CMS SOM App. A, Tag A-1643

utilized;

Interpretive Guidelines §482.61(c)(1)(iii)

This requirement refers to all of the planned treatment modalities used to treat the patient

during hospitalization or in the outpatient setting which includes outside community and

professional resources. Having identified the problems requiring treatment, and defining

the outcome goals to be achieved, appropriate treatment approaches must be identified.

Modalities are methods of therapeutic approach that are adopted in implementing all of

the active treatment interventions provided to the patient by various staff. There must be

enough specificity in the treatment modality to ensure consistent implementation across

staff.

A daily schedule of unit activities does not, in itself, constitute planned modalities of

treatment. It is expected that when a patient receives various specific treatment

interventions, the treatment interventions are a part of the individualized treatment plan

goals, with a specific purpose and focus for that patient.

In addressing treatment modalities, it is required that they be specific to the patient. For

example, simply “naming” modalities (e.g., individual therapy, group therapy,

occupational therapy, and/or medication education) is not acceptable. The focus of the

treatment must be included.

Simply “stating” modality approaches (e.g., “set limits,” “encourage socialization,”

“discharge planning as needed”) is not acceptable. Modality approaches must be

specifically described in order to assure consistency of approach.

Survey Procedures §482.61(c)(1)(iii)

• Review a sample of patient records and verify that the treatment plan documents

the specific treatment modalities to be used.

• Observe the staff during treatment intervention to determine that staff are

following the individualized, specific treatment intervention modalities that are

contained in the treatment plan.

• Review the treatment plan to verify that:

• Individualized, specific treatment modalities are included in the plan.

• The observed treatment methods, approaches and interventions from all

appropriate disciplines are included in the plan.

• Interview staff to determine if modalities are determined for specific needs of

individual patients.

• Interview patients and family members or others significantly involved with the

patient to determine if the patient is offered specific, individualized treatment

modalities.

• Verify that the interventions or treatments, such as medication therapy,

documented in the patient’s treatment plan are supported by the psychiatric

evaluation or other comprehensive assessment. Any change in treatment must be

justified by assessment of the patient’s response to the treatment or a documented

change in the patient’s condition.