CMS SOM App. A, Tag A-1640

comprehensive treatment plan based on an inventory of the patient’s strengths and

disabilities.

Interpretive Guidelines §482.61 (c)(1)

The comprehensive treatment plan is an outline of the identified disabilities that will be

treated during hospitalization. The treatment plan must include an inventory of the

patient’s strengths and disabilities. The inventory is derived from the psychiatric

evaluation, assessment and diagnostic data which have been collected by various

disciplines that comprise the total treatment team. In collaboration with the patient, the

treatment team develops the individualized, comprehensive treatment plan. The hospital

must have a policy for staff to follow in the development of the treatment plan.

NOTE: A disability in this context is any psychiatric, bio-psychosocial problem

requiring treatment/intervention. In this guidance, the terms disability and problem are

used interchangeably. In assessing the patient’s ability to comply and respond to the

treatment, the treatment plan must take into consideration the patient’s strengths that can

be utilized in treatment, as well as weaknesses/disabilities that may negatively influence

the patient’s treatment. (See also §482.61(b)(7) Tag A1637.)

Survey Procedures §482.61(c)(1)

• Review the sample of medical records and verify they contain a comprehensive

treatment plan.

• Review the treatment plan to determine that it is individualized and the patient’s

particular strengths and psychiatric disabilities are documented.

• Interview staff. Ask staff to describe how they develop treatment plans and

comply with the hospital’s policy for treatment plan development.

• Interview patients, family members and caregivers. Verify that the patients, and

their family members or other supportive caregivers, participated in the

development of the treatment plans.