Iowa Administrative Code › Agency 481 - Inspections and Appeals Department › Inspections Division › Chapter 64 - Intermediate Care Facilities for the Intellectually Disabled › Appendix - Interpretive Guidelines**

Current through Register Vol. 47, No. 3, July 24, 2024
§440.150 Intermediate Care Facility Services,
				  Other Than in Institutions for Mental Diseases
W101
W101 is reassigned to §483.410(e). Section 442.251, the
				  standard which requires that facilities meet the requirement for a State
				  license, is redesignated to §483.410(e) and W101 is reassigned as well to
				  afford a sense of continuity.
W102
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410 Condition of participation: Governing
				  body and management (a) Standard: Governing body
W103
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(a) The facility must identify an
				  individual or individuals to constitute the governing body of the
				  facility.
Guidance §483.410(a)
If concerns are noted regarding the governing body, written
				  documentation verifies that the facility has designated the individual or
				  individuals to constitute the governing body and their titles.
W104
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(a)(1) The governing body must exercise
				  general policy, budget, and operating direction over the
				  facility.
Guidance §483.410(a)(1)
The governing body develops, monitors, and revises, as
				  necessary, policies and operating directions which ensure the necessary
				  staffing, training resources, equipment and environment to provide clients with
				  active treatment and to provide for their health and safety. Direction by the
				  Governing Body includes areas such as health, safety, sanitation, maintenance
				  and repair, and utilization and management of staff. Condition level
				  operational deficiencies may be associated with a failure by the Governing Body
				  to exercise general direction of the facility.
W105
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(a)(2) The governing body must set the
				  qualifications (in addition to those already set by State law, if any) for the
				  administrator of the facility.
Guidance §483.410(a)(2)
The policies of the facility must include the qualifications
				  of the administrator, and the qualifications are stated in the job description
				  of the administrator.
W106
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(a)(3) The governing body must appoint the
				  administrator of the facility.
Guidance §483.410(a)(3)
This appointment must be in writing.
(b) Standard: Compliance with Federal, State and local
				  laws
§483.410(b) The facility must be in compliance
				  with all applicable provisions of Federal, State and local laws, regulations
				  and codes pertaining to:
Guidance §483.410(b)
The facility has no final adverse action by a Federal, State,
				  or local authority. Such adverse actions include, but are not limited to fines,
				  limitation on services that may be provided, or loss of licensure.
**Editor's Note: Verbatim from federal regulations. Neither
				  the Department nor the Iowa Administrative Code editors have changed the
				  content of the guidelines.
The facility must be able to provide for review, current
				  licenses and permits as well as applicable reports of inspections by State or
				  local health authorities. If a situation is identified indicating the provider
				  may not be in compliance with Federal, State, or local law, refer that
				  information to the authority having jurisdiction (AHJ) for follow-up actions.
				  See W107, W108, or W109.
W107
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(b) health,
Guidance §483.410(b)
Reference the specific law, regulation, or code not
				  met.
W108
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(b) safety, and
Guidance §483.410(b)
Reference the specific law, regulation, or code not
				  met.
W109
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(b) sanitation.
Guidance §483.410(b)
Reference the specific law, regulation, or code not
				  met.
(c) Standard: Client Records
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
W110
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(c)(1) The facility must develop and
				  maintain a record keeping system that includes a separate record for each
				  client and;
W111
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(c)(1) that documents the client's health
				  care, active treatment, social information, and protection of the client's
				  rights.
Guidance §483.410(c)(1)
The structure and content of a client's record must be an
				  accurate, functional representation of the actual experience of the client in
				  the facility.
The record should contain an accurate account of all
				  information relevant to the client's health care, active treatment, social
				  information and protection of the client's rights, such as communications,
				  correspondence, program plans (to include both in-house and outside service
				  programs), progress summaries, activity plans and activity participation,
				  incidents, consent forms and all medical information.
If the records are maintained electronically, the facility
				  staff should be able to access various parts of the record without difficulty.
				  If they are unable to access components of the record upon request, then this
				  may indicate a lack of training by the facility.
W112
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(c)(2) The facility must keep confidential
				  all information contained in the clients' records, regardless of the form or
				  storage method of the records.
Guidance §483.410(c)(2)
"Keep confidential" means safeguarding the content of
				  information including video, audio, and/or computer stored information from
				  unauthorized disclosure without the specific informed consent of the client,
				  parent of a minor child, or legal guardian, and consistent with the advocate's
				  right of access.
Facility staff and consultants, hired to provide services to
				  the client, sign confidentiality agreements before having access to client
				  records and should have access to only that portion of information that is
				  necessary to provide effective responsive services to the client.
These agreements should be renewed according to the policies
				  of the facility. The agreement may stipulate that the agreements are in place
				  until either the facility or member terminates the agreement.
The facility has in place safeguards to ensure that access to
				  all information regarding clients is limited to those clients designated by
				  Health Insurance Portability and Accountability Act (HIPAA) requirements, the
				  Developmental Disabilities Act, State law and facility policy.
The facility should prevent any instances of unauthorized
				  access or dissemination. For example, the staff is observed to leave the client
				  record (hard copy or electronic version) in the living room of the house when
				  visitors or persons not authorized to access client records are present. Client
				  records must be secured when staff is not present.
The facility must develop and follow procedures for
				  maintaining the confidentiality of client information during transport to
				  medical appointments or to other locations outside the facility.
Confidentiality applies to both central records and
				  information kept at dispersed locations. If there is information considered too
				  confidential to place in the record used by all staff (e.g., identification of
				  the family's financial assets, sensitive medical data), it may be retained in a
				  companion record located in a secure location in the facility with a notation
				  made in the primary record as to the location of confidential information. The
				  facility must ensure that any client information provided to day services
				  programs is maintained confidential.
The sharing of client specific information with members of
				  the "specially constituted committee" required by §483.440(f)(3), who are
				  not affiliated with the agency, does not violate a client's right to have
				  information about him or her kept confidential. The committee must have
				  relevant information to function properly.
Facility confidentiality safeguards include the development
				  and implementation of written policies to assure that members of the specially
				  constituted team maintain confidentiality. Such processes may include signed
				  confidentiality agreements. These agreements should be renewed according to the
				  policies of the facility. The agreement may stipulate that the agreements are
				  in place until either the facility or member terminates the agreement.
W113
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(c)(3) The facility must develop and
				  implement policies and procedures governing the release of any client
				  information, including consents necessary from the client, or parents (if the
				  client is a minor) or legal guardian.
Guidance §483.410(c)(3)
The facility develops and follows written policies governing
				  the release of client information.
Release of any personally identifiable information does not
				  occur unless consent(s) is obtained prior to the release.
These policies must address at a minimum who must give
				  consent for the release of information from records. The policy and procedures
				  should account for other situations involving the release of client
				  information, such as:
* who should be notified when records have been
				  released;
* procedures to be followed with subpoenas;
* time frames for providing requested information; and
* information regarding a client's HIV status may not be
				  released without specific consent and may not be in the record if that consent
				  has not been given.
W114
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(c)(4) Any individual who makes an entry
				  in a client's record must make it legibly, date it, and sign it.
Guidance §483.410(c)(4)
Illegible writing in hard copy records can contribute to
				  communication deficits among staff. Illegible writing which cannot be easily
				  interpreted by facility staff upon surveyor request may constitute a safety
				  issue.
Electronic signatures are acceptable in the electronic record
				  system.
W115
§483.410(c)(5) The facility must provide a legend
				  to explain any symbol or abbreviation used in a client's record.
W116
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(c)(6) The facility must provide each
				  identified residential living unit with appropriate aspects of each client's
				  record.
Guidance §483.410(c)(6)
"Appropriate" means those parts of each client's record are
				  most likely (or known) to be needed by the residential staff to carry out the
				  client's active treatment program in the unit; to alert staff to health risks
				  and other aspects of medical treatment; to support the psychosocial needs of
				  the client; to contact family or emergency contacts, and to provide anything
				  else necessary to the staff's ability to work on behalf of the client.
The staff of the residential living unit has, and can access,
				  all information which is relevant to implementing client program plans,
				  appropriate care of, interaction with, and provision of services for the
				  client.
(d) Standard: Services provided under agreements with
				  outside sources
W117
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(d)(1) If a service required under this
				  subpart is not provided directly, the facility must have a written agreement
				  with an outside program, resource, or service to furnish the necessary service,
				  including emergency and other health care.
Guidance §483.410(d)(1)
If a service is not provided directly, there must be a
				  written agreement for such services.
Written agreements are required for emergency services such
				  as dentists and pharmacies. For those services that require a visit to a
				  hospital, the Intermediate Care Facilities for Individuals with Intellectual
				  Disabilities (ICF/IID) typically utilizes services from an emergency department
				  of the hospital, thus no written contract is required.
Federal statute ( P.L. 94-142) requires all school-aged
				  children to receive a free and appropriate school education. Therefore, a
				  written agreement between ICF/IIDs and public schools is not necessary.
W118
(d)(2)(i) Contain the responsibilities, functions,
				  objectives, and other terms agreed to by both parties; and
W119
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(d)(2)(ii) Provide that the facility is
				  responsible for assuring that the outside services meet the standards for
				  quality of services contained in this subpart.
W120
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(d)(3) The facility must assure that
				  outside services meet the needs of each client.
Guidance §483.410(d)(3)
Outside services are any services needed by the clients and
				  not provided directly by the facility (hospital visits, dental visits, day
				  program services, etc.).
Programs and services must be coordinated between the
				  facility and the outside service, and foster consistency of implementation
				  across settings of teaching strategies and behavior management. The facility
				  monitors outside services on an ongoing basis to ensure that services provided
				  are consistent with the needs of each client as identified in the Individual
				  Program Plan (IPP). For example, if the facility is implementing a behavior
				  management or a communication program for the client, it is shared with the
				  outside program and implemented by the outside program (workshop, day program,
				  etc.) and the outside program agrees to incorporate it into their day program.
				  At periodic intervals, the facility staff visit or communicate with the outside
				  program to verify consistency across the two settings.
With outside resources, it is the responsibility of the
				  facility to assure that the services are provided in a safe clean environment,
				  by appropriately qualified professions, and any untoward outcome of services
				  are promptly addressed. If, in spite of attempts by the facility to assure
				  compliance, the outside program does not implement the program for the client,
				  then the facility remains responsible for the lack of active treatment.
W121
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(d)(4) If living quarters are not provided
				  in a facility owned by the ICF/IID, the ICF/IID remains directly responsible
				  for the standards relating to physical environment that are specified in
				  §483.470(a) through (g), (j) and (k).
Guidance §483.410(d)(4)
Even though the facility's premises may be rented from a
				  landlord, the facility must ensure that the requirements for physical
				  environment are met, either through arrangement with the landlord or through
				  the facility's own services.
(e) Standard: Licensure
§483.420(a) Standard: Protection of Clients'
				  Rights
The facility must ensure the rights of all clients.
				  Therefore, the facility must
Guidelines §483.420(a)
"Ensure" means that the facility actively asserts the
				  individual's rights and does not wait for him or her to claim a right. This
				  obligation exists even when the individual is less than fully competent and
				  requires that the facility is actively engaged in activities which result in
				  the pro-active assertion of the individual's rights, e.g., guardianship,
				  advocacy, training programs, use of specially constituted committee,
				  etc.
§483.410(e) Standard: Licensure
W101
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.410(e) The facility must be licensed under
				  applicable State and local law.
Guidance §483.410(e)
The facility has a current, valid State license when required
				  under State law.
W122
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420 Condition of participation: Client
				  protections
(a) Standard: Protection of clients'
				  rights
§483.420(a) The facility must ensure the rights of
				  all clients. Therefore the facility must
Guidance §483.420(a)
The facility must ensure the client's rights and does not
				  wait for him or her to claim a right. This obligation exists even when the
				  client is less than fully competent and requires that the facility is actively
				  engaged in activities which result in the protection of the client's rights,
				  advocacy for individual clients who have no family or an inactive family, and
				  training programs for clients and staff on the understanding and protection of
				  client rights.
W123
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)1) Inform each client, parent (if the
				  client is a minor), or legal guardian, of the client's rights and the rules of
				  the facility;
Guidance §483.420(a)(1)
The obligation to inform requires that the facility presents
				  information on rights to the client, his or her family or his or her legal
				  guardian in a manner and form which they can understand. In most instances,
				  family means parent. However, in those instances where parents are deceased or
				  choose not to be active in the client's life and there is another family member
				  who does wish to be active, but is not the legal guardian, this family member
				  should be informed of the client's rights. Printed materials should be provided
				  in understandable terms and provided in the language necessary to ensure
				  understanding. Specialized methods, as indicated, should be provided for
				  communication with clients, families or legal guardians with hearing or vision
				  impairment.
Pro-active assertion of client rights includes, but is not
				  limited to:
* Signed evidence that the client, his or her family and/or
				  his or her legal guardian have been informed of the client's rights, and
* Evidence that the communication of these rights were
				  provided at the client's level of comprehension, and in the language
				  understandable to the client.
The obligation to inform also requires that the facility make
				  some determination of whether the client and his or her family, or legal
				  guardian understood the rights presented and made additional efforts to
				  communicate the rights if the rights were not understood.
If the facility has written "rules of the facility", these
				  rules must be communicated to the client, their family and or legal guardians
				  at the time of admission and must not be in conflict with any of the rights
				  listed in
				  42 CFR
				  483.420(a) (1-13).
W124
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(2) Inform each client, parent (if the
				  client is a minor), or legal guardian, of the client's medical condition,
				  developmental and behavioral status, attendant risks of treatment, and of the
				  right to refuse treatment;
Guidance §483.420(a)(2)
Clients, their families or legal guardians are promptly
				  informed of any change in the client's medical or behavioral needs that
				  requires immediate alteration to programmatic or medical intervention. Promptly
				  is defined by the level of severity of the alteration. In each case, they must
				  also be informed of the attendant risks of any recommended treatments or
				  interventions and of their right to refuse treatment, training or
				  services.
If parents or legal guardians wish for other members of the
				  client's family to be informed of such changes, they must put this permission
				  in writing.
The communication of this information must be provided in the
				  manner and language understood by the client or their family or legal guardian
				  (language boards, sign language, etc.).
The term "attendant risks of treatment" describes the risk
				  vs. risk and risk vs. benefit associated with the treatment. These risks
				  include possible side effects, other complications from treatments including
				  medical and drug therapy, unintended consequences of treatment, other
				  behavioral or psychological ramifications arising from treatment, etc.
The facility actively attempts to engage clients who refuse
				  to participate in active treatment. While the regulation recognizes the
				  client's right to refuse treatment, persistent refusal that impacts the health
				  and safety of the client and/or others, or the ability to provide overall
				  active treatment, may result in facility's consideration of alternative
				  placements for the client. It is expected, however, that the facility has
				  assessed the reason for refusal, and developed and implemented all possible
				  interventions to engage the client in active treatment programs prior to
				  referring the client to another therapeutic setting.
A client, his or her family member, or legal guardian who
				  refuses a particular treatment (e.g., a behavior control, seizure control
				  medication or a particular intervention strategy) must be offered information
				  about
acceptable
alternatives to the treatment, if
				  acceptable alternatives are available. The client's preference about
				  alternatives should be elicited and considered in deciding on the course of
				  treatment. If the client, family member, or legal guardian also refuses the
				  alternative treatment, or if no alternative exists to the treatment refused,
				  the facility must consider the effect this refusal may have on other clients,
				  the client himself or herself, and if they can continue to provide services to
				  the client consistent with these regulations.
If the facility is unable to provide services to a client due
				  to consistent refusal to participate, they must weigh all options including an
				  involuntary discharge. Involuntary discharge must be for good cause (see
				  483.440(b)(4)(i)).
When a client is considered for participation in experimental
				  research the client, his/her family and/or legal guardian must be fully
				  informed of the nature of the experiment (e.g., what medications or physical
				  interventions will be utilized, the length of the research, any possible side
				  effects and how the information from the research will be utilized).
				  Information regarding the possible consequences of participating or not
				  participating must be provided to the client, family member or legal guardian.
				  The written consent of the client, his/her family or legal guardian must be
				  received prior to participation. For a client who is a minor or who has been
				  adjudicated as incompetent, the written informed consent of the parents of the
				  minor or the legal guardian is required. The signed, informed consent
				  documentation must be in compliance with HHS Guidelines for Research Involving
				  Human Subjects. The signed consent must also include a clear discussion of what
				  treatments will be included in the research, the time limits for the research
				  and should clearly inform the client, family member or legal guardian that the
				  client may end participation at any time without fear of recrimination. If the
				  research protocol indicates that clients receive compensation, then clients are
				  compensated per the protocol.
Any research must be reviewed and approved by the Specially
				  Constituted Committee. See W263.
W125
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(3) Allow and encourage individual
				  clients to exercise their rights as clients of the facility, and as citizens of
				  the United States, including the right to file complaints, and the right to due
				  process;
Guidance §483.420(a)(3)
To the extent that a client is able, choices are made on
				  his/her own. Each client has autonomy of decision making and choice.
They are free to move about without limitations imposed due
				  to staff preferences or staff convenience.
Clients are not restricted without due cause or due
				  process.
To the extent that the client is able to make decisions for
				  him or herself, it is inappropriate to delegate the person's right to others
				  (e.g. parents, family members, etc.).
The facility has an obligation to assure client health and
				  safety and must balance that obligation with the rights of clients.
If the facility has implemented a restriction, the following
				  should be in place:
* An assessment supporting the need for the
				  restriction;
* An individualized behavior plan to reduce the need for the
				  restriction has been developed and implemented;
* A written informed consent for the behavior plan which
				  includes the restriction;
* Approval of the Specially Constituted Committee; and
* Monitoring by the Committee of the progress of the training
				  program, designed to reduce and eventually eliminate the restriction.
Clients, families, and legal guardians have the right to
				  register a complaint with the facility and the State Survey Agency. If so, the
				  facility must respond promptly and appropriately. The facility must ensure
				  protection of the client from any form of reprisal or intimidation as a result
				  of a complaint or grievance reported by the client, family, or legal
				  guardian.
Issues involving the exercise of constitutional rights such
				  as voting should be addressed as a component of the IPP when the
				  Interdisciplinary Team (IDT) determines a need for training. Clients who have
				  been adjudged to need guardianship or have been assessed as needing assistance
				  to advocate for themselves should receive assistance or support so they may
				  exercise their rights as citizens of the United States.
W126
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(4) Allow individual clients to manage
				  their financial affairs and teach them to do so to the extent of their
				  capabilities;
Guidance §483.420(a)(4)
The regulation is clear that in those cases where a client
				  already possesses the skills necessary to independently manage their own
				  financial affairs, the facility will allow the client to continue to do so.
				  Formal training in financial management must be provided for all other clients
				  in the facility to the extent of their capabilities. The regulation places the
				  responsibility for determining the extent of the client's capabilities in this
				  matter upon an assessment and interdisciplinary process within the facility. To
				  reach a determination as to whether a money management program is appropriate,
				  the facility IDT uses the comprehensive functional assessment (CFA) to evaluate
				  the ability of each client to participate in such a program. Under
				  42 C.F.R.
				  483.440(c)(3), the team
				  evaluation must establish, through documentation, that the IDT considers all of
				  the objective data within the assessment in reaching their determination,
				  especially the identification of client skills which can be used across
				  training programs. Examples of assessment findings that may be considered by
				  the IDT include skills that can be cross-utilized in training programs such
				  as:
1. Fine motor coordination;
2. The ability to make choices;
3. The ability to identify preferences; and 4. Cognitive
				  abilities including tracking, attention span, communication, and the client's
				  ability to understand the cause and effect. (The client understands of cause
				  and effect is significant in the determination.)
Money management includes a broad spectrum of programs with
				  varying levels of participation by the client ranging from the use of choice in
				  money expenditures, to an understanding of the concept of money, and ultimately
				  to actual money handling and budgeting. The IDT must not conclude that a money
				  management program is inappropriate based solely upon the level of intellectual
				  or physical disability of the client.
The CFA must be reviewed at least annually per
				  42 C.F.R.
				  483.440(f)(2). As a part of
				  this annual review, a client's ability to participate in money management will
				  also be reviewed. The annual review should always include an update to the CFA
				  and take into consideration any changes in the client's circumstances since the
				  last IPP. The need for a formal money management program must be addressed in
				  every client's IPP by the IDT on an annual basis.
The determination of the appropriateness of a formal money
				  management program is made by the IDT and must be based upon a CFA. The IDT
				  discussions resulting in that determination must be established through
				  documentation in the client's IPP.
W127
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(5) Ensure that clients are not
				  subjected to physical, verbal, sexual or psychological abuse or
				  punishment;
Guidance §483.420(a)(5)
Identification of patterns or isolated instances of physical,
				  verbal, sexual or psychological abuse or punishment without prompt
				  identification and corrective action by the facility would result in a
				  non-compliance determination for this Standard and Condition level
				  non-compliance.
The facility must develop and implement systems that protect
				  clients from all forms of abuse, neglect, or mistreatment, including client to
				  client abuse, neglect, or mistreatment.
a. The facility is expected to ensure that staff possess and
				  demonstrate needed competencies to effectively and appropriately interact with
				  clients.
b. The facility must monitor to assure that systems are
				  effectively implemented and the facility takes immediate actions to address
				  circumstances where abuse, neglect, or mistreatment have occurred and prevent
				  reoccurrence.
c. The facility must be organized in such a manner as to
				  proactively assure clients are free from any threat to their physical and
				  psychological health and safety.
d. The facility must act to prevent physical, verbal, sexual
				  or psychological abuse. If the facility fails to implement appropriate
				  corrective action, the potential of additional threats to the clients remain at
				  the facility.
"Threat", for the purposes of this guideline, is considered
				  any condition/situation which could cause or result in severe, temporary or
				  permanent injury or harm to the mental or physical condition of clients, or in
				  their death.
"Abuse", for the purposes of this guideline, is the willful
				  infliction of injury, unreasonable confinement, intimidation or punishment with
				  the resulting physical harm, pain or personal anguish.
Physical abuse refers to any action intended to cause
				  physical harm or pain, trauma or bodily harm (e.g., hitting, slapping,
				  punching, kicking, pinching, etc.). It includes the use of corporal punishment
				  as well as the use of any restrictive, intrusive procedure to control
				  inappropriate behavior for purposes of punishment.
Verbal abuse refers to any use of insulting, demeaning,
				  disrespectful, oral, written or gestured language directed towards and in the
				  presence of the client. Psychological abuse includes, but is not limited to,
				  humiliation, harassment, and threats of punishment or deprivation, sexual
				  coercion and intimidation (e.g. living in fear in one's own home). Since many
				  clients residing in ICF/IIDs are unable to communicate feelings of fear,
				  humiliation, etc. associated with abusive episodes, the assumption is made that
				  any actions that would usually be viewed as psychologically or verbally abusive
				  by a member of the general public, would also be viewed as abusive by the
				  client residing in the ICF/IID, regardless of that client's perceived ability
				  to comprehend the nature of the incident.
Sexual abuse includes any incident where a client is coerced
				  or manipulated to participate in any form of sexual activity for which the
				  client did not give affirmative permission (or gave affirmative permission
				  without the attendant understanding required to give permission) or sexual
				  assault against a client who is unable to defend him/herself The facility must
				  implement, through policies, oversight and training, safeguards to ensure that
				  clients are not subjected to abuse by anyone including, but not limited to,
				  facility staff, consultants or volunteers, staff of other agencies serving the
				  client, family members or legal guardians, friends, other clients, or the
				  general public.
The facility must take whatever action is necessary to
				  protect the clients residing there. For example, if a facility is forced by
				  court order or arbitration rulings to retain or reinstate an employee found to
				  be abusive, the facility must take measures to protect the clients of the
				  facility (such as assigning the employee to an area where there is no contact
				  with clients).
W128
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(6) Ensure that clients are free from
				  unnecessary drugs and physical restraints and are provided active treatment to
				  reduce dependency on drugs and physical restraints;
Guidance §483.420(a)(6)
The facility must implement an aggressive active treatment
				  program, which includes appropriate replacement behaviors, to address the
				  reduction/elimination of physical restraints and drugs to manage
				  behaviors.
For purposes of this Guideline drugs to manage behavior are
				  "unnecessary" if there is evidence the drugs are being used:
* In excessive dose (duplicate therapy);
* For excessive duration;
* Not monitored adequately;
* Without adequate indications for its use;
* With adverse consequences which indicate the dose should be
				  reduced or discontinued; or
* Any combination of the reasons listed above.
The long term use of a drug/physical restraint to manage
				  behavior combined with one or more of the following may indicate unnecessary
				  use:
* The client's developmental and/or behavioral needs are not
				  being met and the appropriateness of less restrictive approaches to manage
				  inappropriate behaviors should be questioned;
* Staff behavior may be prompting behaviors in clients which
				  result in the chronic use of physical restraints and drugs to control
				  behavior;
* Staff may have inadequate training and/or experience to
				  provide active treatment and employ preventive measures;
Restraints applied for behaviors when less restrictive
				  measures have not been tried or have been tried and found to be just as
				  effective.
W129
(Rev. 144, Issued: 08-14-15, Effective:
				  08-14-15, Implementation: 08-14-15)
§483.420(a)(7) Provide each client with the
				  opportunity for personal privacy and
Guidance §483.420(a)(7)
The facility must provide areas within the living area in
				  which the client can have time to be alone, when appropriate, and to have
				  privacy (their conversations cannot be overheard) for personal
				  interactions/activities. There should be a location where the client can meet
				  privately with family and/or friends and a telephone available where he/she can
				  hold private telephone conversations.
Personal privacy for clients also includes the right to have
				  certain personal information about them kept confidential. Staff should not
				  discuss one client in front of others (clients, parents, legal guardians,
				  visitors, etc.) and should not post personal information about clients in areas
				  where other clients, families and the public can read the information.
Video/audio taping or live feed must not be used in place of
				  or for the convenience of staff. The facility may install video/audio equipment
				  for purposes of observing client/staff interactions. Video/audio equipment may
				  only be installed in common areas (in no case may videotaping or live feed be
				  done in bathrooms or areas where private visits are conducted). The clients,
				  families and/or legal guardians of the clients residing in the areas where
				  videotaping or live feed will occur must give informed consent for the
				  installation and must be assured that no personal privacy will be jeopardized.
				  The use of the equipment must be presented at and approved by the specially
				  constituted committee for the facility prior to the installation of video or
				  audio devices. Motion sensors should not be considered cameras.
W130
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(7) ensure privacy during treatment and
				  care of personal needs;
Guidance §483.420(a)(7)
Clients must be provided privacy during personal hygiene
				  activities (e.g., toileting, bathing, dressing) and during medical/nursing
				  treatments that require exposure of one's body. People not involved in the care
				  of the client should not be present without their consent while they are being
				  examined or treated.
Whenever possible, the facility should be sensitive to
				  clients' preferences for same sex care in private situations.
W131
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(8) Ensure that clients are not
				  compelled to perform services for the facility and
Guidance §483.420(a)(8)
Clients are not required or expected to be a source of labor
				  for a facility. The client must not be required or expected to do productive
				  work for the facility, other than appropriate care of one's own personal space
				  or shared responsibilities for common areas.
W132
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(8) ensure that clients who do work for
				  the facility are compensated for their efforts at prevailing wages and
				  commensurate with their abilities;
Guidance §483.420(a)(8)
"Work", as used in the regulation, means any directed
				  activity, or series of related activities which results in a benefit to the
				  economy of the facility or in a contribution to its maintenance, or in the
				  production of a salable product. In deciding whether a particular activity
				  constitutes "work" as defined above, the key determinant is whether the
				  facility would be required to hire additional full or part-time staff (or pay
				  overtime to existing staff) to perform the service the client is asked to
				  perform. Clients volunteering to do real work that benefits the facility should
				  give informed consent for such practices and understand that by providing
				  employable services they are able to be compensated. This does not preclude a
				  client from helping out a friend or being kind to others. Self-care activities
				  related to the care of one's own person or property are not considered "work"
				  for purposes of compensation. In general, participation in any household task
				  which promotes greater independent functioning and assists the client to
				  prepare for less restrictive setting (and which the client has not yet learned)
				  is permitted as long as tasks are included in the IPP in written behavioral and
				  measurable terms. This participation must be supervised, and indices of
				  performance should be available. No task may be performed for the convenience
				  of staff (e.g., supervising clients, running personal errands).
"Compensated" means the client is provided with money or
				  other forms of negotiable compensation for work (including work performed in an
				  occupational training program) and such compensation is to be used at the
				  client's discretion.
Prevailing wage refers to the wage paid to non-disabled
				  workers in nearby industry or the surrounding community for essentially the
				  same type, quality and quantity of work or work requiring comparable skills. A
				  client who works in the facility must be paid at least the prevailing minimum
				  wage, unless an appropriate certificate has been obtained by the facility in
				  accordance with current regulations and guidelines issued under the Fair Labor
				  Standards Act, as amended.
Any client performing "work", as defined above, must be
				  compensated in direct proportion to his or her output. The facility should
				  utilize Department of Labor and/or Department of Vocational Rehabilitation
				  formulas and techniques for determining rate of pay. A client's pay is not
				  dependent on the production of other clients when he or she works in a
				  group.
When the client's active treatment program includes
				  assignment to occupational or vocational training or work, specific work
				  objectives of anticipated progress should be included in the IPP along with
				  reasons for the assignments. If the training of clients on particular
				  occupational activities or functions involves "real work" to be accomplished
				  for the facility, the clients must be compensated based on ability. For
				  example, if in the process of work training activities which involve learning
				  to clean a floor, the floor for a particular building is cleaned and does not
				  require further janitorial cleanup, then the client must be compensated for
				  this activity at the prevailing wage.
