Preparing Your Organization for

MEDICARE SPECIAL "CONDITIONS OF PARTICIPATION" SURVEYS

(INCLUDING THE PATIENT RIGHTS—RESTRAINT AND SECLUSION—STANDARDS)

OBJECTIVES

At the completion of the conference the participant will be able to:

• List the types of surveys conducted by CMS for psychiatric providers (initial, re-certification, complaint, and immediate jeopardy)

• Identify the roles of the CMS Central Office, Regional Offices, and State Agencies in the survey process

• Identify documents relative to the survey process including the psychiatric hospital regulations, the interpretive guidelines, and the survey protocol

• Explain what happens after the survey—the role of the Regional Office and the formulation and review of the Plan of Correction

• Review elements of facility preparation for the survey (data that may be requested, how surveyors interact with patients and staff, etc.)

• Identify specific requirements of the Restraint and Seclusion provisions of the Patient Rights Condition of Participation

• Discuss CMS response to areas of concern identified by providers (e.g., qualifications of the director of nursing, content of treatment plans, content of treatment notes, requirements relevant to discharge planning, roles of social work and activity therapy in the environment of shorter lengths of stay, etc.)

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