Survey Procedures and Interpretive Guidelines for Intermediate Care Facilities for Persons with Mental Retardation

PART 1

This revised ICF/MR survey protocol is to assist surveyors to focus attention on the outcomes of individualized active treatment services.  The Health Care Financing Administration (HCFA) intends the revised survey process to be less resource intensive for providers who consistently demonstrate compliance with the regulations.  The survey process is based on the October 3, 1988 regulation and is applicable to all ICFs/MR, regardless of size.

In 1988, when the current ICF/MR regulation was implemented, it was viewed as a great step forward in promoting a focus on the actual outcomes experienced by consumers, rather than on the policies, procedures and paperwork of the facility.  Since that time there has been an evolution on thinking in both the field of developmental disabilities (DD) and in the field of quality assurance (QA).

The field of DD is increasingly emphasizing supporting individuals in their own homes and communities, rather than placing people in facilities.  In addition services in virtually all States are placing increased emphasis on person-centered planning and person-centered services that focus on the preferences, goals and aspirations of each individual and on supporting them in reaching their personal goals.  The field of QA is placing increased emphasis on outcomes related to choice, control, relationships, community inclusion, and satisfaction with life, as well as satisfaction with services and supports.  Many QA systems also include organizational self-assessment and continuous quality improvement components.  These trends have contributed to the perception by providers and advocates that the ICF/MR regulation and oversight process is too prescriptive and cumbersome, and should be altered to reflect newer values of quality enhancement and continuous quality improvement.

This revised survey protocol gives facilities broader latitude to develop the processes by which it implements active treatment services. While the facility practice must comply with the requirements of 42 CFR 483, Subpart I, the survey is to center on the fundamental requirements that produce outcomes for individuals.  When those outcomes occur, review of additional supporting requirements of process and structure is not indicated.

A survey which focuses on observations of staff/consumer interaction and on interviews with consumers regarding their participation and choice of services is sufficiently informative to determine the outcomes of active treatment.  In the presence of problems, a more in-depth review of how the process unfolded for a particular individual(s) occurs.

A facility may receive reimbursement only for the cost of care of individuals classifiedas eligible for the ICF/MR level of care who are receiving active treatment.  Determine facility compliance with Conditions of Participation and with standards in the context of individual experiences within the facility.  When performing certification surveys to assess facility compliance, assess whether individuals are receiving needed active treatment services.

II.     PRINCIPAL FOCUS OF SURVEYS

The principal focus of the survey is on the "outcome" of the facility's implementation of ICF/MR active treatment services.  Direct your principal attention to what actually happens to individuals:  whether the facility provides needed services and interventions; whether the facility insures

individuals are free from abuse, mistreatment, or neglect;  whether individuals, families and guardians participate in identifying and selecting services; whether the facility promotes greater independence, choice, integration and productivity; how competently and effectively the staff interact with individuals; and whether all health needs are being met.

Use observation and interview as the primary methods of information gathering.  Conduct record reviews after completion of observations and interviews to confirm specific issues.  Verify that the facility develops interventions and supports that address the individuals' needs, and provides required individual protections and health services.  Do not conduct in-depth reviews of assessments, progress notes or historical data unless outcomes fail to occur for individuals.

III.   SURVEY PROCESS

The survey process is divided into three stages.  They are the fundamental, extended and full survey.  (Note:  These stages do not apply to the Life Safety Code survey.  Every certification and annual re-certification requires a complete Life Safety Code survey) (see instructions in Appendix I).

A.     Fundamental Survey.--A fundamental survey is conducted to determine the quality of services and supports received by individuals, as measured by outcomes for individuals and essential components of a system which must be present for the outcomes of active treatment to occur.  Certain requirements are designated as fundamental and are reviewed first.  The remaining requirements (that are not designated as fundamental) are supporting structures or processes that the facility must implement.  A decision that a provider is in compliance with the fundamental requirements indicates an outcome-reviewed compliance with the non-fundamental requirements and associated conditions of participation.  Focus initial attention on the fundamental requirements of the conditions of participation for:

42 CFR 483.420  Client Protections

All fundamental requirements must be reviewed in every annual recertification survey.  When observations and interviews are complete, review the individuals' records, as needed, to verify observation and interview findings.  If indicated, verify that individual health needs are met and protections are in place.  When the fundamental requirements are "met", the facility meets the Conditions of Participation.

When fundamental requirements are "not met", review the condition-level compliance principles found in the interpretive guidelines for W122, W195, W266, and W318.  Determine whether deficiencies at the fundamental requirements, when viewed as a whole, lead you to believe that one or more of the "not met" compliance principles is present.  If this is the case, conduct an extended survey, as instructed below.  When the "met" compliance principles are present, the facility is assumed to be in compliance with all conditions of participation.  This is the end of the fundamental survey.  The survey agency would prepare a Form HCFA-2567, Statement of Deficiencies, and report any standard-level deficiencies based on the findings from the fundamental survey.

B.  Extended Survey.--An extended survey is conducted when standard-level deficiencies are found during the fundamental survey and the survey team has determined or suspects that one or more Conditions of Participation examined during the fundamental survey (42 CFR 483.420, 42 CFR 483.440, 42 CFR 483.450, and 42 CFR 483.460) are "not met."  The team would need to gather additional information in order to identify the structural and process requirements that are "not met" and to support their condition-level compliance decision.  The team reviews all of the requirements within the Condition(s) for which compliance is in doubt.  Using the condition-level compliance principles in the interpretive guidelines as a guide, determine if the facility complies with the relevant Condition(s) of Participation.