W133
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(9) Ensure clients the opportunity to
				  communicate, associate and meet privately with individuals of their
				  choice,
Guidance §483.420(a)(9)
Privacy must be provided for both face-to-face interactions
				  and electronic interactions. The facility must provide opportunities for the
				  client to communicate, through regular mail, telephone and/or electronic mail
				  and meet in private with persons of their choice (e.g., friends from the
				  community, family members, and advocates). There may be instances where legal
				  guardians override the wishes of the client. In these instances, the facility
				  should be actively working with the legal guardian and the client to reach the
				  maximum agreeable level of interaction for the client.
Space must be provided for clients to receive visitors in
				  reasonable comfort and privacy.
W134
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(9) and to send and receive unopened
				  mail;
Guidance §483.420(a)(9)
Clients must be provided the opportunity to send/receive all
				  types of mail unopened and read the contents themselves if able. If the staff
				  has to open and read mail to the client, this should be done in a private place
				  allowing the client as much participation as possible. Clients who have their
				  own electronic equipment must be provided the opportunity to send, receive, and
				  read electronic mail with privacy.
W135
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(10) Ensure that clients have access to
				  telephones with privacy for incoming and outgoing local and long distance calls
				  except as contraindicated by factors identified within their individual program
				  plans;
Guidance §483.420(a)(10)
Any restriction of telephone access must be explained in the
				  IPP with a plan to advance the client's access. For persons with hearing loss
				  who could benefit, Text Telephone (TTY) services or other accommodations should
				  be provided. As with any other rights restriction, the restriction must be
				  addressed in the IPP, written informed consent obtained, and the plan must be
				  reviewed and approved by the specially constituted committee.
W136
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(11) Ensure clients the opportunity to
				  participate in social, religious, and community group activities;
Guidance §483.420(a)(11)
Clients should be offered the opportunity to participate in
				  various types of activities in the community (e.g., going to grocery stores,
				  hair salons, restaurants, places of worship, pharmacies, community meetings and
				  events) based on their interests and choices. The facility must make
				  accommodations for physical issues such as hearing impairment and mobility
				  limitations. In addition, clients should be taught the applicable skills to
				  participate in their choice of activities to the fullest extent of their
				  abilities. It is not acceptable for all client activities to be provided in the
				  facility. When a client is identified to be on restriction from community
				  integration opportunities, interview clients, families, legal guardians and
				  staff to determine if due process was afforded for this restriction and whether
				  the restriction is included in the IPP. In the event of a court placement that
				  restricts community access, due process does not apply. There should be
				  evidence that the facility assists and encourages all clients, regardless of
				  functioning levels, to have input into the decisions on community integration
				  activities. It is not acceptable to require clients to attend unwanted
				  activities due to staffing considerations.
W137
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(12) Ensure that clients have the right
				  to retain and use appropriate personal possessions and clothing,
				  and
Guidance §483.420(a)(12)
Clients should have personal possessions and clothing which
				  meet their needs, interests and choices. Clients should have free access to
				  their own possessions and clothing. When considering whether a client has free
				  access to their personal possessions and clothing, ensure that physical
				  limitations have been addressed. Clients who are unable to access and use
				  personal possessions and clothing appropriately are involved in programs to
				  learn the necessary skills to do so. In situations where the behavior of one or
				  more clients in a living area prevents free access to personal possessions for
				  each client, the facility must develop IPPs for the client with disruptive
				  behavior. The facility must also ensure that during the implementation of this
				  program plan that none of the other clients have their rights infringed upon.
				  Clients should not be without personal possessions because of the behavior of
				  others with whom they live. All client possessions, regardless of their
				  apparent value to others are treated with respect for what they may represent
				  to the client. Where those choices include socially stigmatizing materials, the
				  facility should provide learning opportunities to make more socially
				  appropriate choices. The facility should encourage clients to use or display
				  possessions of his or her choice in a culturally normative manner. If a method
				  for identifying personal effects is used, it should be inconspicuous and in a
				  manner that will assist the client to identify them. "Appropriate" clothing
				  means a supply of clothing that is sufficient, in good repair, accounts for a
				  variety of occasions and seasons, and appropriate to age, size, gender, and
				  level of activity. Modification or adaptation of clothing fasteners should be
				  considered based on the needs of a client with a physical disability to become
				  more independent. As appropriate, each client's active treatment program
				  maximizes opportunities for choice and self-direction with regard to choosing
				  and shopping for clothing which enhances his or her appearance, and selecting
				  daily clothing in accordance with age, sex and cultural norms. Clients are
				  permitted to keep personal clothing and possessions for their use while in the
				  facility. Determine how the facility both ensures the safety of personal
				  possessions while at the same time providing client access to them when the
				  client chooses. Clients are provided the opportunity, encouraged, and trained
				  to use age-appropriate materials. The term "age-appropriate" refers to anything
				  that reinforces recognition of the client as a person of a certain
				  chronological age. Clients who choose to keep items traditionally used by
				  children such as dolls or model cars are not an automatic citation. There must
				  be evidence the facility is encouraging the client to use these possessions in
				  a socially appropriate, non-stigmatizing manner. The facility's environment
				  must be furnished with materials and activities that will enhance opportunities
				  for growth.
W138
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(a)(12) ensure that each client is dressed
				  in his or her own clothing each day; and
Guidance §483.420(a)(12)
Clothing such as pajamas, underwear, socks, hats,
				  mittens/gloves, and coats should be the personal property of the client and not
				  considered
"stock"
items. There should be no communal clothes.
				  If clients are unable to do their own personal laundry the facility must ensure
				  that clothing is properly laundered and returned to the appropriate client. The
				  staff of the facility should ensure that clients dress appropriately for the
				  season and the occasion by implementing training programs or guidance for the
				  client as indicated.
W139
§483.420(a)(13) Permit a husband and wife who both
				  reside in the facility to share a room.
§483.420(b) Standard: Client
				  Finances
(b)(1) The facility must establish and maintain a
				  system that
W140
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(b)(1)(i) Assures a full and complete
				  accounting of clients' personal funds entrusted to the facility on behalf of
				  clients; and
Guidance §483.420(b)(1)(i)
All purchases made using client personal funds must be
				  itemized in the accounting record with the exception of pocket money. Pocket
				  money given to the client does not need to be itemized. Pocket money should be
				  considered a nominal amount of five dollars or less at a time. Funds provided
				  by the facility and dispensed to a client as part of a program to train the
				  client in money management, and funds that are not entrusted to the facility
				  (e.g., funds paid directly to the client's representative payee) do not require
				  accounting. In those instances where a legal guardian or the individual client
				  is in control of their personal funds, no accounting is necessary by the
				  facility.
W141
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(b)(1)(ii) Precludes any commingling of
				  client funds with facility funds or with the funds of any person other than
				  another client.
Guidance §483.420(b)(1)(ii)
If the facility elects to pool clients' funds in an
				  interest-bearing account, including common trust accounts, it is expected to
				  know the interest separately accrued by each client, as part of its required
				  accounting of funds. Interest accumulated to a client's account belongs to the
				  client, not the facility.
W142
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(b)(2) The client's financial record must
				  be available on request to the client, parents (if the client is a minor) or
				  legal guardian.
Guidance §483.420(b)(2)
Those persons having legal authority to access the accounting
				  records for personal funds such as the client, parent, or legal guardians
				  should be afforded access upon request unless there is documented rationale for
				  withholding the information. It is not necessary that a facility furnish an
				  annual financial statement to the client, or the client's parent or legal
				  guardian, since the facility is already required to make the financial record
				  available at any time upon request. The client, parent, and/or legal guardian,
				  in turn, is free to choose to make the financial record available to anyone
				  else.
(c) Standard: Communication with clients, parents, and
				  guardians.
§483.420(c)
The Facility must -
W143
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(c)(1) Promote participation of parents
				  (if the client is a minor) and legal guardians in the process of providing
				  active treatment to a client unless their participation is unobtainable or
				  inappropriate;
Guidance §483.420(c)(1)
The facility must maintain an on-going effort to communicate
				  with parents, family members and/or legal guardians regarding the
				  implementation of active treatment programs for the client. The facility
				  encourages and engages parents, family members and legal guardians in the
				  continued implementation of active treatment programs even while spending time
				  outside of the facility setting. "Unobtainable", for the purposes of this
				  guideline, means that the facility has made a good faith effort to seek
				  parental or legal guardian participation in the process, even though the effort
				  may ultimately be unsuccessful (for example, the parent may be impossible to
				  locate or may prove unwilling or unable to participate).
"Inappropriate", for the purposes of this guideline, means
				  that behavior of the parent or legal guardian could be disruptive or
				  detrimental to the client's program outcome. In this case, determine what the
				  facility has done to bring effective resolution to the problem.
W144
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(c)(2) Answer communications from clients'
				  families and friends promptly and appropriately;
Guidance §483.420(c)(2)
It is reasonable to expect that the facility will provide at
				  least an interim response to inquiries from the client's families and friends
				  within 48 hours.
W145
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(c)(3) Promote visits by individuals with
				  a relationship to the client (such as family, close friends, legal guardians
				  and advocates) at any reasonable hour, without prior notice, consistent with
				  the right of that client's and other clients' privacy, unless the
				  interdisciplinary team determines that the visit would not be
				  appropriate;
Guidance §483.420(c)(3)
Any limitations on visitors must be implemented as a result
				  of IDT evaluation and discussion and be documented. This documentation should
				  include evidence of approval from the specially constituted committee.
				  Decisions to restrict a visitor for an individual client must be reviewed and
				  re-evaluated each time the IPP is reviewed or at the client's request. Broad
				  restrictions on visitors such as times of the day or certain days of the week
				  are a violation of this requirement.
W146
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(c)(4) Promote visits by parents or
				  guardians to any area of the facility that provides direct client care services
				  to the client, consistent with the right of that client's and other clients'
				  privacy;
W147
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(c)(5) Promote frequent and informal
				  leaves from the facility for visits, trips, or vacations; and
Guidance §483.420(c)(5)
The facility should assist and encourage the client to
				  communicate with their families or legal guardians concerning possible outside
				  visits and vacations as frequently as possible. When the client does schedule a
				  trip or vacation, the facility must ensure that all necessary preparation is
				  completed to facilitate the departure. The facility should not sponsor or allow
				  clients to take a particular type of trip that would jeopardize their safety or
				  health without consultation with parents/legal guardians and/or the IDT.
W148
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(c)(6) Notify promptly the client's
				  parents or guardian of any significant incidents, or changes in the client's
				  condition including, but not limited to, serious illness, accident, death,
				  abuse, or unauthorized absence.
Guidance §483.420(c)(6)
"Significant" incidents or changes in the client's condition
				  include serious injury, unusual seizure activity, hospitalization, serious
				  illness, accident, death, allegations of abuse, neglect, or mistreatment,
				  unauthorized absence, or any notifications the parent or legal guardian's
				  requests. It is reasonable to expect the facility to contact the family or
				  legal guardian of a client as soon as possible after an incident occurs, but no
				  later than 24 hours after the incident. If notification is done via electronic
				  mail, the facility must request a response from the e- mail recipient to
				  confirm notification. Telephone notification must be accomplished by talking to
				  the person directly. If a message is left, the facility must request a call
				  back to confirm receipt of the notification. Contact by letter may be utilized
				  as follow up confirmation, but not be the initial, primary or sole mode of
				  communication with the family or legal guardian. If unable to contact the
				  family or legal guardian, there should be evidence that the facility attempted
				  to reach alternate emergency contacts. Requests from clients who are their own
				  guardian to limit notifications to their families must be honored.
(d) Standard: Staff treatment of clients.
W149
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(d)(1) The facility must develop and
				  implement written policies and procedures that prohibit mistreatment, neglect
				  or abuse of the client.
Guidance §483.420(d)(1)
The facility, through implementation of its policies, must
				  set up a structure that screens and trains employees, protects clients and
				  prevents, identifies, investigates and reports abuse, neglect and mistreatment
				  of clients. The policies must designate who (either by name or title) has the
				  authority to act in the Administrator's absence and take any immediate
				  corrective actions necessary to assure a client's safety such as removing a
				  staff person from direct client contact. "Mistreatment", for the purposes of
				  this guideline, includes behavior or facility practices that result in any type
				  of client exploitation such as financial, physical, sexual, or criminal.
				  Mistreatment also refers to the use of behavioral management techniques outside
				  of their use as approved by the specially constituted committee and facility
				  policies and procedures. "Neglect" means failure to provide goods and services
				  necessary to avoid physical harm, mental anguish or mental illness. Staff
				  failure to intervene appropriately to prevent self- injurious behavior may
				  constitute neglect. Staff failure to implement facility safeguards, once client
				  to client aggression is identified, may also constitute neglect. Refer to W127
				  for definitions of abuse.
W150
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(d)(1)(i) Staff of the facility must not
				  use physical, verbal, sexual or psychological abuse or
				  punishment.
W151
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(d)(1)(ii) Staff must not punish a client
				  by withholding food or hydration that contributes to a nutritionally adequate
				  diet.
W152
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(d)(1)(iii) The facility must prohibit the
				  employment of individuals with a conviction or prior employment history of
				  child or client abuse, neglect or mistreatment.
Guidance §483.420(d)(1)(iii)
The facility is required to screen potential employees for a
				  prior employment history of child or client abuse, neglect or mistreatment, as
				  well as for any conviction based on those offenses. The abuse, neglect or
				  mistreatment must have been directed toward a child or a
				  client/resident/patient of a health care facility in order for the prohibition
				  of employment to apply. No one with a conviction or substantiated allegation of
				  child or client abuse, neglect or mistreatment regardless of employment date,
				  is employed by the facility. This requirement also applies to acts of abuse,
				  neglect or mistreatment committed by a current ICF/IID employee outside the
				  jurisdiction of the ICF/IID (e.g., in the community or in another health care
				  facility). The facility must follow state guidelines or requirements for
				  background checks to assure that they make every effort to check new employee's
				  background. Where the facility has terminated an employee based upon
				  confirmation that abuse, neglect or mistreatment occurred during the employee's
				  performance, and the termination decision was overturned by either arbitration
				  finding or a court finding, the employee must be returned to a position which
				  does not involve direct contact between that employee and clients of the
				  facility. A person who abused a resident in a nursing facility, and as a
				  result, is barred from employment in the nursing home setting would also be
				  prohibited from employment in the ICF/IID. While facilities are not required to
				  periodically screen existing employees, if the facility becomes aware that such
				  action has been taken against an employee, the facility is required to prohibit
				  continued employment. This is also true of any conviction in a court of law for
				  child, elder, or client (resident, patient) abuse, neglect or mistreatment.
				  Therefore, conviction for abusing one's own child is also a reason employment
				  would be prohibited.
W153
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(d)(2) The facility must ensure that all
				  allegations of mistreatment, neglect or abuse, as well as injuries of unknown
				  source, are reported immediately to the administrator or to other officials in
				  accordance with State law through established procedures.
Guidance §483.420(d)(2)
Injuries of unknown source that give rise to a suspicion that
				  they may be the result of abuse or neglect, should be reported immediately. An
				  injury should be reported as an "injury of unknown source" when:
* The source of the injury was not witnessed by any person
				  and the source of the injury could not be explained by the client; and
* The injury raises suspicions of possible abuse or neglect
				  because of the extent of the injury or the location of the injury (e.g., the
				  injury is located in an area not generally vulnerable to trauma) or the number
				  of injuries observed at one particular point in time or the incidence of
				  injuries over time. It is important to note that members of the ICF/IID
				  population are a mobile population and lead active lives. Therefore, they
				  experience normal day-to-day bumps and minor abrasions as they go about their
				  lives. These minor occurrences which are not of serious consequence to the
				  individual and do not present as a suspicious or repetitive injury (as
				  discussed above) should be recorded by the facility staff once they are aware
				  of them and follow-up should be conducted as indicated. For injuries that do
				  not rise to the level of reportable "injuries of unknown source", the facility
				  should follow its policies and procedures for incident recording,
				  investigation, and tracking. The facility must immediately report any
				  suspicious injuries of unknown source and all allegations of mistreatment,
				  neglect or abuse to a client residing in the facility regardless of who is the
				  alleged perpetrator (e.g., facility staff, parents, legal guardians, volunteer
				  staff from outside agencies serving the client, neighbors, or other clients,
				  etc.). If state law requires reporting to an agency or entity other than the
				  administrator, the Centers for Medicare & Medicaid Services (CMS) expects
				  the administrator to be notified as well, in order to ensure facility response
				  to promptly safeguard the client(s). For the purposes of this regulation
				  "immediately" means there should be no delay between staff awareness of the
				  occurrence and reporting to the administrator or other officials in accordance
				  with State law unless the situation is unstable in which case reporting should
				  occur as soon as the safety of all clients is assured.
W154
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(d)(3) The facility must have evidence
				  that all alleged violations are thoroughly investigated and
Guidance §483.420(d)(3)
In the absence of any pre-survey information that would
				  indicate the need for a more thorough review of reports of investigation,
				  review 5 percent of the total client investigations for the last three (3)
				  months (but no less than 10).
A thorough investigation includes at a minimum:
* The collection of all interviews, statements, physical
				  evidence and any pertinent maps, pictures or diagrams;
* Review of all information;
* Resolution of any discrepancies;
* Summary of conclusions; and
* Recommendations for action both to safeguard all the
				  clients during the investigation and after the completion of the report.
If patterns of possible abuse, mistreatment or neglect are
				  identified, or the incident report logs for the past three (3) months indicate
				  an extremely high incident rate, then a full review of the incidents for the
				  past three (3) months should be completed.
W155
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(d)(3) must prevent further potential
				  abuse while the investigation is in progress.
Guidance §483.420(d)(3)
The facility must take all measures necessary to protect the
				  client, including removal of the staff from working with the client if
				  indicated. See W154.
W156
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(d)(4) The results of all investigations
				  must be reported to the administrator or designated representative or to other
				  officials in accordance with State law within five working days of the incident
				  and,
Guidance §483.420(d)(4)
Some states require that allegations of abuse must be
				  reported to the police. A police investigation may take longer than five (5)
				  working days. Their investigation does not change the requirement that the
				  facility must complete an internal investigation report of findings within the
				  five day timeframe. When outside authorities are involved, the facility will
				  still be required to complete their investigation within five days to the
				  extent authorized by such entities. "Working days" means Monday through
				  Friday,
excluding state and Federal holidays.
W157
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.420(d)(4) if the alleged violation is
				  verified, appropriate corrective action must be taken.
Guidance §483.420(d)(4)
The facility is required to ensure that clients residing in
				  the facility are not subjected to physical, verbal, sexual or psychological
				  abuse or punishment. Appropriate corrective action is required for findings of
				  abuse, neglect or mistreatment by other clients residing in the facility, staff
				  of outside agencies, parents or any other person, and for injuries to clients
				  resulting from controllable environmental factors. If the facility receives
				  allegations of abuse, neglect, or mistreatment of a client during out of
				  facility visits with their family, they must report these allegations to the
				  appropriate state authority for investigation. The facility does not have to
				  conduct an internal investigation regarding the alleged violation. Appropriate
				  corrective action is defined as that action which is reasonably likely to
				  prevent the abuse, neglect, mistreatment or injury from recurring. This
				  regulation does not require staff termination as the only appropriate
				  corrective action. The corrective action imposed by the facility is
				  commensurate with the violation. When a facility is forced to re-hire a staff
				  person, determined by the facility investigation to have been responsible for
				  abuse, neglect, or mistreatment, the facility continues to be responsible for
				  ensuring the health and safety of the clients, and ensures that those staff
				  members do not work directly with clients.
W158
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430 Condition of participation: Facility
				  staffing.
(a) Standard: Qualified intellectual disability
				  professional
W159
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(a) Each client's active treatment program
				  must be integrated, coordinated and monitored by a qualified intellectual
				  disability professional who -
Guidance §483.430(a)
The position of qualified intellectual disability
				  professional (QIDP) is unique to the ICF/IID program. This position can be
				  central to the overall responsiveness and effectiveness of an active treatment
				  program. Whether a supervisory or non-supervisory position, the QIDP is
				  responsible to:
* Orchestrate all facets of the active treatment effort,
				  including the IDT creation of relevant IPPs tailored to meet individual client
				  needs;
* Effectively coordinate internal and external program
				  services and supports to facilitate the acquisition of client skills and
				  adaptive behaviors; and
* Promote competent interactions of residential staff with
				  clients in program implementation and behavior management.
Breakdowns in the provision of needed services does not
				  automatically equate with deficient practice with QIDP regulations.
				  Non-compliance with QIDP regulations exist where the facility has failed to
				  provide a QIDP or sufficient numbers of QIDPs to effectively perform these
				  required functions or the QIDP(s) has failed to assertively attempt to
				  integrate, coordinate and/or monitor each client's active treatment program.
				  Elements of integrating, coordinating and monitoring active treatment programs
				  include:
* Routinely observing clients across settings in program
				  areas to assess effectiveness of program implementation and consistency of
				  training effort to determine effectiveness of IPPs and making timely
				  modifications to facilitate achieving desired skills or goals.
* Routinely interacting with program staff across settings to
				  assist in determining the effectiveness and continued relevance of program
				  plans in meeting identified client needs.
* Determining the need for program revision based on client
				  performance.
* Identifying inconsistencies in training approaches or
				  programs not being implemented as written and facilitating the resolution of
				  these inconsistencies.
* Assures follow-up occurs for any recommendation for
				  services, equipment or programs so that needed services and supplies are
				  provided in a timely manner to meet the client's needs. The number of QIDPs
				  will vary depending on such factors as the number of clients the facility
				  serves, the complexity of needs manifested by these clients, the number,
				  qualifications and competencies of additional professional staff members, and
				  whether or not other duties are assigned to the QIDP function. The QIDP
				  function may not be delegated to other employees even though the QIDP co- signs
				  their work.
W160
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(a)(1) Has at least one year of experience
				  working directly with persons with intellectual disability or other
				  developmental disabilities; and
Guidance §483.430(a)(1)
"Experience" means providing professional or direct services,
				  either paid or volunteer, in a setting that serves persons with intellectual
				  disabilities. The experience working directly with persons with intellectual or
				  other developmental disabilities can be obtained prior to or after obtaining
				  the qualifying degree or credentials.
§483.430(a)(2) Is one of the
				  following:
W161
(a)(2)(i) A doctor of medicine
				  osteopathy.
W162
(a)(2)(ii) A registered nurse.
W163
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(a)(2)(iii) An individual who holds at
				  least a bachelor's degree in a professional category specified in paragraph
				  (b)(5) of this section
Guidance §483.430(a)(2)(iii)
The individual must have at least a bachelor's degree in one
				  of the professions listed in §483.430(b)(5)(i-xi)
(b) Standard: Professional program
				  services
W164
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430 (b)(1) Each client must receive the
				  professional program services needed to implement the active treatment program
				  defined by each client's individual program plan.
Guidance §483.430 (b)(1)
The effectiveness of the active treatment effort is dependent
				  on a facility's assembly of a competent team of professional program staff,
				  with knowledge of contemporary care practices in intellectual disabilities
				  specific to their field of expertise, that work cooperatively as members of an
				  IDT. The facility is responsible for the acquisition of professional staff
				  necessary to provide direct and indirect professional services to meet client
				  needs. Professional program services are those services that meet the needs
				  identified by a client's CFA that must be provided by a member of a vocation
				  founded upon specialized education/training. Professional staff services also
				  include on-going monitoring of the effectiveness of programs and plans
				  developed by professional staff but implemented by non -professional staff.
				  Indirect professional staff services also include on-going, technical support
				  to staff implementing these programs as well as timely assessment of the need
				  for modification of the program with appropriate communication to the QIDP and
				  IDT. The needs identified in the initial CFA, as required in
				  §483.440(c)(3)(v), should guide the team in deciding if a particular
				  professional's involvement is necessary and, if so, to what extent professional
				  involvement must continue on a direct or indirect basis. Since such needed
				  professional expertise may fall within the purview of multiple professional
				  disciplines, based on overlapping training and experience, determine if the
				  facility's delivery of professional services is adequate by the extent to which
				  clients' needs are aggressively and competently addressed. Some examples in
				  which professional expertise may overlap include, but are not limited
				  to:
*
Physical development and health
:
				  nurse, dietitian, pharmacist.
*
Nutritional status
: nurse,
				  nutritionist or dietitian.
*
Sensorimotor development
:
				  educators, recreation therapists, and occupational therapist, physical
				  therapist.
*
Affective (emotional) development
:
				  special educators, social workers, psychologists, psychiatrists, mental health
				  counselors, rehabilitation counselors, behavior therapists, behavior management
				  specialists, behavior analyst, and medical staff.
*
Speech and language (communication)
				  development
: speech-language pathologists, special educators for
				  people who are deaf or hearing impaired, and medical staff.
*
Auditory functioning
: audiologists
				  (basic or comprehensive audiologic assessment and use of amplification
				  equipment); speech-language pathologists (like audiologists, may perform aural
				  rehabilitation); special educators for clients who are hearing impaired and
				  medical staff.
*
Cognitive development
: teachers
				  (if required by law, e.g., school aged children, or if pursuit of GED is
				  indicated), behavior analysts, psychologists, speech-language
				  pathologists.
*
Vocational development
:
				  occupational therapists, vocational rehabilitation counselors, or other work
				  specialists (if development of specific vocational skills or work placement is
				  indicated).
*
Social Development
: teachers,
				  professional recreation staff, social workers, behavior analysts, psychologists
				  (specialized training needs for social skill development).
*
Adaptive behaviors or independent living
				  skills
: special educators, occupational therapists, behavior
				  analysts, and medical staff.
W165
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(1) Professional program staff must
				  work directly with clients
Guidance §483.430(b)(1)
Examples of professional staff working directly with clients
				  include: performing professional assessments of clients, provision of direct
				  support and services and periodic monitoring by the professional of the client
				  working on the program. The amount and degree of direct care that professionals
				  must provide will depend on the needs of the client and the ability of other
				  staff to effectively work with clients on a day-to-day basis. For those
				  services that must be provided by a professional due to either law, licensure
				  or registration, the client receives the services directly from the
				  professional. Professionals may deliver services through the supervision and
				  direction of subordinates where provided by law.
W166
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(1) and with paraprofessional,
				  nonprofessional and other professional program staff who work with
				  clients.
Guidance §483.430(b)(1)
Paraprofessionals are persons in various occupational fields
				  who are trained to assist professionals but are themselves not licensed at the
				  professional level. Examples of "working with" these other staff may include,
				  but not be limited to:
* Modeling the correct technique for interacting with clients
				  or implementing a specific program objective.
* Designing residential activity programs and teaching staff
				  how to implement them.
* Conducting classes on discipline specific topics.
* Answering questions of staff related to program
				  implementation or specific behavioral management issues.
* Monitoring active treatment areas to identify program
				  implementation or staff-client interaction issues.
W167
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(2) The facility must have available
				  enough qualified professional staff to carry out and monitor the various
				  professional interventions in accordance with the stated goals and objectives
				  of every individual program plan.
Guidance §483.430(b)(2)
There should be sufficient professional staff in the facility
				  to ensure that:
* needed assessments by professionals are completed
				  timely;
* direct professional services are provided when
				  indicated;
* clients are receiving interventions as specified in the
				  IPP;
* client outcomes are being monitored by the
				  professional;
* assessments and outcomes are being communicated to the IDT;
				  and
* professional staff are available to consult with team
				  members when needed.
W168
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(3) Professional program staff must
				  participate as members of the interdisciplinary team in relevant aspects of the
				  active treatment process.
Guidance §483.430(b)(3)
When a professional does an assessment and determines there
				  are client needs which become incorporated into the IPP, with a current
				  prioritized objective, the professional should actively participate on the IDT.
				  This participation may be through written reports or verbally while attending
				  the IPP meeting or participating via telephone or other electronic means, to
				  provide team members with the opportunity to review and discuss information and
				  recommendations relevant to the client's needs, and to reach decisions as a
				  team, rather than individually, on how best to address those needs.
W169
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(4) Professional program staff must
				  participate in on-going staff development and training in both formal and
				  informal settings with other professional, paraprofessional, and
				  nonprofessional staff members.
Guidance §483.430(b)(4)
Professional program staff provides various types of training
				  to staff as indicated by the IPP and IDT. Formal training: a specific training
				  done at the time a program is implemented or updated by the professional, with
				  all staff who works with the client. Informal training: when the professional
				  observes the staff not correctly implementing a program, the professional
				  provides informal guidance on correct implementation. Training on programs that
				  apply to multiple clients: when a particular program applies to several clients
				  in a facility, a professional may provide training to several staff on a
				  particular topic that applies to multiple clients (such as safe transfer
				  techniques). Professional staff of the facility should participate in ongoing
				  training such as conferences and workshops to maintain current standards of
				  practice in the field of intellectual and developmental disabilities as
				  required by their professional licensure or certification.
W170
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(5) Professional program staff must be
				  licensed, certified, or registered, as applicable, to provide professional
				  services by the State in which he or she practices. Those professional program
				  staff who do not fall under the jurisdiction of State licensure, certification,
				  or registration requirements, specified in §483.410(b), must meet the
				  following qualifications:
W171
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(5)(i) To be designated as an
				  occupational therapist, an individual must be eligible for certification as an
				  occupational therapist by the American Occupational Therapy Association or
				  another comparable body.
