CMS SOM App. J, Tag W323

Guidance §483.460(a)(3)(i)

Information relevant to the client’s ability to see and hear is a critical component in the

development of appropriate active treatment strategies.

All clients, including clients who are non-verbal, should have evidence in his/her record that

they receive an annual evaluation of their vision and hearing which includes a screening as a

minimum, follow-up examination as indicated by the screen and timely referrals as indicated by

the examination. Screening is a gross assessment of the client’s vision and hearing and usually

does not include a measurement of acuity. Examinations are conducted to follow-up on issues

noted in the screening and are conducted by qualified professionals.

Clients who appear to have vision or hearing problems or the staff indicate that they have vision

or hearing problems and no accommodations have been made. The annual vision and hearing

evaluation verifies that clients appearing to have vision/hearing issues or if staff indicate that a

client has vision/hearing issues that these issues have been/are being addressed.

If a client’s vision or hearing can only be assessed through examinations conducted by specialists

(e.g., comprehensive ophthalmological examinations and evoked response audiometry (ERA)),

these tests need not be conducted yearly, but rather upon the specialist's expressed

recommendations. During discussions at the annual IPP review the team reviews information

from the health professional, speech and hearing professional, and direct support staff and

makes referrals back to the specialist if indicated.