When the survey team determines that the facility is in compliance with the relevant Conditions of Participation, conclude the survey and prepare a HCFA-2567 for facility practices not in compliance with standards.  When the facility is not in compliance with one or more Conditions of Participation, prepare a HCFA-2567 describing the deficient facility practices which are not in compliance with the Conditions of Participation of either 42 CFR 483.420, 42 CFR 483.440, 42 CFR 483.450, or 42 CFR 483.460.  Base any required adverse action on these findings.  Review of additional requirements under other

Conditions of Participation is at the option of the survey agency based on the criteria under paragraph "C" of this section.

NOTE:    Neither the fundamental or the extended survey process preclude the survey agency from review of any standard, if evidence of non-compliant facility practice is suspected during any survey.

C.  Full Survey.--A full survey is conducted at an initial survey and at the discretion of the survey agency, based on the survey agency's identification of concerns related to the provider's capacity to furnish adequate services.  This decision may be based on criteria, including but not limited to, the following:

o      A condition-level deficiency on the previous year's recertification survey,

o      The existence of a time-limited agreement of less than twelve months due to programmatic deficiencies, or

o      Evidence related to diminished capacity to provide services based on other sources, such as complaints, inspection of care findings or State licensure deficiencies that are relevant to Federal requirements.

The team reviews all the requirements in all Conditions of Participation to determine if the facility maintains the process and structure necessary to achieve the required outcomes.  Based on the information collected, determine whether facility practice is in compliance with all Conditions of Participation.

IV.  COMPONENTS OF ACTIVE TREATMENT

The definition of "active treatment in intermediate care facilities for persons with mental retardation" in 42 CFR 435.1009 refers to treatment that meets the requirements specified in the standard for active treatment 42 CFR 483.440(a).  The components of the active treatment processare:

A.    Comprehensive Functional Assessment (42 CFR 483.440(c)(3)).--The individual's interdisciplinary team must produce accurate, comprehensive functional assessment data, within 30 days after admission, that identify all of the individual's:

o  Specific developmental strengths, including individual preferences;

o  Specific functional and adaptive social skills the individual needs to acquire;

o  Presenting disabilities, and when possible their causes;  and

o  Need for services without regard to their availability.

B.     Individual Program Plan (IPP) (42 CFR 483.440(c))--The interdisciplinary team must prepare an IPPwhich includes opportunities for individual choice and self-management and identifies: the discrete, measurable, criteria-based objectives the individual is to achieveand the specific individualized program of specialized and generic strategies, supports, and techniques to be employed. The IPP must be directed toward the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible, and the prevention or deceleration of regression or loss of current optimal functional status.

C.    Program Implementation (42 CFR 483.440(d)).--Each individual must receive a continuous active treatment program consisting of needed interventions and services in sufficientintensity and frequency to support the achievement of IPP objectives.

D.    Program Documentation (42 CFR 483.440(e)).--Accurate, systematic, behaviorally stated data about the individual's performance toward meeting the criteria stated in IPP objectives serves as the basis for necessary change and revision to the program.

E.     Program Monitoring and Change (42 CFR 483.440(f)).--At least annually, the comprehensive functional assessment of each individual is reviewed by the interdisciplinary team for its relevancy and updated, as needed.  The IPP is revised, as appropriate.

V.    TASK 1 -SAMPLE SELECTION

A.    Purpose of the Sample.--The purpose of drawing a sample of individuals from the facility is to reflect a proportionate representation of individuals by the four functional levels (mild, moderate, severe, and profound mental retardation) as defined by the American Association on Mental Deficiency, Classification in Mental Retardation(eighth edition, 1983).

The sampling process is not designed to produce a "statistically valid" sample.  Apply the method with flexibility based upon the prevailing developmental strengths and needs presented by the individuals served by the facility.  A "statistically valid" sample would not accommodate this need.

While the individuals in the sample are targeted for observation and interview, conduct each program audit of the individual within the context of each of the environments in which the individual lives, works, and spends major leisure time.  Although you focus on the individual, the behavior and interactions of all other individuals and staff within those environments also contribute to the total context and conditions for active treatment. Therefore,other individuals will be included in the overall sample.

As the sample is built, additional information about the facility's services and special individual needs may emerge.  If you find that a disproportionate number of disabilities or needs are present within the facility'spopulation add to or replace originally selected individuals of the same functional level in the program audit sample to ensure that the appropriate care and services arereviewed.  Staff interview for individual characteristics (see the back of Form HCFA-3070G) may help identify areas of individual need that should be reflected in the sample.

For example, if you discover a significant percentage of individuals are nonambulatory, and this characteristic has not been represented in the sample, add additional individuals.  Likewise, if while observing Individual A (a member of the sample), you note that Individual B (who was not targeted for the sample) engages in a particular problematic behavior for which staffdo not appear to provide appropriate intervention, add Individual B to the sample in order to probe further if needs are addressed.  You are free by this methodology to add to the sample on an as needed basis.

B.     Sample Size.--Calculate the size of the sample by the following guidance:

C.    Sample Selection.--Do not allow the facility staff to select the sample.

1.     Facilities Serving 100 or Fewer Individuals.--Draw a sample that evenly distributes the individuals among buildings and functioning levels.  Usually, this can be done by asking the staff to provide a full list of the individuals with their building locatons and functional levels and you
choosing the names.