Guidance §483.430(b)(5)(i)
If a professional is not nationally certified, they would
				  have to show evidence they completed the degree and field work in their
				  designated field and are eligible to sit for the national exam. The American
				  Occupational Therapy Association is now known as the National Board for
				  Certified Occupational Therapists (NBCOT). There is no "other comparable body."
				  Eligibility means the professional must have completed a degree in their
				  designated field, completed all field work required for a license, must meet
				  licensure requirements in the state they are practicing in, and are registered
				  or certified nationally as applicable.
W172
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(5)(ii) To be designated as an
				  occupational therapy assistant, an individual must be eligible for
				  certification as a certified occupational therapy assistant by the American
				  Occupational Therapy Association or another comparable body.
Guidance §483.430(b)(5)(ii)
If a professional is not nationally certified, they would
				  have to show evidence they completed the degree and field work in their
				  designated field and are eligible to sit for the national exam. The American
				  Occupational Therapy Association is now known as the National Board for
				  Certified Occupational Therapists (NBCOT). There is no "other comparable body."
				  Eligibility means the professional must have completed a degree in their
				  designated field, completed all field work required for a license, must meet
				  licensure requirements in state they are practicing in, and are registered or
				  certified nationally as applicable.
W173
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(5)(iii) To be designated as a physical
				  therapist, an individual must be eligible for certification as a physical
				  therapist by the American Physical Therapy Association or another comparable
				  body.
Guidance §483.430(b)(5)(iii)
If a professional is not nationally certified, they would
				  have to show evidence they completed the degree and field work in their
				  designated filed and are eligible to sit for the national exam. Eligibility
				  means the professional must have completed a degree in their designated field,
				  completed all field work required for a license, must meet licensure
				  requirements in state they are practicing in, and are registered or certified
				  nationally as applicable.
W174
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(5)(iv) To be designated as a physical
				  therapy assistant, an individual must be eligible for registration by the
				  American Physical Therapy Association or be a graduate of a two year
				  college-level program approved by the American Physical Therapy Association or
				  another comparable body.
Guidance §483.430(b)(5)(iv)
If a professional is not nationally certified, they would
				  have to show evidence they completed the degree and field work in their
				  designated filed and are eligible to sit for the national exam. Eligibility
				  means the professional must have completed a degree in their designated field,
				  completed all field work required for a license, must meet licensure
				  requirements in State they are practicing in, and are registered or certified
				  nationally as applicable.
W175
§483.430(b)(5)(v) To be designated as a
				  psychologist, an individual must have at least a master's degree in psychology
				  from an accredited school.
§483.430(b)(5)(vi) To be designated as a social
				  worker, an individual must-
W176
§483.430(b)(5)(vi)(A) Hold a graduate degree from
				  a school of social work accredited or approved by the Council on Social Work
				  Education or another comparable body; or
§483.430(b)(5)(vi)(B) Hold a Bachelor of Social
				  Work degree from a college or university accredited or approved by the Council
				  on Social Work Education or another comparable body.
§483.430(b)(5)(vii) To be designated as a
				  speech-language pathologist or audiologist, an individual must-
W177
§483.430(b)(5)(vii)(A) Be eligible for a
				  Certificate of Clinical Competence in Speech-Language Pathology or Audiology
				  granted by the American Speech-Language-Hearing Association or another
				  comparable body; or
§483.430(b)(5)(vii)(B) Meet the educational
				  requirements for certification and be in the process of accumulating the
				  supervised experience required for certification.
W178
§483.430(b)(5)(viii) To be designated as a
				  professional recreation staff member an individual must have a bachelor's
				  degree in recreation or in a specialty area such as art, dance, music or
				  physical education.
W179
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(5)(ix) To be designated as a
				  professional dietitian, an individual must be eligible for registration by the
				  American Dietetics Association.
Guidance §483.430(b)(5)(ix)
If a professional is not nationally registered as a
				  dietician, they would have to show evidence they completed the degree and field
				  work in their designated field and are eligible to sit for the national
				  exam.
W180
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(5)(x) To be designated as a human
				  services professional an individual must have atleast a bachelor's degree in a
				  human services field (including, but not limited to: sociology, special
				  education, rehabilitation counseling, and psychology).
Guidance §483.430(b)(5)(x)
Human Services is a diverse field focused on improving the
				  quality of life of clients in communities in which the professional serves. A
				  human services professional works directly with the population being served.
				  Surveyors should see evidence that a human service professional has a
				  bachelor's degree at a minimum.
W181
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(b)(5)(xi) If the client's individual
				  program plan is being successfully implemented by facility staff, professional
				  program staff meeting the qualifications of paragraph (b)(5)(i) through (x) of
				  this section are not required-
(A) Except for qualified intellectual disability
				  professionals;
(B) Except for the requirements of paragraph (b)(2) of
				  this section concerning the facility's provision of enough qualified
				  professional program staff; and
(C) Unless otherwise specified by State licensure and
				  certification requirements.
Guidance §483.430(b)(5)(xi)
An individual client program may not require that
				  professional staff perform all of the services as outlined by the IPP (e.g. the
				  direct support staff may be trained by the professional to safely and
				  effectively carry out the designed program), however, any specialized therapy
				  must involve evaluation, program development, and re-assessment by the
				  appropriate professional at periodic intervals.
(c) Standard: Facility staffing
W182
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(c)(1) The facility must not depend upon
				  clients or volunteers to perform direct care services for the facility.
Guidance §483.430(c)(1)
The facility must have sufficient staff to provide needed
				  care and services without the use of volunteers or enlisting the help of
				  clients residing in the facility to perform the duties normally performed by
				  facility staff. The facility may not rely on volunteers in lieu of paid staff
				  to fill required staff positions and perform direct care services. Volunteers
				  are permissible, but must be in addition to the number of paid staff required
				  to carry out a function. Volunteers should have an orientation to the policies
				  and procedures of the facility and oversight is required by facility
				  staff.
W183
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(c)(2) There must be responsible direct
				  care staff on duty and awake on a 24-hour basis, when clients are present, to
				  take prompt, appropriate action in case of injury, illness, fire or other
				  emergency, in each defined residential living unit housing- -
(i) Clients for whom a physician has ordered a medical
				  care plan;
(ii) Clients who are aggressive, assaultive or security
				  risks;
(iii) More than 16 clients; or
(iv) Fewer than 16 clients within a multi-unit
				  building.
Guidance §483.430(c)(2)
Indicators of staff not being awake in relation to the
				  occurrence of incidents, accidents, and injuries may include, but are not
				  limited to:
* incidents of unplanned client absences;
* untimely reaction to a medical emergency;
* injuries from client to client aggression; or
* a pattern of injuries of unknown origin.
If even one client meets 483.430(c)(2) (i-ii) then staff must
				  be awake on a 24-hour basis. A client has a medical care plan when an acute or
				  chronic occurrence requires clinical assessment and monitoring on a scheduled
				  basis.
W184
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(c)(3) There must be a responsible direct
				  care staff person on duty on a 24 hour basis (when clients are present) to
				  respond to injuries and symptoms of illness, and to handle emergencies, in each
				  defined residential living unit housing- -
(i) Clients for whom a physician has not ordered a
				  medical care plan;
(ii) Clients who are not aggressive, assaultive or
				  security risks; and
(iii) Sixteen or fewer clients.
Guidance §483.430(c)(3)
At all times, there must be at least one staff person on-duty
				  in the facility if even one client is present. For purposes of this provision,
				  "on duty" staff need not be awake during normal sleeping hours, but do need to
				  respond to injuries, illness, and emergencies promptly.
W185
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(c)(4) The facility must provide
				  sufficient support staff so that direct care staff are not required to perform
				  support services to the extent that these duties interfere with the exercise of
				  their primary direct client care duties.
Guidance §483.430(c)(4)
Direct care staff should not be performing support services
				  (e.g., making beds, cooking, cleaning, etc.) independently which takes them
				  away from client interaction and teaching. If support services in the house
				  cannot be done jointly as chores between clients, as part of their training
				  program, and the support staff, additional staff should be added to perform the
				  chores. This does not include any staff chores done during client's sleeping
				  hours. "Support staff include all personnel hired by the facility that are not
				  either direct care staff or professional staff. For example, support staff
				  includes, but are not limited to, secretaries, clerks, housekeepers,
				  maintenance and laundry personnel.
(d) Standard: Direct care residential living unit
				  staff
W186
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(d)(1) The facility must provide
				  sufficient direct care staff to manage and supervise clients in accordance with
				  their individual program plans.
Guidance §483.430(d)(1)
"Sufficient" means enough direct care staff to effectively
				  implement the active treatment programs as defined in the IPP, to meet client
				  needs, and to respond to emergencies, illness, or injuries. Even though minimum
				  ratios are defined at §483.430(d)(3), active treatment may require more
				  staff than the minimums required ratios, therefore compliance should not be
				  based on staffing ratios alone.
§483.430(d)(2) Direct care staff are defined as
				  the present on-duty staff calculated over all shifts in a 24-hour period for
				  each defined residential living unit.
Guidance §483.430(d)(2)
"Direct care staff are those personnel who are assigned to
				  work directly with the clients providing support during activities of daily
				  living and active treatment programs. Professional staff who work with clients
				  in a living unit on a periodic basis are not included in direct care staff
				  ratios. Supervisors of direct care staff can be counted only if they share in
				  the actual work of the direct care of clients on a continuous basis (e.g. take
				  client assignment). Direct care supervisors whose principle assigned function
				  is to supervise direct care staff may not be included in direct care staff
				  ratios although they may occasionally provide direct services to clients.
				  Non-direct care staff supervisors whose principle assigned function is to
				  supervise non- direct care staff may not be included in direct care staff
				  ratios.
W187
(Rev. 144, Issued: 08-14-15, Effective:
				  08-14-15, Implementation: 08-14-15)
§483.430(d)(3) Direct care staff must be provided
				  by the facility in the following minimum ratios of direct care staff to
				  clients:
(i) For each defined residential living unit serving
				  children under the age of 12, severely and profoundly retarded clients, clients
				  with severe physical disabilities, or clients who are aggressive, assaultive,
				  or security risks, or who manifest severely hyperactive or psychotic-like
				  behavior, the staff to client ratio is 1 to 3.2.
(ii) For each defined residential living unit serving
				  moderately retarded clients, the staff to client ratio is 1 to 4.
(iii) For each defined residential living unit serving
				  clients who function within the range of mild retardation, the staff to client
				  ratio is 1 to 6.4.
Guidance §483.430(d)(3)
The minimum ratios in this standard indicate the
minimum
number of direct-care staff that must be present and on
				  duty, 24 hours a day, 365 days a year, for each discrete living unit. For
				  example, to calculate the minimum number of living unit staff that must be
				  present and on duty in a discrete living unit serving 16 individuals with
				  multiple disabilities: divide the number of individuals "16, " by the number
				  corresponding to the regulation "3.2, " the result equals "5. " Therefore, the
				  facility must determine how many staff it must hire to ensure that at least 5
				  staff will be able to be present and on duty during the 24hour period in which
				  those individuals are present. Using the living unit described above,
				  "calculated over all shifts in a 24-hour period" means that there are present
				  and on duty every day of the year: one direct care staff for each eight
				  individuals on the first shift (1:8), one direct care staff for each eight
				  individuals on the second shift (1:8), and one direct care staff for each 16
				  individuals on the third shift (1:16). Therefore, there are five (5) direct
				  care staff present and on duty for each twenty-four hour day, for 16
				  individuals. The same calculations are made for the other ratios, whichever
				  applies. Determine if absences of staff for breaks and meals results in a
				  pattern of prolonged periods in which present and on-duty staff do not meet the
				  ratios.
W188
§483.420(d)(4) When there are no clients present
				  in the living unit, a responsible staff member must be available by
				  telephone.
§483.430(e) Standard: Staff Training
				  Program
W189
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(e)(1) The facility must provide each
				  employee with initial and continuing training that enables the employee to
				  perform his or her duties effectively, efficiently, and competently.
Guidance §483.430(e)(1)
Newly employed staff receive a supported orientation program
				  (mentor or ongoing supervision) during their early employment. All staff
				  receive continuing education on such issues as abuse and neglect, handling
				  emergency situations, behavior management, and treating people with respect and
				  dignity, etc. The primary evidence of an effective staff training program is
				  the observed competent interaction between staff and clients.
§483.430(e)(2) For employees who work with
				  clients, training must focus on skills and competencies directed toward
				  clients'
W190
(Rev. 144, Issued: 08-14-15, Effective:
				  08-14-15, Implementation: 08-14-15)
§483.430(e)(2) developmental,
Guidance §483.430(e)(2)
Staff receive training in the following areas:
* developmental programming principles and techniques (e.g.
				  techniques to involve clients in their programs to their highest capability,
				  use of positive reinforcement, use of assistive technology, use of appropriate
				  materials and providing informal opportunities to practice skills);
* use of adaptive equipment and augmentative communication
				  devices and systems;
* and
* effective recordkeeping procedures.
W191
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(e)(2) behavioral,
Guidance §483.430(e)(2)
Staff receive training in the following areas:
* use of behavioral principles during interactions between
				  staff and clients;
* use of accurate procedures regarding abuse detection and
				  prevention, restraints, drugs to manage behaviors, client safety, emergencies,
				  etc.;
* use of least restrictive interventions;
* use of positive behavior intervention programming;
				  and
* training clients in appropriate replacement
				  behaviors.
W192
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(e)(2) and health needs
Guidance §483.430(e)(2)
Staff receive training in the following areas:
* signs and symptoms of the client's changing health (e.g.
				  constipation, urinary tract infections, adverse drug reactions, as
				  indicated);
* exercise and diet;
* first aid;
* infection control;
* reporting to appropriate healthcare professionals;
				  and
* for those staff who can administer medications, how to
				  include clients in their medication administration by recognizing and
				  encouraging the use of applicable skills.
W193
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(e)(3) Staff must be able to demonstrate
				  the skills and techniques necessary to administer interventions to manage the
				  inappropriate behavior of clients.
Guidance §483.430(e)(3)
Staff correctly and consistently implement the interventions
				  specified in the behavior plans of clients with whom they are working.
				  Inadequate training is evident when staff do not correctly implement behavioral
				  programs, use inappropriate management techniques, cannot explain what
				  intervention is to be used and how it is to be implemented.
W194
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.430(e)(4) Staff must be able to demonstrate
				  the skills and techniques necessary to implement the individual program plans
				  for each client for whom they are responsible.
Guidance §483.430(e)(4)
Staff are observed in various settings during the day
				  correctly and consistently implementing the specific IPPs of the clients with
				  whom they are working.
W195
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440 Condition of participation: Active
				  treatment services
(a) Standard: Active treatment
W196
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(a)(1) Each client must receive a
				  continuous active treatment program, which includes aggressive, consistent
				  implementation of a program of specialized and generic training, treatment,
				  health services and related services described in this subpart, that is
				  directed toward-
(i) The acquisition of the behaviors necessary for the
				  client to function with as much self-determination and independence as
				  possible; and
(ii) The prevention or deceleration of regression or
				  loss of current optimal functional status.
Active treatment embodies an individually- tailored series of
				  daily life and living experiences that serve as the primary opportunity for the
				  acquisition, development and expression of functional skills and adaptive
				  behaviors necessary for the client to experience optimal independence and
				  promote purposeful "self-expression". The uniqueness of each client is a core
				  consideration in the design of active treatment programs. It is expected that
				  individual clients are given the opportunity to provide input into the content
				  of their day-to-day living experiences. An active treatment program includes
				  the following elements as substantiated through observation, interview and
				  record review:
a)
Each client's needs and strengths have
				  been accurately assessed and relevant input has been obtained from team
				  members; (Observations and interviews with the client by the surveyor should be
				  consistent with the current assessment information. Interview the QIDP
				  regarding any needs observed but not addressed through assessment/programming
				  by the facility).
b)
Each client's IPP is based on assessed
				  needs and strengths, and addresses major life areas such as personal skills,
				  home living skills, community living skills, employment skills, etc., essential
				  to increasing independence and ensuring rights;
c)
Needs identified as a priority are
				  addressed formally and through activities which are relevant and responsive to
				  client need, interest and choice;
d)
Active treatment is consistently
				  implemented in all relevant settings both formally and informally as the need
				  arises or opportunities present themselves. It should not be limited to
				  specific periods of time during the day or environments. Each client should
				  receive aggressive and consistent training, treatments and supports in
				  accordance with their needs and IPP. New skills and appropriate behaviors are
				  encouraged and reinforced across environments and times of day. Each client has
				  the adaptive equipment and environmental adaptations necessary for him/her to
				  progress toward heightened independence as recommended and contained in their
				  IPP. Active treatment means taking advantage of opportunities for the practice
				  of new skills and the use of other skills during the normal rhythm of each
				  client's day.
e)
Each client's performance related to IPP
				  objectives is accurately and consistently measured and documented and programs
				  are modified on an ongoing basis based on data and major life changes;
				  and
i. Clients with degenerative conditions receive training,
				  treatment and services designed to retain skills and functioning and to prevent
				  further regression to the extent possible.
ii. Clients may need adjustments to their active treatment
				  programs as functional or endurance limitations are identified associated with
				  the aging process. In such cases, there may be more of an emphasis on the
				  retention of skills already attained and reducing the rate of loss of skills,
				  than on the acquisition of new skills.
In large part, it is this pervasive and continuous
				  reinforcement of "formal" training through "informal" routine daily living
				  experiences and interactions with staff and others that makes active treatment
				  programs effective. Formal settings are those that are planned and specifically
				  structured for training on objectives and interventions. Informal settings are
				  times that are not anticipated or planned but that offer the opportunity for
				  training.
Active treatment programs mirror normal living experiences
				  such as leisure activities and social conversation at the dinner table. It must
				  be clear that active treatment programs are far more than implementation of
				  discreet formal training sessions or programs that are conducted at prescribed
				  times by defined personnel. Learning occurs in the process of the normal rhythm
				  of life and life experiences.
W197
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(a)(2) Active treatment does not include
				  services to maintain generally independent clients who are able to function
				  with little supervision or in the absence of a continuous active treatment
				  program.
Guidance §483.440(a)(2)
All active treatment programs must be based upon assessed
				  developmental needs which are prohibiting the client from living in a more
				  independent setting. Active treatment moves clients to a more independent
				  setting.
* When a client is in the facility simply for protective
				  oversight and is not in need of training for developmental deficits, this does
				  not constitute active treatment (e.g. a court placement to protect the
				  community or the client from the client's behavior).
* Programs that are simply being provided to maintain a
				  client's independence would not be considered active treatment since the client
				  is not actively being trained to live in a more independent setting. If a
				  client already possesses the skills that enables them to live in a less
				  restrictive environment, and does not require the structure, support and
				  resources that services that only an ICF/IID can provide, they can be
				  considered generally independent. For example, a client is admitted to the
				  ICF/IID for the primary purpose of competency determination for a court
				  hearing. This client lived independently prior to admission. The active
				  treatment programs they are receiving are focused on maintaining that
				  independence and do not address specific developmental deficits that inhibit
				  independent living. This would not be considered active treatment.
(b) Standard: Admissions, transfers, and
				  discharge
W198
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(b)(1) Clients who are admitted by the
				  facility must be in need of and receiving active treatment
				  services.
Guidance §483.440(b)(1)
All client admissions must be based upon assessed
				  developmental deficits which are prohibiting the client from living in a more
				  independent setting and which require those intensive specialized supports,
				  services, and supervision that only an ICF/IID can provide. The individual
				  components of the provision of active treatment include CFA, IPP, program
				  implementation, program documentation, and program monitoring and change. When
				  any of these individual components of active treatment are not in place,
				  resulting in the clients not receiving active treatment, this regulation this
				  not met.
W199
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(b)(2) Admission decisions must be based
				  on a preliminary evaluation of the client that is conducted or updated by the
				  facility or by outside sources.
Guidance §483.440(b)(2)
Preliminary evaluations should support the need for an
				  admission to an ICF/IID (e.g., deficits in functional skills or adaptive
				  behaviors). The information from the preliminary evaluation must be used by the
				  facility to make an admission decision. Occasionally, emergency admissions of
				  clients may occur without benefit of a preliminary evaluation having been
				  conducted
prior to admission
. When situational
				  emergencies necessitate admission before a preliminary evaluation can be
				  conducted, or when pre-admission information is incomplete, the completion of
				  the preliminary admission evaluation within seven (7) calendar days after
				  admission will satisfy compliance with this requirement.
W200
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(b)(3) A preliminary evaluation must
				  contain background information as well as currently valid assessments of
				  functional developmental, behavioral, social, health and nutritional status to
				  determine if the facility can provide for the client's needs and if the client
				  is likely to benefit from placement in the facility.
Guidance §483.440(b)(3)
The preliminary evaluation contains specific information
				  useful to determine if the facility can meet the client's needs and if the
				  client can benefit from placement. The facility makes every reasonable effort
				  to gather all available data to assist in their determination. Background
				  information would include information that gives insight into the clients'
				  previous living environments and programming efforts. The assessment must
				  include a consideration as to whether reasonable accommodation as required by
				  the Americans with Disabilities Act would enable the client to benefit from
				  placement in facility.
§483.440(b)(4) If a client is to be either
				  transferred or discharged, the facility must -
W201
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(b)(4)(i) Have documentation in the
				  client's record that the client was transferred or discharged for good cause;
				  and
Guidance §483.440(b)(4)(i)
Transfer or discharge occurs only when the facility cannot
				  meet the client's needs, the client no longer requires an active treatment
				  program in an ICF/IID setting; the individual/guardian chooses to reside
				  elsewhere, or when a determination is made that another level of service or
				  living situation would be more beneficial to the client. "Transfer" means the
				  temporary movement of a client to another facility (e.g. another ICF/IID,
				  psychiatric hospital, medical hospital) with the intention of return to the
				  original site. "Discharge" means the permanent movement of a client to another
				  facility or setting which operates independently from the ICF/IID (e.g. the
				  facility is not under the jurisdiction of the facility's governing body).
				  Documentation includes evidence of an assessment that evaluated the pros and
				  cons of the transfer or discharge and the rationale for the final
				  decision.
W202
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(b)(4)(ii) Provide a reasonable time to
				  prepare the client and his or her parents or guardian for the transfer or
				  discharge (except in emergencies).
Guidance §483.440(b)(4)(ii)
The client and their family or the client and their legal
				  guardian are involved in planning for any transfer or discharge and receive the
				  services necessary to assist in preparing for movement, unless an emergency
				  (medical) situation prevents that involvement. If the client has an advocate,
				  the advocate should participate in the decision-making process. Orderly,
				  planned transfers and discharges usually take place over an extended period of
				  time. The IPP should reflect objectives or interventions which prepare the
				  client for transfer or discharge. Transfers or discharges executed on short
				  timeframes (e.g. less than 30 days) without "good cause" would not comply with
				  the "reasonable" intent of the regulations. "Reasonable" time is the time
				  required to provide clients and their families with planned steps and
				  established timeframes to facilitate the successful transition. Time frames are
				  modified based on client needs and emergent situations. Preparation of the
				  client for transfer may include orientation or trial visits to the new
				  location. Staff should take steps to minimize potential anxiety or any
				  behavioral reactions which could result from the client's transfer.
§483.440(b)(5) At the time of the discharge, the
				  facility must-
W203
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(b)(5)(i) Develop a final summary of the
				  client's developmental, behavioral, social, health and nutritional
				  status
Guidance §483.440(b)(5)(i)
The final summary should be useful for continued services in
				  the client's new setting. The final discharge summary should be entered into
				  the client's record, provide a summary of the client's course of stay in the
				  ICF/IID, provide a final summary of the client's developmental, behavioral,
				  social, health and nutritional status, and include the current status of the
				  objectives listed in the client's IPP. The status should address whether or not
				  a clients' skills have been maintained, deteriorated, or improved during their
				  stay.
W204
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(b)(5)(i) and, with the consent of the
				  client, parents (if the client is a minor) or legal guardian, provide a copy to
				  authorized persons and agencies; and
Guidance §483.440(b)(5)(i)
When the client is discharged, the receiving entity (another
				  ICF/IID, waiver home, family home, nursing home, etc.) is provided a copy of
				  the discharge summary. The ICF/IID should obtain written consent to share this
				  information with the persons who will be providing services to the client in
				  the future and their parents/or legal guardians. Sharing the discharge summary
				  with State Agencies as applicable is determined by state requirements.
W205
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(b)(5)(ii) Provide a post-discharge plan
				  of care that will assist the client to adjust to the new living
				  environment.
Guidance §483.440(b)(5)(ii)
The post discharge plan of care is a component of the
				  discharge summary. The facility utilizes the information from the discharge
				  summary to prepare the discharge plan of care. The post-discharge plan of care
				  identifies the essential supports and services necessary for the client to
				  successfully adjust to the new living environment and describe necessary
				  coordination of services. It should incorporate the client's preferences. It
				  should identify specific client needs after discharge such as personal care,
				  physical therapy, client/caregiver education needs, and the ability of the
				  client or caregiver to meet those needs after discharge.
(c) Standard: Individual program plan
W206
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(1) Each client must have an individual
				  program plan developed by an interdisciplinary team that represents the
				  professions, disciplines or service areas that are relevant to- -
i) Identifying the client's needs, as described by the
				  comprehensive functional assessments required in paragraph (c)(3) of this
				  section; and
ii) Designing programs that meet the client's
				  needs.
Guidance §483.440(c)(1)
If a need is identified in the CFA, the professional
				  associated with that need will conduct an initial evaluation for the
				  development of the IPP. The needs identified in the CFA determine the
				  professional, paraprofessional, direct support staff, disciplines or service
				  areas that must participate in the development of the IPP.
W207
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(2) Appropriate facility staff must
				  participate in interdisciplinary team meetings.
Guidance §483.440(c)(2)
While there is no correct number of individuals that comprise
				  the IDT, the team should include appropriate facility staff (professional and
				  paraprofessional staff), that are responsible for designing, developing, and/or
				  implementing the client's IPP and direct support staff who work closely with
				  the clients. For any prioritized objective, the paraprofessional or
				  professional personnel responsible for the development and monitoring of that
				  program should participate on the team, either through actual attendance or
				  written or verbal input. Members of the IDT may change as the assessed needs of
				  the client change (e.g. medical issues, nutritional issues, communication
				  needs, fine motor skill needs, gross motor skill needs, social issues or
				  behavioral concerns).
W208
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(2) Participation by other agencies
				  serving the client is encouraged.
Guidance §483.440(c)(2)
The facility must make every effort to coordinate the
				  Individual Education Plan (IEP) from the school or the client's program plan
				  from outside program, work site or workshop with the IPP. This may result in a
				  single document, but there is no requirement for a single combined document.
				  There must be evidence that all applicable plans were coordinated (evidence of
				  discussion across the plans and observation would confirm integration of the
				  IPP across the various settings). The QIDP is responsible for the coordination
				  of the plans. The facility should communicate changes in the IPP or in the
				  clients' life situation with teachers and workplace representatives either
				  directly or through written communication.
W209
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(2) Participation by the client, his or
				  her parent (if the client is a minor), or the client's legal guardian is
				  required unless the participation is unobtainable or inappropriate.
Guidance §483.440(c)(2)
The facility should make every effort to schedule team
				  meetings at a time that enables the client parent or legal guardian, to attend
				  without having to forfeit work time or pay. The facility should make every
				  effort to schedule team meetings at a time that enables the client parent or
				  legal guardian, to attend without having to forfeit work time or pay. It is
				  expected that the client will routinely attend team meetings unless their
				  participation is unobtainable. Examples of when client participation is not
				  available include, but are not limited to: 1) the client is away from the
				  facility for medical reasons or hospitalization; or 2) although the facility
				  has documented repeated attempts to engage the client, the client refuses to
				  participate. If families/legal guardians are unable to attend a program
				  planning meeting, the facility provides them information regarding the meeting
				  outcome and gives them an opportunity to discuss the plan with the facility
				  staff.
"Unobtainable", for the purposes of this guideline, means
				  that the facility has made a good faith effort to seek parental or legal
				  guardian participation in the process, even though the effort may ultimately be
				  unsuccessful (for example, the parent may be impossible to locate or may prove
				  unwilling or unable to participate).
"Inappropriate", for the purposes of this guideline, means
				  that the parent or legal guardian's behavior is so disruptive or uncooperative
				  that others cannot effectively participate; the client does not wish his or her
				  parent to participate, and the client is competent to make this decision; or
				  there is strong and documented evidence that the parent or legal guardian is
				  not acting on the client's behalf or in the client's best interest. In the case
				  of the latter, determine what the facility has done to bring effective
				  resolution to the problem.
Instances when it is not appropriate for the client, parent
				  or legal guardian, to attend the team discussion are rare. If the client does
				  not attend the meeting, the facility must document the reason for his/her
				  non-participation.
There may also be instances where a parent or legal guardian
				  is considered unobtainable for a team meeting, such as being out of the
				  country. In these instances, the parent or legal guardian should still be
				  notified of the meeting, provided with information concerning the outcome of
				  the meeting and documentation in the client record should describe why the
				  parent or legal guardian could not attend and what information was provided to
				  them.
If the client is an adult who is competent to make decisions
				  and who is not adjudicated, parents may not participate in the process if their
				  participation is opposed by the client.
In the event that a non-adjudicated adult chooses not to have
				  their family involved in the active treatment process, the surveyor should see
				  evidence in the record of efforts made by the facility to understand why the
				  client has declined family participation. If the client continues to decline
				  family involvement after the facility has held discussions with him/her about
				  the importance of this issue, the facility should honor the wishes of the
				  client.
In general, the more involvement and communication among the
				  team members, the client and the parent or legal guardian the more likely the
				  plan will be successful. The facility goal should be to routinely include these
				  parties unless rare circumstances exist.
W210
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3) Within 30 days after admission, the
				  interdisciplinary team must perform accurate assessments or reassessments as
				  needed to supplement the preliminary evaluation conducted prior to
				  admission.
Guidance §483.440(c)(3)
For new admissions, the CFA is completed within 30 days after
				  admission and is utilized as the basis for the IPP. New, revised or updated
				  assessments completed within the first 30 days of admission, accurately
				  identify the functional abilities of the client.
"Accurate" assessments refer to assessment data that are
				  current, relevant and valid, and the skills, abilities, and training needs
				  identified by the assessment correspond to the client's actual, observed
				  status. Assessments must be administered with appropriate adaptations such as
				  specialized equipment, use of an interpreter, use of manual communication and
				  tests designed to measure performance in the presence of visual
				  disability.
The content of or format of the assessments or the particular
				  assessment tools which are to be used for the CFA are not specified.
				  Assessments must include identification of those functional life skills in
				  which the client needs to be more independent and those services needed for the
				  client to become more community integrated.
W211
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3) The comprehensive functional
				  assessment must take into consideration the client's age (for example, child,
				  young adult, elderly person) and the implications for active treatment at each
				  stage, as applicable, and must -
Guidance §483.440(c)(3)
During assessment, the client is given opportunities to
				  participate in age-appropriate activities to assess the person's functioning in
				  those activities or settings. For example, the use of baby toys during the
				  assessment of an adult would not be appropriate.
W212
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(i) Identify the presenting problems
				  and disabilities and where possible, their causes;
Guidance §483.440(c)(3)(i)
The CFA includes:
* all diagnoses and developmental deficits for the
				  client;
* the supporting information for each; and
* each evaluation should include conclusions and
				  recommendations which go into the development of an active treatment program
				  for the client.
W213
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(ii) Identify the client's specific
				  developmental strengths;
Guidance §483.440(c)(3)(ii)
The client's identified developmental strengths, preferences,
				  methods of coping/compensation, community use and awareness, friendships and
				  positive attributes and capabilities are clearly described in functional terms
				  in the assessments. Identified strengths are consistent with the client's
				  observed functional status.
W214
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(iii) Identify the client's specific
				  developmental and behavioral management needs;
Guidance §483.440(c)(3)(iii)
The CFA must address and identify those skill deficits/needed
				  supports that may be amenable to training, those that must be treated by
				  therapy and/or provision of assistive technology, and those that require
				  adapting the environment and/or providing personal support. Assessment of
				  needed supports should be done within the context of the client's age, gender,
				  and culture. "Behavioral management needs" include those behaviors that
				  interfere with progress, prevent assimilation into the community, decrease
				  freedom or increase the need for restriction of activities (e.g. spitting,
				  pica, self-injurious behavior, aggressive behavior toward others or
				  self-injurious behavior). A functional behavioral assessment is a
				  problem-solving process for evaluating client inappropriate behavior. It relies
				  on a variety of techniques and strategies to identify the purpose of the
				  specific behavior(s) and to help the IDT select interventions to directly
				  address the behavior(s). A functional behavior assessment looks beyond the
				  behavior itself. The focus when conducting a functional behavioral assessment
				  is on identifying significant client-specific social, affective, cognitive,
				  and/or environmental factors associated with the occurrence (and
				  non-occurrence) of specific behaviors. The CFA must identify the specific
				  accommodations that address the client's needs to ensure better opportunity for
				  the client's success. The identified accommodations may be assistive technology
				  which can help a person learn, play, complete tasks, get around, communicate,
				  hear or see better, control their own environment and take care of their
				  personal needs (e.g. door levers instead of knobs, plate switches, audio books,
				  etc.).
W215
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(iv) Identify the client's needs for
				  services without regard to the actual availability of the services needed;
				  and
Guidance §483.440(c)(3)(iv)
Identification of needed services is based on the CFA. In the
				  presence of significant developmental deficits, it is not acceptable for the
				  facility to say that a particular professional therapy or treatment is not
				  needed or not available if the CFA identifies a deficit. The assessment must
				  identify the course of specific interventions recommended to meet the client's
				  needs, both through direct professional services and non-professional services.
				  For example, a client's communication skill development may not require the
				  intensive services of a speech-language pathologist however, the direct care
				  staff will need to work with the client and use a pre-determined communication
				  system.
§483.440(c)(3)(v) Include
Guidance §483.440(c)(3)(v)
The CFA should include an assessment of each of the areas
				  listed below. Assessments should include specific information about the
				  person's ability to function in different environments, specific skills or lack
				  of skills, and how function can be improved, either through training,
				  environmental adaptations, or provision of adaptive, assistive, supportive,
				  orthotic, or prosthetic equipment. If assessments are done separately by
				  professional disciplines, there should be evidence that the assessments are
				  brought together in an interdisciplinary approach to address the client's
				  various developmental areas. The CFA must be completed upon admission and
				  annually as indicated. While the assessment may not have the specific titles of
				  the areas listed below, the surveyor must be able to identify information
				  within assessments from each of the areas below.
W216
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(v) physical development and
				  health,
Guidance §483.440(c)(3)(v)
Physical development and health
:
				  This portion of the CFA includes the client's developmental history, results of
				  the physical examination conducted by a licensed physician, physician
				  assistant, or nurse practitioner, health assessment data (including a
				  medication and immunization history); a review and summary of all laboratory
				  reports since the last comprehensive evaluation, a summary of all required
				  medical interventions since the last CFA; skills of the client normally
				  associated with the monitoring and supervision of one's own health status, and
				  administration and/or scheduling of one's own medical treatments. Reports of
				  all specialist consultations should be included in the assessment as indicated
				  by physical examination results. IDT reviews any current advanced directives
				  that the client may have in place as part of the CFA.
W217
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(v) nutritional
				  status,
Guidance §483.440(c)(3)(v)
Nutritional status
: Nutritional
				  status includes height and weight, the client's eating habits and preferences,
				  favorite foods, determination of appropriateness of diet, adequacy of total
				  food intake, bowel habits, means through which the client receives nutrition
				  (e.g. feeding tube) and the skills associated with eating (including chewing,
				  sucking and swallowing disorders).
W218
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(v) sensorimotor
				  development,
Guidance §483.440(c)(3)(v)
Sensorimotor development
:
				  Sensorimotor development includes the development of perceptual skills that are
				  involved in observing the environment and making sense of it. Identified
				  sensory deficits should be evaluated in conjunction with the impact they will
				  have on the client's life. A sensory deficit in eye contact may not have a
				  detrimental effect on the client's life if it will not hold the client back
				  from further accomplishments or skill acquisitions. Motor development includes
				  those behaviors that primarily involve: muscular, neuromuscular, or physical
				  skills and varying degrees of physical dexterity. Because sensory and motor
				  development are intimately related and because activities in these areas are
				  functionally inseparable, attention to these two aspects of bodily activity is
				  often combined in the concept of sensorimotor development. For those motor
				  areas that are identified by the assessment as limited, the assessment should
				  specify the extent to which corrective, orthotic, prosthetic, or support
				  devices would impact on functional status and the extent of time the device is
				  to be used throughout the day.
W219
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(v) affective
				  development,
Guidance §483.440(c)(3)(v)
Affective (Emotional) development
:
				  Affective or emotional development includes the development of behaviors that
				  relate to one's interests, attitudes, values, morals, emotional feelings and
				  emotional expressions.
W220
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(v) speech and language
				  development
Guidance §483.440(c)(3)(v)
Speech and language (communication)
				  development
: One of the most contributable causes of behaviors,
				  frustration by the clients, etc. is lack of effective communication. It is
				  imperative that the CFA identifies how the client communicates, what barriers
				  are present, what services are available and what programs and services will be
				  provided to assist the client to go out into and participate fully in the
				  world. Observed client communication skills match the evaluation results and
				  that training programs are in place to address needs.
Communication development refers to the development of both
				  verbal and nonverbal and receptive and expressive communication skills.
				  Assessment data identify the appropriate intervention strategy to be applied,
				  and which, if any, augmentative or assistive devices will improve communication
				  and functional status. These intervention strategies should provide the client
				  with a viable means of communication which is appropriate to their sensory,
				  cognitive and physical abilities.
W221
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(v) and auditory
				  functioning,
Guidance §483.440(c)(3)(v)
Auditory functioning
: Auditory
				  functioning refers to the extent to which a person can hear, to the maximum use
				  of residual hearing if a hearing loss exists, and whether or not the client
				  will benefit from the use of amplification, including a hearing aid or a
				  program of amplification.
W222
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(v) cognitive
				  development,
Guidance §483.440(c)(3)(v)
Cognitive development
: Cognitive
				  development refers to the development of those processes by which information
				  received by the senses is stored, recovered, and used. It includes the
				  development of the processes and abilities involved in memory, reasoning and
				  problem solving. It is also the identification of different learning styles the
				  client has and those best used by the trainers. It is critical that the CFA
				  address the individual learning style of the client in order to best direct the
				  way the trainers will teach formal and informal programs.
W223
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(v) social
				  development,
Guidance §483.440(c)(3)(v)
Social Development
: Social
				  development refers to the formation of those self-help, recreation and leisure,
				  and interpersonal skills that enable a client to establish and maintain
				  appropriate roles and fulfilling relationships with others. Assessments may
				  address family supports and relationships, sexual awareness and sexuality,
				  friendships, social awareness, social skills and social interests.
W224
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(v) adaptive behaviors or
				  independent living skills necessary for the client to be able to function in
				  the community,
Guidance §483.440(c)(3)(v)
Adaptive behaviors or independent living
				  skills
: Adaptive behavior refers to the effectiveness or degree
				  with which clients meet the standards of personal independence and social
				  responsibility and community orientation and integration expected of their age
				  and cultural group. Adaptive behaviors are those behaviors that are developed
				  to cope with deficits in order to be able to perform every day skills as
				  independently as possible. Independent living skills include, but are not
				  limited to, such things as food shopping, meal preparation, housekeeping and
				  kitchen chores, laundry, bed making, and budgeting. Assessment may be performed
				  by anyone trained to do so. Standardized tests are not required. Standardized
				  adaptive behavior scales which identify all or predominantly all "developmental
				  needs" are not sufficient to meet this requirement, but can serve as a basis
				  for screening.
W225
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(3)(v) and as applicable, vocational
				  skills.
Guidance §483.440(c)(3)(v)
Vocational development, "as
				  applicable"
: Vocational development refers to work interests, work
				  skills, work attitudes, work-related behaviors, and present and future
				  employment options. The determination of whether or not a vocational assessment
				  is "applicable" is typically based on age (adolescents or adults more than
				  likely require this type of assessment). The vocational assessment for each
				  client may address job sampling, job development, on-site job training and long
				  term follow-up, as appropriate to the client and determined by the IDT.
				  Vocational assessments should describe, for all domains, what clients can and
				  cannot do in terms of skills needed within the context of their daily lives and
				  jobs.
Assessments should be individualized and based on:
* Actual performance of the client against objective
				  criteria;
* Reports by staff/parents/legal guardians; and
* Observed performance in a variety of settings.
W226
§483.440(c)(4) Within 30 days after admission, the
				  interdisciplinary team must prepare for each client an individual program
				  plan
W227
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(4) that states the specific objectives
				  necessary to meet the client's needs, as identified by the comprehensive
				  assessment required by paragraph (c)(3) of this section,
Guidance §483.440(c)(4)
Objectives are developed for those needs that are identified
				  by the CFA and which are considered to be most likely to improve the client's
				  ability to independently function in his/her daily life, as determined by the
				  IDT. There is a clear link between the specific objectives and the functional
				  assessment data and recommendations. Objectives are developed for those needs
				  that are observed to most likely impact the client's ability to function in
				  daily life. Training objectives should be developed to address client needs
				  rather than staff oriented objectives. Clients are expected to have training
				  objectives in the areas of activities of daily living, based on the client's
				  assessed needs and as prioritized by the IDT. If clients have eyeglasses,
				  dentures and/or other assistive devices it is expected that the team considers
				  objectives, based upon the assessment of client needs, addressing the care and
				  use of such devices. However, in the area of programs to teach the clients'
				  money management it is not expected that every client will automatically have a
				  formal training objective to participate in such a program. The decision to
				  prioritize such a program and to what level the program is developed is decided
				  by the IDT based upon the results of the CFA and in consideration of such
				  factors as, transferable skills, the ability to make choices, the ability to
				  identify preferences and cognitive abilities such as attention span and an
				  understanding of the principle of cause and effect. Similarly, the decision to
				  prioritize and develop a training objective for a client to participate in a
				  self-administration program for medications must be made by the IDT and be
				  based upon information from the CFA. Formal self administration programs should
				  not be confused with informal efforts to include the client in the
				  administration process such as allowing them to hold a glass of water, identify
				  the box where his/her medications are stored or put a pill into their own mouth
				  themselves under the supervision of a person who is qualified to administer
				  medications.
W228
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(4) and the planned sequence for
				  dealing with those objectives.
Guidance §483.440(c)(4)
The objectives identified in W227 are organized in a logical
				  sequence, determined by the team that will assist the client toward the
				  attainment of skills resulting in greater self- choice, independence, and
				  community integration. The logical sequencing of objectives means there is a
				  completion of one objective that serves as the building block for the next with
				  relevance to the client's functional status. Where objectives are logically
				  ordered but do not have relevance to the client's functional status, refer to
				  483.440(c)(4). If the IPP is organized in a logical sequence, this requirement
				  is met. For example, if the long term goal is to travel independently in the
				  community, the objective sequencing may involve training the client to
				  recognize traffic signs, cross the street safely, and to obtain help when
				  needed if lost or an emergency arises.
These objectives must -
W229
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(4)(i) Be stated separately, in terms
				  of a single behavioral outcome;
Guidance §483.440(c)(4)(i)
Each objective clearly states one expected learning result.
				  "Single" behavioral outcome means that there is a separate objective assigned
				  for each discrete behavior that the team intends the client to learn. For
				  example, "Mary will bake a cake and clean the oven" are two separate behaviors
				  and, therefore, should be stated in two separate objectives. Completion of the
				  morning hygiene routine includes programs for performance of face washing,
				  tooth brushing and hair combing which are three separate objectives; however,
				  the behavioral outcome for each would be the same (e.g. completion of the
				  morning hygiene routine).
W230
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(4)(ii) Be assigned projected
				  completion dates;
Guidance §483.440(c)(4)(ii)
Completion dates are based on the client's rate of learning.
				  Completion dates are assigned to each objective on which the client is
				  currently working. Completion dates are individualized (e.g. not all the same
				  for all clients and all objectives). The "projected date of completion" for an
				  IPP objective is not the same as a "review" date. For each objective assigned a
				  priority, the team should assign a projected date (month and year) by which it
				  believes the client will have learned the new skill, based on all of the
				  assessment data. This date triggers the team to evaluate continuously whether
				  or not the client's progress or learning curve is sufficient to warrant a
				  revision to the training program.
W231
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(4)(iii) Be expressed in behavioral
				  terms that provide measurable indices of performance;
Guidance §483.440(c)(4)(iii)
The desired learning outcome is stated in a manner which
				  enables all staff working with the client to consistently identify the target
				  behavior and to clearly identify when it is being displayed. The objective is
				  stated in a manner which permits it to be measured with quantifiable data.
				  "Behavioral" terms include only those behaviors which are "client" rather than
				  staff oriented and those that any person would agree can be seen or heard.
				  Determine if all staff who work with the client can define the exact same
				  outcome on which to measure the client's performance. "Measurable indices of
				  performance" are the quantifiable criteria to use in determining successful
				  achievement of the objective. Quantifiable criteria include various
				  measurements of intensity and duration. For example, "Client X will walk ten
				  feet, with the use of her tripod walker, on each of five (5) consecutive
				  days."
W232
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(4)(iv) Be organized to reflect a
				  developmental progression appropriate to the individual; and
Guidance §483.440(c)(4)(iv)
Objectives must be relevant to the client's current skill
				  sets and abilities as identified in the CFA. The ICF/IID must consider the
				  person's current functional abilities and project what steps, methods, and
				  strategies are likely to be effective in achieving the objective.
W233
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(4)(v) Be assigned
				  priorities.
Guidance §483.440(c)(4)(v)
Priorities are established based on the needs and in
				  consideration of the desires of the client and emphasize the development of
				  greater independence, self-choice, and community integration. The team
				  determines which objectives are the highest priority to be addressed, either
				  because the client has an immediate need or the priority objectives must be
				  accomplished before other priorities are addressed.
§483.440(c)(5) Each written training program
				  designed to implement the objectives in the individual program plan must
				  specify:
Guidance §483.440(c)(5)
The following regulations (5) (i-iv) apply to formal training
				  programs developed for current implementation.
W234
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(5)(i) The methods to be
				  used;
Guidance §483.440(c)(5)(i)
The training program provides clear directions to any staff
				  person working with the client on how to implement the teaching strategies. To
				  comply with this requirement the methodologies must be written in a clear
				  enough manner that a substitute staff person will be able to read the
				  methodologies and implement them without substantial differences from a
				  regularly assigned staff person. Methodologies should be consistent across
				  settings, such as when the client is in the day program.
W235
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(5)(ii) The schedule for use of the
				  method;
Guidance §483.440(c)(5)(ii)
Active treatment (the implementation of training programs
				  pursuant to objectives) should be provided in formal and informal settings
				  throughout the rhythm of the client's day. While there may be structured
				  episodes when the client works intensively and singularly on one or more
				  objectives (schedule), the provision of active treatment is not adequate when
				  confined solely to these types of formal settings but should be incorporated
				  into all activities when appropriate (client's routine). For example,
				  objectives on grasping may be as effectively carried out during the client's
				  use of a toothbrush and a spoon as in an isolated session.
W236
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(5)(iii) The person responsible for the
				  program;
Guidance §483.440(c)(4)(v)
The IPP should include the actual name of the staff person
				  who is responsible for the ongoing monitoring of the client's program to ensure
				  it is being implemented appropriately, as well as the designated position which
				  will implement the program. The QIDP should be familiar with the assessment and
				  recording requirements for each client for each formal objective, including who
				  is responsible for making these observations and completing the recording, and
				  demonstrate a familiarity with the current data recorded for each
				  client.
W237
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(5)(iv) The type of data and frequency
				  of data collection necessary to be able to assess progress toward the desired
				  objectives;
Guidance §483.440(c)(5)(iv)
The IDT must determine the type of data necessary to judge a
				  client's progress on an objective, and describe the data collection method in
				  the written training program. The facility determines what data to collect, but
				  whatever system is chosen for collection must yield accurate measurement of the
				  criteria stated in the client's IPP objectives. For example, if the criteria in
				  the client's IPP objective specified a behavior to be measured by "accuracy,"
				  or "successes out of opportunities," then it would not be acceptable for the
				  prescribed data collection method to record "level of prompt".
Examples of a few data collection systems include, but are
				  not limited to:
* level of prompt;
* successful trials completed out of opportunities
				  given;
* frequency counts; and
* frequency sampling.
The IDT must consider and select the type and frequency of
				  data collection for each objective based upon the need to measure appropriately
				  the client's performance toward the targeted IPP skill development. The
				  facility should collect data with enough frequency and content to be able to
				  appropriately measure the client's performance toward the targeted IPP skill
				  development. The frequency of data collection may vary with the objective but
				  must be made at sufficient intervals to allow analysis of the progress of the
				  client.
W238
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(5)(v) The inappropriate client
				  behavior(s), if applicable; and The inappropriate client behavior(s), if
				  applicable; and
Guidance §483.440(c)(5)(v)
Any specific behaviors which would interfere with the
				  client's ability to function in, or benefit from the training program are
				  identified (e.g. a fear of water could interfere with the client's bathing
				  program).
W239
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(5)(vi) Provision for the appropriate
				  expression of behavior and the replacement of inappropriate behavior, if
				  applicable, with behavior that is adaptive or appropriate.
Guidance §483.440(c)(5)(vi)
The training program provides specific information as to how
				  to elicit or strengthen appropriate behavior and what behaviors to teach
				  reinforce or encourage which would reduce or replace the inappropriate
				  behavior. If a client is exhibiting an inappropriate behavior, the CFA should
				  discover why the behavior is occurring and the team should develop associated
				  training objectives to help the client develop more appropriate behaviors. The
				  objective for decelerating targeted inappropriate behaviors is not solely the
				  reduction of these behaviors. The objective should also include the positive
				  functional replacement behavior (adaptive behavior). A replacement behavior
				  allows a client to substitute an unconstructive or disruptive behavior with
				  something more constructive and functionally equivalent. For example, instead
				  of throwing work materials as a way to get a break from vocational task
				  demands, teach the client to say or sign for 'break'.
§483.440(c)(6) The individual program plan must
				  also:
W240
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(6)(i) Describe relevant interventions
				  to support the individual toward independence.
Guidance §483.440(c)(6)(i)
Appropriate materials, adaptations and modifications to
				  equipment and the environment are available in order to promote and support
				  individual training programs. Examples may include, but are not limited, to
				  built-up toilet seats, adaptive eating utensils, extended reach devices, and
				  modification to the facility van to accommodate a wheelchair. The IPP describes
				  supports and services, in addition to the individual goals and objectives that
				  will be provided by the facility to assist the client to function with greater
				  independence.
W241
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(6)(ii) Identify the location where
				  program strategy information (which must be accessible to any person
				  responsible for implementation) can be found.
Guidance §483.440(c)(6)(ii)
This requirement refers to the training program plans,
				  objectives, descriptions of staff interventions and data collection tools which
				  must be readily accessible to any staff in order for the programs to be
				  consistently and effectively carried out and data collected.
W242
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(6)(iii) Include, for those clients who
				  lack them, training in personal skills essential for privacy and independence
				  (including, but not limited to, toilet training, personal hygiene, dental
				  hygiene, self-feeding, bathing, dressing, grooming, and communication of basic
				  needs), until it has been demonstrated that the client is developmentally
				  incapable of acquiring them.
Guidance §483.440(c)(6)(iii)
All clients who lack the skills listed within this standard
				  have associated training programs developed to meet their needs according to
				  prioritization. These programs are consistently implemented in both formal and
				  informal settings.
"Developmentally incapable" is a decision made by the IDT
				  that means a client does not have the capacity to acquire certain skill sets.
				  The decision must be based on an assessment of the client's strengths, needs,
				  and functional limitations.
The determination of developmental incapability must be
				  accompanied by written evidence supporting this determination.
Such evidence may include training programs which failed
				  after many different strategies were tried, or physical limitations that
				  preclude the acquisition of the skill. Examples are:
1) Eye contact program was attempted using seven different
				  methods over a two year period;
2) An client has two frozen elbow joints which do not allow
				  her to get her hands to her mouth and consequently she will not be trained on
				  any hand to mouth skills; and
3) Some clients may have insufficient neuromuscular and
				  sensory control to ever be totally independent in toileting skills.
Toilet scheduling alone without any plan to progress would
				  not be considered a toilet training program. The components of functional
				  skills "training" as used in this regulation means aggressive implementation of
				  a systematic program of formal and informal techniques, which are:
* targeted toward assisting the client achieving the
				  measurable behavioral level of skill competency specified in IPP
				  objectives;
* implemented at natural occurrences of activity and training
				  programs; (e.g.: an objective for a client to increase grasping may be
				  implemented as easily in the workshop with a built up tool as in the bathroom
				  with a toothbrush);
* conducted by all personnel involved with the client
				  including those outside the home such as in day programs; and
* carried out in conversation and interaction with the client
				  appropriate to the situation.
§483.440(c)(6)(iv) Identify mechanical supports,
				  if needed, to achieve proper body position, balance, or alignment. The plan
				  must specify
Guidance §483.440(c)(6)(iv)
The use of mechanical supports are based upon an individual
				  assessment and fitting. Mechanical devices are used to support a client's
				  proper body position or alignment and may be essential to prevent contractures
				  or deformities. However, mechanical supports restrict movement and the client
				  should be released from the support periodically for exercise and free
				  movement. Mechanical supports may not be used as a substitute for programs or
				  therapy. For example, the use of a bolster to position a client upright in a
				  sitting position without any indication there has been an assessment for the
				  need for muscle re-training may be an indication of a mechanical device in lieu
				  of programming. Some supports allow movement and provide opportunity for more
				  increased functioning. Some examples of devices used as mechanical supports
				  include splints, wedges, bolsters, lap trays, etc. Wheelchairs are not
				  generally used to position or align the body and would not alone constitute a
				  mechanical support. However, adaptations to a wheelchair which facilitate
				  correct body alignment by inhibiting reflexive, involuntary motor activity are
				  mechanical supports and should be included in the plan for the client.
W243
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(6)(iv) the reason for each
				  support,
W244
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(6)(iv) the situations in which each is
				  to be applied,
W245
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(6)(iv) and a schedule for the use of
				  each support.
W246
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(6)(v) Provide that clients who have
				  multiple disabling conditions spend a major portion of each waking day out of
				  bed and outside the bedroom area, moving about by various methods and devices
				  whenever possible.
Guidance §483.440(c)(6)(v)
Clients with sensory or physical difficulties should be given
				  the same opportunities to move around in their environments as clients who do
				  not have those difficulties. Even clients who use specialized wheelchairs
				  should be given the opportunity to utilize other devices such as walkers,
				  wagons and scooters to move about and/or change their positions. With the
				  exception of those clients who are acutely ill (such as those who are
				  hospitalized or incapacitated by a "short term" illness), all clients should be
				  out of bed and outside their bedroom area as long as possible each day, and in
				  proper body alignment at all times. This is a necessity in order to prevent
				  regression, contractures, and deformities and to provide sensory stimulation.
				  Bed rest is a temporary situation associated most usually with a medical
				  condition and must be ordered by the medical staff of the facility. The term
				  implies that the client will remain in his/her bed for most of any 24-hour
				  period. Although active treatment programs may be carried out to some extent
				  while the client is on bed rest, the client's program cannot be completed in
				  its entirety. While there may be situations where continuous bed rest may be
				  necessary, these situations are rare. For those rare instances where out-of-bed
				  activity is a threat to a client's health and safety (e.g., blood clot in the
				  leg), active treatment adapted to the medical capacity of the client must be
				  continued.
W247
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(6)(vi) Include opportunities for
				  client choice and self-management.
Guidance §483.440(c)(6)(vi)
Choice and self-management are integral components of
				  becoming independent. Clients should be given opportunities for choice and
				  self-management in both formal and informal settings through the IPP process,
				  leisure activities, and other life choices.
The ICF/IID must incorporate opportunities into daily life
				  experiences that promote choice making and decision making by clients. Examples
				  of some activities leading toward responsibility for one's own self-management
				  include, but are not limited to:
1) choosing housing or roommates;
2) choosing clothing to purchase or wear;
3) choosing what, where, and how to eat (e.g., the use of
				  family style dining, access to condiments and second helpings).
Choices can be made by all clients. The type of choices the
				  person makes may vary from simple to complex, dependent upon client
				  abilities.
Clients are provided opportunities for choice and
				  self-management and the facility does not limit choices by making decisions for
				  the people being served without their input. Clients are provided the
				  opportunity to demonstrate skills to the degree they are capable and only
				  assisted by staff as indicated in their IPP. A lack of facility staffing or
				  staff convenience must not result in a limitation of choices of self-management
				  for the clients.
W248
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(c)(7) A copy of each client's individual
				  plan must be made available to all relevant staff, including staff of other
				  agencies who work with the client, and to the client, parents (if the client is
				  a minor) or legal guardian.
Guidance §483.440(c)(7)
The client or legal representative, as well as the facility
				  staff, and staff from outside agencies, with appropriate consent, have, or can
				  access, a copy of the IPP.
(d) Standard: Program implementation
W249
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(d)(1) As soon as the interdisciplinary
				  team has formulated a client's individual program plan, each client must
				  receive a continuous active treatment program consisting of needed
				  interventions and services in sufficient number and frequency to support the
				  achievement of the objectives identified in the individual program
				  plan.
Guidance §483.440(d)(1)
There should be no delay in the development and
				  implementation of the IPP. To promote a team process and meaningful discussion,
				  IPP development should take place during IDT meetings. Any IPP objective or
				  modification that is critical to the health and safety of any client should be
				  implemented immediately following IDT discussion." Each individual receives
				  training and services consistent with the current IPP. The time period between
				  admission and the 30 day IDT meeting is primarily to assist the client to
				  become adjusted and acclimated to his or her new living environment and to
				  enable the facility to complete the CFA. During this time period the facility
				  should also be providing those services and activities determined during the
				  pre-admission assessment as essential to the client's daily functioning. The
				  active treatment program for the client is consistently implemented in all
				  relevant settings both formally and informally as opportunities present
				  themselves. It should not be limited to specific periods of time during the day
				  or specific environments. Each client should receive aggressive and continuous
				  training, treatments and supports in accordance with their needs and IPP. New
				  skills and appropriate behaviors are encouraged and reinforced across
				  environments and times of day.
* During observations confirm that the client activities
				  relate directly to the strengths, needs and objectives in the IPP for each
				  client and are not "busy work," generalized or non-developmental time fillers.
				  For example, screwing nuts on bolts and then unscrewing them repeatedly with no
				  goal or transferable skills is "busy work." Screwing nuts on bolts that will be
				  part of a product is functional reinforcement of skill acquisition.
