by the professional staff. None of these evaluations specified any skill deficits that may have contributed to the diagnosis of his reported developmental level of functioning. This example illustrates how material in the ICF/IID interpretive guidelines can be used to support the citation. The critical factor is whether the evidence relates directly to the language of the regulation.