2.     Facilities with over 100 individuals.--

o      Request a listing of all individuals by overall functional (cognitive and adaptive) level (i.e., mild, moderate, severe, profound) and building location.

o      Determine the number of individuals to draw based upon the total individuals from Section III B.

o      Determine the percentage occurrence of each functional level in the overall population (e.g., 12 percent mild; 24 percent moderate; 63 percent severe).

o      Determine the number of individuals to draw in each functional category (for example, if the sample size is 50, and 12 percent of the individuals have mild mental retardation, then multiply 50 by .12 = 6, and draw 6 individuals who have mild mental retardation into the sample).

o      Draw the sample for each functional category.  (Assume there are 60 with mild mental retardation, and 6 are to be sampled.  Divide 60 by 6 = 10, and draw every tenth individual.)  The interval of selection varies with each functional category because there will be a different percentage occurrence at each.  Thus, assuming there are 16 individuals with severe mental retardation and 4 are to be sampled, draw every fourth name from the list of individuals with severe mental retardation.

o      Locate each selected individual's living unit on a map of the facility building(s) to see if too many are concentrated in too few buildings.  To provide a comprehensive look at the facility, drop some individuals and add others in other buildings for a better distribution.  Each individual replacing an originally selected individual must be of the same functional level.

3.     Alternate Sampling Procedure.--In the rare situation in which the facility is unable to produce the necessary data on which to draw the sample, draw a random sample, to the maximum extent possible.  Supplement it as described in Section VA.

Mental retardation, as defined by the American Association on Mental Retardation (AAMR) in Mental Retardation:  Definition, Classification and Systems of Supports (ninth edition, 1992), is no longer classified in four functional levels (mild, moderate, severe, and profound.)  Most facilities have not yet adopted the 1992 classification system; however, when the facility does use the 1992 classification system and information regarding the four functional levels is not available, revise the sampling procedure. Follow the instructions in A and B above but, instead of using the four functional levels referenced in AAMR's Classification System of 1983, use the four levels of intensity of supports (intermittent, limited, extensive, and pervasive) on Dimension I for Self-Care from the new classification system.  Although not equivalent to the 1993 classifications, this method should provide a sample of individuals within the facility who represent a variety of functional abilities.

D.    Program Audit Approach.--To maximize the advantage of an interdisciplinary survey team, the team leader assigns each member an equitable number of individuals on whom to focus.  For each individual, assess all applicable fundamental requirements of the ICF/MR Conditions of Participation based on the individual's need for that particular service.  Each member of the team shares salient data about findings relative to his or her assigned individuals.  Consult with one another, on a regular basis during the survey, to maximize sharing of knowledge and competencies.

E.     Sampling on Follow-up Survey.--The purpose of the follow-up survey is to verify correction of deficiencies previously cited on the HCFA-2567.  It is NOT necessary to do a full review of all services being received, only those areas in which deficiencies were previously cited.  Sample selection on the follow-up survey is, therefore, dependent on the nature of the deficiencies for which follow-up must be done.

If the last survey found multiple standard-level deficiencies that are not limited to a specific area or issue, follow the procedure described in paragraphs A through D above to select a new sample and use the same sample size specified in paragraph B.  This procedure may result in inclusion of some individuals from the previous sample, however, approximately 50% of the sample on the follow-up survey should be individuals who were not previously reviewed in order to assure systemic correction of the identified deficiencies.  This can be accomplished by beginning the interval of selection at a different point on the list of individuals residing at the facility.  The maximum sample size on a follow-up survey is 30.

When Conditions of Participation have been found not met in the annual survey and the types of deficiencies are limited to a specific need or service area, then the follow-up sample may be drawn from the specific universe of individuals who have that specific need.   To select the sample, start with the total number of individuals affected by the specific need, then choose the sample size.  The sample universe will be the total number of individuals who have that specific need.  For example, if the facility has 20 individuals receiving medications to manage behavior, the sample size would be 8, in accordance with paragraph B. 

VI.   TASK 2 -        REVIEW OF FACILITY SYSTEMS TO PREVENT ABUSE, NEGLECT AND MISTREATMENT AND TO RESOLVE COMPLAINTS

During the entrance conference, determine how the facility resolves individual complaints and allegations of abuse, mistreatment and neglect.  While no specific system is required, 42 CFR 483.420(d)(4) does require that the results of all investigations are reported to the administrator and are reported in

accordance with State law.  The facility, therefore, should have a reproducible mechanism to assure its responsiveness to concerns of individuals and their families.  That system must assure prompt detection, reporting, investigation and resolution of complaints and of allegations and occurrences of abuse, mistreatment and neglect and injuries from unknown sources.

Review the facility's system (e.g., accident and injury logs and reports) for any evidence that suggests that individuals are being abused or are vulnerable to abuse and injury.  Data that is derived from these reports are important in the event that you find an immediate and serious threat to an individual's health and safety.  If you discern any patterns that suggest abuse, follow up on the status and condition of those individuals.  Also review investigations completed and those in process to determine that the facility protects individuals from abuse, mistreatment and neglect while the allegation is under investigation.  If the State law or regulation requires the facility to report such allegation to other agencies, determine that this occurs.

Conducting this review early in the survey process facilitates any necessary follow-up during later observations, interviews or record reviews of individuals.  Use the Interpretive Guidelines and Additional Data Probes at 42 CFR 483.420(a)(5) or W127 for further guidance.  If you believe serious and immediate threat to individual's health and safety exists, consult Appendix Q.

