Source: http://www.scribd.com/doc/2003162/Health-and-Human-Services-som107ap-aa-psyc-hospitals
Timestamp: 2015-03-02 06:02:48
Document Index: 791980654

Matched Legal Cases: ['§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482']

Health and Human Services: som107ap aa psyc hospitals
P. 1Health and Human Services: som107ap aa psyc hospitalsHealth and Human Services: som107ap aa psyc hospitalsRatings: (0)|Views: 9|Likes: 0Published by HHSMore info:Published by: HHS on Jan 30, 2008Copyright:Attribution Non-commercialAvailability:Read on Scribd mobile: iPhone, iPad and Android.download as PDF, TXT or read online from ScribdFlag for inappropriate content|Add to collectionSee moreSee lesshttps://www.scribd.com/doc/2003162/Health-and-Human-Services-som107ap-aa-psyc-hospitals09/06/2012pdftextoriginal State Operations ManualAppendix AA - Psychiatric Hospitals – InterpretativeGuidelines and Survey Procedures
- (Rev 1, 05-21-04)
I - Principal Focus of SurveysII - Task 1 - Representative Sample of Patients - Selection MethodologyA - Purpose of the SampleB - Sample SizeC - Sample SelectionD - Program Audit ApproachIII - Task 2 - Record Review of Individuals in the SampleA - IntroductionB - Other Pertinent InformationIV - Task 3 - Other Record ReviewsA - Death RecordsB - Discharge RecordsC - Complaint InvestigationsV - Task 4 - Direct Patient ObservationsA - PurposeB - DocumentationVI - Task 5 - InterviewsA - Patient InterviewsB - Purpose of Structured Interviews Related to Patient StaffingC - DocumentationD - Interviews with Major Department DirectorsVII - Task 6 - Visit To Each Area of the Hospital Serving Certified PatientsA - PurposeB - ProtocolVIII - Task 7 - Team Assessment of Compliance
A - Pre-exit MeetingB - Role of the Team LeaderC - GeneralD - Special CircumstancesIX - Completing Forms CMS-724 Through CMS-729 for Psychiatric Hospital OutcomeOriented Survey
§482.60 Condition of Participation: Special Provisions Applying to Psychiatric Hospitals§482.61 Condition of Participation: Special Medical Record Requirements forPsychiatric Hospitals§482.61(a) Standard: Development of Assessment/Diagnostic Data§482.61(b) Standard: Psychiatric Evaluation§482.61(c) Standard: Treatment Plan§482.61(d) Standard: Recording Progress§482.61(e) Standard: Discharge Planning and Discharge Summary§482.62 Condition of Participation: Special Staff Requirements for Psychiatric Hospitals§482.62(a) Standard: Personnel§482.62(b) Standard: Director of Inpatient Psychiatric Services; Medical Staff §482.62(c) Standard Availability of Medical Personnel§482.62(d) Standard: Nursing Services§482.62(e) Standard Psychological Services§482.62(f) Standard: Social Services§482.62(g) Standard: Therapeutic Activities
Part I – Investigative ProceduresSurvey Protocol - Psychiatric HospitalsI - Principal Focus of Surveys
The principal focus of the survey is on the “outcome” of the hospital’s implementation of requirements. Direct your principal attention to what actually happens to patients. Thecustomer of the survey is the hospital, and/or the patient. What the hospital does isintended to reach the patient. The patient’s need, and whether desired outcomes areachieved determine compliance.
II - Task 1 - Representative Sample of Patients - Selection MethodologyA -
The purpose of drawing a sample of patients from the hospital is to reflect a proportionaterepresentation from all certified program areas within the hospital. If the facility has adistinct part certified for participation in Medicare, care should be taken to assure that thepatient sample is drawn only from program areas that participate in the distinct partcertification.While the patients in the sample are targeted for observation and interview, conduct eachprogram audit of the patient within the context of the environments in that the patientlives, receives treatment and spends major leisure time. Although you may focus on theindividual, the behavior and interactions of all other patients and staff within thoseenvironments also contribute to the total context and conditions for active treatment.Therefore, you may decide to include other patients in the overall sample.The sampling process results in survey team judgments, rather than quantitative, criteria-based projections. It is not designed to be a “statistically valid” sample. Use flexibilitywhen applying this method.As the sample is built, additional information about the hospital’s programs and services,as well as additional patient information may emerge. If you find a great disparity innumbers of patients in particular programs, adjust the sample to ensure that appropriatecare and services are surveyed. Use your judgment in deciding the sample specificswithin the parameters of the numerical requirements. Document your reasons for addingpatients to the sample.If you discover a significant group of patients with characteristics that has not beenrepresented in the sample, add additional patients. Some examples are, finding severalpatients on specific Behavior Modification Programs; rapid tranquilization regimens; ordiscovering patients in seclusion and/or restraint during the course of the survey. Youare free to add to the sample on a problem-oriented basis, or as dictated by individualneeds. Substitute patients in the sample only if you find that it will be harmful and/orcounter-therapeutic to include a specific patient. An example may be a patient with acuteparanoid schizophrenia, who might become agitated if interviewed and observed.
Use the number of patients in the certified portion of the hospital rather than the numberof beds in the certified portion of the hospital since those two figures may differsignificantly. Calculate the size of the sample by using the following: