CMHC Conditions of Participation

CMHC Conditions of Participation Mary Rossi-Coajou Center for Clinical Standards and Quality/Clinical Standards Group The Centers for Medicare and Medicare Services March 4,2014

Key Themes The CMHC NPRM has been published in the Federal Register on June 17, 2011. Comment period ended on August 16, 2011. Final rule published October 29, 2013 Effective date October 29, 2014 The rule is client-centered, focuses on health and safety of the client, and supports quality improvement.

What are the Conditions of Participation? Requirements that providers and suppliers must meet to be Medicare-certified, and be paid for furnishing services to Medicare beneficiaries. These requirements are enforced by the State Survey Agency.

Changing Focus Present /Future Focus Client centered Emphasizes quality improvement and client outcomes

General Departmental Objectives for the Regulation Modernization New Conditions: - Are founded on evidence and standards of practice Are Client-centered Promote outcomes desired for Medicaid and Medicare Beneficiaries

Regulation Modernization (continued) Establish a framework for Quality Assessment and Performance Improvement Set clear expectations for CMHC accountability Stimulate improvements in processes, outcomes of care, and beneficiary satisfaction

Affect on Client Care Regulatory Priority Client Centered The client/family is a member of the interdisciplinary team. A framework is set up that allows client outcomes of care to drive improvements in care. Process requirements are updated where necessary to protect client safety.

CMHC Conditions will not Change Payment Rates How does Medicare define a CMHC? Definition: (i) Provides outpatient services, including specialized outpatient services for children, elderly individuals, individuals with serious mental illness, and residents of its mental health service area who have been discharged from inpatient mental health facilities. (ii) Provides 24-hour-a-day emergency care services. (iii) Provides day treatment, partial hospitalization services other than in an individual s home or in an inpatient or residential setting, or psychosocial rehabilitation services.

CMHC Conditions will not Change Payment Rates How does Medicare define a CMHC? Definition cont d: (iv) Provides screening for clients being considered for admission to State mental health facilities to determine the appropriateness of such services, unless otherwise directed by State law. (v) Provides at least 40 percent of its items and services to individuals who are not eligible for benefits under title XVIII of the Act. **Under the Medicare program, CMHCs are recognized as Medicare providers only for Partial Hospitalization services.** (42CRF410.110)

CMHC Conditions will not Change Payment Rates Does this Medicare rule apply to me? If you are Medicare certified, meaning you are Medicare enrolled based on CMS Regional Office determination, that you meet the definition of a CMHC at 1861(ff)(3)(B) of the Act and provide the core services described in section 1913(c)(1) of the PHS Act.. Then this rule applies to you!

What are the new final requirements?

Subpart J: Conditions of Participation: Community Mental Health Centers (CMHC) 485.900 Statutory basis and Scope 485.902 Definitions

485.904 Personnel Qualifications 485.904(a)General qualification requirements: All professionals who furnish services directly, under an individual contract, or under arrangements with the CMHC, must be legally authorized (licensed, certified or registered),in accordance with applicable Federal, State and local laws

485.904 Personnel Qualifications and must act only within the scope of their state licenses certifications, or registrations. All personnel qualifications must be kept current at all times.

485.904 Personnel Qualifications Cont d 485.904(b) Personnel qualifications for certain disciplines. The following qualifications must be met: - Administrator of a CMHC - Clinical Psychologist - Clinical Social worker - Mental Health Counselor - Occupational Therapist

485.904 Personnel Qualifications Cont d 485.904(b) Personnel qualifications for certain disciplines cont d - Physician - Physician Assistant - Advanced Practice Nurse -Psychiatrist

485.910 Client Rights 485.910 Client rights The client has the right to be informed of his or her rights. The CMHC must protect and promote the exercise of these rights.

485.910 Client Rights Cont d (a) Notice of rights and responsibilities. (1)During the initial evaluation the CMHC must provide the client, the clients representative (if appropriate) or surrogate with verbal and written notice of the clients rights and responsibilities (2)During the initial evaluation, the CMHC must inform and distribute written information to the client concerning its policies on filing a grievance.