VII.  TASK 3 - INDIVIDUAL OBSERVATIONS

Upon completion of Task 2, surveyors are to conduct observations of the individuals selected for the sample.  DO NOT:

o      Conduct a detailed review of individual's records;

o      Conduct an inspection tour of the facility's environment; or

o      Request facility staff to keep people home from scheduled activities, such as work or day programs.

A.    Purpose.--Determine if the necessary relationship between the individual's needs and preferences, and what staff know and do with individuals, in both formal and informal settings throughout the day and evening, is made.

As a result of any observation, the surveyor should be able to determine whether:

o      Competent interaction occurs between staff and the individual(s);

o      Individuals are given the opportunity to exercise choice and function with as much self-determination and independence as possible; and

o      Staff provide the needed supports and interventions to increase skills or prevent loss of functioning.

The primary purpose of the visit to the out-of-home program is to determine whether the individual is receiving services that promote growth and independence and how the residence assures consistent delivery of services.  Generally the out-of-home program and residence should be using the same interventions, communication methods, and behavior shaping strategies.  If not, determine the justification for the difference in services.  For example, if the day program is using physical restraints as an intervention and the home is not, determine the justification for the restraints.

B.     Survey Conduct.--Be present when individuals are present. If individuals are in a program other than in the residence, go to that location. Observe each person in the sample in the home environment and in the day

program.  Observations across the entire survey (e.g., early morning, afternoon and evening observations) are absolutely essential.  One method to conduct observations over this time span is to alter the work day of the survey team members. For example, some members might work from 6:30 a.m. to 3:00 p.m., while others work from 1:00 p.m. to 9:30 p.m.

Schedule your time to observe special training programs that are critical to the individuals' development.  Use your observations to determine if individual training is carried out consistently at all appropriate times throughout the day. Observations of meal times, individuals' communication with staff and others, behavior shaping interventions, and routine activities should reflect a consistent pattern of interaction with the individual and demonstrate the staff's knowledge of the individual.  Take steps to validate any discrepancies noted.  Additional observations within similar situations, locations or activities may be necessary to identify a systemic deficient practice as opposed to a one time occurrence. 

Show respect for the individuals' home and their privacy.  As a courtesy, alway request permission before entering a bedroom.  Do not observe activities in which individuals are undressed unless that observation is essential to your assessment of facility compliance and the information cannot be obtained from other reliable sources.  Most information about routine hygiene activities during which individuals are undressed can be obtained through interview of individuals or staff.  As a general policy, it is preferable to ask permission to make these types of observations from the individual, or from the staff person who is present if the individual cannot communicate.  An individual's request not to be observed while undressed should be honored, when possible.  The surveyor does have authority, however, to access information that is essential to determining compliance without asking permission.This authority may need to be exercised in regard to an individual who is undressed, for example, in order to observe for bruises or other signs of injury when it is suspected that the individual is being abused.  These observations should be conducted in private, with as little of the body exposed as possible, and with a staff person present.  Consent from staff or guardians is not required in order to access information or make observations.

For individuals who are working in competitive employment sites, ask the individual's permission to visit that site.  If the individual is unable to communicate, discuss with the staff the advisability of visiting the competitive site.  The intent is that the individual is not identified as different from other workers at the site.  If the individual works in a restaurant, for example, you may be able to visit as a "customer" to observe the work environment.  If an interview with a job supervisor or support person is indicated, attempt to conduct this interview in a private or inconspicuous area.  Upon arrival, introduce yourself to the individual and to the staff and explain the purpose of your visit.

C.  Observation Procedure.--Initially the surveyor should note the general impressions of the area.  Note things such as:

1.     General Impressions.--

o  How are individuals dressed?

o  What activities are taking place?

o  What materials and supplies are present?

o  Is the environment pleasant and conducive to learning?  (e.g., odors, noise, furniture, and adequate bathroom facilities)

o  How many staff are present?  How many individuals?

o  What  types of adaptive equipment or assistive devices are used?

2.     Specific Activities and Interactions.--After noting the general setting, the surveyor should begin to focus on the specific activities and interactions.  For example:

o      Are individuals involved and participating in the activity?  Are the activities active or passive?  Does the activity appear to have a purpose?  Are staff able to explain how the activity is promoting greater independence for each of the individuals present?

o      Are there supplies and materials used to assist the individuals?  Do individuals use the materials?  Do they seem appropriate for the task or activity?  Are they appropriate for the individuals?

o      What interaction is occurring between staff and individuals?  Do the interactions give evidence of  respect, dignity?  Do staff recognize efforts made by the individuals and provide positive reinforcement?

o      Is the number of staff present sufficient for the number of individuals based on the individual needs or the type of activity?

o      Are individuals encouraged to make their own choices and decisions?  Are they encouraged to complete tasks with as much independence as possible? Are staff doing the activity for the person, or is the person encouraged to do things for him or herself?

o      Are any maladaptive behaviors exhibited?  How do staff respond?

o      Are any individuals ignored or isolated from the activity?  If so, what is the reason or justification for this?

3.     Individuals in Sample.--The third step of the observation process focuses on the individual(s) in the sample.  The surveyor should specifically note:

o      What is the appearance of the individual?  Is the individual dressed neatly?  Does the person appear clean and is his/her hair combed?

o      Does the individual exhibit any apparent physical or medical needs?  Is the individual over or under weight, edentulous, continent? Does the individual have contractures, vision or hearing impairments?

o      What adaptive devices/assistive devices are used?  Does the individual use a hearing aid, glasses, plate guard , etc.?  Does the device(s) appear to be used correctly?

o      How does the individual move about in the environment?  Does the individual use a walker, ambulate, move his own wheelchair, etc.?

o      How does the person communicate?  Does the person talk, use sign or a communication board, make facial expressions or behavioral responses?  Do others appear to understand the person's communications?

o      What is the person's level of social skill or behavior toward others?  What types of interactions occur and with whom?  Does the individual exhibit any maladaptive behaviors?

o      What are the individual's observed skills relative to the activity or task observed?  For example, if observed during dining, does the individual eat without assistance?  What utensils

are used?  Are applicable skills developed or encouraged during the activity, such as passing food, pace of eating, social conversations?  Is the individual receiving any special diet?

o      What level of assistance is provided by staff?  What types of assistance are used - verbal prompts, gestures, hand over hand?

o      Are there any individual needs that are not being addressed?  Are staff  aware of the observed needs?  Is there a reason it is not being addressed?

4.     Areas for Further Observation.--The surveyor will then identify areas to which to pay attention during other observations.  Those areas may include any supports, interventions or skills that would be expected to occur consistently across settings or any apparent needs, concerns or discrepancies noted during the observation.  For example, if the surveyor notes that the individual uses sign language for communication, do all staff working with the individual understand and use sign with him/her?   Or if an individual is observed to have good gross motor skills, do staff feed the person or perform other tasks for him/her that your observation indicates the person could possibly do independently?  Focus interviews and record review based on concerns, issues, inconsistencies and needs noted from these observation(s).

D.    Documentation.--Record your observations.  The optional individual observation worksheet (HCFA-3070I (10/95)) may be used.  If your behavior or presence disrupts the activity being observed, wait five minutes before recording the observation.

VIII.TASK 4 - REQUIRED INTERVIEWS WITH INDIVIDUALS AND/OR FAMILY/ADVOCATE, AND DIRECT CARE STAFF

A.    Purpose.--Individuals living in the facility, their families/guardians and advocates, and direct care staff are important sources of information about the receipt of active treatment on a daily basis.  Interviews are conducted for two purposes:  to determine how the individual perceives the services delivered by the facility, and to clarify information gathered during observations. Only interviews with the individuals, their family members/guardians, advocates, and direct care staff count toward the total number of required interviews (as reflected in the sample chart shown in Section 5B - Sample Size).

B.    Interview Procedure.--Start with the individual in the sample and the people most closely associated with the individual's daily program implementation.  Use the following hierarchy of sources, to the maximum extent possible, in the order shown:

o      Individual;

o      Families, legal guardian, or advocate;

o      Direct care staff;

o      Qualified mental retardation professional (QMRP) and/or professional staff; and

o      Managers, administrators, or department heads

Determine from your observations and from the staff how the individual communicates with others. Also determine from the staff the extent of involvement of family members, guardians or advocates with the individuals in the sample.  Based on this information, select the individuals from the sample with whom you will conduct more in-depth interviews.  Select those individuals who will be able to communicate at least some basic information or those who have actively involved family members, guardians or advocates.  Do not exclude from interviews individuals who use alternate means of communication, such as communication boards, sign language, and gestures.  Most individuals are able to communicate in some manner.  At a minimum conduct the number of in-depth interviews specified in Section V, Task 1B.

Attempt to obtain the required number of interviews first from individuals and then from family members, guardians or advocates.  In the absence of individuals who are able to communicate and active significant others, interview the direct care staff person who works most closely with the individual in order to obtain the required number of in-depth interviews.

The questions and communication method will vary from person to person.  For individuals who use a specialized communication method, attempt to begin the interview on a one to one basis.  If you find you are unable to communicate with the individual, ask someone familiar with the person to assist you (e.g., a family member or a staff person.)  For this individual, pay close attention to how the staff communicates with him or her.  If the person uses sign language or a communication board, do staff understand and interact with the individual using the same method?  If the person uses gestures, do staff take time to determine his or her needs?

Family members, guardians or advocates may be interviewed at the facility, at a location convenient to both the surveyor and the interviewee, or by telephone.  All interviews should be conducted in  private locations and scheduled at mutually agreed upon times in order to minimize disruptions to individual, family, or staff activities.

C.  Content of In-depth Interviews.--Determine what the facility does to provide individualized services and supports; and how individuals and families participate in service planning and in making choices about matters important to them.  Are individuals treated with respect and dignity?  Does the facility attempt to help the person set and attain individual goals?  Are there consistent opportunities for making choices?  When a choice is not an option, how is the individual assisted to understand?  For example, if a planned activity is to go to a restaurant for dinner, who chooses the restaurant?  Staff or the individuals living in the facility?  If one group of people does not want to go, how is this choice accommodated?  Is the accommodation based on individual choice, staff convenience, or a reasonable justification if a choice is not an option?

See section D for suggested interview questions.  Unless designated to be directed to a certain person, questions are relevant to whomever is being interviewed (individual, family member, advocate or staff person.)  Modify the wording of the questions based on the person being interviewed (individual, family member, or staff) and on the communication skills of that individual.  For example, you may discover that the person responds better to questions that can be answered "yes" or "no" than to open-ended questions.  Be sensitive to signs that the individual is tiring or becoming uncomfortable and either end the interview or continue it at a later time if this occurs.  It is not necessary to ask every question in the guide, but do try to ask at least one question from each topic area. 

