Survey Process

2833 – Survey Process (Rev. 132; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15) 2833A – Survey Types 2833A.1 – Recertification Surveys SAs are required to validate the attestation statements for a 20 percent of all PRTFs in their state on an annual basis. Validation requires that the SA review attestation letters, conduct on-site review of PRTFs based on criteria established in 42 CFR 441.151 through 441.156, and determine compliance with federal standards and regulations, as set forth in 42 CFR 483, Subpart G and further discussed in the interpretive guidelines. 2833A.2 – Complaint Surveys 1. Immediate Jeopardy The SA conducts an investigation of all allegations which may represent an immediate jeopardy situation within 2 working days of complaint receipt. “Immediate Jeopardy,” as defined in 42 CFR 489.3, is a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. “Serious injury” is defined as any significant impairment of the physical condition of the resident as determined by qualified medical personnel. The term “serious injury” can be equated with “abuse or neglect.” Appendix Q lists abuse and neglect as a trigger to call an immediate jeopardy. Refer to appendix Q for complete guidance on immediate jeopardy. To determine if an immediate jeopardy situation is present and ongoing, an assessment of each complaint intake must be made. Exception – If the SA receives a restraint/seclusion death report, the SA should complete the investigation of this report within 5 working days of receipt of survey authorization from the RO. This investigation involves both on-site and off-site review. The ACTS report should be reviewed to determine facility history. 2. Non-immediate jeopardy For non-immediate jeopardy situations, the SMA in conjunction with the SA will establish a mechanism by which to prioritize the nature of complaints. The SA should assess facility compliance with the established standards and regulations as provided in 42 CFR part 483 subpart G, (§§483.350 through 483.376) with additional guidance at §§441.150 through 441.156. If a complaint is received by CMS, CMS will notify the appropriate SA, who will then notify the SMA about the complaint, any ongoing investigation, findings, or decision regarding the complaint. The SMA must report all serious occurrences, as defined in 42 CFR 483.374(b), to its SA and the SA must conduct both recertification and complaint surveys based on regulations established by the 42 CFR 483 subpart G and further discussed within the interpretive guidelines as established in Appendix N. The SA will be advised annually in the CMS Mission and Priority Document (MPD) on the expected validation requirements for its State’s psychiatric residential treatment facilities. 2833B – Survey Frequency 1. Frequency – The SAs are required to conduct recertification surveys for 20 percent of all PRTFs in the state each year and for all PRTFs within a State within a 5-year period. Complaint surveys do not count towards a State’s 20 percent required recertification surveys. 2833C – Survey Procedures Pre-survey procedures, onsite survey procedures, required CMS forms, and the interpretive guidelines are located in Appendix N. 2833C 1 PRE-SURVEY PROCEDURES Under CMS policy, surveys for all providers and suppliers must be unannounced. While the unannounced surveys may sometimes result in some minor difficulties, this policy and practice represents public attitudes and expectations toward effective compliance with the regulation and survey standards. If there is any conflict with internal State policies and practices, the State survey agency (SA) should discuss the problem with its State Medicaid Agency (SMA). 2833C.2 ON-SITE SURVEY PROCEDURES 2833C.2a ENTRANCE CONFERENCE The entrance conference sets the tone for the entire survey. The surveyor should be well prepared, courteous, and make requests, not demands. Upon arrival, the surveyor does the following: • Presents the appropriate identification; • Introduces other team members who must also furnish appropriate identification; • Informs the facility’s administrator, director, or supervisor of the purpose of the Survey; • Provides expected duration and time schedule of the survey; and • Provides the facility with an overview of the survey and explains the process. During the entrance conference, the surveyors should: A. Request a listing of all residents at the facility, including their age or date of birth, and who in the past 12 months: • Have been secluded or restrained; • Have been placed in time out; • Received medication for behavior management; • Have been injured or hospitalized as a result of restraint or seclusion intervention; • Had a serious occurrence that was reported regardless of whether it is related to a safety intervention. A Serious occurrence as defined in the regulations is a resident’s death, serious injury to a resident, or a resident’s suicide attempt; • Was transferred to a hospital for acute care services; and • Died while in the facility. B. Inform the facility that the survey process will include: • A physical onsite tour of the facility; • Direct observations, and interviews with residents, families/guardians, and personnel involved in the residents’ care, (ask that appropriate family and guardians be made aware of potential interviews); and • Review of relevant program, treatments, and residents records. C. Establish personnel availability and discuss approximate time frames for survey completion. D. Provide approximate or expected exit date and time. E. Ask if there are any locked areas which require a key for entry, and if there are locked areas, how would the surveyor be able to access those areas. F. Ask the facility to identify which staff will be available for questions/assistance. G. Provide a list and category of the facility staff the surveyor will need to interview during the course of the survey. 