485.910 Client Rights Cont d (a) Notice of rights and responsibilities cont d. (3)Obtain clients and/or client s representative signature confirming that he or she has received a copy of the notice of rights and responsibilities.

485.910 Client Rights Cont d (b) Exercise and rights and respect of property and person. (1)The client has the right to - Exercise his or her rights as a client of the CMHC - Have his or her property and person treated with respect - Voice grievances and understand the CMHC grievance process - Not be subjected to discrimination or reprisal for exercising his or her rights

485.910 Client Rights Cont d (b) Exercise and rights and respect of property and person cont d. (2) If a client has been adjudged incompetent under state law by a court of proper jurisdiction, the rights of the client are exercised by the person appointed in accordance with State law to act on the clients behalf

485.910 Client Rights Cont d (b) Exercise and rights and respect of property and person cont d. (3) If a State court has not adjudged a client to be incompetent, any legal representative designated by the client in accordance with State law may exercise the client's rights to the extent allowed under State law.

485.910 Client Rights Cont d (c) Standard: Rights of the Client. The client has the right to: (1) Be involved in developing his or her active treatment plan (2) Refuse care or treatment (3) Have a confidential clinical record (4) Be free from mistreatment, neglect or abuse (5) Receive information about specific limitations on services that he or she will be furnished (6) Not be compelled to perform services for the CMHC

485.910 Client Rights Cont d (d) Addressing violations: (1) Ensure all violations are reported immediately to the CMHC administrator by CMHC employees, volunteers and contracted staff (2) Immediately investigate all alleged violations involving anyone furnishing services on behalf of the CMHC and immediately take action to prevent further potential violations during the investigation process.

485.910 Client Rights Cont d (d) Addressing violations cont d: (3) Take appropriate corrective action if the alleged violation is investigated by the administration or by an outside entity have jurisdiction (law enforcement or State agency; and (4)Within 5 working days of becoming aware of the violation, all violations are reported to the State survey and certification agency and verified violations are reported to the State and local entities having jurisdiction.

485.910 Client Rights Cont d (e) Restraint and seclusion: Only imposed to ensure the immediate safety of the client, staff or other individuals. Used while awaiting transfer of the client to the hospital. Contrary to targeted client outcomes, so use of restraints or seclusion would be considered an adverse event and would be tracked as part of the CMHC QAPI program

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client 485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client 485.914 (a) Admission, must determine that the client is appropriate for the services provided at 410.2 - For clients assessed and admitted for partial hospitalizations services, the CMHC must also meet the requirements at 485.918(f)

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(b) (1)Initial evaluation: A licensed mental health professional employed by the CMHC and acting within his or her State scope of practice must complete the initial evaluation within 24 hours of admission to the CMHC (2)Initial evaluation at a minimum must include the following: admitting Dx and other Dx, referral source, reason for admission, immediate care needs r/t Dx, current Rx

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d - For PHP admissions: an explanation as to why the client would be at risk for hospitalization if PHP were not provided (3) Based on the finding of the initial evaluation, the CMHC must determine the appropriate members of each clients interdisciplinary treatment team

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(c) Comprehensive assessment (1) Comprehensive assessment must be completed by a licensed mental health professionals who are members of the interdisciplinary treatment team performing within their State scope of practice (2) Comprehensive assessment must be completed in a timely manner, consistent with the client s immediate needs, but no later than 4 working days after admission to the CMHC

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(c) Comprehensive assessment (3) Comprehensive assessment must identify the physical, psychological, emotional, therapeutic, and other needs related to the clients psychiatric illness. The CMHCs interdisciplinary treatment team must ensure that the active treatment plan is consistent with the finding of the comprehensive assessment

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(c) Comprehensive assessment (4) Comprehensive assessment at a minimum must include the following: Reason for admission, a psychiatric evaluation, info on previous and current mental status, information regarding the onset of symptoms, factors that may affect Tx plan, assessment of functioning, complications and risk factors, functional status, factors affecting client safety, Rx profile, referrals, support systems and

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(c) Comprehensive assessment cont d for pediatric patients, the CMHC must assess the social service needs of the client, and make referrals to social services and child welfare agencies as appropriate

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(d) Update of the comprehensive assessment (1) The CMHC must update the comprehensive assessment via the CMHC interdisciplinary team, in consultation with the primary health care provider (if any), when changes in the client s status, responses to treatment, or goal achievement have occurred

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(d) Update of the comprehensive assessment (2) the comprehensive assessment must be updated no less frequently than every 30 days (3) The update must include information on the client s progress toward desired outcomes, a reassessment of the clients responses to care and therapies, and the client s goals.