D.    Suggested Interview Questions.--If you have not met the person before, begin the interview by explaining who you are and what your role is.  To put the person at ease you may want to begin with some general conversation, e.g., about the weather or a special event coming up.   At the end of the interview, if you think you may need to discuss or confirm personal information with staff or family, ask the person if it is OK to share that information.

1.     Questions Related to Choice and Community Participation (W136, W147, W247):

o      What sorts of things do you like to do for fun?

o      Do you go out to activities or events in the community (like shopping, movies or church)?

o      How often do you do this?

o      How do you get there?

o      Who chooses where you go?

o      Do you go to visit family members or take vacations?

o      Is there something you would like to do more often?

2.     Questions Related to Personal Finances and Possessions(W126, W137):

o      Do you earn money on your job (at your day program)?

o      What do you like to buy with your money?

o      Do you have enough money to buy the things you want or need?

o      Does someone help you with spending or saving your money?

o      When you go to the store, do you pay for items or does a staff person pay for them?

o      Do you have enough clothes and shoes?

o      Do you always have enough deodorant and toothpaste, etc.?

o      What do you do if you need to buy something?

3.     Questions Related to Personal Relationships and Privacy (W129-W130, W133, W143 -W148):

o      Do you have family or friends who visit you?

o      Does your family write to you or telephone you?

o      Does someone help you read their letters/ call them on the phone?

o      If you feel like being alone or spending private time with a friend or family where do you go?

o      Do staff knock on your door before they come into the room?

For family member/advocate:

o      How do you learn about things like the services your family member receives, an illness or a change in medication?

o      Are there any restrictions on when you visit your family member or where you can go within the home?

4.     Questions Related to Individual's and Family's Participation in the IPP Process (W209, W247):

o      Do you go to (team) meetings with the staff where they talk about the services you get?

o      Does your family/advocate come to these meetings?

o      Were you asked if the date and time of the meeting were OK with you?

o      What would you like to learn to do for yourself?

o      Do the staff ask you what you want?

o      Who chooses what you do?

o      Does the staff listen to you and make changes based on what you want?

For staff:

o      How do you communicate with this individual?

o      What does (s)he like and dislike?  How do you know that?

5.     Questions Related to Service Delivery (W242, W249, W436):

o      What help do you need from staff to dress, eat, bathe, etc?

o      Do you get any special therapy (e.g., speech or physical therapy)?

o      What new things are you learning to do?

o      What chores do you help with around the house?

o      Who helps you when you do not know how to do something?

o      What special equipment do you use?

6.     Questions Related to Individual's Rights and Protections: W124-W125, W127, W153-W157, W127-W128, W263

o      Who do you tell if you do not like something, or something is wrong?

o      Are there rules that everyone who lives here must follow?

o      What sorts of things are you allowed to do or not do?

o      How does the staff treat you?

o      Are staff  loud?

o      Does staff yell, swear or hit?

o      Do you ever do things you are not supposed to do? What happens then?

o      Were you ever asked to give consent for any treatments or services?

o      Were you told the benefits, risks and alternatives?

7.     Questions Related to Health Status (W322, W356):

o      How often do you see a doctor? A dentist?

o      Do you have any health problems?

o      Do you take any medicines?  Do you know what they are for?

8.     Wrap-up Questions:

o      Is there anything you especially like about living here?  Anything you especially dislike?

o      Is there anything else you think I should know about what it is like to live here?

E.     Interviews to Clarify Observations.--In the absence of finding appropriate interaction between staff and individuals during observations, it may be necessary to judge whether or not staff are knowledgeable about individual objectives and techniques for implementation of programs. If possible, interview staff following the interval in which the individual was observed with the particular staff member.  (For example, if you have just observed Individual A engaging in stereotypical behaviors, ask:  "Can you tell me what, if anything, you do when he rocks back and forth?")  Ask questions that elicit information about how staff learn what to do with individuals across the spectrum of support and programming activities they are expected to perform.  Ask professional staff questions to see if they know how to implement programs for an individual other than their professional discipline (e.g., how to carry through with a behavior program in the midst of communications training).

Ascertain whether the staff are competent to carry out the individual's choices and skill development activity.  Is there evidence that programs are in fact being carried out throughout the individual's waking hours?  Are interventions revised based on changes in the individual's progress toward goals?  If staff cannot demonstrate the skills necessary to implement the individual's programs and choices, if interventions are not being carried out consistently, or if revisions to interventions do not occur, you have findings that active treatment is not being delivered.

E.     Documentation.--Record each interview you conduct with individuals, staff, consultants, off-site day program staff, legal guardians, etc., in your personal notes or on the optional observation worksheet (HCFA-3070I). Include the following information in your notes for each interview:

o      Date and time of interview;

o      Job title and assignment at the ICF/MR;

o      Relationship to the individual or reason for the interview; and

o      Summary of the information obtained.

IX.   TASK 5 - DRUG PASS OBSERVATION

Observe the preparation and administration of medications to individuals.  With this approach, there is no doubt that the errors detected, if any, are errors in drug administration, not documentation.  Follow the procedure in the interpretive guidelines at W369 for conducting the drug pass observation.  Notes on observations of the drug pass may be recorded on Form HCFA-677 (LTC Medication Pass Worksheet) or in the surveyor's personal notes. The purpose of the review is to direct the facility's attention to assuring an error free drug distribution system and away from the paper processes that often do not represent actual errors in medication administration.  For the purposes of this task, a "small" facility is one which houses 16 or fewer residents.

