CMS SOM App. A, Tag A-1700

The hospital must have a qualified director of

psychiatric nursing services. In addition to the director of nursing, there must be

adequate numbers of registered nurses, licensed practical nurses, and mental health

workers to provide nursing care necessary under each patient’s active treatment

program and to maintain progress notes on each patient.

Interpretive Guidelines §482.62(d)

NOTE: Psychiatric hospitals must additionally comply with the Nursing Services CoP at

42 CFR §482.23.

There can be only one Director of Nursing Services for the entire hospital. Therefore,

the director of psychiatric nursing services required at §482.62(d) must be the same

person as the director of nursing that is required at §482.23(a).

The organized department of nursing in a psychiatric hospital must have sufficient

nursing staff (including RNs, licensed practical nurses (LPNs), nursing assistants (NAs),

and mental health aides) with the appropriate qualifications to ensure the nursing needs

of all patients are met, to ensure the provision of nursing care necessary under each

patient’s active treatment program, and to maintain progress notes on each patient.

Additionally, sufficient numbers, qualifications, and training of nursing staff, must be

considered when taking into account the number of patients, acuity of patients, and

layout of the hospital.

The progress notes are kept current by documenting assessments of the patient’s needs,

the care provided to the patient, and the patient’s response to these nursing interventions.

Survey Procedures §482.62(d)

• Determine if the hospital has one designated director of psychiatric nursing

services who is the same person as the director of nursing services in any other

parts of the hospital.

• Review staffing schedules and staffing assignments to determine if the staffing

numbers are adequate to meet the nursing care demands, taking into

consideration the following:

• Number of patients,

• Patient acuity,

• Availability of RNs, LPNs, NAs, and mental health aides.

• Review a sample of medical records and verify that nursing care identified in the

patient’s active treatment program is being provided and documented.

• Verify that progress notes contain nursing documentation of:

• Assessments,

• Procedures,

• Treatments, and

• Other interventions received while hospitalized.