* Clients use adaptive equipment, assistive devices,
				  environmental supports, materials, supplies, etc., as specified in each
				  client's IPP to assist the client to accomplish stated objectives. There is no
				  specific number or frequency of interventions that meets this requirement. The
				  surveyors should see that the facility capitalizes on all opportunities
				  throughout the course of the day that promote progress toward the achievement
				  of goals and objectives. Informal opportunities ("teachable moments") should be
				  utilized to reinforce learning or appropriate skill development and needs are
				  addressed as they present. Although a client may not be able to reach complete
				  independence in a functional skill, it is crucial that retention of their
				  current skills be supported. Clients may have defined periods of time where
				  they may engage in leisure activities of their choice which are not necessarily
				  directly associated with their IPP goals and objectives.
W250
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(d)(2) The facility must develop an active
				  treatment schedule that outlines the current active treatment program and that
				  is readily available for review by relevant staff.
Guidance §483.440(d)(2)
The schedule is individualized, consistent with the client's
				  objectives, and reflects normal daily routines. The staff working with
				  individual clients are familiar with their daily schedules and can produce the
				  schedule upon request. The active treatment schedule allows flexibility and is
				  adjusted to the needs and preferences of the client, as necessary. It's a
				  schedule of the client's general daily plans, but can be changed. The active
				  treatment schedule is a functional schedule which enables client and staff to
				  be in the right location in order to participate in the training as scheduled
				  by the IPP.
W251
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(d)(3) Except for those facets of the
				  individual program plan that must be implemented only by licensed personnel,
				  each client's individual program plan must be implemented by all staff who work
				  with the client, including professional, paraprofessional and nonprofessional
				  staff.
Guidance §483.440(d)(3)
All disciplines, including direct care staff, interacting
				  with the client work together to provide a uniform, consistent approach to
				  implementation of the IPP.
(e)
Standard: Program documentation
W252
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(e)(1) Data relative to accomplishment of
				  the criteria specified in client individual program plan objectives must be
				  documented in measurable terms.
Guidance §483.440(e)(1)
"Data" are defined to be performance information collected
				  and reported in numerical or quantifiable form for each training objective
				  assigned priority in the IPP. Data are those performance measurements collected
				  at the time the treatment, procedure, intervention or interaction occurs with
				  the client and recorded as soon as possible. The data should be located in a
				  place accessible to staff who conduct training. Data should be collected in a
				  form and frequency as required by the plan to enable quantitative (frequency or
				  numbers) analysis of the client's progress. Data are accurate (e.g., reflective
				  of actual client performance.)
§483.440(e)(2) The facility must document
				  significant events that
W253
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(e)(2) are related to the client's
				  individual program plan and assessments and
Guidance §483.440(e)(2)
Significant events are those events which would cause a
				  reasonable person to be affected and which impact a normal routine. Such events
				  include changes in the client's functional status, emotional health, physical
				  health, accomplishments, activities or needs which impact the CFA and IPP, as
				  well as instances of abuse, neglect or mistreatment. The client record should
				  contain documentation that such events are evaluated and monitored.
W254
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(e)(2) that contribute to an overall
				  understanding of the client's ongoing level and quality of functioning.
(f) Standard: Program monitoring and
				  change
§483.440(f)(1) The individual program plan must be
				  reviewed at least by the qualified intellectual disability professional and
				  revised as necessary, including, but not limited to situations in which the
				  client- -
Guidance §483.440(f)(1)
Program implementation is a critical piece of each client's
				  active treatment program. The QIDP must review or revise client programs
				  according to 483.440(f)(1) (i-iv) and at such an interval that any of the
				  requirements are promptly identified and addressed.
W255
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(f)(1)(i) Has successfully completed an
				  objective or objectives identified in the individual program
				  plan;
Guidance §483.440(f)(1)(i)
The QIDP ensures the program has been modified or changed in
				  response to the client's specific accomplishments or need for new
				  program.
W256
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(f)(1)(ii) Is regressing or losing skills
				  already gained;
W257
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(f)(1)(iii) Is failing to progress toward
				  identified objectives after reasonable efforts have been made; or
Guidance §483.440(f)(1)(iii)
There should be evidence that the QIDP has reviewed and
				  revised the IPP in those situations when the client's IPP has been consistently
				  implemented yet the client fails to achieve their objectives.
W258
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(f)(1)(iv) Is being considered for
				  training towards new objectives.
§483.440(f)(2) At least annually,
Guidance §483.440(f)(2)
For the "annual" review to meet this requirement, it must be
				  completed by at least the 3 65th day following the previous review, unless in
				  an isolated or rare instance a client or the client's family is not available
				  for a projected period of time and the subsequent delay is a minimal number of
				  days.
W259
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(f)(2) the comprehensive functional
				  assessment of each client must be reviewed by the interdisciplinary team for
				  relevancy and updated as needed;
Guidance §483.440(f)(2)
The CFA is reviewed at least annually.
The review of the CFA occurs sooner than annually if:
* indicated by the needs of the client;
* reflects any changes in the client since their last
				  evaluation; and
* incorporates information about the client's progress or
				  regression with objectives.
The review of the CFA applies to all evaluations conducted
				  for a client. It is not required that each assessment be completely redone each
				  year, except the physical examination. It is required that at least annually
				  the assessment(s) be updated when changes occur so as to accurately reflect the
				  client's current status.
W260
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(f)(2) and the individual program plan
				  must be revised, as appropriate, repeating the process set forth in paragraph
				  (c) of this section.
Guidance §483.440(f)(2)
The IPP reflects the functional changes for the client which
				  occurred since the last IPP. It is unlikely that an active treatment program
				  will have no changes from year to year without documentation to support not
				  changing the plan. Question an IPP that is a duplication of the prior year's
				  plan without explanation.
W261
(Rev. 144, Issued: 08-14-15, Effective:
				  08-14-15, Implementation: 08-14-15)
§483.440(f)(3) The facility must designate and use
				  a specially constituted committee or committees consisting of members of
				  facility staff, parents, legal guardians, clients (as appropriate), qualified
				  persons who have either experience or training in contemporary practices to
				  change inappropriate client behavior, and persons with no ownership or
				  controlling interest in the facility to- -
Guidance §483.440(f)(3)
The facility must have a specially constituted committee
				  whose primary function is to proactively protect client rights by monitoring
				  facility practices and programs. The purpose of the committee is to assure that
				  each client's rights are protected utilizing a group of both internal staff and
external participants who have no vested interest in the facility as
				  well as clients as appropriate.
There should be evidence that the
				  committee members have been trained annually on the rights of the clients, what
				  constitutes a restriction of a right and the difference between punishment and
				  training. Depending on size, complexity and available resources, the ICF/IID
				  may establish more than one specially constituted committee. However, each
				  committee must contain the required membership and participate regularly and
				  perform the functions of the committee according to the requirements.
				  Participation on the specially constituted committee(s) must be in real time
				  allowing all membership to speak and discuss in an interactive mode. The
				  regulation does not specify the professional credentials of the "qualified
				  persons" (who have either experience or training in contemporary practices to
				  change inappropriate client behavior). There is no requirement that any
				  specific discipline, such as nurse, physician or pharmacist be a member of the
				  committee. The intent of including "persons with no ownership or controlling
				  interest" on the committee is to assure that, in addition to having no
				  financial interest in the facility, at least one member of each constituted
				  committee is an impartial outsider in that he/she would not have an "interest"
				  represented by any other of the required members or the facility itself. Staff
				  and consultants employed by the facility or at another facility under the same
				  governing body, cannot fulfill the role of person with no ownership or
				  controlling interest. Although occasional absences from committee meetings are
				  understandable, patterns of absence by the required membership of the committee
				  is not acceptable. At least a quorum of committee members (as defined by the
				  facility) must review, approve and monitor the programs which involve risk to
				  client rights and protections and that quorum must include one person from each
				  of the required categories.
W262
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(f)(3)(i) Review, approve, and monitor
				  individual programs designed to manage inappropriate behavior and other
				  programs that, in the opinion of the committee, involve risks to client
				  protection and rights;
Guidance §483.440(f)(3)(i)
Any program that utilizes restrictive or intrusive techniques
				  must be reviewed and approved by the specially constituted committee prior to
				  implementation. This includes, but is not limited to:
* restraints;
* drugs to manage behavior;
* restrictions on community access;
* contingent denial of any right; or
* restrictions of materials or locations in the home.
The committee should ensure that consequences within a
				  written behavior management program do not violate the client's rights. There
				  is no requirement for the committee to evaluate whether the proposed program is
				  consistent with current practices in the field. Documentation should verify
				  that the specially constituted committee considered factors, such as whether
				  less intrusive methods have been attempted, whether the severity of behavior
				  outweighs the risks of the proposed program and whether replacement behaviors
				  are included within the plan. Any revision to a behavior plan that increases
				  the level of intrusiveness must be re- reviewed by the specially constituted
				  committee. The committee need not reapprove a program when revisions are made
				  in accordance with the approved plan. For example, if the physician changes the
				  dosage of a medication in accordance with the drug treatment component of the
				  active treatment plan to which the legally authorized person has given consent
				  and which has already been approved by the committee, then there is no need for
				  the committee or the legally authorized person to reapprove the plan.
				  Generally, this would also apply if the medication was changed to another
				  within the same therapeutic class or family.
W263
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(f)(3)(ii) Insure that these programs are
				  conducted only with the written informed consent of the client, parents (if the
				  client is a minor) or legal guardian; and
Guidance §483.440(f)(3)(ii)
The committee must ensure that written informed consent must
				  be obtained prior to implementation of any restrictive or intrusive program. In
				  the event of an emergency, the facility may obtain a verbal consent, which must
				  be authenticated in writing as soon as possible and subsequently submitted to
				  the committee as verification. The consent is required for the entire behavior
				  management program not just the specific restrictive technique.
Consent is informed when the person giving consent is fully
				  aware of the:
* specific treatment;
* reason for treatment or procedure;;
* the attendant risks vs. benefits;
* alternatives;
* right to refuse; and
* the consequences associated with consent or refusal of the
				  program.
Informed consent must be in writing and must be specific to
				  the program and restrictive practice and reflect a specific time frame. Blanket
				  consents are not allowed. In the case of unplanned events such as assault and
				  property destruction requiring immediate action, verbal consent may be
				  obtained. However,it should be authenticated in writing as soon as reasonably
				  possible (within 30 days). For clients up to the age of 18, their parent or
				  legally appointed guardian must give consent for him or her. At the age of 18,
				  however, clients become adults and are assumed to be competent unless otherwise
				  determined by a court. For clients who are adults and have not been adjudicated
				  incompetent and have not been assigned a legal guardian who may not fully
				  understand the consequences of the program, informed consent for use of
				  restrictive programs, practices or procedures should be obtained from a person
				  or an entity in accordance with state law, to act as the representative or
				  advocate of the client's interests. The specially constituted committee must
				  ensure that the informed and voluntary consent of the client, parent of a
				  minor, legal guardian, or the person or organization designated by the state is
				  obtained prior to each of the following circumstances:
* The involvement of the client in research activities;
				  or
* Implementation of programs or practices that could abridge
				  or involve risks to client protections or rights.
W264
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.440(f)(3)(iii) Review, monitor and make
				  suggestions to the facility about its practices and programs as they relate to
				  drug usage, physical restraints, time-out rooms, application of painful or
				  noxious stimuli, control of inappropriate behavior, protection of client rights
				  and funds, and any other areas that the committee believes need to be
				  addressed.
Guidance §483.440(f)(3)(iii)
The committee has been made aware of and reviewed:
* facility policies and procedures;
* facility services;
* programs; and
* practices which may restrict or violate the rights of
				  client.
The committee has established and uses a mechanism for
				  monitoring clients' rights issues and informs the governing body of any issues
				  of concern in a timely manner. This process is at the discretion of the
				  committee. There is no requirement for periodic review of the policies by the
				  committee.
The function of the committee is not limited to the review,
				  approval and monitoring of restrictive behavior management practices. Examples
				  of issues involving client rights that might be reviewed by the committee, in
				  addition to behavior management, include, but are not limited to:
1) Research proposals involving clients;
2) Abuse, neglect and mistreatment of clients;
3) Allegations dealing with theft of a client's personal
				  property or funds;
4) Damage to a client's goods or denial of other client
				  rights;
5) Client grievances;
6) Visitation procedures;
7) Guardianship/advocacy issues;
8) Rights training programs;
9) Confidentiality issues;
10) Advance directives/DNR orders;
11) Practices which restrict clients (e.g., locked doors,
				  fenced in yards); and
12) Video monitoring.
W265
§483.440(f)(4) The provisions of paragraph (f)(3)
				  of this section may be modified only if, in the judgment of the State survey
				  agency, Court decrees, State law or regulations provide for equivalent client
				  protection and consultation.
W266
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450 Condition of participation: Client
				  behavior and facility practices
(a) Standard: Facility practices- Conduct toward
				  clients
W267
(Rev.135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(a)(1) The facility must develop and
				  implement written policies and procedures for the management of conduct between
				  staff and clients.
Guidance §483.450(a)(1)
The primary survey emphasis is on the implementation of the
				  policies and procedures developed by the facility.
Conduct between staff and clients refers to language,
				  actions, discipline, rules, order and other types of interactions exchanged
				  between staff and clients or imposed upon clients by the staff during a
				  client's daily experiences that affect the quality of a client's life.
§483.450(a)(1) These policies and procedures must
				  -
W268
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(a)(1)(i) Promote the growth, development
				  and independence of the client;
Guidance §483.450(a)(1)(i)
Consistent with facility policies, staff is observed to be
				  engaged in activities which promote the client's growth, development and
				  independence.
1) IPPs and data support the fact that from the time of
				  admission, clients are learning new adaptive and functional skills while
				  becoming more independent.
2) Interactions between clients and staff are consistent and
				  positive.
3) Staff teach and encourage clients to interact with each
				  other in a manner that promotes social integration both in the facility and out
				  in the community.
4) All opportunities to teach and reinforce skill acquisition
				  are utilized.
5) Staff identify and remove impediments in the learning
				  environment (e.g. client is unable to concentrate in a room with a television
				  because when they see the television, they want to watch their favorite show.
				  Staff must identify this learning impediment and train in an environment
				  without a television).
6) Staff encourage clients to complete tasks with as much
				  independence as possible.
7) Staff encourage clients to take risks while providing
				  reasonable safeguards to prevent injury.
8) Encourage clients to make choices during their daily
				  activities.
W269
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15) §483.450(a)(1)(ii) Address the extent to which
				  client choice will be accommodated in daily decision-making, emphasizing
				  self-determination and self-management, to the extent possible; Guidance
				  §483.450(a)(1)(ii)
Written facility policies describe how the facility will
				  offer choice to the clients during the course of their day. Written policies
				  describe how self-determination, as defined by free choice of one's own acts
				  and decisions without external coercion or direction, to the extent possible
				  and self- management, as defined by control of one's own routine and daily
				  responsibilities, to the extent possible, are incorporated into the development
				  of program plans and daily routines.
W270
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15) §483.450(a)(1)(iii) Specify client conduct to be
				  allowed or not allowed; and Guidance §483.450(a)(1)(iii)
"Client conduct" refers to any behavior, choice, action, or
				  activity in which a client may choose to engage alone or with others. Written
				  policies and procedures which may be in the form of "house rules", must not
				  impinge on individual client rights and must not be used as a substitute for
				  the development of individualized programs and plans.
W271
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(a)(1)(iv) Be available to all staff,
				  clients, parents of minor children, and legal guardians.
Guidance §483.450(a)(1)(iv)
Policies and procedures for management of conduct between
				  staff and clients (483.450(a)(1)) should be provided to clients, parents of
				  minor children, and legal guardians at admission and upon request. Policies and
				  procedures are available on the residential and program areas if these are in
				  separate buildings.
W272
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15) §483.450(a)(2) To the extent possible, clients
				  must participate in the formulation of these policies and
				  procedures.
Guidance §483.450(a)(2)
"To the extent possible" does not mean that the clients are
				  excluded due to the clients' schedule or intellectual or developmental level.
				  Facilities should be able to provide documentation that substantiates that
				  clients were offered the opportunity and participated in the development of the
				  policies. This could be accomplished through client committees or in house
				  meetings. There should be documentation of these discussions between the client
				  representatives and the facility.
W273
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(a)(3) Clients must not discipline other
				  clients, except as part of an organized system of self-government, as set forth
				  in facility policy. Guidance §483.450(a)(3)
Staff will promptly intervene when any clients tries to
				  independently impose discipline upon another client. For example, a client who
				  is serving dessert to the group withholds dessert from another client based
				  upon their own evaluation of that client's behavior.
(b) Standard: Management of inappropriate client
				  behavior W274
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15) §483.450(b)(1) The facility must develop and
				  implement written policies and procedures that govern the management of
				  inappropriate client behavior
Guidance §483.450(b)(1)
At a minimum, the facility must have written policies and
				  procedures regarding the management of maladaptive behaviors addressing the
				  following: 483.450(b)(1) (W 275 - W284).
* the use of a functional behavior assessment in the
				  development of behavior management programs;
* a hierarchy of least to most intrusive measures; and
* incorporation of behavior management programs into the IPP.
§483.450(b)(1) These policies and procedures must be
W275
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(1) consistent with the provisions of
				  paragraph (a) of this section.
§483.450(b)(1) These procedures must
W276
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(1)(i) Specify all facility approved
				  interventions to manage inappropriate client
behavior;
Guidance §483.450(b)(1)(i)
All interventions for the management of inappropriate client
				  behaviors which are approved for use in the facility are clearly stated and
				  described in its policy. Examples of positive interventions include, but are
				  not limited to, verbal praise reward systems, and prompting. Examples of
				  negative interventions include, but are not limited to, removal of a privilege,
				  implementation of restraint, and/or the use of exclusionary time out.
W277
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(1)(ii) Designate these interventions
				  on a hierarchy to be implemented, ranging from most positive or least
				  intrusive, to least positive or most intrusive;
Guidance §483.450(b)(1)(ii)
Policies and procedures must include a clear progression as
				  to how staff implement interventions to manage inappropriate client behavior.
				  Facility policy and procedures must define the entire hierarchy of possible
				  interventions from the most positive, functionally appropriate approaches to
				  most intrusive approaches authorized. The facility determines at what level in
				  the hierarchy the IPP will begin for each client based on their individual
				  assessment. The plan must still begin at the least intrusive technique shown
				  effective for that client. Individual plans should specify the specific
				  techniques that have been determined through assessment to be least restrictive
				  for each client. The facility policy for unexpected behavioral incidents must
				  provide direction for the staff in the utilization of the hierarchy. For
				  clients not on a behavior plan, staff must apply the appropriate level of
				  intervention per the established hierarchy, including emergency measures to
				  prevent harm to self or others.
W278
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(1)(iii) Insure prior to the use of
				  more restrictive techniques, that the client's record documents that programs
				  incorporating the use of less intrusive or more positive techniques have been
				  tried systematically and demonstrated to be ineffective; and
Guidance §483.450(b)(1)(iii)
Policies must be implemented to ensure that all restrictive
				  procedures begin at the lowest level of the hierarchy unless there is
				  documented evidence that less intrusive interventions have been tried and have
				  been found to be ineffective. The facility is not required to justify
				  discontinuing the use of a more restrictive technique before initiating a less
				  restrictive technique, since the intent of the regulation is to use the most
				  positive, least intrusive technique possible. In emergency situations where an
				  unanticipated behavior requires immediate protection of the client or others,
				  the technique chosen is the least restrictive appropriate technique
				  possible.
§483.450(b)(1)(iv) Address the
				  following:
W279
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(1)(iv)(A) The use of time-out
				  rooms;
Guidance §483.450(b)(1)(iv)(A)
"Time-out room" is defined as a separate room that is used to
				  remove a client from stimulation that may be triggering and reinforcing
				  maladaptive behavior. The facility must have written policies and procedures
				  for the use of time out rooms which address all the requirements of 483.450 (c)
				  (1-4) standard: time out room.
W280
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(1)(iv)(B) The use of physical
				  restraints;
Guidance §483.450(b)(1)(iv)(B)
"Physical restraint" is defined as any manual hold or
				  mechanical device that the client cannot remove easily, and which restricts the
				  free movement of, normal functioning of, or normal access to a portion or
				  portions of a client's body. Examples of mechanical devices may include arm
				  splints and mittens.
Policies and Procedures must address:
* the types of physical restraint that are allowed in the
				  facility;
* the persons who apply such restraints;
* the parameters for duration of application;
* the methods that assure the health and safety of clients
				  while in restraints; and
* the specific training required for staff allowed to apply
				  such restraints.
W281
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(1)(iv)(C) The use of drugs to manage
				  inappropriate behavior; Guidance §483.450(b)(1)(iv)(C)
Applicable policies may include a discussion of: When a drug
				  can be used to manage inappropriate behavior; Consistency with diagnosis;
				  Alternatives tried before a drug is used; Precautions that must be followed
				  prior to and during the use (lab values, monitoring of side effects);
				  Implementation of a plan to address the behaviors for which the drug was
				  prescribed; and Plan to reduce the medication as appropriate. Drugs to manage
				  inappropriate behavior are defined as any medication prescribed and
				  administered for purposes of modifying the maladaptive behavior of a
				  client.
W282
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(1)(iv)(D) The application of painful
				  or noxious stimuli;
Guidance §483.450(b)(1)(iv)(D)
"Application of painful or noxious stimuli" is defined as any
				  procedure by which staff apply, contingent upon the exhibition of maladaptive
				  behavior, startling, unpleasant, or painful stimuli, or stimuli that have a
				  potentially noxious effect.
While the regulation permits the use of painful or noxious
				  stimuli these techniques are the last resort and can only be utilized for
				  behaviors that are causing significant harm and have not responded to
				  competently administered interventions of less intrusive nature. Facility
				  policies must state that:
* The use of noxious stimuli is only permitted when the
				  client exhibits behaviors so severe that they present a potential risk for
				  significant or even life-threatening circumstances;
* the IDT and facility must weigh the potential risk of the
				  behavior against the risk involved in the use of the painful or noxious
				  techniques to manage behavior;
* that safeguards and strict oversight must be in place for
				  consideration to use techniques that may be painful or even unpleasant;
* techniques that may be painful or noxious must be time
				  limited;
* the proposed use of these techniques requires scrutiny of
				  clinical effectiveness and specially constituted committee review; and
* on-going monitoring and safeguards must be in place during
				  implementation of the technique.
W283
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(1)(iv)(E) The staff members who may
				  authorize the use of specified interventions;
Guidance §483.450(b)(1)(iv)(E)
W284
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(1)(iv)(F) A mechanism for monitoring
				  and controlling the use of interventions.
Guidance §483.450(b)(1)(iv)(F)
Facility policies must address what supervisory oversight is
				  provided during the application of the intervention in order to ensure that
				  procedures were followed correctly. Procedures should also address what
				  retrospective analysis is done on each intervention to ensure that procedures
				  are being consistently followed.
W285
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(2) Interventions to manage
				  inappropriate client behavior must be employed with sufficient safeguards and
				  supervision to ensure that the safety, welfare and civil and human rights of
				  clients are adequately protected.
§483.450(b)(3) Techniques to manage inappropriate
				  client behavior must never be used
W286
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(3) for disciplinary
				  purposes,
Guidance §483.450(b)(3)
No intervention, whether as a part of a formal program or in
				  emergency situations (see W289) may be used as punishment, retaliation or
				  retribution. A staff member cannot employ a behavior management technique
				  simply because a client refuses to follow a staff request. The implementation
				  of all interventions, except in emergency situations, must be administered
				  consistent with the IPP and the specific behaviors identified in the IPP
				  requiring the intervention. Instances where an intervention is done as a
				  punishment because the client did not comply with staff instructions and not
				  associated with the IPP include:
* Personal property confiscated for behavior at staff
				  discretion;
* Rights restricted without approved plans; and
* Punitive house rules, such as prohibiting reentry into the
				  kitchen for snacks if a meal is not eaten completely.
W287
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(3) for the convenience of
				  staff
Guidance §483.450(b)(3)
Inadequate numbers of staff, inefficient deployment of staff,
				  and insufficient training of staff can lead to restrictive practices used for
				  staff convenience.
Examples of techniques used to manage client behavior for
				  staff convenience including, but are not limited to:
* Clients allowed to discipline other clients;
* Clients restricted to one area of the home; and
* Unauthorized use of restraints (e.g., lap trays, bean bags,
				  gait belt, and merry walkers for the purpose of restricting movement)
W288
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15) §483.450(b)(3) or as a substitute for an active
				  treatment program.
Guidance §483.450(b)(3)
Substitutions for active treatment programming occur when the
				  staff utilizes interventions and restrictive techniques on their own, either
				  because there is not a formal behavioral program to address the client's
				  behaviors or because the staff do not follow the plan as written.
W289
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(4) The use of systematic interventions
				  to manage inappropriate client behavior must be incorporated into the client's
				  individual program plan, in accordance with §483.440(c)(4) and (5) of this
				  subpart.
Guidance §483.450(b)(4)
The use of behavior interventions are expected to be
				  incorporated into the IPP and be based upon the results of the functional
				  behavioral assessment. However, there may be isolated and rare instances when a
				  client exhibits unexpected behavior that requires immediate intervention on the
				  part of the staff. In these instances, the least restrictive intervention must
				  be employed and removed as soon as the client is no longer an immediate threat
				  to self or others. The IPP team must then discuss the need for adding a
				  behavioral plan into the clients program.
W290
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(b)(5) Standing or as needed programs to
				  control inappropriate behavior are not permitted.
Guidance §483.450(b)(5)
The staff of the facility may not maintain or use, outside of
				  the IPPs, any list of "as needed" interventions that can be used with any
				  client at any time. With the exception of isolated and rare emergency
				  situations, all restrictive behavior interventions must be incorporated into
				  the formal IPP and individualized for the client.
(c) Standard: Time-out rooms
W291
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(c)(1) A client may be placed in a room
				  from which egress is prevented only if the following conditions are
				  met:
(i) The placement is a part of an approved systematic
				  time-out program as required by paragraph
(b) of this section. (Thus, emergency placement of a
				  client into a time-out room is not allowed.)
(ii) The client is under the direct constant visual
				  supervision of designated staff.
(iii) The door to the room is held shut by staff or by
				  a mechanism requiring constant physicalpressure from a staff member to keep the
				  mechanism engaged.
Guidance §483.450(c)(1)
Seclusion, defined as the placement of a client alone in a
				  locked room, is never allowed. Time out procedures allows a client to be alone
				  in a room, but do not allow that room to be locked. During a time out
				  procedure, egress can only be prevented by a person standing in the door way,
				  or holding the door closed, but as soon as the staff move from the door way or
				  let go of the door the client can come out. Use of the timeout room or
				  procedure must be part of an approved behavioral plan and may involve the
				  separation of a client from a group or a particular situation, in a non- locked
				  setting for the purpose of calming or removing the client from the reinforcing
				  stimuli that are sustaining an identified maladaptive behavior. Designated time
				  out rooms must be set up so that the staff has continuous, direct observation
				  of the client at all times. Because of the danger that staff can get distracted
				  by other events or duties, this cannot be accomplished by a camera in lieu of
				  the staff having direct visual of the client. Key locks, latch locks, and doors
				  that open inward without an inside doorknob are not permitted by the
				  regulations for use in time out rooms as they do not require constant physical
				  pressure from a staff member to keep the door shut. In each instance where a
				  time out room is used, the client's IPP must include:
* The functional behavioral assessment which resulted in a
				  recommendation for the use of time out procedures; and
* Instructions on how often data is to be collected during
				  the time out period and the criteria for release from time out.
The use of a time out room must be approved by the Specially
				  constituted committee as part of an approved program.
W292
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(c)(2) Placement of a client in a time-out
				  room must not exceed one hour.
W293
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(c)(3) Clients placed in time-out rooms
				  must be protected from hazardous conditions including, but not limited to,
				  presence of sharp corners and objects, uncovered light fixtures, unprotected
				  electrical outlets.
Guidance §483.450(c)(3)
Because placement in the time out room is typically secondary
				  to extreme behaviors, it is acceptable that there be no furniture in this
				  room.
A door that opens inward can potentially be held closed,
				  either intentionally or inadvertently, by the client in the room, thereby
				  denying staff immediate access to the room.
W294
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(c)(4) A record of time-out activities
				  must be kept.
Guidance §483.450(c)(4)
The documentation in the client's record accurately reflects
				  planned (e.g. part of the IPP) usage and presents a picture of events prior to,
				  during, and following the use of time-out. The IPP should include direction as
				  to how often data must be collected during each use of time out for each
				  individual client.
(d) Standard: Physical restraints
§483.450(d)(1) The facility may employ physical
				  restraint only- -
W295
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(1)(i) As an integral part of an
				  individual program plan that is intended to lead to less restrictive means of
				  managing and eliminating the behavior for which the restraint is
				  applied;
Guidance §483.450(d)(1)(i)
The use of physical restraint is specified within the IPP.
				  The plan must address:
1) The specific type of client behavior to be managed by this
				  plan;
2) The less restrictive behavioral approaches which were
				  previously used, but were unsuccessful;
3) The hierarchy of measures that must be utilized prior to
				  the application of physical restraint;
4) The type of physical restraint;
5) The type of client behavior that would indicate that the
				  patient is calm and can be released from the restraint; and
6) The replacement behavior being taught to the client to
				  reduce the need for future restraints.