X.    TASK 6 - VISIT TO EACH AREA OF FACILITY SERVING CERTIFIED INDIVIDUALS

A.    Purpose.--By the end of the survey, visit each area of the facility serving certified individuals in order to:

o      Ensure that all areas of the facility (including those which are not represented by individuals in the sample) are providing services in the manner required by the regulations.

o      Assess generally the physical safety of the environment.

o      Assess that individual rights are proactively asserted and protected.

B.    Protocol.--After individuals in the sample have been assigned to team members, review the facility's map or building layout.  Assign members to visit each remaining residential and on-campus day program site prior to completing the survey.   Insure that each area of the facility that is utilized by individuals has been visited.  This visit may be done with or without facility staff accompanying you, as you prefer, and subject to their availability.  Record your observations in your notes.

Converse with individuals, family members/significant others (if present), and staff.  Ask open-ended questions in order to confirm observations, obtain additional information, or corroborate information, e.g., accidents, odors, apparent inappropriate dress, adequacy and appropriateness of training activities.  Observe staff interactions with other staff members as well as with individuals for insight into matters such as individual rights and staff responsibilities.

XI.   TASK 7 - RECORD REVIEW OF INDIVIDUALS IN THE SAMPLE

A.    Introduction.--Do not spend an excessive amount of time looking at fine details in the record review of the selected sample.  The purposes are to:

o      Verify the applicable information obtained from your observations and interviews;

o      Review revisions that have been made to the objectives; and

o      Verify that needed health and safety supports are in place.

Do not review in detail the written training programs that are developed for each individual unless you discover serious differences between the record and your observations and interviews.  Review those parts of the record most relevant to your purposes as described below.

B.    The Individual Program Plan (IPP).--Identify the developmental, behavioral, and health objectives the facility has committed itself to accomplish during the current IPP period.  Identify what, if any, behavioral strategies (e.g., behavior modification programs, use of psychotropics) are being used with individuals in your sample. Determine what, if any, health or other problems might interfere with participation in program services.

C.    Program Monitoring and Change.--Skim the most recent interdisciplinary team review notes to identify what revisions were made to the IPP. Determine whether revisions were based on objective measures of the individual's progress, regression, or lack of progress toward his/her objectives. 

D.    Health and Safety Supports.--Verify, either through the interdisciplinary team review notes or through the most recent nursing notes, that the individual has received follow-up services for any health or dental needs identified in the IPP and check the person's current drug regimen.  For individuals with whom restrictive or intrusive techniques are used, verify that the necessary consents and approvals have been obtained.

If this information is consistent with your observations and interviews, conclude the record review.  If discrepancies are found, conduct further observations or interviews as needed to verify your findings.

A.    General.--TheSurvey Report Form (HCFA-3070H) is composed during the pre-exit conference and containsthe negative findingsthat contribute to a determination that an ICF/MR requirement is "not met."  Meet as a team, in a pre-exit conference, to discuss the findings and make conclusions about the deficiencies, subject to additional information provided by facility officials. Review the summaries/conclusions from each task and decide whether further information and/or documentation is necessary.  Ask the facility for additional information or clarification about particular findings, if necessary.  Consider information provided by the facility. If the facility maintains that a practice in question is acceptable, request reference material or sources that support the facility's position.

B.    Team Assessment of Compliance.--During the pre-exit conference, the survey team reviews each survey tag numberreviewed during either the fundamental, extended or full survey, and comes to a consensus as to whether or not the facility complies with each requirement.  The team reviews all data collected.  For each standard determined to be not met, record salient findings on theHCFA-3070H.  With the exception of the Life Safety Code Survey, compliance decisions are not made by individual surveyorswhen more than one surveyor has conducted the survey.

C.    Analysis.--Analyze your findings relative to each requirementreviewed during either the fundamental, extended or full survey for the degree of severity, frequency of occurrence and impact on delivery of active treatment or quality of life.  The threshold at which the frequency of occurrences amounts to a deficiency varies.  One occurrence directly related to a life-threatening or fatal outcome can be cited as a deficiency.  On the other hand,

a few sporadic occurrences may have so slight an impact on delivery of active treatment or quality of life that they do not warrant a deficiency citation.

The interpretive guidelines contain two types of guidance designed to assist the survey team in analyzing their findings and making consistent compliance decisions:

1.     Facility Practice Statements.--The purpose of facility practice statements is to clarify the information that is relevant to specific requirements, and to increase the survey focus on outcomes for individuals.  Facility practice statements are provided for those requirements which experience has shown, are difficult to interpret.  The practice statements are not necessarily all inclusive, but rather represent the practices most commonly associated with compliance for specific requirements.  Each facility practice statement relates directly to the language of the requirement to which it applies.  Positive outcomes identified by the practice statements should be observed in operation in the facility during the survey.  When the team's negative findings indicate that a practice is not present, a citation of the requirement may be appropriate, depending upon the frequency and the severity of those findings.  Use the practice statements during the pre-exit conference to assist the team in analyzing negative findings and determining the appropriate requirement at which to cite negative findings.  When stated in the negative, facility practice statements may form the basis for a citation on the HCFA-2567.

