CMS SOM App. J, Tag W261

committees consisting of members of facility staff, parents, legal guardians, clients (as

appropriate), qualified persons who have either experience or training in contemporary

practices to change inappropriate client behavior, and persons with no ownership or

controlling interest in the facility to- -

Guidance §483.440(f)(3)

The facility must have a specially constituted committee whose primary function is to

proactively protect client rights by monitoring facility practices and programs. The purpose of

the committee is to assure that each client's rights are protected utilizing a group of both

internal staff and external participants who have no vested interest in the facility as well as

clients as appropriate. There should be evidence that the committee members have been

trained annually on the rights of the clients, what constitutes a restriction of a right and the

difference between punishment and training.

Depending on size, complexity and available resources, the ICF/IID may establish more than one

specially constituted committee. However, each committee must contain the required

membership and participate regularly and perform the functions of the committee according to

the requirements. Participation on the specially constituted committee(s) must be in real time

allowing all membership to speak and discuss in an interactive mode.

The regulation does not specify the professional credentials of the "qualified persons” (who

have either experience or training in contemporary practices to change inappropriate client

behavior). There is no requirement that any specific discipline, such as nurse, physician or

pharmacist be a member of the committee.

The intent of including "persons with no ownership or controlling interest" on the committee is

to assure that, in addition to having no financial interest in the facility, at least one member of

each constituted committee is an impartial outsider in that he/she would not have an "interest"

represented by any other of the required members or the facility itself. Staff and consultants

employed by the facility or at another facility under the same governing body, cannot fulfill the

role of person with no ownership or controlling interest.

Although occasional absences from committee meetings are understandable, patterns of

absence by the required membership of the committee is not acceptable. At least a quorum of

committee members (as defined by the facility) must review, approve and monitor the

programs which involve risk to client rights and protections and that quorum must include one

person from each of the required categories.