2833C.3. Survey Team Composition Survey team size and composition will vary according to the size of the facility and the purpose of the survey. Professional disciplines and experience represented on the survey team should reflect the expertise needed to determine compliance with the CoP. All survey team members must meet education and training qualifications as specified in the SOM §4009 and must have successfully completed the CMS Basic PRTF survey training course. Any SA or federal surveyor who serves on the PRTF survey team must have completed the PRTF basic survey training course successfully. 2833C.4- INFORMATION GATHERING 2833C.4a TASK 1 - REPRESENTATIVE SAMPLE OF RESIDENTS - SELECTION METHODOLOGY Purpose of the Sample - The purpose of drawing a sample of residents from the facility is to ensure all the regulatory requirements is applied to a proportionate representation of all residents. The sampling methodology outlined below is not intended to create a "statistically valid" sample. The methodology allows for flexibility in sample selection based on the surveyor’s observations while on-site at the facility. The surveyor must conduct interviews and observations of the sampled residents within the context of the environment in which the resident lives, receives treatment and spends leisure time. Although focus should be on the sampled residents, the behavior and interactions of all other residents and staff within the environment also contributes to the total context. After the resident sample is collected, additional information about the facility's practices, as well as additional resident information may emerge. Surveyors may add residents to the sample based on observations or incidents that occur during the survey. The reason for adding residents to the sample must be documented. Surveyors must add any resident who is restrained or secluded during the survey to the sample. A resident substitution may be made in the sample only if it is determined that including such a resident in the sample would negatively impact his/her treatment. For example, when interviewing/observing a resident with diagnosis of paranoid schizophrenia, may result in acute exacerbation of psychiatric symptoms. When a substitution is made within the sample, surveyors must ensure that the resident added to the sample meets the same requirements, and is selected from the same age group as the resident he/she is replacing. Sample Considerations– • Survey team should not allow the facility to select the resident sample. • Sample selection should be completed before beginning review of residents or other survey activities. • Survey team must randomly select sample from the list of all the residents provided by the facility. • The sample should represent various age groups of the facility residents. The three main age groups are: ages 18 to 21; 9 to 17 and under 9 years. • The sample should include residents who experienced restraint, seclusion or time-out in the past 12 month (if any); these residents should make up at least 50% of total sample. Sample Selection: Follow the guidance below using the appropriate ratio to select and calculate the size of the sample. Census : Sample Ratio: 4-8 residents 4 residents 9-16 residents 6 residents 17-50 residents 8 residents 51 or more residents 10 residents NOTE: • Due to unique characteristics the PRTF population and the seriousness of the Condition of Participation, surveyors should investigate further when a facility reports they have no current residents who have experienced either an ESI or time out procedure. To maximize the advantage of an interdisciplinary survey team, the survey team leader assigns each member an equitable number of individuals on whom to focus. Each member of the team shares salient data about findings relative to his or her assigned individuals. Consult with one another, on a regular basis during the survey, to maximize sharing of data, knowledge and competencies. Documentation – Document the sample on form CMS-807 Surveyor Notes Worksheet - The team leader must ensure that information related to the sample is well documented and includes the following: 1. Summary listing of all resident information comprising the survey sample (including any additions or substitutions to the sample). At a minimum, identify: • The record number of each resident chosen to be part of the sample; • Any resident-identifier codes used as a reference to protect the resident's confidentiality; and • The record number of each death record reviewed. 2. Description of the representative sample selection must include: • The number of residents in the sample; • The distribution of the individuals in the sample; • The number, if any, of the residents added to the sample, including the reason added,e.g., complaint investigation; and • The number, if any, of the residents substituted in the sample, including the reason for withdrawing the original resident record. 2833C.4b TASK 2 - RECORD REVIEW OF INDIVIDUALS IN THE SAMPLE Review each resident's record to determine appropriate compliance with the condition of participation (CoP) for the use of restraint or seclusion, and the regulation requirements in 42 CFR §§ 441.151 through 441.182. The primary purpose of the record review is to determine if the facility is complying with the requirements of: 1) Certification of need for services; 2) Individual plan of care (treatment plan); 3) Documentation of emergency situation and all events surrounding it; 4) Management and outcome of emergency safety intervention; and 5) Health and wellness of the residents. During record review, surveyors should be alert to instances of intramuscular medication use, safety hold and escort procedures, and any other procedures that could be mislabeled as not being restraints or seclusion. Utilize direct observations, resident interviews and record review to make informed compliance decisions. Ensure that the facility’s definitions and perception of seclusion and restraint is in consonance with the definition that is contained