2.     Condition Level Compliance Principles.--The purpose of the compliance principles is to assist in consistent decision-making about facility compliance at the Condition of Participation level. The primary focus of those decisions is placed on the outcomes to the individuals and their actual experiences of daily life.  At each Condition of Participation, the guidelines contain compliance principles which identify those outcomes that must be present in order for the Condition to be found "met," and those outcomes that indicate the Condition is "not met."  The compliance principles are based on the requirements which fall under the Condition.  This guidance is NOT to replace professional surveyor judgement.  It is possible that the surveyor may encounter a situation which is not covered by the compliance principles, however, such instances are expected to be rare.  In the event the survey team makes a determination that the Condition is "not met," and the situation causing that determination is not identified in one of the "not met" compliance principles, notify HCFA's Central Office in writing within 10 days after the completion of the survey for purposes of review, possible dissemination to other surveyors, and to ensure consistency within the survey process.

Some of the compliance principles for the Conditions of governing body, facility staffing and physical environment reference other Conditions.  Governing body, facility staffing and physical environment tend to address organizational processes which support the provision of active treatment, protection of rights and adequate health and dietary services.  Therefore, the governing body, facility staffing and physical environment Conditions are usually "met" unless it is first determined that there are serious deficiencies in services or protections which fall under one or more of the other areas. 

After the survey team reviews its positive and negative findings for the requirements within a particular Condition of Participation and determines which of those requirements are deficient, examine the findings for that Condition as a whole.  When analysis of these findings leads the team to conclude that each of the "met" compliance principles for that Condition is present, then the facility is in compliance with that Condition.  When analysis 

of the standard level deficiencies viewed as a whole, leads the team to conclude that one or more of the "not met" compliance principles for that Condition is present for one or more individuals or situations, consider the frequency and the severity of the negative finding(s) in relation to the applicable "not met" compliance principle(s) in order to determine whether Condition level noncompliance is warranted.

D.    Composing the Report of ICF/MR Deficiencies (HCFA-3070H/(10/95)).--

During the pre-exit conference, the survey team records on the HCFA-3070H those requirements that are determined to be deficient and the findings which support that determination.  Write the deficiency statement in terms specific enough to allow a reasonably knowledgeable person to understand the aspect(s) of the requirement(s) that is (are) not met.  Do not delve into the facility's policies and procedures to determine or speculate on its root cause, or sift through various alternatives to prescribe an acceptable remedy. Indicateon the HCFA-3070H the data prefix tag, followed by a summary of the deficient facility practice(s).  Briefly identify the supporting findings for each deficiency (i.e., transfer to the HCFA-3070H the identifier numbers of all individuals to whom the deficient practice applies.)  It is not necessary to write a full description of the findings on the HCFA-3070H since they will be described in more detail on the completed Statement of Deficiencies (HCFA-2567).  It is necessary to complete the HCFA-3070H for each survey because the HCFA-3070H is the only document in which the survey team's recommendations for deficiencies are recorded (which may be changed later on the final HCFA-2567 as a result of supervisory review) and because not all individual examples may be used on the HCFA-2567.  Instructions for the HCFA-3070H are found on page J-18.6.

Alternatively, when the survey team enters its findings directly into a computerized system such as Automated Survey Processing Environment during the pre-exit conference, the statement of deficiencies (HCFA-2567) that is generated onsite at the facility may be substituted for the HCFA-3070H.  The HCFA-2567 generated onsite then must contain the information required for the HCFA-3070H and must be clearly marked "DRAFT - SUBJECT TO STATE AGENCY REVIEW" on each page.

XIII -  ADDITIONAL SURVEY REPORT DOCUMENTATION (FOR THE FILE)

Upon the completion of each survey, the team leader completes the following additional documentation.  This information remains at the survey agency with the HCFA-3070G-H (10/95) in the official file:

A.    Summary Listing of all ICF/MR Individuals Comprising the Survey Sample (include any additional individuals added to the sample).--At a minimum, identify:

o      The name or Medicaid number of each individual chosen to be part of the sample;

o      Any individual identifier codes used as a reference to protect the individual's confidentiality; and

o      The reason for including the individual in the sample (e.g.,  "Random Program Audit," "Discharge," "New Admission," "Death," "Abuse Investigation", "Drugs to Control Behavior").  This listing serves as a future reference to any individual identifiers recorded in surveyors' notes, the HCFA-3070G-I, and the HCFA-2567.

B.    Description of the Representative Sample Selection.--At a minimum, identify, at the time of the survey:

o      How the sample was selected;

o      What was the percentage occurrence of each functional level of mental retardation in the facility's overall population;

o      The distribution of the individuals in the sample across the facility's living units;

o      The number of people in the sample;

o      The number, if any, of individuals substituted in the sample, and the reason; and

o      Any other characteristic of individuals served that was specifically introduced into the sampling process and the reason.

C.  Summary of Individual Observations.--Include all individual observation worksheets (HCFA-3070I) and any surveyor notes containing information regarding observations.  These notes should include the dates, locations, and starting and ending times for each observation.

D.  Summary of Interviews.--Include all surveyor notes containing information obtained during interviews with individuals, families, guardians, direct care staff, QMRPs, professional staff or consultants, administrators and managers, and others.  These notes should identify the person interviewed by name or position, and date and time of interview.

E.  Drug Pass Worksheets (HCFA-677) or Surveyor Notes of the Drug Pass Observation

F.  Other Relevant Facility Data.--Include other salient data used in support of the survey findings with the HCFA-3070G-H (10/95) (e.g., photographs, affidavits).  The survey agency's documentation of the justification for the decision to conduct a full survey must be maintained in the survey agency's file.