Assistance in Surveying Psychiatric Hospitals

2718 - Assistance in Surveying Psychiatric Hospitals (Rev. 1, 05-21-04) 2718A - Use of CMS Surveyors (Rev. 1, 05-21-04) To participate in Medicare and Medicaid, a psychiatric hospital must meet the special medical records and special staffing requirements. (See 42 CFR 482.61 and 482.62.) Surveys to determine whether these requirements are met are to be performed by board- certified psychiatrists and Masters-prepared psychiatric nurses, and, if necessary, Masters- prepared psychiatric social workers. If the SA does not have qualified psychiatric personnel to conduct the surveys, CMS strongly encourages using the services of specialist surveyors who are under contract with CMS. All State-owned and operated psychiatric hospitals are to be surveyed by CMS contract specialist surveyors to the extent possible, depending on availability and the scope of the program. The SA submits annual requests for survey assistance for the subsequent year to the RO in July. Provide the following information for each hospital: • Name and address of the hospital to be surveyed; • Number of beds in the certified component (call the hospital and verify whether the number of beds in previous records is still accurate); • Identification of the distinct part, if the entire institution is not a psychiatric hospital; • JCAHO status (i.e., accredited, non-accredited, in appeal); • Date of last survey; • Name and telephone number of the SA person responsible for coordinating the survey (a SA surveyor should accompany the CMS psychiatric surveyors during the survey, if possible); and • Whether the institution is privately or publicly owned. Upon receipt of the SA request, the RO forwards a copy to CO. The SA and the RO will receive a memo confirming the dates of scheduled surveys and the names of the surveyors that will participate. In the interest of timely scheduling of complaint and revisit surveys of psychiatric hospitals, the RO should initiate requests by telephone to CO. 2718B - CO Responsibility (Rev. 1, 05-21-04) CMS CO contracts with an independent contractor to handle the scheduling of the surveys, e.g., notifying SA and RO of dates of survey by letter, names of CMS surveyors, and hotel accommodations. 2718C - Survey Responsibility (Rev. 1, 05-21-04) CMS surveyors are responsible for the opening conference, the survey of the two special Conditions, 42 CFR 482.61 and 482.62, and the exit conference. They discuss their findings at the exit conference. Following this, the surveyors’ involvement in the survey process ceases. For further clarification regarding the surveyor’s findings, contact the RO. CMS surveyors forward the Psychiatric Hospital Survey Report (Form CMS-724), and all necessary documentation for recertifications, follow-up visits, and initial certifications to CO. The completed report is sent by the CMS mental health surveyors to CO within 10 working days after the survey for review of appropriateness and completeness of documentation. In turn, CO mails the completed report to the RO for their determination of compliance or noncompliance along with an informational copy to the SA. The termination process for psychiatric hospitals using CMS mental health surveyors is consistent with the 90-day timeframe for other providers. However, due to the additional administrative process of sending the survey findings to CO, day 1 of the 90-day termination timeframe begins on the date of receipt of the completed psychiatric survey report in the RO. When CMS surveyors find either of the two psychiatric special conditions out of compliance, they will telephone the findings to CO. CO will telephone the RO. 2718D - RO Responsibility (Rev. 1, 05-21-04) The RO acts as a liaison between the SA and CO for activities other than those described above. On an annual basis the RO obtains SA requests for psychiatric hospital survey assistance and forwards them to CO. During the year, the RO monitors development of statements of deficiencies and PoCs and SA revisit activities for psychiatric hospital surveys not performed by CMS surveyors. The RO is also responsible for determining whether the provider has made a credible allegation of compliance and for requesting revisits to be made by the CMS surveyors via CO. If the RO has any questions or problems arising regarding any aspect of the surveys (e.g., scheduling of surveys, interpretation of survey findings), it contacts the CO project officer responsible for the psychiatric survey program. The ROs and SAs do not contact CMS mental health surveyors directly. In most cases, if CMS surveyors cite deficiencies that result in a termination action being initiated, the CMS surveyors will perform revisit(s) if the provider makes a credible allegation of compliance. (See §3016.) The CO project officer will notify the RO if the SA is to perform the revisit.