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(e) Discharge or transfer of the client (1) If the client is discharges to another entity, the CMHC must, within 2 working days forward to the entity: - a copy of the discharge summary - the clients clinical record, if requested

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(e) Discharge or transfer of the client (2) If the client refuses the services of a CMHC, or is discharges from a CMHC due to noncompliance with the treatment plan, the CMHC must forward to the primary health care provider (if any) a copy of : - the discharge summary - the clients clinical record, if requested

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(e) Discharge or transfer of the client (3) The CMHC discharge summary must include: - a summary of services provided, including the client s symptoms, treatment and recovery goals and preferences, treatments and therapies - the clients current active treatment plan at the time of discharge - most recent physicians orders - Any other documentation that will assist with continuity of care

485.914 Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client cont d 485.914(e) Discharge or transfer of the client (4) The CMHC must adhere to all Federal and Staterelated requirements pertaining to the medical privacy and release of client information

485.916 Treatment plan, client-centered active treatment plan, and coordination of services CMHC designates an interdisciplinary treatment team that is responsible, with the client for directing, coordinating, and managing the care and services for each client. IDT works together to meet the physical, medical, psychosocial, emotional and therapeutic needs of the clients. IDG is paramount in directing and monitoring client care.

485.916 Treatment plan, client-centered active treatment plan, and coordination of services 485.916(a) Delivery of services. (1) The IDG is led by a MD, NP, PA, CNS, psychologist or CSW, must provide the care and services offered by the CMHC

485.916 Treatment plan, client-centered active treatment plan, and coordination of services 485.916(a) Delivery of services cont d. - (2) Based on the finding of thee comprehensive assessment, the CMHC must determine the appropriate mental health professional, who is a member of the IDT, to coordinate care and treatment decisions with each client, to ensure client needs are assessed and that the active Tx plan is implemented as indicated

485.916 Treatment plan, client-centered active treatment plan, and coordination of services 485.916(a) Delivery of services cont d. (3) IDT may include: -A doctor of medicine or osteopathy or psychiatry (who is an employee or under contract with the CMHC) - A psychiatric registered nurse - A clinical social worker - A clinical psychologist - An occupational therapist - Other licensed health professionals, as necessary

485.916 Treatment plan, client-centered active treatment plan, and coordination of services 485.916(a)(4) If the CMHC has more than 1 IDT, it must designate the team responsible for establishing policies and procedures governing the coordination of services and the day to day provision of CMHC care and services

485.916 Treatment plan, client-centered active treatment plan, and coordination of services 485.916(b) Person-centered active treatment plan - Care and services furnished to the clients must be consistent with an individualized written active treatment plan that is established by the IDT, the client, and the client s primary caregiver in accordance with the client s recovery goals and preferences, within 7 days of admission to the CMHC

485.916 Treatment plan, client-centered active treatment plan, and coordination of services 485.916(b) Person-centered active treatment plan - (b) cont d: The CMHC must ensure that the clients primary care giver (as applicable), receive education and training by the CMHC that are consistent with the client s and caregivers responsibilities as identified in the active treatment plan

485.916 Treatment plan, client-centered active treatment plan, and coordination of services 485.916(c) Content of the person-centered active treatment plan - A person-centered individualized active treatment plan must be developed for each client - The active treatment plan must take into consideration client recovery goals and issues identified in the comprehensive assessment