W296
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(1)(ii) As an emergency measure, but
				  only if absolutely necessary to protect client or others from injury;
				  or
Guidance §483.450(d)(1)(ii)
Physical restraint may be used as an emergency intervention
				  only in situations where the client is exhibiting behaviors which:
1) the client has not exhibited before;
2) were not identified in the functional analysis of
				  behavior; or
3) are harming other people or themselves.
When there are repeated episodes of the use of physical
				  restraint as an emergency safety measure, these episodes should be assessed for
				  their predictability by the IDT, and revisions to the IPP considered addressing
				  the behaviors through a formal behavior plan in order to reduce/eliminate the
				  use of physical restraint.
W297
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(1)(iii) As a health-related protection
				  prescribed by a physician, but only if absolutely necessary during the conduct
				  of a specific medical or surgical procedure, or only if absolutely necessary
				  for client protection during the time that a medical condition exists.
Guidance §483.450(d)(1)(iii)
Physical restraint during medical procedures must be utilized
				  only when absolutely necessary and be used as a last resort in order for the
				  facility or practitioners to deliver needed medical care to the client.
The restraint must be released as soon as the medical
				  procedure is completed unless it is necessary to continue restraint for a
				  longer period of time to continue to deliver care or to prevent the client from
				  displacing tubes or dressings. These restraints may only be used as long as the
				  physician indicates them to be necessary.
For instances where physical restraint are used by the
				  facility or a practitioner during a medical procedure, the client record and
				  interviews should verify that less restrictive measures were attempted before
				  using physical restraint and verify whether any injuries occurred during the
				  use of the physical restraint. Written orders by medical personnel for the
				  application of a physical restraint should include the reason that the
				  restraint is necessary, the type of restraint to be used and the length of time
				  the restraint will be applied.
A restraint device used to prevent a client engaging in
				  self-injurious behavior is not considered a restraint for medical
				  condition.
§483.450(d)(2) Authorizations to use or extend
				  restraints as an emergency measure must be:
Guidance §483.450(d)(2)
Facility policies should list who in the facility is allowed
				  to authorize the emergency use of restraints or to extend the use of an
				  emergency restraint, and the training that is required for those persons who
				  may authorize. Documentation in the client record in those instances should
				  confirm that the facility follows that policy.
W298
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(2)(i) In effect no longer than 12
				  consecutive hours; and
Guidance §483.450(d)(2)(i)
This regulation does not mean that restraints may be
				  authorized to be applied for up to a 12 hour period. The client must be
				  released from the physical restraint as soon as the client is no longer a risk
				  to self or others. Once the behavior has ceased, the emergency has ended, and
				  the client has been released, another authorization would be required for any
				  new emergency situation. The 12 consecutive hour period is the absolute maximum
				  period of time that emergency physical restraint may be utilized for a client
				  during an individual behavioral incident. It is reasonable to expect that the
				  facility will reassess the emergency situation for any client who remains in
				  physical restraint for longer than one hour and reassess the situation at least
				  every 30 minutes thereafter up to 12 hours when the physical restraint must be
				  removed.
W299
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(2)(ii) Obtained as soon as the client
				  is restrained or stable.
Guidance §483.450(d)(2)(ii)
There may be instances where the maladaptive behaviors of a
				  client or clients escalate into a serious and immediate event that must be
				  de-escalated quickly in order to prevent harm to clients, staff, other clients,
				  or by standers when incidents occur in the community. In these instances, the
				  staff should contact the appropriate person to obtain authorization for the use
				  of physical restraint as soon as the situation is stable. Retrospective
				  documentation of the incident should confirm the need for authorization after
				  application.
W300
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(3) The facility must not issue orders
				  for restraint on a standing or as needed basis.
Guidance §483.450(d)(3)
All instances of physical restraint must be ordered on a case
				  by case basis with individual assessment of the situation and authorization
				  based upon the individual client. Authorizations should include the rationale
				  for the use of the physical restraint versus other less restrictive
				  measures.
W301
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(4) A client placed in restraint must
				  be checked at least every 30 minutes by staff trained in the use of
				  restraints,
Guidance §483.450(d)(4)
The frequency of monitoring will vary according to the type
				  and design of the device and the psychological and physical well-being of the
				  client. The facility should be checking the client often enough to adequately
				  assess the physical status of the client (e.g., circulation, respiration and
				  vital signs) of the client and the need to continued restraint. The more
				  restrictive the intervention, the greater the risk to the client and the more
				  often the client must be assessed. Frequent assessment will assure that the
				  client will be released as soon as possible, however, in no instance may the
				  staff go longer than 30 minutes without checking the client.
W302
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(4) released from the restraint as
				  quickly as possible, and
Guidance §483.450(d)(4)
"As quickly as possible" means as soon as the client is no
				  longer a danger to self or others. Documentation should support that the client
				  was released from restraint as soon as they became calm.
W303
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(4) a record of these checks and usage
				  must be kept.
§483.450(d)(5) Restraints must be designed and
				  used
W304
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(5) so as not to cause physical injury
				  to the client
Guidance §483.450(d)(5)
Physical restraints to include mechanical devices must be the
				  correct size for the client and be applied with the correct amount of pressure
				  according to manufacturer's directions. In addition to observation of any
				  physical mechanical restraint in use at the time of the survey, review incident
				  reports for any injuries as a result of restraint use.
W305
§483.450(d)(5) and so as to cause the least
				  possible discomfort.
§483.450(d)(6) Opportunity for motion and exercise
				  must be provided
W306
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(6) for a period of not less than 10
				  minutes during each two hour period in which restraint is employed,
Guidance §483.450(d)(6)
This requirement does not apply to cases of medical
				  restraints that are specifically ordered for the immobilization of bones and
				  joints during the physical healing process involved with fractures, sprains,
				  etc. (e.g. a broken bone immobilized by a cast or splint). See 331 483.460(c)
				  regarding surveillance of skin integrity during the use of medical
				  restraints.
However, if a mechanical physical restraint is applied to an
				  extremity to prevent a client from removing post-operative sutures, the
				  restraint must be released every two (2) hours for a period of not less than
				  ten (10) minutes in order to maintain adequate circulation. Mechanical
				  restraints placed on the client during sleeping hours must be medically based
				  and specifically ordered by a physician. There should be evidence in the
				  client's record why the mechanical physical restraint is necessary during
				  sleeping hours. While it is not necessary to wake the client every two (2)
				  hours to release the restraint and provide opportunity for exercise, the staff
				  must check the restraint frequently during the night to ensure that the
				  restraint is still properly applied and the client appears comfortable.
W307
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(6) and a record of such activity must
				  be kept.
§483.450(d)(7) Barred enclosures
Guidance §483.450(d)(7)
A bed or play equipment with bars that prevent the client
				  from leaving the bed or voluntarily climbing out of the bed are barred
				  enclosures. The use of such enclosures must be a part of the written IPP and
				  behavioral assessments must clearly state why such an enclosure is necessary,
				  the risks of using the enclosure versus not using it and what less restrictive
				  measures have been tried prior to the implementation of the barred enclosures.
				  Such devices may not be used in lieu of adequate staffing.
W308
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(7) must not be more than three feet in
				  height and
W309
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(d)(7) must not have tops.
(e) Standard: Drug usage
§483.450(e) Standard: Drug Usage
W310
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(e)(1) The facility must not use drugs in
				  doses that interfere with the individual client's
daily living activities.
Guidance §483.450(e)(1)
Clients are alert and available for participation in daily
				  living activities.
Some medications administered for medical reasons or to
				  manage behavior may cause drowsiness as a side effect or due to an accumulation
				  of the drug in the client's system. For clients who are observed to be sleeping
				  in chairs during their work day, their programs or recreational times, there
				  should be evidence that the facility staff notified the medical staff and an
				  assessment was performed of the client including their medication regimen.
				  Medical staff should make adjustments to address the issue if indicated.
§483.450(e)(2) Drugs used for control of
				  inappropriate behavior must
W311
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(e)(2) be approved by the
				  interdisciplinary team and
Guidance §483.450(e)(2)
The physician and other team members discuss the risks and
				  benefits of the medication to address the target behavior/symptoms, and approve
				  the use of the drug as being consistent with the active treatment program.
				  Decisions about the necessity of the use of drugs to manage inappropriate
				  behavior should be made by the IDT. It is the responsibility of the IDT members
				  to provide the physician with sufficient information regarding the need for a
				  client to receive a drug for inappropriate behavior. The physician will make
				  the ultimate decision to order the use of the drug. The IDT should document any
				  disagreement with the physician's order.
In those instances where a client returns from a physician's
				  visit with an order for an unsolicited drug to manage client's inappropriate
				  behaviors, there must be evidence (e.g. IDT meeting notes or clients record)
				  that the team concurred with the necessity for the order without trying less
				  restrictive measures first and discussed any concerns with the
				  physician.
W312
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(e)(2) be used only as an integral part of
				  the client's individual program plan that is directed specifically towards the
				  reduction of and eventual elimination of the behaviors for which the drugs are
				  employed.
Guidance §483.450(e)(2)
All medications to manage behavior must be integrated into
				  the IPP and the IPP must specify how the specific target behavior for which the
				  medication is prescribed will be reduced or eliminated. This includes
				  medications which are typically used for medical conditions that may be used to
				  manage behavior (e.g. 1. propranolol (Inderal), an antihypertensive used for
				  self-injurious behavior, and 2. carbamazepine (Tegretol), an anticonvulsant,
				  used for aggression). Drugs for behavior management must not be ordered on a
				  PRN basis for a client. The facility staff must contact the physician to obtain
				  a one-time order if the situation necessities the use of medication. The
				  facility policy must address the maximum number of times a medication can be
				  used as an emergency prior to being incorporated in the IPP, side effects of
				  such medications, and the frequency of re-evaluation of ongoing behavior and
				  its treatment. Clients or their legal guardian have the right to choose
				  sedation for medical and dental procedures.
However, the facility cannot do routine administration of
				  medication for sedation for medical and dental procedures without the
				  agreement/consent of the client or their parent/legal guardian and they must
				  follow the specific orders of the healthcare practitioner who will be providing
				  services to the client. Decisions to order medications prior to medical and
				  dental procedures must be made on an individual basis. Clients who demonstrate
				  severe anxiety around these procedures should be considered for desensitization
				  programs.
W313
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(e)(3) Drugs used for control of
				  inappropriate behavior must not be used until it can be justified that the
				  harmful effects of the behavior clearly outweigh the potentially harmful
				  effects of the drugs.
Guidance §483.450(e)(3)
The risk(s) associated with the drug being used is consistent
				  with the type and severity of the behavior/symptoms it is intended to affect.
				  At the time the drug was started and incorporated into the IPP, the behaviors
				  were discussed and presented to team members. It was the documented decision of
				  the team that the behaviors were of such a severity that pharmacological
				  intervention was required and the physician was provided with the team
				  information to assist him in his decision to prescribe the medication.
§483.450(e)(4) Drugs used for control of
				  inappropriate behavior must be- -
§483.450(e)(4)(i) Monitored closely,
W314
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(e)(4) in conjunction with the physician
				  and the drug regimen review requirement at §483.4600(j),
Guidance §483.450(e)(4)
The physician and pharmacist must regularly review use of
				  drugs for control of inappropriate behavior for their effectiveness in changing
				  the targeted behavior/symptoms, untoward side effects, contraindications for
				  continued use, and communicate this information to relevant staff.
W315
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(e)(4) for desired responses and adverse
				  consequences by facility staff; and
Guidance §483.450(e)(4)
Direct support staff members are the people who most closely
				  and most frequently observe and record client behaviors. There should be
				  evidence that the direct support staff receive information via the IPP as to
				  the behaviors to be observed, the side effects associated with the medication,
				  the amount and types of documentation required and the communication with
				  clinical staff which is indicated. See 483.430 (e)(1) for training on
				  observations, documentation and communication related to behavior
				  management.
§483.450(e)(4)(ii) Gradually
				  withdrawn
W316
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(e)(4) at least annually
Guidance §483.450(e)(4)
Clients receiving medications to control behavior must be
				  evaluated at least annually for a possible reduction of the medication
				  progressing the client toward final elimination of the drug or lowest possible
				  therapeutic level of the drug. However, evaluation should be done earlier than
				  annually if observations indicate that the client's behavior has improved to
				  the point that reduction may be considered as determined by the IPP, unless
				  otherwise ordered by the client's physician.
W317
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.450(e)(4) in a carefully monitored program
				  conducted in conjunction with the interdisciplinary team, unless clinical
				  evidence justifies that this is contraindicated.
Guidance §483.450(e)(4)
The IDT is aware of and involved in planning the drug
				  reduction program and participates in its implementation and monitoring.
				  Progress or regression of the client is monitored and taken into consideration
				  in determining the rate of withdrawal and whether to continue withdrawal. In
				  determining whether there is clinical contraindication to the annual drug
				  withdrawal, the physician and IDT should consider the client's clinical
				  history, diagnostic/behavioral status, previous reduction/discontinuation
				  attempts, and current regimen effectiveness. If a client also has a diagnosis
				  of a psychiatric condition that requires a stable level of a psychiatric
				  medication in order to control the symptoms associated with the psychiatric
				  diagnosis, the annual evaluation for reduction of that particular medication
				  for the symptoms of the psychiatric diagnosis would not apply. Documentation in
				  the client's record from their psychiatrist or physician that medication
				  reduction would be contraindicated or that the current level of medications is
				  therapeutic meets the intent of this regulation.
W318
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460 Condition of participation: Health care
				  services
(a) Standard: Physician services
W319
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(a)(1) The facility must ensure the
				  availability of physician services 24 hours a day.
Guidance §483.460(a)(1)
A designated physician must be available via telephone,
				  pager, e-mail or on-site in the facility on a 24 hour per day basis for
				  consultation regarding both emergency and non-emergency medical issues. If the
				  facility employs a fulltime physician, there must be procedures in place for
				  coverage in the absence of the physician from the facility.
If the facility contracts with a community-based physician
				  for 24 hour per day coverage, there must be written arrangements in place to
				  detail the responsibilities of the contract physician regarding direct services
				  to the clients, interactions with the direct support staff and the interactions
				  between the nursing staff of the facility and the contract physician. The
				  contract with the contract physician must delineate the process for coverage
				  when he/she is not available.
Upon interview, the staff should be aware of the procedures
				  they are to follow to contact a physician in the event of an illness or injury.
				  Routinely sending clients to emergent care or the emergency room of a hospital
				  because there are no facility physicians available for consultation is not
				  consistent with the regulations.
Interview and record review verify that the physician is
				  available and responsive 24 hours a day.
W320
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(a)(2) The physician must develop, in
				  coordination with licensed nursing personnel, a medical care plan of treatment
				  for a client if the physician determines that an individual client requires
				  24-hour licensed nursing care.
Guidance §483.460(a)(2)
A medical care plan of treatment is developed for those
				  clients who are either acutely ill and require licensed nursing care and
				  monitoring temporarily on a 24 hour basis or clients whose chronic medical
				  conditions require or indicate 24 hour licensed nursing care and monitoring.
				  The physician determines when 24 hour nursing care is required.
The medical care plan is based upon the orders from the
				  physician for treatments and care and nursing standards of practice. There is
				  evidence in the client's record that the physician and the nursing staff at the
				  facility work together to ensure that the medical care plan is current and
				  appropriate (e.g. changes in physician written orders for care pursuant to
				  observations from the nursing staff and/or direct observations and interactions
				  with the client, and nursing documentation of care).
The fact that a client has a medical care plan in place
				  should not preclude him/her from an active treatment program, except in
				  instances of acute illness where the active treatment program is temporarily
				  suspended. For clients with chronic medical conditions, it may be necessary for
				  their active treatment program to be modified due to the tolerance level of the
				  client or adapted to accommodate medical limitations. However, active treatment
				  must be provided on a continuous basis.
W321
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(a)(2) This plan must be integrated in the
				  individual program plan.
Guidance §483.460(a)(2)
Although the medical care plan can be a separate document, it
				  is always an integral part of the IPP process. There should be evidence that
				  the plans are shared and discussed at the time of all interdisciplinary
				  discussions and the information from the medical care plan is utilized in the
				  development of the IPP objectives.
§483.460(a)(3) The facility must provide or
				  obtain
W322
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(a)(3) preventive and general
				  care
Guidance §483.460(a)(3)
The facility has procedures in place to ensure that the
				  clients receive general health care services to assure optimal levels of
				  wellness. General health care services include assessment and treatment of
				  acute and chronic complaints or situations; teaching relevant heath care
				  principles to staff and clients; and periodic surveillance of the health status
				  of the clients. As a result of clinical assessment, referrals are made for
				  specialized assessment and tests. Facility health care staff follow-up to
				  ensure the assessments are done and the findings incorporated into the medical
				  care plan and/or the IPP. The facility must have arrangements in place to
				  provide routine or episodic laboratory, and radiology services for the clients
				  if not provided in-house or through the clients physician. There must be a
				  written agreement that specifies the responsibilities of the facility and
				  outside provider. (See §483.410(a)). Preventive health care services
				  include screening procedures designed to identify health concerns and initiate
				  treatment as early as possible. The facility should have a health prevention
				  program in place and follow the plan to address those screenings that the
				  facility will perform periodically that are relevant to all clients, and those
				  screenings associated with a particular gender or age or vulnerability.
				  Physician refusal to perform a test, such as a pap smear, must be consistent
				  with guidelines for clients, per the local standard in the community. If the
				  facility has a physician that refuses to provide preventative healthcare based
				  on the client's level of functioning, medical staff at the facility should meet
				  with and consult with this physician in order to ensure that clients receive
				  the same health services as persons living in the local community.
Refer to these websites for current recommended screenings:
				  Agency for Healthcare Research and Quality (AHRQ)
For men:
http://www.ahrq.gov/ppip/healthymen.htrm
Centers for Disease Control (CDC)
For women:
http://www.cdc.gov/women/pubs/cancer.htm
§483.460(a)(3) as well as annual physical
				  examinations of each client that at a minimum include the
				  following:
W323
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(a)(3)(i) Evaluation of vision and
				  hearing;
Guidance §483.460(a)(3)(i)
Information relevant to the client's ability to see and hear
				  is a critical component in the development of appropriate active treatment
				  strategies. All clients, including clients who are non-verbal, should have
				  evidence in his/her record that they receive an annual evaluation of their
				  vision and hearing which includes a screening as a minimum, follow-up
				  examination as indicated by the screen and timely referrals as indicated by the
				  examination. Screening is a gross assessment of the client's vision and hearing
				  and usually does not include a measurement of acuity. Examinations are
				  conducted to follow-up on issues noted in the screening and are conducted by
				  qualified professionals. Clients who appear to have vision or hearing problems
				  or the staff indicate that they have vision or hearing problems and no
				  accommodations have been made. The annual vision and hearing evaluation
				  verifies that clients appearing to have vision/hearing issues or if staff
				  indicate that a client has vision/hearing issues that these issues have
				  been/are being addressed. If a client's vision or hearing can only be assessed
				  through examinations conducted by specialists (e.g., comprehensive
				  ophthalmological examinations and evoked response audiometry (ERA)), these
				  tests need not be conducted yearly, but rather upon the specialist's expressed
				  recommendations. During discussions at the annual IPP review the team reviews
				  information from the health professional, speech and hearing professional, and
				  direct support staff and makes referrals back to the specialist if
				  indicated.
W324
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(a)(3)(ii) Immunizations, using as a guide
				  the recommendations of the Public Health Service Advisory Committee on
				  Immunization Practices or of the Committee on the Control of Infectious
				  Diseases of the American Academy of Pediatrics;
Guidance §483.460(a)(3)(ii)
These immunization guides may be obtained from: American
				  Academy of Pediatrics
www, aap.
				  oxg/healthtopics/immunizations. cfm
Centers for Disease Control (CDC)
www.cdc.gov/vaccines/recs/schedule/default.htm
.
W325
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(a)(3)(iii) Routine screening laboratory
				  examinations as determined necessary by the physician,
Guidance §483.460(a)(3)(iii)
The facility may have a set of routine laboratory tests which
				  are to be done on every client annually which is developed and approved by the
				  facility physician. However, such a list is not required. The physician may
				  write orders individually for the clients based upon their medical history,
				  age, gender or medical vulnerabilities.
W326
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(a)(3)(iii) and special studies when
				  needed;
W327
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(a)(3)(iv) Tuberculosis control,
				  appropriate to the facility's population, and in accordance with the
				  recommendations of the American College of Chest Physicians or the section on
				  diseases of the chest of the American Academy of Pediatrics, or
				  both.
Guidance §483.460(a)(3)(iv)
The facility should have in place a system for the
				  identification, reporting, investigation, and control of Tuberculosis (TB) in
				  order to prevent its transmission within the facility. This system should
				  include:
1) Policies and procedures for screening new employees, new
				  clients, and other people who interact on a consistent basis with clients
				  residing in the facility when those persons are volunteers or professional
				  staff hired or utilized directly by the facility (such as volunteers and
				  contract professional staff);
2) Policies and procedures for subsequent screening for
				  clients and for employees, and other people (such as volunteers and contract
				  professional staff) who interact on a consistent basis with clients residing in
				  the facility when those persons are volunteers or professional staff hired or
				  utilized directly by the facility per State Health Department
				  requirements;
3) Policies and procedures for reporting positive TB test
				  results to the appropriate State authorities;
4) Policies for the investigative procedures, per the local
				  health department, that would be put in place should a client or staff person
				  test positive for TB;
5) Policies and procedures for treatment and precautions to
				  be used with clients who display TB symptoms, as substantiated by positive skin
				  testing or x-ray results; and
6) Policies and procedures for the evaluation of the
				  effectiveness of the surveillance system. When one or more clients or staff
				  display TB symptoms, as substantiated by positive skin testing or x-ray
				  results, they do not return to work until a physician has cleared them to
				  return to work.
W328
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(a)(4) To the extent permitted by State
				  law, the facility may utilize physician assistants and nurse practitioners to
				  provide physician services as described in this section.
Guidance §483.460(a)(4)
Refer to the applicable State Nurse Practice Act or
				  applicable Board of Medicine Practice Act to determine the extent that the
				  nurse practitioner or physician assistant may provide physician
				  services.
(b) Standard: Physician participation in the individual
				  program plan
§483.460(b) A physician must participate
				  in-
W329
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(b)(1) The establishment of each newly
				  admitted client's initial individual program plan as required by §456.380
				  of this chapter that specifies plan of care requirements for ICFs;
				  and
Guidance §483.460(b)(1)
During the admission process, which takes place from the time
				  the client is admitted to the facility to the time the initial IPP is
				  completed, a physician is required to ensure that an assessment of the client's
				  medical status is thoroughly considered and incorporated into the IPP planning
				  process by the team as it develops the IPP. The physician's input may be by
				  means of written reports, evaluations, and recommendations. The physician
				  (consistent with Medicaid Utilization Control regulations at §456.380)
				  must evaluate the client at the time of admission to identify all diagnoses and
				  complaints, provide orders for all medications and treatments and provide
				  recommendations for restorative and rehabilitative services. §456.380
				  requires that a physician conduct this initial assessment therefore, it may not
				  be done by a physician extender
(e.g., Physician assistant or
				  Advanced Practice Registered Nurse).
W330
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(b)(2) If appropriate, physicians must
				  participate in the review and update of an individual program plan as part of
				  the interdisciplinary team process either in person or through written report
				  to the interdisciplinary team.
Guidance §483.460(b)(2)
The need for physician participation on an individual
				  client's IPP team is determined by the medical needs of the client. How the
				  physician participates (whether through written report, telephone consultation,
				  attendance at the meeting, etc.) is to be left to the discretion of the
				  facility. In instances where a client has no overriding medical issues, the
				  nurse of the facility can represent the medical component on the IDT process or
				  consult with the appropriate physician and share the information with the team.
				  However, in situations where a client's medical condition is unstable/fragile
				  to the extent that it impacts the training/work that may be planned, the
				  physician must participate in providing guidance on the types and extent of
				  programs that would be appropriate considering the client's physical/medical
				  limitations. If a client is noted to be having difficulty participating in the
				  objectives set forth in his/her IPP due to serious medical concerns, review the
				  input that was provided by the physician into the development of the plan and
				  whether the IPP team requested such input.
(c) Standard: Nursing services
W331
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c) The facility must provide clients with
				  nursing services in accordance with their needs.
Guidance §483.460(c)
The nurse responds in a timely manner to all medical concerns
				  reported, conducts assessments as indicated, effects timely and appropriate
				  interventions, communicates with the client's physicians and other health care
				  professionals as indicated, provides treatments as ordered, monitors client
				  progress following illness or injury and provides training to clients and/or
				  staff as indicated.
§483.460(c) These services must
				  include
W332
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(1) Participation as appropriate in the
				  development, review, and update of an individual program plan as part of the
				  interdisciplinary team process;
Guidance §483.460(c)(1)
For those clients who have had an uneventful year medically
				  and have no medical/health concerns at the time of the IPP meeting the facility
				  nurse may submit a summary report to the IDT unless the IDT determines that
				  his/her attendance is necessary. An eventful year medically would include a
				  year which required unplanned hospital admissions or in which medical issues
				  necessitated treatment for a prolonged or continuing period. However when a
				  client has had an eventful year medically or current medical/health concerns,
				  this could have an impact on their objectives and accordingly the nurse should
				  participate in the IDT discussion directly.
W333
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(2) The development, with a physician,
				  of a medical care plan of treatment for a client when the physician has
				  determined that an individual client requires such a plan;
Guidance §483.460(c)(2)
A medical care plan addresses those clinical treatments and
				  observations that are to be done for the client by the medical staff and other
				  staff of the facility in order to either improve an acute medical condition or
				  to maintain a medically fragile client as clinically stable as possible. The
				  medical care plan is an adjunct to the IPP and is not considered a substitution
				  for the IPP.
§483.460(c)(3) For those clients certified as not
				  needing a medical care plan, a review of their health status which
				  must-
W334
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(3)(i) Be by a direct physical
				  examination;
Guidance §483.460(c)(3)(i)
A direct physical examination means a visual review of the
				  body as well as examination/assessment of body systems. This includes
				  observations made through non- verbal communication (including visual, tactile,
				  nonverbal gestures, grimaces, etc.) which may be an indication that there is a
				  potential for further assessment and/or monitoring. A paper review of the
				  client's medical record and health statistics does not meet the intent of the
				  regulation for a direct physical examination.
W335
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(3)(ii) Be by a licensed
				  nurse;
Guidance §483.460(c)(3)(ii)
The term "licensed nurse", for purposes of these guidelines,
				  means a registered nurse, a licensed practical nurse or a licensed vocational
				  nurse currently licensed by the State in which the facility is located. The
				  nurse must operate consistent with the requirements of the applicable Nurse
				  Practice Act. If this direct physical examination is done by a physician, it is
				  not necessary for the nurse to repeat the exam.
W336
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(3)(iii) Be on a quarterly or more
				  frequent basis depending on client need;
Guidance §483.460(c)(3)(iii)
"On a quarterly basis" means that the examinations are
				  conducted approximately 90 days apart (e.g. scheduled to be conducted
				  approximately once every 90 days). If during the course of a calendar year,
				  there were three quarterly examinations conducted by a licensed nurse and in
				  the fourth quarter the annual physical examination was performed by a
				  physician, the intent of this requirement is met without the nurse performing
				  an additional examination.
W337
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(3)(iv) Be recorded in the client's
				  record; and
Guidance §483.460(c)(3)(iv)
The actual findings of each examination and the date
				  conducted must be incorporated into the client's record.
W338
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(3)(v) Result in any necessary action
				  (including referral to a physician to address client
health problems).
Guidance §483.460(c)(3)(v)
The nursing staff document that referrals are made in a
				  timely manner, if indicated, for any concerns identified. Nurses must ensure
				  all concerns they identify are communicated and addressed appropriately,
				  including:
* Need is fully identified in assessment;
* Appropriate referrals are made;
* Revisions are made to IPP/Medical care plan; and
* Follow-up occurs to the new plan.
W339
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(4) Other nursing care as prescribed by
				  the physician or as identified by client needs; and
Guidance §483.460(c)(4)
Nursing interventions are implemented as indicated by the
				  needs of the client and consistent with either standard nursing practice
				  principles or orders from the attending physician. Health and wellness are
				  actively promoted, problems are attended to before they negatively impact the
				  client's health and wellness, and steps are taken to prevent the recurrence of
				  such problems while responding promptly to client's needs. Client health care
				  complaints that are reported either directly by the client or by the direct
				  care staff are addressed promptly by the nursing staff. Client health care
				  complaints and response by nursing staff are documented in the client's
				  record.
§483.460(c)(5) Implementing with other members of
				  the interdisciplinary team, appropriate protective and preventive health
				  measures that include, but are not limited to -
W340
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(5)(i) Training clients and staff as
				  needed in appropriate health and hygiene methods;
Guidance §483.460(c)(5)(i)
Nursing staff periodically provides training to clients and
				  staff on how to care for health needs or conditions, personal hygiene, health
				  maintenance, and disease prevention. Nursing staff actively participates in
				  periodic discussions with client and staff to promote health habits in the
				  areas of diet, exercise and non-smoking. Based upon individual training needs,
				  the nursing staff provides training to individuals in areas such as
				  medications, family planning, prevention of sexually transmitted diseases,
				  control of other infectious diseases, self-monitoring of health status and
				  self-prevention of health problems, etc. The nurses may train clients directly
				  on their objectives or train other staff to do this training as
				  appropriate.
