CMS SOM App. A, Tag A-1702

interdisciplinary formulation of individual treatment plans; to give skilled nursing

care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

Interpretive Guidelines §482.62(d)(1)

The DON is not required to formulate individual treatment plans or directly provide

skilled nursing care and therapy but must be able to demonstrate competency in these

skills. The DON is expected to be responsible for ensuring that the nursing staff

demonstrate the competency to participate in interdisciplinary formulation of

individualized treatment plans and to provide skilled nursing care and therapy; and to

ensure the staff actually provide these services. Staff may demonstrate competence

through direct observation of skills or through appropriate documentation of

competencies.

The hospital must provide sufficient documented evidence (based on nationally

recognized standards of practice) that the DON possesses the current competence to

fulfill the requirements of this standard.

Sufficient documentation could include evidence of current:

• Professional certification in psychiatric-mental health nursing,

• Training in the formulation of individual treatment plans, or

• Continuing education in psychiatric nursing care and therapy.

Evidence that might demonstrate the DON’s competence to direct, monitor and evaluate

the nursing care furnished should include at a minimum:

• Having measures in place to monitor and evaluate the nursing care furnished by

nursing staff as part of a quality improvement program,

• Assisting with the development and review of nursing service policies and

procedures,

• Approving nursing service policies and procedures, and

• Ensuring the provision of ongoing in-services and continuing education programs

for psychiatric nurses and mental health care staff.

Survey Procedures §482.62(d)(1)

• Review the personnel file of the DON to assess for evidence of current training:

• Professional certification in psychiatric-mental health nursing,

• In interdisciplinary formulation of individual treatment plans, or

• In skilled psychiatric nursing care and therapy.

• Determine if the DON has a mechanism in place to monitor and evaluate the

nursing care furnished by nursing staff as part of a quality improvement program

or another program which would evaluate care.

• Determine if the DON is assisting with the development and review of nursing

service policies and procedures.

• Determine if the DON is approving the nursing service policies and procedures.

• Determine if the DON is ensuring the on-going and continuing education for

psychiatric nurses and mental health care staff.