in the regulation. While reviewing the records, pay attention to key requirements such as: compliance with treatment team members’ credentials, facility/program accreditation, and trends that may suggest that seclusion and restraint intervention are being overused or misused. Also look for records of accidents and incidents which may suggest resident’s abuse, neglect, bullying or vulnerability to injury. If there is any evidence of physical, verbal, emotional, or sexual abuse; surveyors must follow-up on the status and if required, implement the immediate jeopardy procedure as directed by Chapter 5 and Appendix Q of the SOM. 2833C.4c TASK 3- REVIEW OF OTHER RECORDS A. Death Records - Review a list of all resident deaths, in the past 12 months. All team members must participate in the record review of residents who have died while at the facility. For death records, refer to form CMS-726, CMS Death Record Review Data Sheet. Evidence should exist of documented contact with appropriate Federal, State and local agencies notifying of the circumstances and demographics surrounding the resident’s death and resulting outcomes from investigation by the PRTF and/or any of the appropriate Federal, State or local agencies. B. Complaint Investigations - If a complaint is being investigated at the time of the survey, include the record(s) of the resident(s) of the complaint as part of the record review. If the resident named in the complaint is still in the facility, add him/her to the sample. C. Policy and Procedures – Review the facility’s policy and procedure documents on restraint, seclusion, and time out interventions. The policy must contain information about management of emergency safety intervention (ESI), and the facility’s procedures regarding all the requirements of the CoP. D. Serious Injury and Occurrence Report– Review all PRTF’s serious injury and occurrence reports for at least past twelve months prior to the date of the present survey. Some individual state laws may preclude the facility from sharing detailed records of the incident. In such case, provide PRTFs an option as to whether or not they share these actual reports. In these States, surveyors should request a written summary of these reports. The PRTFs should provide this summary, as well as a copy of or citation to the applicable state law, within one working day of the entrance conference. 2833C.4d TASK 4 - DIRECT RESIDENT OBSERVATIONS The purpose of direct observation is to determine the existence of effective therapeutic relationship between the facility staff and the residents. Staff must respect the rights of the residents and interact with them in a mutually productive manner. Direct observation also helps to determine how effective staff manages the milieu and efficiency of the application of de-escalation and other behavior management techniques. De-escalation techniques include: limit setting, therapeutic communication, redirection, conflict resolution, active listening techniques, and visualization. Observe each sampled resident in as many treatment settings (therapy groups, activities, treatment team meetings, other types of meetings, and milieu interactions in the resident's environment) as possible. Visit as many treatment areas as time permits, and observe residents’ activities during different time periods, including day and evening hours, if possible; for team member’s convenience or preference. Surveyors must never request the facility to alter a resident's schedule so that the surveyor will not have to work at other than their regular work times in order to observe the resident during the survey. The observation should be conducted for an amount of time sufficient to assess the sampled resident's responses and behaviors as well as staff responses to resident behaviors. Documentation - If during resident observation the process of documentation will disrupt the activity in progress, the best option is to document after the observation is completed. Form CMS-3070I is an optional form but can be used to record observations if the surveyor so chooses. After observations are completed, compare observation result with the program/individual treatment plan for consistency. Record the following information for each observation: • Date and location; • Beginning and ending times of observation; • Number of residents present; • Approximate number of staff present • What the resident is doing (regardless of whether or not a scheduled therapeutic modality was in progress); • What the staff is doing; • The presence of disruptive behavior, and staff's intervention, if any; and, • Any other pertinent information. 2833C.4e TASK 5 INTERVIEWS Resident Interviews Surveyors must interview all sample residents individually. However, an interview may not be conducted with a resident when it is determined by one of the individual plan of care team members, as described in §441.156(c), as being inappropriate for the resident’s condition. Staff information and medical record documentation should support the rationale for not interviewing the resident. When interviewing residents of a PRTF a surveyor should take into consideration the resident’s age and psychiatric condition. Interviews with residents consist of questions directed at determining the resident's understanding of the treatment services indicated in their individual care plan and progress towards goals, type and quality of relationship with program staff, and their restraint or seclusion episode. In addition, the resident should be asked to what degree they felt safe while restrained or secluded and if they feel as if staff are working with them to prevent future restraint or seclusion usage. Also ascertain if the resident felt that the restraint or seclusion was warranted based on their behavior. Interviewing should not take place in the direct presence of staff. However, a resident should be given an opportunity to have a staff member be within visual proximity if the resident so chooses. When an interview is deemed inappropriate by the facility staff, the survey activities for review of that resident will consist of observations, staff interviews, and record reviews. Resident confidentiality must be respected, but if the surveyor does find a life-threatening situation, that information is shared with the staff. Listed below are suggested processes and questions that a surveyor may use during an interview. Interview Setting: Surveyors must respect resident’s rights and ensure the setting of the interview is conducive and less restrictive. The surveyor should: 1. Request permission of the resident to talk with him/her individually. 