W341
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(5)(ii) Control of communicable
				  diseases and infections, including the instruction of other personnel in
				  methods of infection control; and
Guidance §483.460(c)(5)(ii)
Nursing staff should actively participate in surveillance and
				  reporting of communicable diseases per the Centers for Disease Control (CDC)
				  guidelines and applicable state laws. They should teach and promote infection
				  control techniques such as hand washing by clients and staff and should be
				  making periodic observations to ensure that such good infection control
				  techniques are consistently utilized.
W342
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(c)(5)(iii) Training direct care staff in
				  detecting signs and symptoms of illness or dysfunction, first aid for accidents
				  or illness, and basic skills required to meet the health needs of the
				  clients.
Guidance §483.460(c)(5)(iii)
Nursing staff must train and ensure direct support staff
				  demonstrate competency in detecting signs and symptoms of illness, injury, or
				  change in the client's health baseline (e.g. responsiveness, fatigue,
				  irritability, constipation, diarrhea, dehydration, confusion, unexplained
				  weight loss, changes in endurance and changes in respiratory function). Staff
				  is responsive to health care needs or injuries of clients and receives
				  instruction and support during temporary illness of clients. If not, review
				  staff training records to determine whether training was provided periodically
				  to the involved employee. Interview direct care staff to determine their level
				  of understanding regarding the signs and symptoms of illness that are to be
				  reported to the medical staff. The records of clients with recent
				  hospitalizations verify that staff detected and reported relevant symptoms
				  promptly.
(d) Standard: Nursing staff
W343
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(d)(1) Nurses providing services in the
				  facility must have a current license to practice in the State.
Guidance §483.460(d)(1)
The facility should have a procedure in place to ensure that
				  any contract nursing staff members are currently licensed prior to the
				  provision of services. Include any contract nurses used by the facility in the
				  sample of nurses reviewed for licensure.
W344
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(d)(2) The facility must employ or arrange
				  for licensed nursing services sufficient to care for clients' health needs
				  including those clients with medical care plans.
Guidance §483.460(d)(2)
The facility provides for nursing services based on the
				  health needs and conditions of clients residing there. Examples include:
1) physician ordered treatments that require the skills of a
				  licensed nurse;
2) preventive screenings;
3) assessment and intervention;
4) direct physical examination and examination of body
				  systems;
5) teaching; and
6) advocacy for the medical services needed by the
				  client.
Client health care needs are met in a timely manner (within
				  24 hours) by the available nursing staff. If nurses who do not have experience
				  in the care of persons with intellectual disabilities are employed by the
				  facility, they should be provided with a formal orientation period and on-going
				  educational opportunities to increase their understanding of the client
				  population. When one or more clients in the facility has an active medical care
				  plan, there must be 24 hour nursing services available to come to the facility
				  as needed to make skilled assessments and interventions.
W345
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(d)(3) The facility must utilize
				  registered nurses as appropriate and required by State law to perform the
				  health services specified in this section.
Guidance §483.460(d)(3)
Refer to the applicable State Nurse Practice Act.
W346
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(d)(4) If the facility utilizes only
				  licensed practical or vocational nurses to provide health services, it must
				  have a formal arrangement with a registered nurse to be available for verbal or
				  onsite consultation to the licensed practical or vocational
				  nurse.
Guidance §483.460(d)(4)
The facility must have written arrangements with a registered
				  nurse (RN) to provide consultation in those instances where LPNs/LVNs provide
				  all the direct nursing care for the clients. Verify that the agreement requires
				  the RN to respond promptly to all calls from the LPN/LVN and to come on-site to
				  the facility if necessary. The facility must also ensure registered nurse
				  back-up when the primary registered nurse consultant is unavailable (vacations,
				  etc.). Review documentation in the client records to confirm that the LPNs/LVNs
				  of the facility are consulting the registered nurse consultant when indicated
				  and that she/he responds promptly to such calls.
W347
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(d)(5) Non- licensed nursing personnel who
				  work with clients under a medical care plan must do so under the supervision of
				  licensed persons.
The work of any direct support staff (caring for clients with
				  a medical care plan) is directed by an onsite licensed nurse). The nurse
				  evaluates the care provided by the staff as needed, but at least each shift. If
				  observations of care indicate that direct care staff are not providing care as
				  directed by the medical care plan, then review the supervision provided by the
				  nursing staff.
(e) Standard: Dental services
W348
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(e)(1) The facility must provide or make
				  arrangements for comprehensive diagnostic and treatment services for each
				  client from qualified personnel, including licensed dentists and dental
				  hygienists either through organized dental services in-house or through
				  arrangement.
Guidance §483.460(e)(1)
It is expected that the clients will obtain dental services
				  (both diagnostic and treatment) from community dentists whenever possible. In
				  some instances, there may be clients residing in the facility who are
				  physically unable to travel to the community for services. The facility must
				  secure dental services (both diagnostic and treatment) for these clients either
				  through an in-house program, which is part of the organizational and
				  administrative structure of the facility, or through a written agreement with
				  an outside dental service to come into the facility to provide such
				  services.
W349
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(e)(2) If appropriate, dental
				  professionals must participate, in the development, review and update of an
				  individual program plan as part of the interdisciplinary process either in
				  person or through written report to the interdisciplinary team.
Guidance §483.460(e)(2)
Reports of dental care may be submitted to the IDT for
				  inclusion in their discussions surrounding either development of the plan or
				  update to the plan. This includes procedures a client may have had or be having
				  during the plan development period, such as root canal or singular extractions.
				  Actual attendance at the IDT meeting by the dentist may be left to the request
				  of the IDT.
W350
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(e)(3) The facility must provide education
				  and training in the maintenance of oral health.
Guidance §483.460(e)(3)
Formal or informal training in the maintenance of oral
				  hygiene is provided to clients who require it, and to those staff who are
				  responsible for carrying out such activities. The IPP should include an
				  assessment of the client's ability to perform oral hygiene independently and an
				  associated program if the client is not independent.
(f) Standard: Comprehensive dental diagnostic
				  services
§483.460(f) Comprehensive dental diagnostic
				  services include
W351
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(f)(1) A complete extraoral and intraoral
				  examination, using all diagnostic aids necessary to properly evaluate the
				  client's condition not later than one month after admission to the facility
				  (unless the examination was completed within twelve months before
				  admission);
Guidance §483.460(f)(1)
A "month" is defined as the interval between the date of
				  admission and close of business of the corresponding day in the following
				  month.
A complete intraoral examination includes an oral cancer
				  screen.
§483.460(f)(2) Periodic examination and diagnosis
				  performed
W352
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(f)(2) at least annually,
Guidance §483.460(f)(2)
Dental examinations occur no less frequently than annually.
				  Clients without teeth must receive an annual oral cancer screening examination
				  by a dental professional.
W353
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(f)(2) including radiographs when
				  indicated and detection of manifestations of systemic disease;
				  and
Guidance §483.460(f)(2)
There should be evidence in dental reports that dentists
				  follow current standards of practice for the performance of x-rays in order to
				  assist in the diagnosis and treatment of the client.
W354
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(f)(3) A review of the results of
				  examination and entry of the results in the client's dental
				  record.
Guidance §483.460(f)(3)
The entry referenced at this regulation is the dental entry
				  into the dental record. See W359 for requirement of copying this dental record
				  into the facility record.
(g)
Standard: Comprehensive dental
				  treatment
§483.460(g) The facility must ensure comprehensive
				  dental treatment services that include- -
W355
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(g)(1) The availability for emergency
				  dental treatment on a 24-hour-a-day basis by a licensed dentist;
				  and
Guidance §483.460(g)(1)
The facility should be able to produce upon request, a
				  written contract/agreement between the facility and a licensed dentist for 24/7
				  guidance/provision of emergency services for the clients. The agreement should
				  also indicate what back-up coverage will be provided when the dentist is not
				  available.
W356
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(g)(2) Dental care needed for relief of
				  pain and infections, restoration of teeth, and maintenance of dental
				  health.
(h) Standard: Documentation of dental
				  services
§483.460(h)(1) If the facility maintains an
				  in-house dental service, the facility must
W357
keep a permanent dental record for each
				  client,
W358
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(h)(1) with a dental summary maintained in
				  the client's living-unit.
Guidance §483.460(h)(1)
The "dental summary" refers to the summary of each visit
				  entered by the dental professional. The note includes any care instructions to
				  be followed up by facility staff as a result of treatment.
§483.460(h)(2) If the facility does not maintain
				  an in-house dental service, the facility must
W359
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(h)(2) obtain a dental summary of the
				  results of dental visits
Guidance §483.460(h)(2)
The facility should receive a written report of each dentist
				  visit for inclusion in the client's record at the facility and for reference by
				  the medical and direct support staff.
W360
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(h)(2) and maintain the summary in the
				  client's living unit.
See guideline above at W359.
(i) Standard: Pharmacy services
W361
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(i) The facility must provide or make
				  arrangements for the provision of routine and emergency drugs and biologicals
				  to its clients. Drugs and biologicals may be obtained from community or
				  contract pharmacists or the facility may maintain a licensed
				  pharmacy.
Guidance §483.460(i)
The facility either has an onsite pharmacy or has formal
				  arrangements in place for the provision of routine, unanticipated, or emergency
				  drugs. There are no instances where a client does not receive needed
				  medications due to the unavailability of drugs.
(j) Standard: Drug regimen review
W362
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(j)(1) A pharmacist with input from the
				  interdisciplinary team must review the drug regimen of each client at least
				  quarterly.
Guidance §483.460(j)(1)
The primary function of the pharmacist during the quarterly
				  drug review is to identify possible drug interactions, check for evidence of
				  any side effects associated with the drug usage, determine if laboratory
				  results associated with the drug are within normal limits and verify that the
				  facility is administering the medication appropriately and to comment upon the
				  efficacy of the drug use (e.g. blood sugar controlled, blood pressure within
				  normal limits). In the case of drugs used to manage behavior, the pharmacist
				  may need information from the IDT to determine efficacy. See Appendix PP,
				  Indicators for Surveyor Assessment of the Performance of Drug Regimen Reviews,
				  to the State Operations Manual (Pharmaceutical Service Requirements in Long
				  Term Care Facilities).
W363
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(j)(2) The pharmacist must report any
				  irregularities in clients' drug regimens to the prescribing physician and
				  interdisciplinary team.
Guidance §483.460(j)(2)
The physician and IDT members must discuss, document and take
				  necessary follow-up action for any irregularities noted.
W364
§483.460(j)(3) The pharmacist must prepare a
				  record of each client's drug regimen reviews and the facility must maintain
				  that record.
W365
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(j)(4) An individual medication
				  administration record must be maintained for each client.
W366
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(j)(5) As appropriate the pharmacist must
				  participate in the development, implementation, and review of each client's
				  individual program plan either in person or through written report to the
				  interdisciplinary team.
Guidance §483.460(j)(5)
Pharmacist participation on the IDT is at the request of the
				  team. It would not be necessary for the pharmacist to routinely attend all team
				  meetings when the client is on a stable drug regimen that does not appear to be
				  influencing his/her active treatment programs. Pharmacist participation may be
				  appropriate, in situations such as assisting the IDT develop the most effective
				  training programs for when the client is in an evolving situation with their
				  medication.
For example:
* A client begins a new or more complex drug regimen;
* The physician orders off-label use of a medication;
* Frequent changes in the drug regimen are affecting IPP
				  implementation.
(k) Standard: Drug administration
W367
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(k) The facility must have an organized
				  system for drug administration that identifies each drug up to the point of
				  administration.
§483.460(k) The system must assure
				  that
W368
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(k)(1) All drugs are administered in
				  compliance with the physician's orders;
Guidance §483.460(k)(1)
Administration errors identified in previous medication
				  administration records qualify as non-compliance with physician's
				  orders.
W369
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(k)(2) All drugs, including those that are
				  self-administered, are administered without error;
Guidance §483.460(k)(2)
A medication error is an observed discrepancy during the
				  medication pass between what is ordered and what is administered.
This also applies to self-administered medications. For small
				  facilities (16 beds or less), the medication administration pass will encompass
				  a total of eight (8) drug doses. The observations should be split between two
				  separate drug passes 4/4 (one in the morning and one in the late afternoon or
				  early evening). The medications observed during the observations may or may not
				  be for clients in the survey sample. Any concerns regarding a medication that
				  is about to be administered should be brought to the attention of the person
				  administering the medication. The record of observation should be reconciled
				  with the most current signed physician's orders. For large facilities (17 or
				  more beds) with either single or multiple buildings, the medication
				  administration pass will encompass a total of 12 doses. The observations should
				  be split between two separate passes 6/6 (one in the morning and one in late
				  afternoon or early evening). Any concerns regarding a medication that is about
				  to be administered should be brought to the attention of the person
				  administering the medication. The record of observation should be reconciled
				  with the most current signed physician's orders.
W370
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(k)(3) Unlicensed personnel are allowed to
				  administer drugs only if State law permits;
Guidance §483.460(k)(3)
Unlicensed personnel administer only those forms of
				  medication which state law permits. Licensed nurse(s) in the facility oversee
				  any administration of medications by unlicensed persons and periodically
				  evaluate their performance.
W371
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(k)(4) Clients are taught to administer
				  their own medications if the interdisciplinary team determines that
				  self-administration of medications is an appropriate objective, and if the
				  physician does not specify otherwise;
Guidance §483.460(k)(4)
The IDT decision that a self-administration program is
				  appropriate, as is the case for all formal training objectives, must be based
				  upon accurate, current, valid assessment of the client's skills and potential.
				  The determination as to the appropriateness of a self- administration program
				  must never be made singularly on the client's diagnosis or current functional
				  abilities. For clients assessed to be inappropriate for a self-administration
				  program, but determined by the IDT to possess the capacity to functionally,
				  cognitively, emotionally or developmentally benefit from participation in the
				  drug administration process, it is expected that the facility will provide
				  opportunities for the client to participate in the medication administration
				  process under direct supervision. This participation can include but is not
				  limited to, identifying the medication taken, reaching/grasping a cup of water
				  during the process and placing oral medications in the mouth, etc.
W372
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(k)(5) The client's physician is informed
				  of the interdisciplinary team's decision that self-administration of
				  medications is an objective for the client;
Guidance §483.460(k)(5)
While the IDT may set an objective of self administration of
				  medication for a client, they are required to notify the client's physician of
				  this proposed objective. If the client's physician objects on medical grounds,
				  the team must not proceed with the objective until such time as a discussion is
				  held with the physician and he/she agrees to proceed after receiving additional
				  information.
W373
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(k)(6) No client self-administers
				  medication until he or she demonstrates the competency to do so;
Guidance §483.460(k)(6)
The written self-administration program for a client must
				  detail the criteria that will be employed by the facility staff to verify that
				  the client successfully completes all phases of the program and continues to
				  comply with all necessary requirements for self administration. Clients who
				  self-administer medications must secure all medications in such a manner as to
				  protect access by other clients or visitors.
W374
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(k)(7) Drugs used by clients while not
				  under the direct care of the facility are packaged and labeled in accordance
				  with State law;
Guidance §483.460(k)(7)
When clients go out of the facility for home visits, or to
				  attend work or school, drugs they are taking must be packaged and labeled in
				  accordance with state law by a person authorized by state law to package and
				  label.
§483.460(k)(8) Drug administration errors and
				  adverse drug reactions are
Guidance §483.460(k)(8)
Documentation of any medication error should be entered into
				  the client's record and should include what error was made, who was notified of
				  the error, the response of the medical person notified, the physical condition
				  of the client at the time of the notification and subsequent observations of
				  the clients physical condition related to the error.
W375
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(k)(8) recorded
Guidance §483.460(k)(8)
Documentation of adverse drug reactions must be entered into
				  the client's record and should include all complaints made by the client or
				  observations made by the staff following the drug administration, the
				  notification of medical personnel, and the response of the medical personnel,
				  any emergency actions that were required and all subsequent observations of the
				  client's condition related to the reaction.
W376
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(k)(8) and reported immediately to a
				  physician.
Guidance §483.460(k)(8)
"Immediately" means at the time the error or reaction is
				  identified.
(1) Standard: Drug storage and
				  recordkeeping
§483.460(1)(1) The facility must store drugs under
				  proper conditions of
Guidance §483.460(1)(1)
Drugs are stored according to manufacturer's
				  recommendations.
W377
sanitation,
W378
temperature,
W379
light,
W380
humidity,
W381
and security.
W382
§483.460(1)(2) The facility must keep all drugs
				  and biologicals locked except when being prepared for
				  administration.
W383
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(1)(2) Only authorized persons may have
				  access to the keys to the drug storage area.
Guidance §483.460(1)(2)
"Authorized persons" is restricted to those who administer
				  the drugs (as allowed by state law) and nursing supervisors (if any). No other
				  personnel should have access to these keys.
W384
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(1)(2) Clients who have been trained to
				  self-administer drugs in accordance with
§483.460(k)(4) may have access to keys to their
				  individual drug supply.
Guidance §483.460(1)(2)
Drugs that are self-administered do not have to be double
				  locked. The purpose for the double locking is to limit access to scheduled
				  drugs. Since the client is generally the only one who has access to his/her
				  drug supply (with perhaps the exception of a licensed nurse or whoever has
				  overall responsibility for medication administration at the facility and a
				  facility's Director of Nursing Services, who may have access to all of the
				  facility's drug supplies), there is no need to further limit access.
W385
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(1)(3) The facility must maintain records
				  of the receipt and disposition of all controlled drugs.
Guidance §483.460(1)(3)
The facility must follow state requirements for the control
				  and disposition of controlled drugs.
W386
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(1)(4) The facility must, on a sample
				  basis, periodically reconcile the receipt and disposition of all controlled
				  drugs in schedules II through IV (drugs subject to the Comprehensive Drug Abuse
				  Prevention and Control Act of 1970,
				  21
				  U.S.C. 801
et seq.
,
				  as implemented by 21 CFR Part 308).
Guidance §483.460(1)(4)
The facility should follow state requirements for the
				  reconciliation of controlled drugs.
W387
§483.460(1)(5) If the facility maintains a
				  licensed pharmacy, the facility must comply with the regulations for controlled
				  drugs
§483.460(m) Standard: Drug Labeling
§483.460(m)(1) Labeling of drugs and biologicals
				  must
W388
§483.460(m)(1)(i) Be based on currently accepted
				  professional principles and practices; and
W389
§483.460(m)(1)(ii) Include the appropriate
				  accessory and cautionary instructions, as well as the expiration date, if
				  applicable.
§483.460(m)(2) The facility must remove from
				  use-
W390
§483.460(m)(2)(i) Outdated drugs;
				  and
W391
§483.460(m)(2)(ii) Drug containers with worn,
				  illegible, or missing labels.
W392
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(m)(3) Drugs and biologicals packaged in
				  containers designated for a particular client must be immediately removed from
				  the client's current medication supply if discontinued by the
				  physician.
(n) Standard: Laboratory services
W393
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(n)(1) If a facility chooses to provide
				  laboratory services, the laboratory must meet the requirements specified in
				  part 493 of this chapter.
Guidance §483.460(n)(1)
If the facility performs laboratory services, it must have a
				  current, valid Clinical Laboratory Improvement Amendment (CLIA) certificate for
				  the types of tests it is performing. For the purposes of this regulation, a
				  "laboratory service or test" is defined as any examination or analysis of
				  materials derived from the human body for purposes of providing information for
				  the diagnosis, prevention, or treatment of any disease or impairment of, or the
				  assessment of the health of human beings.
W394
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.460(n)(1) If the laboratory chooses to refer
				  specimens for testing to another laboratory, the referral laboratory must be
				  certified in the appropriate specialties and subspecialties of service in
				  accordance with the requirements of part 493 of this chapter.
Guidance §483.460(n)(1)
A facility performing any laboratory service or test must
				  have applied to CMS, and received a Certificate of Waiver, Certificate of
				  Compliance, or Certificate of Accreditation. An application for a Certificate
				  of Waiver may be made if the facility performs only those tests on the waived
				  list. A complete list of waived tests can be found at:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/analyteswaived.cfm
.
				  If the facility performs any test, not appearing on the waived list, a
				  Certificate of Compliance or Certificate of Accreditation is required. An
				  appropriate CLIA certificate is required regardless of the frequency with which
				  the laboratory services or tests are conducted. When no tests are performed, a
				  CLIA certificate is not needed. Facilities only collecting specimens and not
				  performing testing do not need a certificate. A not-for-profit, a state, or
				  local government organization may have one certificate covering all the
				  facilities it operates (e.g., all the separately certified residences which
				  fall under its governing body), if no more than a total of 15 types of waived
				  or moderately complex laboratory tests are used. This exception applies only to
				  laboratories performing limited public health testing. See State Operations
				  Manual (SOM) 6008. Each location where a laboratory tests are performed must
				  file a separate application to be separately certified unless the laboratory
				  meets one if the exceptions outlined at
				  42CFR
				  493.35(b), 493.443(b), or
				  493.55(b).
				  Any laboratory located in a state that has a CMS-approved laboratory program is
				  exempt from CLIA certification. Currently there are two states with approved
				  programs: Washington and New York. New York has a partial exemption; therefore,
				  if the laboratory is located in New York, contact the New York State Agency to
				  determine if the exemption applies.
W406
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.470 Condition of participation: Physical
				  environment, (a) Standard: Client living environment.
W407
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(1) The facility must not house clients of grossly
				  different ages, developmental levels, and social needs in close physical or
				  social proximity unless the housing is planned to promote the growth and
				  development of all those housed together.
Guidance §§483.470(a)(1)
Clients of grossly different ages, functional levels, and/or
				  social needs should not be housed together unless all of the following
				  documentation supports the placement:
* Assessment;
* Client program plan;
* Staff documentation of client response to training
				  programs; and
* QIDP notes.
W408
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(2) The facility must not segregate clients solely on
				  the basis of their physical disabilities. It must integrate clients who have
				  ambulation deficits or who are deaf, blind, or have seizure disorders, etc.,
				  with others of comparable social and intellectual development.
(b) Standard: Client bedrooms.
(1) Bedrooms must- -
W409
§483.470(b)(1)(i) Be rooms that have at least one
				  outside wall
W410
§483.470(b)(1)(ii) Be equipped with or located
				  near toilet and bathing facilities;
W411
§483.470(b)(1)(iii) Accommodate no more than four
				  clients unless granted a variance under paragraph (b)(3) of this
				  section;
§483.470(b)(1)(iv) measure
W412
At least 60 square feet per client in multiple client
				  bedrooms
W413
And at least 80 square feet in single client bedrooms;
				  and
W414
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(v) In all facilities initially certified, or in
				  buildings constructed or with major renovations or conversions on or after
				  October 3,1988, have walls that extend from floor to ceiling.
Guidance §483.470(b)(1)(v)
If a facility was initially certified on or after October 3,
				  1988 and/or is under renovations or conversions, they must have walls that
				  extend floor to ceiling.
W415
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(2) If a bedroom is below grade level, it must have a
				  window that-
(i) Is usable as a second means of escape by client(s)
				  occupying the room; and
(ii) Is no more than 44 inches (measured to the window
				  sill) above the floor unless the facility is surveyed under the Health Care
				  Occupancy Chapter of the Life Safety Code, in which case the window must be no
				  more than 36 inches (measured to the window sill) above the
				  floor.
Guidance §483.470(b)(2)
The intent of the regulation is to prohibit the housing of
				  clients in basements that are entirely below grade. Clients may be housed on
				  the lower level of housing (e.g. a bi- level house), provided the window height
				  requirements are met and the window is of sufficient size to be used as a means
				  of escape.
W416
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(3) The survey agency may grant a variance from the
				  limit of four clients per room only if a physician who is a member of the
				  interdisciplinary team and who is a qualified intellectual disabilities
				  professional-
(i) Certifies that each client to be placed in a
				  bedroom housing more than four persons is so severely medically impaired as to
				  require direct and continuous monitoring during sleeping hours;
				  and
(ii) Documents the reason why housing in a room of only
				  four or fewer persons would not be medically feasible.
Guidance §483.470(b)(3)
The medical care plan for each client housed in a room with
				  more than four clients should indicate the need for continuous monitoring. The
				  medical care plan will include:
* the physician certification that the client is severely
				  medically impaired and requires direct and continuous monitoring during
				  sleeping hours; and
* the reason why this housing arrangement for fewer than four
				  people would not be medically feasible.
(4) The facility must provide each client
				  with-
W417
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(i) A separate bed of proper size and height for the
				  convenience of the client;
Guidance §483.470(b)(4)(i)
The client's preference, chronological age, and physical and
				  medical needs are the determining factors in bed size and height.
W418
§483.470(b)(4)(ii) A clean, comfortable,
				  mattress;
W419
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(iii) Bedding appropriate to the weather and climate;
				  and
W420
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(iv) Functional furniture, appropriate to the client's
				  needs,
Guidance §483.470(b)(4)(iv)
Client preferences and program needs should be considered in
				  furniture selection. For clients with physical disabilities, furniture is
				  adapted to accommodate the client's physical challenges and enable the client
				  to use the furniture with minimal support.
W421
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
and individual closet space in the client's bedroom
				  with clothes racks and shelves accessible to the client.
Guidance §483.470(b)(4)(iv)
Closets should have enough space for a reasonable amount of
				  the current season's clothing. Clients who use wheelchairs or have other
				  physical challenges can reach the racks and shelves in their closets. The
				  facility is permitted either to provide the client with an individualized
				  closet or with a designated area in a shared closet. The use of central
				  clothing bins in a facility clothing room, in the absence of required client
				  closet space in the bedroom, is not an acceptable practice.
(c) Standard: Storage space in bedrooms.
The facility must provide-
W422
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(1) Space for equipment for daily out-of-bed activity
				  for all clients who are not yet mobile, except those who have a short-term
				  illness or those few clients for whom out-of-bed activity is a threat to health
				  and safety; and
Guidance §483.470(c)(1)
Sufficient space that permits the use of wheelchairs, walkers
				  and other adaptive equipment should be provided within the bedroom.
W423
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(2) Suitable storage space, accessible to clients, for
				  personal possessions, such as TVs, radios, prosthetic equipment and
				  clothing.
Guidance §483.470(c)(2)
Each client should have storage in their bedroom for their
				  personal belongings. Clients should have free access to this storage without
				  the assistance of staff. If it is necessary for clients' personal belongings to
				  be locked due to the behavior of other clients, the client must still be
				  provided free access to his own possessions (See W137 for requirements for
				  locked areas).
(d) Standard: Client bathrooms
The facility must-
W424
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(1) Provide toilet and bathing facilities appropriate
				  in number, size, and design to meet the needs of the clients;
Guidance §483.470(d)(1)
In a home setting, the toilet facilities need to be of
				  sufficient number to meet the needs of the client without prolonged delay.
				  There must be enough toilets in the living units to meet the program needs of
				  the clients at any given time, as well as provide for intermediate toileting
				  needs of the clients living in the unit. In a home setting, it may be
				  unrealistic to say a client would never have to wait for a shower or bath or to
				  brush his/her teeth. Bathrooms and fixtures must be adapted to accommodate
				  clients with physical disabilities.
W425
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(2) Provide for individual privacy in toilets,
				  bathtubs, and showers; and
Guidance §483.470(d)(2)
A bathroom containing multiple toilets, showers or bathtubs,
				  must have doors, curtains, or some other means of protecting the client from
				  view when fully or partially unclothed. Clients should not be able to be seen
				  through the door or window by passersby when they are using the bathrooms.
				  Client privacy does not preclude the assistance provided by facility staff when
				  necessitated by the client's condition.
W426
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(3) In areas of the facility where clients who have not
				  been trained to regulate water temperature are exposed to hot water, ensure
				  that the temperature of the water does not exceed 110°
				  Fahrenheit.
(e) Standard: Heating and ventilation.
(1) Each client bedroom in the facility must
				  have-
W427
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(i) At least one window to the outside;
				  and
Guidance §483.470(e)(1)(i)
(See also W415)
W428
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(ii) Direct outside ventilation by means of windows,
				  air conditioning, or mechanical ventilation.
(2) The facility must-
W429
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(i) Maintain the temperature and humidity within a
				  normal comfort range by heating, air conditioning or other means;
				  and
Guidance §483.470(e)(2)(i)
A "normal comfort range" in most instances is defined as not
				  going below a temperature of 68 degrees Fahrenheit or exceeding a temperature
				  of 80 degrees Fahrenheit in facilities in most geographic areas of the country.
				  In extremely hot or extremely cold weather, precautions are taken by the
				  facility to protect the clients, particularly those who are medically
				  compromised, from ill effects of the temperature.
W430
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(ii) Ensure that the heating apparatus does not
				  constitute a burn or smoke hazard to clients.
Guidance §483.470(e)(2)(ii)
Refer to Life Safety Code Chapters 32 and 33
Unvented fuel fired heaters are prohibited. NFPA 101 2000
				  Edition.
32/33.2.5.23
(f) Standard: Floors.
The facility must have-
W431
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(1) Floors that have a resilient, nonabrasive, and
				  slip-resistant surface.
W432
§483.470(f) (2) Nonabrasive carpeting, if the area
				  used by clients is carpeted and serves clients who lie on the floor or ambulate
				  with parts of their bodies, other than feet, touching the floor;
				  and
§483.470(f) (3) Exposed floor surfaces and floor
				  coverings that
W433
promote mobility in areas used by
				  clients,
W434
and promote maintenance of sanitary
				  conditions.
