CMS SOM App. A, Tag A-1680

Hospitals

The hospital must have adequate numbers of qualified professional and supportive

staff to evaluate patients, formulate written, individualized comprehensive

treatment plans, provide active treatment measures, and engage in discharge

planning.

Interpretive Guidelines §482.62

The purpose of this Condition of Participation is to ensure that the psychiatric hospital is

adequately staffed with qualified mental health professionals and supportive staff to carry

out an intensive and comprehensive active treatment program and to protect and promote

the physical and mental health of the patients.

Adequate numbers are defined to mean the numbers, types, and utilization of staff with

qualifications to evaluate, plan, implement and document active treatment.

An RN should make all patient care assignments. The director of psychiatric nursing

services and the hospital ensures that nursing personnel with the appropriate education,

experience, licensure, competence and specialized qualifications are assigned to provide

nursing care for each patient in accordance with the individual needs of each patient.

The regulatory text of this condition of participation regarding special staff requirements

for psychiatric hospitals is duplicated in standard (a) of the condition, Tag A-1685. This

means non-compliance with the requirements may be cited at either the standard or

condition level, based on the manner and degree of non-compliance. Substantial non-compliance with the requirements listed in the condition of participation would warrant a

Condition-level citation.

Survey Procedures §482.62

Assess the adequacy of the Special Staffing Condition by:

• Observing patients in a variety of settings, including both structured and

unstructured, to determine if there is adequate staff available to implement the

patients’ individualized treatment plans.

• Interviewing staff to determine if the number, type, and utilization of staff

available is appropriate to the volume and acuity of patients in order to

evaluate patients, formulate written, individualized comprehensive treatment

plans, provide active treatment measures and engage in discharge planning.

• Observing structure of units to ensure adequate programming is provided by

various interdisciplinary staff, i.e., therapeutic groups, social work therapy,

recreational therapy, or occupational therapy.

• Review the nursing assignments. Verify that the assignments take into

consideration the complexity of patient’s care needs and the competence and

specialized qualifications of the nursing staff.

• Interview patients, family members and others involved with the patient to

determine if staffing appears adequate for the proper care and treatment of

the patient to meet the needs as documented in the medical record.

• Review incident logs to determine if staffing may have played a part in any

recorded incidents.

• Review observation logs to ensure rounds are being conducted in real time,

and if not, determine if lack of staff may be contributing to this failure.

• If necessary, review video monitoring to determine if rounds are being

conducted and recorded in real time. If not, determine if lack of staff may be

contributing to this failure.