2. Provide the resident with information, such as surveyor name and purpose of the survey. 3. Ensure resident privacy by conducting the interview in an appropriate location (low stimulus, on or off unit depending on resident restrictions, staff visible for surveyor and resident protection, if necessary). Staff should be easily available and may be present in the room, but should not be able to overhear conversation unless the resident makes a request for staff close physical presence. Suggested Interview Questions: • Can you tell me why you are in this facility? • Tell me about your treatment goals? • Do you think you are making progress towards your treatment? Can you tell me the names of your medications and why you are taking them? • Do you have the opportunity to talk to members of your treatment team on a regular basis and how responsive are they to your interaction? • Can you describe to me your experience with the last time you were restrained/ secluded/ in timeout? • Where was staff located during your restraint/seclusion/ time out? • Has the treatment team discussed the incident with you? Did you and the team agree on a plan to reduce the frequency of these incidents? Please describe the plan to me. • Describe to me what incident that led to the restraint/seclusion/time out? Age Appropriate Adjustments – Surveyors should keep in mind varying age range of residents in the PRTF (toddlers to adolescents or young adults) and adjust their interview approach accordingly for a better result. For example, there are times when kneeling or sitting in a chair may be less intimidating to residents, and more appropriate to begin a conversation. Also the way a question is framed may determine how much information one can elicit, for instance, instead of asking: “Can you tell me why you are in this facility?” The question can be reworded into different series of probing questions to get at a better answer. For example, “Do you like living here?” “Do you know why you are living here?” “Can you tell me about living here?” It is important to note that different facilities and residents may perceive or interpret restraint/seclusion intervention based on their own understanding and frame of reference. Staff Interviews Because milieu interaction and therapeutic intervention involve both the staff and the residents, it is also important to interview the staff in order to ascertain their level of knowledge and understanding of the facility’s restraint and seclusion policies and procedures. In order to ensure improved safety, staff must be adequately educated and oriented to their work environment. Staff should also be familiar with resident treatment plans and understand their role in facilitating the residents’ attainment of the target treatment goals. Assess for consistent treatment approaches and collaboration among the interdisciplinary treatment team, as well as the outcomes experienced by the residents. Interview the following: • Treatment team member who has assigned treatment responsibility for each sample resident (case manager, primary therapist, resident care coordinator, advocate); and • Other staff members who are involved with the resident, either through multidisciplinary treatment assignment (social worker, dance therapist, dietician) or through work assignment (professional and paraprofessional staff members assigned to resident's unit). During staff interviews, asking the following questions may help to elicit improved cooperation and more information: • Do you participate in the interdisciplinary treatment team; if yes, what role do you play? • Did you contribute to treatment plan objectives/goals for sample residents and updates? • How often is each resident’s treatment plan reviewed? • Can you describe the discharge plans for sample residents? • Give examples of de-escalation techniques you were taught and how you utilize them when dealing with residents? • How do you integrate treatment plan goals and objectives that have been developed as a result of seclusion or restraint episodes? • How do you manage resident’s emergency safety situation, and how you determine when to utilize a restraint or seclusion intervention? • Describe to me, how staff implement, manage, and discontinue time out, restraint or seclusion. • What behavior typically warrants interventions such as restraint or seclusion? • Do you feel you are adequately prepared (through education and training) to handle behavioral safety situations and emergencies related to residents’ care? Interviews with Parents and Legal Guardians Surveyors will make a request to facility/program staff after the entrance conference to give sample residents family/guardian notice of a potential for interview. The interviews with parents and legal guardians should be conducted in addition to interviews with sampled residents. Interviews with parents and legal guardians should be conducted at their convenience with an opportunity for face-to-face interviews when feasible. In cases where parents or legal guardians reside in another state or are unable or unwilling to meet face-to-face, telephone interviews should be conducted. Suggested questions: • Were you involved in formulation of your family member’s treatment plan and discharge plans? • Are you aware of the psychiatric medications your family