485.916 Treatment plan, client-centered active treatment plan, and coordination of services 485.916(c) Content of the person-centered active treatment plan The active treatment plan must include all services necessary to assist the client in meeting his or her recovery goals, including: Client diagnosis Treatment goals Interventions Detailed statement of the type, duration and frequency of services, necessary to meet the client s needs

485.916 Treatment plan, client-centered active treatment plan, and coordination of services 485.916(c) Content of the personcentered active treatment plan -Drugs, treatments, and individual and/or group therapies -Family psychotherapy with the primary focus on treatment of the client s condition -IDT s documentation of the client s or representative s and primary caregiver (if any) understanding, involvement, and agreement with the plan of care, in accordance with CMHC s policies

485.916 Treatment plan, client-centered active treatment plan, and coordination of services 485.916(d) Review of the person-centered active treatment plan - The IDT must review, revise, and document the individualized active treatment plan as frequently as the client s condition requires, but no less than every 30 calendar days

485.916 Treatment plan, client-centered active treatment plan, and coordination of services (d) cont d: The revised active treatment plan must include information from : Initial evaluation and comprehensive assessments The clients progress towards outcomes and goals specified in the active treatment plan Changes in the clients goals The CMHC must meet partial hospitalizations program requirements in 424.24(e) of this chapter if such services are included in the active treatment plan

485.916 Treatment plan, client-centered active treatment plan, and coordination of services (e) Coordination of services: - The CMHC must develop and maintain a system of communication that assures the integration of services in accordance with its policies and procedures and, at a minimum, would do the following: (1) Ensures that the IDT maintains responsibility for directing, coordinating, and supervising the care and services provided

485.916 Treatment plan, client-centered active treatment plan, and coordination of services (e) Coordination of services cont d: (2) Ensure that care and services are provided in accordance wit the active treatment plan (3) Ensure that the care and services provided are based on all assessments of the client (4) Provide for and ensure the ongoing sharing of information among all disciplines providing care and services, whether the care and services are provided by employees or those under contract with the CMHC

485.916 Treatment plan, client-centered active treatment plan, and coordination of services (e) Coordination of services cont d: (5) Provide for ongoing sharing of information with other health care and non-medical providers, including the primary health care provider, furnishing services to a client for conditions unrelated to the psychiatric condition for which the client has been admitted, and nonmedical supports addressing environmental factors such as housing and employment.

485.917 Quality assessment and performance improvement 485.917(a), Program scope: Show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve behavioral health or other healthcare outcomes and CMHC services; and takes actions to demonstrate improvement in CMHC performance. Measure, analyze, and track quality indicators, adverse events (including restraint and seclusion) and other aspects of performance that enable the CMHC to assess process of care, services and operations

485.917 Quality assessment and performance improvement 485.917(b), Program data; The program must utilize quality indicator data, including client care, and other relevant data, in the design of its program CMHC must use data collected to: -Monitor effectiveness and safety of services and quality of care and identify opportunities for improvement -Frequency and detail of the data collection must be specified by the CMHC s governing body

485.917 Quality assessment and performance improvement 485.917(c), Program activities (1)The CMHC s performance improvement activities must: - Focus on high risk, high volume or problem prone areas - Consider incidence, prevalence, and severity of problems in those areas - Give priority to improvements that affect behavioral outcomes, client safety and clientcentered quality of care

485.917 Quality assessment and performance improvement 485.917(c), Program activities cont d (2) Performance activities must track adverse client events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the CMHC

485.917 Quality assessment and performance improvement 485.917(c), Program activities cont d: (3) Take action aimed at performance improvement - Implement those actions Then: - Measure its success - Track performance to ensure that improvements are sustained

485.917 Quality assessment and performance improvement 485.917(d), Performance improvement projects (1) The number and scope of projects conducted annually is based on the needs of the CMHC population and internal organizational needs and must reflect the scope, complexity and passed performance of the CMHC services and operations

485.917 Quality assessment and performance improvement 485.917(d), Performance improvement projects cont d: (2) Document what quality improvement projects are being conducted, reasons for conducting the projects and measurable progress achieved on these projects

