Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.62(a)(3) [The hospital must employ or undertake to provide adequate numbers of qualified professional, technical, and consultative personnel to:]

## (3) Provide active treatment measures; and

## Interpretive Guidelines §482.62(a)(3)

Active treatment occurs when the patient receives treatment interventions that are delivered under the direction of a physician, and which are specific to patient strengths, disabilities, and problems identified in the treatment plan. Treatment interventions and other services are furnished in accordance with accepted standards of professional practice. Although the active treatment process must be identifiable in documentation, it must be first and foremost observable and evident in daily practice.

Treatment interventions need to be individualized, in that the patient receives assistance with resolving or ameliorating the problems/circumstances that led to hospitalization. Expect to see treatment focused on the unique needs of individual patients. For example, several patients may be referred to 'Anger Management Group,' but the focus of discussion and therapeutic intervention may differ depending on the individual patient's particular issue regarding managing anger.

Whether structure must be imposed by staff or whether the patient can direct his or her own activities for periods of time (without staff supervision), is based on the patient's ability to engage in constructive, appropriate behavior (without engaging in harm to self or others). Be certain that the patient's time on the unit is maximized toward the further development of appropriate desired outcomes, including but not limited to leisure and recreation.

## Survey Procedures §482.62(a)(3)

Through observation, interviews and record reviews, can you determine that patients receive active treatment?

Is the distribution of staff consistent with particular patient needs? Is appropriate staffing sufficient to carry out treatment plans?

Does the patient attend therapies that are relevant to the identified problems that brought the patient to the hospital?

Are staff absences and/or vacancies preventing the patient from receiving active treatment? Are patients not attending therapeutic activities off the unit because there is no staff to escort them? Are therapeutic groups not available on the unit for patients who are not able to go off the unit?

Are patients observed not engaged in activities while staff attend to administrative tasks?

Are active treatment sessions or activities carried out at discrete time intervals exclusively? Or is active treatment implemented as the patient's needs emerge during the course of the day, as well?

Does a review of quality assurance data reveal a pattern of serious incidents occurring on particular shifts and/or days of the week?

What do patients report to the surveyor are their treatment modalities?

Do patient interviews indicate that patients believe the treatment being provided is helpful?

Does the scheduling of activities and their content relate directly to the patient's treatment objectives or are the activities/content generalized, non-therapeutic 'timefillers'?

Can staff describe how their activities relate to the patient's treatment objectives?

At any point in time, in any of the patient's experiences in the hospital is the thrust of the patient's treatment plan observable during the staff and/or patient interactions?

Is there a consistent, observable pattern of evidence that hospital staff provide, reinforce and otherwise implement measures to achieve active treatment objectives?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "active treatment"}, "rule_type": "existence", "scope_tags": ["clinical", "facility", "legal"]}