member is taking and/or being prescribed while in treatment? • Have you been able to communicate with members of your family member’s treatment team? • Do you know your family members treatment diagnosis, and do you understand what it means? • Were you informed of the facility’s policy on restraint and seclusion? • Was the information presented in a manner that you could understand? • Did you receive the information regarding the State Protection and Advocacy organization? What type of information should be reported to them? • Were you contacted after a restraint or seclusion intervention? • Were you given an opportunity to participate in the debriefing following restraint/seclusion use? Interviews with Department Heads and/or Facility Administrator Conduct these interviews near the end of the survey if it is determined that questions were unanswerable by facility staff and interviewing directors or other facility leaders would prove useful to the survey process and the gathering of information. Base the interview on information that was gathered during observations and direct interviews with residents and staff. Documentation – Use form CMS-807 to record each observation and interview conducted with residents/ parents/ legal guardians and staff. Clearly delineate the documentation as an interview. Include the date and time of each interview and the following information in every recorded entry: Resident: • The record number, any resident-identifier codes used as a reference to protect the resident's confidentiality, and the resident’s age; • Dates of restraint, seclusion or time out; and, • Summary of information obtained. Parent/ Legal Guardian: • Relationship to the resident; • Method of interview (face-to-face or telephone contact); and, • Summary of information obtained. Staff/ Management/ Directors: • Position, title and assignment of staff member; • Relationship to the resident or reason for interview; and, • Summary of information obtained. 2833C.4f TASK 6 - VISIT TO EACH AREA OF THE FACILITY SERVING RESIDENTS Visit all areas in the facility where residents are permitted to spend their time, both structured and unstructured, as these are places where unanticipated behavior may occur that would require emergency interventions. Also examine the area that is used for restraint as well as those devices that the facility uses as a restraint. Other examples of areas to visit are: restrooms, bathrooms, activity areas, visitation areas, therapy rooms, seclusion/time-out room, dining areas, bedrooms, and classrooms. During the visit or tour, converse with residents and staff. Ask open-ended questions in order to confirm observations, obtain additional information, or corroborate information regarding perceived problems. Observe staff interactions with both residents and other staff members for insight into matters such as individual rights and staff responsibilities. Protocol - After residents in the sample have been assigned to team members, review the facility's map or building layout. Be sure that at least one team member visits each residential and treatment unit prior to completing the survey. The visit or tour can be conducted at any time during the course of the survey. Always obtain permission from the resident before entering his/her room. 2833C.4g TASK 7 – COMPLIANCE DETERMINATION AND PREPARATION FOR EXIT CONFERENCE Preparation for Exit Conference.—In preparation for an exit conference, the surveyors should hold a pre-exit survey team conference at the conclusion of the survey and prior to the facility exit conference. The survey team leader must ascertain that all survey team members have completed their respective survey tasks before the pre-exit meeting. At this meeting, the surveyors will share their respective findings, and make team decisions regarding compliance with each standard, requirement, and Condition of Participation. Deficiencies found in more than one aspect of the CoP may be cumulative and interrelated and result in general or across-the-board inadequacies in resident care that may constitute actual or potential hazards to residents. The team leader should record the survey team decisions on the CMS-807 as a record of the team’s non-compliance determinations. This would be the basis for a finding of noncompliance. All necessary forms must be completed, which may include: CMS-807 - Surveyor Notes Worksheet CMS-2567 - Statement of deficiencies and Plan of Correction (Post Survey) And if applicable CMS-726 - CMS Death Record Review Data Sheet Optional CMS-3070I - Individual Observation Worksheet General - It is recommended to complete the CMS-2567 as a post survey document. Include in the CMS-2567 all examples of evidence obtained from observations, interviews, and record reviews that contribute to a determination that the facility is deficient in a certain area. Special Circumstances - If at any time during the survey one or more team members identify a possible immediate jeopardy, the team should meet immediately to confer. See Appendix Q for the definition of and for guidance regarding determination of immediate jeopardy. Exit Conference. — Following the survey team meeting to determine compliance, the survey team should conduct an exit conference with the PRTF’s administrator, designee, and other invited staff. The purpose of the exit conference is to communicate preliminary survey team findings. Although it is CMS’ general policy to conduct an exit conference, be aware of situations that may justify discontinuation of an exit conference. For example, if the PRTF is represented by a lawyer (all participants in the exit conference should identify themselves), surveyors may refuse to conduct or continue with the exit conference if the facility lawyer tries to turn it into an evidentiary hearing, or the staff creates an environment that is hostile, overly intimidating, or inconsistent with the informal and preliminary nature of an exit conference. Refer to §2724 of the SOM.