485.917 Quality assessment and performance improvement 485.917(e), Executive responsibilities CMHC governing body is responsible for ensuring: (1)That an ongoing program for quality improvement and client safety is defined, implemented and maintained -Clear expectations for client safety are established

485.917 Quality assessment and performance improvement 485.917(e), Executive responsibilities CMHC governing body is responsible for ensuring (cont d): (2) the CMHC wide quality assessment and performance improvement efforts address priorities of improved quality of care and client safety and all improvement actions are evaluated for effectiveness. (3) CMHC must designate 1 or more individuals who are responsible for operating the QAPI program

485.918 Organization, governance, administration of services, and partial hospitalization services 485.918 Serving the CMHC client 485.918(a) Governing body and administrator 485.918(b) Provision of services -40% requirement: provides 40% of its items and services to individuals who are not eligible for benefits under Title XVIII of the Act, as meaured by the total number CMHC clients treated by the CMHC for whom services are not paid for by Medicare, divided by the total number of clients treated by the CMHC for each 12 month period of enrollment.

485.918 Organization, governance, administration of services, and partial hospitalization services 485.918(c) Professional management responsibility 485.918(d) Staff Training 485.918(e) Physical environment 485.918(f) Partial hospitalization 485.918(g) Compliance with Federal, State, and local laws and regulations related to the health and safety of clients

Benefits of CMHC CoPs Establishes for the first time health and safety standards for all CMHC clients Provides flexibility in how a CMHC uses its resources The client centered rule stimulates advances in client and family care practices A quality assessment and performance improvement program that is designated by each individual CMHC

Take Home Messages The CMHC Final Rule published in the Federal Register on October 29, 2013. Effective date of the rule is Oct. 29, 2014 The rule is client-centered to allow the client and family to experience optimal care.

Additional Proposed Requirements that may apply to CMHCs Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers; Proposed Rule. (CMS-3178-P) Published December 31, 2013. Comment period has been extended until March 31, 2014

Additional Proposed Requirements that may Apply to CMHCs Four standards: (1) An emergency plan based on a risk assessment, using an all-hazards approach focusing on capacities and capabilities (2) Develop and implement policies and procedures based on the plan and risk assessment, (3) Communication plan that complies with both Federal and State law (4) Training and testing program that requires developing and maintaining training and testing programs.

Additional Proposed Requirements that may Apply to CMHCs CMS believes that these standards are reflective of best practices already known to hospitals and other health care providers. Outpatient providers and suppliers will not be required to have policies and procedures for provision of subsistence needs.

Additional Proposed Requirements that may Apply to CMHCs The proposed rule (CMS-3178-P) can be found at: http://www.gpo.gov/fdsys/pkg/fr-2013-12- 27/pdf/2013-30724.pdf A link to regulations.gov to submit comments on the regulation: http://www.regulations.gov/#!searchr esults;rpp=25;po=0;s=cms-2013-0269;fp=true;ns=true

Contact Information Mary Rossi-Coajou Mary.rossicoajou@cms.hhs.gov 410-786-6051

C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 www. T h e N a t i o n a l C o u n c i l. o r g National Council for Behavioral Health Survey of Community Mental Health Centers (CMHC) Don Howard, CMS Program Lead March 4, 2014

CMHC Agenda www. T h e N a t i o n a l C o u n c i l. o r g New CMHC Conditions of Participation (COP) Overview of the survey process Survey Types On Site Survey Process On Site Survey findings Preparing for a survey C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 74

CMHC COP s (In a Nutshell) 1. Personnel qualifications; 2. Client rights; www. T h e N a t i o n a l C o u n c i l. o r g 3. Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client; 4. Treatment team, client- centered active treatment plan, and coordination of services; 5. Quality assessment and performance improvement; and 6. Organization, governance, administration of services, and partial hospitalization services. C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 75

Overview of Survey Process Who: www. T h e N a t i o n a l C o u n c i l. o r g All survey activity has been previously conducted by the Regional Offices; With the implementation of the new regulations all future survey activity will be conducted by the State Survey Agencies (SA); What: Survey types are: certification (initial and recert), complaint (Non-Immediate Jeopardy or Immediate Jeopardy), and followup; C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 76