§483.470(g) Standard: Space and
				  Equipment
The facility must-
W435
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(1) Provide sufficient space and equipment in dining,
				  living, health services, recreation, and program areas (including adequately
				  equipped and sound treated areas for hearing and other evaluations if they are
				  conducted in the facility) to enable staff to provide clients with needed
				  services, as required by this subpart and as identified in each client's
				  individual program plan.
Guidance§483.470(g)(1)
Staff and clients must have the space, materials and
				  equipment needed to implement formal and informal active treatment programs.
				  There must be sufficient space to accommodate group activities, including
				  groups with clients who use wheelchairs. Recreational supplies, equipment, and
				  materials are available and reflect the interests, physical abilities and
				  chronological age of the clients.
W436
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(2) Furnish, maintain in good repair, and teach clients
				  to use and to make informed choices about the use of dentures, eyeglasses,
				  hearing and other communications aids, braces, and other devices identified by
				  the interdisciplinary team as needed by the client.
Guidance §483.470(g)(2)
The term "furnish" means that the facility is responsible for
				  obtaining or purchasing these items once an assessment has identified the need
				  and is responsible for making any necessary arrangements for the client to
				  receive them. Clients' personal funds should not be used for these items since
				  this is a covered service under the ICF/IID benefit. The term "maintain in good
				  repair" means that the facility is responsible for ensuring that these items
				  are kept in good working order, and is responsible for any resulting expense
				  that may be incurred. Programs must be in place, when identified by assessment
				  and determined by the ID team, to teach clients about the use and care for
				  their equipment to the extent of their capabilities.
W437
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(3) Provide adequate clean linen and dirty linen
				  storage areas.
Guidance §483.470(g)(3)
Clean linen must be is separated from dirty linen and stored
				  in a manner which prevents contamination. Linen soiled with bodily fluids must
				  be stored separately and in a manner which protects clients from exposure to
				  possible infectious sources. A bedroom hamper can be an acceptable dirty linen
				  storage "area" if kept odor free and consistent with the infection control
				  requirements at §483.470(1).
(h) Standard: Emergency plan and
				  procedures.
W438
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(1) The facility must develop and implement detailed
				  written plans and procedures to meet all potential emergencies and disasters
				  such as fire, severe weather, and missing clients.
Guidance §483.470(h)(1)
These plans may include identification of transportation and
				  alternative shelter needs in cases when the facility must be evacuated and may
				  incorporate state-specific emergency preparedness requirements as
				  applicable.
W439
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(2) The facility must communicate, periodically review,
				  make the plan available, and provide training to the staff.
Guidance §483.470(h)(2)
"Periodic review" is a judgment made by the facility based on
				  the circumstances of the facility. If the facility changes its physical plant
				  or if changes external to the facility necessitates a review of the disaster
				  plan, then the facility is responsible for carrying out the review. Interview
				  staff about where emergency plans and procedures are located and what the
				  facility policy is regarding how often, and under what circumstances the plans
				  and procedures are reviewed and updated.
(i) Standard: Evacuation drills.
(1) The facility must hold evacuation
				  drills
W440
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
at least quarterly for each shift of
				  personnel
Guidance §483.470(i)(1)
Life Safety Code NFPA 101, 2000 Edition (LSC):
Chapter 32/33 code: Clients have to participate in an
				  evacuation drill each shift at least quarterly. Chapter 18/19 code: There must
				  be an evacuation drill on each shift at least quarterly. This drill is designed
				  to train staff on evacuation procedures. Review facility records to verify that
				  evacuations drills are held each shift at least once in each 3-month period.
				  Refer to (S&C 10-26-LSC)
W441
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
and under varied conditions to-
Guidance §483.470(i)(1)
Life Safety Code NFPA 101, 2000 Edition (LSC): Chapter 32/33:
				  Expects that all clients living in that unit are capable of self-evacuation
				  during an emergency. This self evacuation should be practiced under varying
				  conditions including various times of the day or night and in various weather
				  conditions. Chapter 18/19: Requires drills which simulate emergency situations
				  which familiarize facility staff with emergency actions they may be required to
				  perform. The general emphasis of these sections of the code is upon training of
				  the staff and not upon providing practice for the client. Drills should be
				  practiced under varying conditions including various times of the day or night
				  and in various weather conditions.
W442
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(i) Ensure that all personnel on all shifts are trained
				  to perform assigned tasks;
Guidance §483.470(i)(1)(i)
For facilities under Chapter 18/19 of the LSC Staff should be
				  able to verbalize the proper procedures to be followed during emergency drills.
				  Staff training records should document that all staff have received training on
				  emergency drills and evacuations.
W443
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(ii) Ensure that all personnel on all shifts are
				  familiar with the use of the facility's fire protection features;
				  and
Guidance §483.470(i)(1)(ii)
Staff on all shifts are able to express familiarity with the
				  use of fire extinguisher, alarms, and any other safety features in the
				  facility.
W444
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(iii) Evaluate the effectiveness of emergency and
				  disaster plans and procedures.
Guidance §483.470(i)(1)(iii)
See also W448. The plan(s) must be revised as needed and must
				  be based upon analysis completed under W448.
The facility must-
W445
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(i) Actually evacuate clients during at least one drill
				  each year on each shift;
Guidance §483.470(i)(2)(i)
All clients totally evacuate the building at least once per
				  year per shift, regardless of the occupancy chapter under which the building
				  falls. All facilities, regardless of their size require actual evacuation.
				  "Actually evacuate", as used in this standard, applies to all clients. The
				  drills are conducted not only to rehearse the clients and staff for a fire
				  emergency (see §483.470(i)(2)(v)), but for other disasters such as
				  hurricanes, tornadoes, floods, etc. Such disasters would require the entire
				  occupancy to be evacuated, and, therefore, the actual evacuation must be
				  practiced, as required.
W446
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(ii) Make special provisions for the evacuation of
				  clients with physical disabilities;
Guidance §483.470(i)(2)(ii)
Clients with physical or medical disabilities may require
				  special procedures for evacuation, taking into account equipment or staff that
				  must be maintained for the client's care at all times. The facility's
				  evacuation plan should:
* identify such clients;
* clearly delineate any special evacuation procedures for
				  those clients.
Staff should be familiar with the facility's special
				  evacuation procedures when working with clients who are in need of unique
				  provisions.
W447
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(iii) File a report and evaluation on each evacuation
				  drill;
Guidance §483.470(i)(2)(iii)
There is a written report of each evacuation drill
				  held.
W448
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(iv) Investigate all problems with evacuation drills,
				  including accidents,
Guidance §483.470(i)(2)(iv)
The documentation for each evacuation drill includes an
				  analysis of:
* The timeliness of the evacuation;
* Any difficulties observed during the drill;
* Investigates the cause of the difficulties; and
* Develops a plan to ensure the difficulties will not
				  reoccur.
W449
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
and take corrective action; and
Guidance §483.470(i)(2)(iv)
When a problem is identified during the evacuation drill and
				  the facility develops a plan to prevent reoccurrence, there is evidence the
				  facility implemented corrective action and follow-up completed to ensure
				  corrective action was successful.
W450
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(v) During fire drills, clients may be evacuated to a
				  safe area in facilities certified under the Health Care Occupancies Chapter of
				  the Life Safety Code.
Guidance §483.470(i)(2)(v)
The Life Safety Code NFPA 101, 2000 Edition at 3.3.167
				  defines safe location as "a location remote or separated from the effects of a
				  fire so that such effects no longer pose a threat."
W451
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(3) Facilities must meet the requirements of paragraph
				  (i)(1) and (2) of this section for any live-in and relief staff they
				  utilize.
Guidance §483.470(i)(3)
In the case of live-in staff, drills must occur quarterly.
				  Typically, live-in staff can be found in facilities that fall under Chapter
				  32/33 of the LSC code. Drills should be held at varying times of the day and
				  night for clients to practice evacuation including morning, afternoon, evening
				  and the middle of the night.
(j) Standard: Fire protection.
Guidance §483.470(j)
These standards are covered by the Life Safety Code (LSC)
				  survey. The facility must meet the appropriate chapter of the Life Safety Code,
				  2000 edition. When surveying an ICF/IID for compliance with the LSC, it is
				  first necessary to determine whether the facility will be surveyed under Health
				  Care (HC) or Board and Care (BC) occupancy.
* If clients receive nursing services, or if the provider
				  elects to use Health Care, the facility should be surveyed as a Health Care
				  Facility under Chapter 18 or 19 of the LSC, as appropriate.
* If clients receive personal care and protective oversight
				  but not continuing nursing services, the facility is to be surveyed under Board
				  and Care and the following three steps should be followed:
1) Determine the size (16 or less = small; 17 or more =
				  large);
2) Determine the Evacuation Difficulty (PROMPT, SLOW, or
				  IMPRACTICAL) using Appendix F of the fire safety evaluation system for board
				  and care facilities (FSES/BC); and
3) Survey the building using one of two methods:
a. The prescriptive requirements of Chapters 32 or 33;
				  or
b. The FSES/BC, Appendix G.
(1) General. Except as otherwise provided in this
				  section-
(i) The facility must meet the applicable provisions of
				  either the Health Care Occupancies Chapters or the Residential Board and Care
				  Occupancies Chapter of the 2000 edition of the Life Safety Code of the National
				  Fire Protection Association. The Director of the Office of the Federal Register
				  has approved the NFPA101®2000 edition of the Life Safety Code, issued
				  January 14, 2000, for incorporation by reference in accordance with
				  5
				  U.S.C. 552(a) and
				  1 CFR part 51. A copy
				  of the Code is available for inspection at the CMS Information Resource Center,
				  7500 Security Boulevard, Baltimore, MD or at the National Archives and Records
				  Administration (NARA). For information on the availability of this material at
				  NARA, call 202-741-6030, or go to:
http://www.archives.gov/federal
register/code of federal regulations/ibr locations.html. Copies may be
				  obtained from the National Fire Protection Association, 1 Batterymarch Park,
				  Quincy, MA 02269. If any changes in this edition of the Code are incorporated
				  by reference, CMS will publish notice in the Federal Register to announce the
				  changes.
(ii) Chapter 19.3.6.3.2, exception number 2 of the
				  adopted LSC does not apply to a facility.
Guidance §483.470(j)(1)(ii)
Roller latches are prohibited on corridor doors as a latching
				  device.
(2) The State survey agency may apply a single chapter
				  of the LSC to the entire facility or may apply different chapters to different
				  buildings or parts of buildings as permitted by the LSC.
(3) A facility that meets the LSC definition of a
				  residential board and care occupancy must have its evacuation capability
				  evaluated in accordance with the Evacuation Difficulty Index of the Fire Safety
				  Evaluation System for Board and Care facilities (FSES/BC).
Guidance §483.470(j)(3)
The evacuation capability of residents is determined using
				  Chapter 6 of NFPA 101A, 2001 edition.
4) If CMS finds that the State has a fire and safety
				  code imposed by State law that adequately protects a facility's clients, CMS
				  may allow the State survey agency to apply the State's fire and safety code
				  instead of the LSC.
5) Beginning March 13, 2006, a facility must be in
				  compliance with Chapter 19.2.9, Emergency Lighting.
Guidance §483.470(j)(5)
Battery powered emergency lighting must last at least 90
				  minutes.
6) Beginning March 13, 2006, Chapter 19.3.6.3.2,
				  exception number 2 does not apply to a facility. Guidance
				  §483.470(j)(6)
Roller latches are prohibited on corridor doors as a latching
				  device.
(7) Facilities that meet the LSC definition of a health
				  care occupancy.
(i) After consideration of State survey agency
				  recommendations, CMS may waive, for appropriate periods, specific provisions of
				  the Life Safety Code if the following requirements are met:
Guidance §483.470(j)(7)(i)
Waivers may be granted only to facilities that meet the Life
				  Safety Code definition of a Health Care Occupancy. Waivers are not granted to
				  facilities that met the requirements of a Residential Board and Care
				  Occupancy.
Waivers are recommended by the State Survey Agency and
				  approved by the Regional Office.
(A) The waiver would not adversely affect the health
				  and safety of the clients.
B) Rigid application of specific provisions would
				  result in an unreasonable hardship for the facility.
ii) Notwithstanding any provisions of the 2000 edition
				  of the Life Safety Code to the contrary, a facility may install alcohol-based
				  hand rub dispensers if-
(A) Use of alcohol-based hand rub dispensers does not
				  conflict with any State or local codes that prohibit or otherwise restrict the
				  placement of alcohol-based hand rub dispensers in health care
				  facilities;
(B) The dispensers are installed in a manner that
				  minimizes leaks and spills that could lead to falls;
(C) The dispensers are installed in a manner that
				  adequately protects against inappropriate access;
D) The dispensers are installed in accordance with
				  chapter 18.3.2.7 or chapter 19.3.2.7 of the 2000 edition of the Life Safety
				  Code, as amended by NFPA Temporary Interim Amendment 00-1(101), issued by the
				  Standards Council of the National Fire Protection Association on April 15,2004.
				  The Director of the Office of the Federal Register has approved NFPA Temporary
				  Interim Amendment 00-1(101) for incorporation by reference in accordance with
				  5
				  U.S.C. 552(a) and
				  1 CFR part 51. A copy
				  of the amendment is available for inspection at the CMS Information Resource
				  Center, 7500 Security Boulevard, Baltimore, MD and at the Office of the Federal
				  Register, 800 North Capitol Street NW., Suite 700, Washington, DC. Copies may
				  be obtained from the National Fire Protection Association, 1 Batterymarch Park,
				  Quincy, MA 02269; and
(E) The dispensers are maintained in accordance with
				  dispenser manufacturer guidelines
(k) Standard: Paint.
The facility must-
W452
§483.470(k)(1) Use lead-free paint inside the
				  facility; and
W453
§483.470(k)(2) Remove or cover interior paint or
				  plaster containing lead so that it is not accessible to clients.
§483.470(1) Standard: Infection
				  Control
W454
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(1) The facility must provide a sanitary environment to
				  avoid sources and transmission of infections.
Guidance §483.470(1)(1)
The facility is clean and staff have eliminated opportunities
				  for cross-contamination of infections. Food is stored, prepared, distributed,
				  and served in a sanitary manner to prevent food borne illness.
W455
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
There must be an active program for the prevention,
				  control, and investigation of infection and communicable
				  diseases.
Guidance §483.470(1)(1)
Facilities maintain an ongoing surveillance program of
				  communicable disease control and investigation of infections and an active
				  training program that ensures the clients served receive adequate prevention of
				  transmission information and skills, according to needs.
The facility's infection control program should include
				  procedures for:
* identification of the extent of infestation or
				  infection;
* protection of clients;
* treatment of clients;
* notification of family or legal guardian;
* reporting to the health department as indicated; and
* continued follow-up to resolution.
Both the Occupational Safety and Health Administration (OSHA)
				  and the CDC have specific requirements regarding human immuno-deficiency virus
				  (HIV), TB, and hepatitis precautions. These requirements should be incorporated
				  into the facility's practices when relevant to the clients residing in the
				  facility. Concerns about OSHA violations should be referred to OSHA.
W456
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(2) The facility must implement successful corrective
				  action in affected problem areas. W457
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(3) The facility must maintain a record of incidents
				  and corrective actions related to infections. W458
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
(4) The facility must prohibit employees with symptoms
				  or signs of a communicable disease from direct contact with clients and their
				  food.
Guidance §483.470(1)(4)
The facility should have and implement a policy that clearly
				  delineates those signs and symptoms for which they will restrict staff access
				  to clients or to clients' food.
W459
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480 Condition of participation: Dietetic
				  services
(a) Standard: Food and nutrition services
W460
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(a)(1) Each client must receive a
				  nourishing, well balanced, diet including modified and specially prescribed
				  diets. Guidance §483.480(a)(1)
"Well balanced diets" are defined as diets that contain a
				  variety of foods from the food groups currently recommended by the Academy of
				  Nutrition and Dietetics (AND).
"Modified and specially-prescribed" diets are defined as
				  diets that are altered in any way to enable the client to eat (e.g. food that
				  is chopped, pureed) or diets that are intended to correct or prevent a
				  nutritional deficiency or health problem.
Refer to W463 and W474 regarding modified and specially
				  prescribed diets.
The following may be indicators of or may lead to compromised
				  nutritional status:
* Unplanned significant weight gain or loss;
* Fever/infection;
* Diarrhea;
* Chronic disease;
* Chewing and Swallowing problems;
* Teeth and gum diseases;
* Excessive use of laxatives;
* Abnormal laboratory values;
* Brittle, dry hair;
* Ridged or spoon shaped nails;
* Dry flaky skin; and
* Unexplained changed in mood such as general fatigue,
				  apathy, irritability, lack of concentration. If one or more of these indicators
				  are present, determine the facility's response through observation, interview,
				  and record review.
Surveyors should assure the facility is responsive to client
				  food allergies and the potential for adverse food/drug interactions. If
				  surveyors suspects these may exist, investigate further.
Examples of facility responsiveness to allergies and
				  food/drug interactions include, but are not limited to:
* Clients on long term anticonvulsant drug regimens (e.g.,
				  phenobarbital, phenytoin, primidone) are periodically monitored per facility
				  policy for decreased serum levels of folic acid and vitamin D;
* Therapeutic doses of nutrients are provided to decrease the
				  likelihood of anemia and prevent decreased bone density, etc.; and
* Fiber and fluids are increased in the diet of clients to
				  decrease the likelihood of constipation.
Guidance
				  §483.470(a)(1)
Clients of grossly different ages, functional levels, and/or
				  social needs should not be housed together unless all of the following
				  documentation support the placement:
* Assessment;
* Client program plan;
* Staff documentation of client response to training
				  programs; and
* QIDP notes.
W461
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(a)(2) A qualified dietitian must be
				  employed either full-time, part-time, or on a consultant basis at the
				  facility's discretion.
Guidance §483.480(a)(2)
The facility employs a registered dietitian either on a
				  part-time, full-time or on a consultant basis.
W462
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(a)(3) If a qualified dietitian is not
				  employed full-time, the facility must designate a person to serve as the
				  director of food services.
Guidance §483.480(a)(3)
Where the facility does not have a full-time qualified
				  dietitian, verify that the director of food services coordinates with a
				  dietitian to assure the nutritional adequacy of meals and snacks. The food
				  service director coordinates with the part-time or consultant dietitian to
				  develop client meal plans and monitor client nutritional status. The
				  qualifications of the food service director may be dictated by facility policy
				  or by state law, if applicable. In small group home settings where the staff
				  and clients plan and prepare meals cooperatively, there may not be a designated
				  food services director. In these cases, the consultant or part-time dietitian
				  would meet with the available home staff to ensure adequacy of menus and
				  diets.
§483.480(a)(4) The client's interdisciplinary
				  team, including a qualified dietitian and physician must
				  prescribe
W463
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(a)(4) all modified and special
				  diets
W464
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(a)(4) including those used as a part of a
				  program to manage inappropriate client behavior.
Guidance §483.480(a)(4)
Modifying a clients' diet must never be used as
				  punishment.
W465
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(a)(5) Foods proposed for use as a primary
				  reinforcement of adaptive behavior are evaluated in light of the client's
				  nutritional status and needs.
Guidance §483.480(a)(5)
This regulation addresses the use of food in shaping positive
				  adaptive behavior. Where clients have specialized nutritional needs, these
				  needs must be taken into consideration. When food is used as a primary
				  reinforcement of behavior for a client who has a dietary restriction, these
				  foods should be consistent with the foods allowed by the prescribed diet. Food
				  used as a reinforcement must be part of a behavior plan approved by the IDT and
				  consistent with nutritional parameters for that client. For example, a client
				  with diabetes does not receive concentrated sweets as a reinforcement.
W466
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(a)(6) Unless otherwise specified by
				  medical needs, the diet must be prepared at least
in accordance with the latest edition of the
				  recommended dietary allowances of the Food and Nutrition Board of the National
				  Research Council, National Academy of Sciences, adjusted for age, sex,
				  disability and activity.
Guidance §483.480(a)(6)
For suggested guidelines write to: U.S. Department of
				  Agriculture Human Nutrition Information Services Washington, D.C. 20250
http://fnic.nal.usda.gov
(b) Standard: Meal services
W467
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(b)(1) Each client must receive at least
				  three meals daily,
Guidance §483.480(b)(1)
Meal times may be flexible and accommodate a variety of
				  activities (e.g. holiday and weekend activities). Clients should be offered the
				  opportunity of three meals every day, but may be given the choice of not
				  participating in a meal due to their schedule or preference. For example, a
				  client wakes up late on a Saturday morning and decides to have brunch.
W468
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(b)(1) at regular times comparable to
				  normal mealtimes in the community Guidance §483.480(b)(1)
Generally, meal times conform to the norms of the community,
				  however the clients' schedules and preferences may result in slight variations.
				  Slight variations are acceptable, but gross variations such as breakfast at 3
				  am would not be acceptable.
§483.480(b)(1) with -
W469
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(b)(1)(i) Not more than 14 hours between a
				  substantial evening meal and breakfast of the following day,
Guidance §483.480(b)(1)(i)
A "substantial evening meal" is defined as an offering of
				  three or more items at one time, one of which includes a high quality protein
				  such as meat, fish, eggs, or cheese. The meal should represent no less than 20
				  percent of the day's total nutritional requirements.
W470
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(b)(1)(i) except on weekends and holidays
				  when a nourishing snack is provided at bedtime, 16 hours may lapse between a
				  substantial evening meal and breakfast; and
Guidance §483.480(b)(1)(i)
A "nourishing snack" is an offering of items, single or in
				  combination, from the basic food groups. Snack supplies are available in the
				  facility and are accessible to clients. Interview staff and clients about their
				  access to snacks.
W471
§483.480(b)(1)(ii) Not less than 10 hours between
				  breakfast and the evening meal of the same day, except as provided under
				  paragraph (b)(1)(f).
§483.480(b)(2) Food must be served-
Facility Practices §483.480(b)(2)(i)
Portions served, either by staff or by the individuals
				  themselves, closely match designated serving sizes on menus. Slight variations
				  are not significant enough or frequent enough to affect individual's
				  health.
W472
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(b)(2)(i) In appropriate
				  quantity;
Guidance §483.480(b)(2)(i)
Meal observations verify that portions served, either by
				  staff or by the clients, match the designated serving sizes on menus.
W473
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(b)(2)(ii) At appropriate
				  temperature;
Guidance §483.480(b)(2)(ii)
Hot foods are served hot and cold foods are served cold,
				  according to facility policy specific to the type of food or as desired by the
				  client. The facility follows current state requirements for safe food
				  temperatures.
W474
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(b)(2)(iii) In a form consistent with the
				  developmental level of the client; and
Guidance §483.480(b)(2)(iii)
The term "form", as used in this requirement, refers to food
				  consistency (e.g., pureed, chopped, ground, etc.). Food that is ground, chopped
				  or pureed is based on assessed client need, and only to the extent required.
				  Food consistency modifications due to an acute medical or dental condition are
				  temporary and; client's food consistency is upgraded at the soonest possible
				  time. Clients with chronic medical or dental conditions are periodically
				  reviewed and at least annually for the possibility of an upgrade in food
				  consistency. Client assessments must document the justification for modified
				  texture of the client's diet.
W475
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(b)(2)(iv) With appropriate
				  utensils.
Guidance §483.480(b)(2)(iv)
"Appropriate utensils" refers to eating utensils and adaptive
				  eating equipment that enable clients to eat as independently as possible in
				  accordance with their highest functional level. Commonly used utensils (fork,
				  knife, and spoon) appropriate to the food being consumed are provided to all
				  clients except those using adaptive equipment instead. Clients should be
				  afforded the opportunity to use forks, spoons, and knives as indicated by the
				  food served. Utensils must be in good condition, clean, allow portion sizes
				  appropriate to the client's prescribed diet and meet the client's needs.
W476
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(b)(3) Food served to clients individually
				  and uneaten must be discarded.
Guidance §483.480(b)(3)
This standard does not apply to food served in family-style
				  dishes, unless the length of time the food is on the table or other
				  considerations (such as clients fingering or drooling in the food) compromise
				  the safety and nutritive value for later consumption of the food.
(c) Standard: Menus
W477
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(c)(1)(i) Be prepared in
				  advance;
Guidance §483.480(c)(1)(i)
The facility should be able to produce a copy of client menus
				  prospectively to verify that meal planning is done in advance.
W478
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(c)(1)(ii) Provide a variety of foods at
				  each meal;
Guidance §483.480(c)(1)(ii)
A "variety" of food at each meal includes offerings from each
				  of the food groups.
W479
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(c)(1)(iii) Be different for the same days
				  of each week and adjusted for seasonal changes; and
Guidance §483.480(c)(1)(iii)
Menus should make use of seasonal foods in order to
				  capitalize on the availability of fresher more vitamin enriched foods. In
				  certain portions of the country, there may be cultural preferences that
				  influence the frequency with which a food appears on the menu. This is
				  acceptable in the facility if it is acceptable in the community.
W480
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(c)(1)(iv) Include the average portion
				  sizes for menu items.
Guidance §483.480(c)(1)(iv)
Verify the menu lists client portion sizes and observe that
				  the portions served correspond to the clients prescribed diet.
W481
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(c)(2) Menus for food actually served must
				  be kept on file for 30 days.
(d) Standard: Dining areas and service
§483.480(d) The facility must -
W482
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(d)(1) Serve meals for all clients,
				  including persons with ambulation deficits, in dining areas, unless otherwise
				  specified by the interdisciplinary team or a physician;
Guidance §483.480(d)(1)
For purposes of this standard, "dining areas" mean discrete
				  eating areas located outside of bedrooms, established, furnished, and equipped
				  for the purpose of eating meals. When a client is not eating in a designated
				  dining area, there must be either a medical rationale or this must be an
				  isolated instance when the client has a personal reason to eat in another area,
				  such as a television area to watch his or her favorite program. Interview with
				  the client should confirm that this is not routine, but is for a particular
				  isolated reason.
W483
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(d)(2) Provide table service for all
				  clients who can and will eat at a table, including clients in
				  wheelchairs;
Guidance §483.480(d)(2)
Clients must have the opportunity to participate in the
				  normal dining experience with their companions in the dining room. Clients in
				  wheelchairs are included in dining groupings of their peers without physical
				  disabilities. Clients in wheelchairs eat at the table and not with lap
				  trays/hospital trays unless medically contraindicated.
W484
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(d)(3) Equip areas with tables, chairs,
				  eating utensils, and dishes designed to meet the developmental needs of each
				  client;
Guidance §483.480(d)(3)
Clients use adaptive equipment or are being trained to use
				  such equipment when the need is identified in the IPP.
Examples of adaptive equipment that may be needed are:
* Double suction cups or other devices to anchor dishes on a
				  table or tray for clients with major coordination problems;
* Rocking one-handed knife-fork or knife-spoon for a client
				  with the use of only one hand;
* Built-up or extended handles or silverware for those with
				  problems of grasp or range of motion;
* Plate guards or plates with raised rims to provide a
				  surface against which the client with a physical disability can push food onto
				  a fork or a spoon;
* Flexible drinking straws;
* Spoon bent to a 90 degree angle at the bowl or a swivel
				  spoon to assist a client without normal wrist motions; and
* Any other adaptive device deemed by the team as needed by
				  the client to eat more independently.
W485
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(d)(4) Supervise and staff dining rooms
				  adequately
Guidance §483.480(d)(4)
There should be sufficient staff to implement eating programs
				  for clients who require them and to provide necessary intervention and
				  supervision for normalization including normal meal time behavior. Client
				  mealtime should not be inadequately delayed due to insufficient staff
				  assistance.
W486
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(d)(4) to direct self-help dining
				  procedures,
Guidance §483.480(d)(4)
Staff is present during meal times to monitor clients who are
				  able to eat independently, promoting, supporting, reinforcing and encouraging
				  them to eat in an appropriate and normalized manner (e.g., manners, social
				  behaviors, etc.)
W487
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(d)(4) to assure that each client receives
				  enough food and
Guidance §483.480(d)(4)
Clients can request and receive second helpings unless
				  contraindicated by a prescribed diet. For clients on restrictive diets that
				  prefer not to be on these diets or seek seconds, the facility resolves the
				  personal choice issues vs. health risks.
W488
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(d)(4) to assure that each client eats in
				  a manner consistent with his or her developmental level; and
Guidance §483.480(d)(4)
The intent of this regulation is to promote the acquisition
				  of skills that lead to greater independence in eating.
Clients should be actively encouraged to eat independently to
				  the extent possible and in accordance with their assessed abilities.
Clients should receive training to develop independent eating
				  skills consistent with their developmental potential as identified through the
				  CFA.
Clients learn skills in accordance with their functional
				  levels. Skills may include:
* Use of utensils;
* Meal preparation;
* Socialization during meals;
* Family style dining; and
* Ordering food in restaurants.
Clients' eating programs are implemented in accordance with
				  their training objectives. To the maximum extent possible, staff model
				  appropriate mealtime behavior and conversation by sitting at the table with
				  clients, and when possible, eating meals with clients.
W489
(Rev. 135, Issued: 02-27-15, Effective: 04-27-15,
				  Implementation: 04-27-15)
§483.480(d)(5) Ensure that each client eats in an
				  upright position, unless otherwise specified by the interdisciplinary team or a
				  physician.
Guidance §483.480(d)(5)
If a client eats in any position other than an upright
				  position, the physician should document the medical necessity for the position,
				  and/or the IPP should include the program plan to teach the client the physical
				  skill necessary for eating upright.
This applies to all clients, including those fed by
				  nasogastric tube or gastrostomy tube. The IPP should identify the most
				  appropriate position for the client to be positioned during mealtime, in
				  relation to the placement of the food contents.