CMS SOM App. A, Tag A-1687

of qualified professional, technical, and consultative personnel to:]

(3) Provide active treatment measures; and

Interpretive Guidelines §482.62(a)(3)

Active treatment occurs when the patient receives treatment interventions that are

delivered under the direction of a physician, and which are specific to patient strengths,

disabilities, and problems identified in the treatment plan. Staff, in accordance with

nationally recognized standards of professional practice, furnish treatment interventions

and other services. Although the active treatment process must be identifiable in

documentation, it must be first and foremost observable and evident in daily practice.

Treatment interventions need to be individualized, in that the patient receives assistance

with resolving or improving the problems/circumstances that led to hospitalization.

Treatment intervention(s) must target/address the unique needs of individual patients. If

active treatment measures are not provided, this could indicate a lack of adequate staff.

Survey Procedures §482.62(a)(3)

• Determine through observation, interviews and record reviews that patients

receive active treatment measures. Do the treatment measures match the

treatment plan?

• Verify the hospital’s distribution of staff is consistent with particular patient

needs, and an adequate number of staff with an appropriately skilled staffing mix

is sufficient to carry out the therapeutic activities of patients’ individualized,

comprehensive treatment plans.

• Review a sample of medical records and verify in the individualized,

comprehensive treatment plan that the patient is receiving psychiatric treatment

or psychiatric therapy that is relevant to the identified problems that brought the

patient to the hospital.

• Verify if staff absences and/or vacancies are preventing the patient from receiving

active treatment.

• Determine if the patient’s inability to attend therapeutic activities off the

patient care unit (if occurring) is because there is no staff to escort them.

• Determine if therapeutic groups are available on the patient care unit for

patients who are not able to go off the unit.

• Observe treatment activities to ensure active treatment sessions or therapeutic

activities are provided at discrete time intervals and according to the treatment

scheduled.

• Verify through record review that active treatment is implemented as the patient’s

needs emerge during the course of the day.