Overview of Survey Process (cont) What (cont): www. T h e N a t i o n a l C o u n c i l. o r g The SA in preparation for the unannounced surveys, reviews all necessary documentation, including any previous complaints; Where: All currently Medicare certified CMHC s and new CMHC applicants When: The surveys for CMHCs will be unannounced; The survey interval will be every five (5) years; or 20% a year over the course of the next 5 years; C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 77

Survey Types www. T h e N a t i o n a l C o u n c i l. o r g Initial and Recertification Survey of compliance with all the CMS CoP s under 42 CFR Part 485, subpart J Complaint Non-Immediate Jeopardy(IJ) o High Priority Non-IJ. o Medium Priority Non-IJ o Low Priority Non-IJ C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 78

Survey Types (cont) www. T h e N a t i o n a l C o u n c i l. o r g Immediate jeopardy o A situation in which the provider s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a client Follow-up A re-visit or multiple re-visits may be necessary after a Complaint survey which may lead to a full-survey depending on findings. C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 79

On-Site Survey Process www. T h e N a t i o n a l C o u n c i l. o r g Survey Site visit Onsite visits allows for verification that the information providers submit to CMS to enroll in the Medicare program is accurate. During the onsite visit, the State Survey Agency (SA) will review, document, and obtain information that will help CMS determine whether the applicants are operating and meeting applicable federal requirements and CMS criteria for Medicare participation. C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 80

On-Site Survey Process (cont) www. T h e N a t i o n a l C o u n c i l. o r g The SA s role is to verify and gather information, using the CMHC Site Visit Assessment Tool. The information obtained during the onsite visit is subject to CMS review, and a final decision will be issued by the CMS Regional Office. The SA determines whether and how each standard is met. While an CMHC may fail to comply with one or more of the standards during any given survey, it cannot participate in Medicare unless it meets each and every CoP or attains substantial compliance with requirements for CMHC s. C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 81

On-Site Survey Process (cont) www. T h e N a t i o n a l C o u n c i l. o r g Surveyors will generally follow these survey steps: Entrance Conference Task 1- Sample Selection Task 2- Record Review of Individuals in Sample Task 3-Other Records (policy/procedures, incident/accident reports, etc) Task 4- Direct Client Observations and Documentation of those Observations (groups and/ or individual therapy sessions after appropriate permission) C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 82

On-Site Survey Process (cont) www. T h e N a t i o n a l C o u n c i l. o r g Surveyors will generally follow these survey steps (cont): Task 5- Interviews (client, staff/management, parents or legal guardians, if appropriate ) and Documentation of Interviews Task 6- Visit and make observations of all areas in the CMHC Task 7- Decision Making or Pre-Exit discussion, to assure that all tasks have been sufficiently completed and agreement on compliance with each standard and the CoP has been reached. Exit Conference- Preliminary survey findings are informally conveyed to appropriate CMHC staff/management. C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 83

On-Site Survey findings www. T h e N a t i o n a l C o u n c i l. o r g Deficiency types Standard Level Condition Level o The SA prepares its certification for the CMS Regional Office, sends the CMHC a "Statement of Deficiencies," Form CMS-2567. o If the CMHC has not come into compliance with all Conditions or Requirements for CMHC s within the time period accepted as reasonable, the SA certifies noncompliance notwithstanding a Plan of Correction. C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 84

How to Prepare for Survey C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 www. T h e N a t i o n a l C o u n c i l. o r g Review and/or update: Staff training on the updated CMHC six CoP s Tx program compliance (core services, PHP) Policies and Procedures Client files for accurate/compliant/signed documentation Copies of treatment professionals credentials Physical environment 85

Questions and Contact Information www. T h e N a t i o n a l C o u n c i l. o r g Don Howard, MSW CMS Program Lead email: donald.howard@cms.hhs.gov C o n t a c t : C o m m u n i c a t i o n s @ T h e N a t i o n a l C o u n c i l. o r g 2 0 2. 6 8 4. 7 4 5 7 86