CMS SOM App. J, Tag W475

With appropriate utensils

B. Extended Survey

During a focused fundamental survey, if a key standard of a CoP is found to be out of compliance,

then the surveyor will review all corresponding standards under that key standard to determine

compliance with that condition (i.e., to determine condition-level compliance). If the review of the

key standard and corresponding standards could result in a condition-level non-compliance

finding, then the SA can decide to survey all the standards within that CoP. This review of all the

standards within an ICF/IID CoP is known as an extended survey.

However, if the review of the key standard and corresponding standards results in a CoP non-compliance finding at 42 CFR 483.420, 42 CFR 483.450 or 42 CFR 483.460, then the team must

convert the extended survey to a full survey and follow the procedures for a full survey as indicated

below.

NOTE: Neither the focused fundamental nor the extended survey processes preclude the survey

agency from review of any standard, if evidence of non-compliant facility practice is suspected

during any survey.

C. Full Survey

A full survey is a review of all of the standards within all eight ICF/IID CoPs. In addition to

the entrance and exit, a full survey follows the procedures outlined in all seven tasks.

A full survey is conducted when any one or more of the following criteria are met:

• The survey team is conducting an initial survey;

• An immediate jeopardy is called;

• The survey team determines from the extended survey that Condition-level deficiencies

exist at one or more of the specific CoPs at 42 CFR 483.420, 42 CFR 483.450 or CFR

483.460; or

• At the discretion of the SA

III - Entrance

In addition to standard entrance procedures, the surveyor will complete the Form CMS-3070G

“Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report,” to

capture characteristics of the facility and the facility’s population. Furthermore, the surveyor will

establish the client sample selection by requesting a complete and accurate list of all the

clients that currently reside in the facility. After the core number of clients are selected (see Task 1

below), the surveyor will request a copy of each selected client’s Individual Program Plan (IPP).

Each IPP will be utilized during observations to determine:

1. If the client’s skills matches the IPP;

2. If the IPP is being followed;

3. If staff understand the IPP;

4. Staff and client interactions during the programs; and

5. Health concerns interfering with the IPP.

IV - Task One - Sample Selection

(Rev. 178; Issued: 04-13-18; Effective: 04-13-18; Implementation: 04-13-18)

The complete sample for the facility will include a core number of clients selected at the beginning

of the survey and additional clients are added during the process of the survey as needed based on

observations and/or interviews. Do not permit the facility staff to select the sample.

A full review (observation, record review and interview) will be conducted on all clients in the

core sample to include:

1. Comparison of the Comprehensive Functional Assessment to the Individualized Program

Plan (IPP);

2. Comparison of the IPP to actual activity observed;

3. Review of documentation of client participation and progress compared toobservations;

4. Timely and appropriate behavior program plan development and implementation as

indicated; and

5. Medical assessments conducted as indicated and indicated medical care or interventions.

The core sample of clients is selected from a list of the facility’s current client list without regard

to client developmental levels or locations in the facility. At minimum, the core sample should

include clients that meet any one or more of the following criteria:

 Admission within the last six (6) months;

 Participation in a day program;

 On a self-administration program; and/or

 Frequent hospitalizations or ER visits.

Table 2: Guidance to Calculate Core Sample Size:

Number of Clients Residing in the Facility Minimum Number in Core Sample

4 2

5-16 3

17-50 4

51-100 6

101-150 8

Over 150 10

During observations, additional clients should be added to the core sample if areas of concern

are identified. Examples may include, but are not limited to:

1. Clients with significant medical involvement which may be impacting

the implementation of their IPP;

2. Clients with significant behaviors with lack of or inappropriate staff intervention;

3. Clients that are idle for extended periods oftime;

4. Clients that appear to have strengths but are not encouraged to use those skills

or are performing activities below their skill levels; and

5. Clients who are not provided appropriate medical care.

Additional Sample Clients:

A client added to the core sample, during observations, does not require a full review of his/her

program record. There is no minimum or maximum number of additional clients that must be

added to the core sample. The program records for clients added to the core sample (additional

clients), should only be reviewed for the observed areas of concern. For instance, in the case of a

client observed to be doing work that appears to be for the benefit of the facility, the record

should be reviewed to determine whether the work is included in the client’s IPP; whether fair

compensation is provided; and whether the client’s needs are being addressed by the facility.

The client and the staff should be interviewed and the information compared to the program

records.

Another client may be added to the sample based solely on the fact that he/she is on a self -

administration program for medication. In this case, the surveyor would focus the record review

on:

Whether the comprehensive assessment supported the indication for such a

program;

What the current objectives of the program are and whether the client is

following those objectives; and

What documentation is maintained of oversight of the objectives and whether the

objectives are revised as indicated.

Observations and interviews with the client and staff would focus on the medication

administration.

V - Task Two - Review of Facility Systems to Prevent Abuse, Neglect and

Mistreatment and to Resolve Complaints

(Rev. 178; Issued: 04-13-18; Effective: 04-13-18; Implementation: 04-13-18)

When determining whether or not facility systems are in place to prevent abuse, neglect, and

mistreatment and to resolve complaints, surveyors will use Task Two.

Task Two consists of two phases. In the absence of pre-existing characteristics as described

below, only Phase One should be completed. If there are pre-existing criteria or if in the course of

the survey concerns with client protections are identified, the surveyor should extend to the Phase

Two review. Any one or more of the following are pre-existing criteria that would initiate a Phase

Two review.

Substantiated complaints or facility reported events in Client Protections since the

last recertification survey;

A survey history of citations at W127, W153-W157; or

Concerns identified by the SA that warrant a Phase Two review.

A. Task Two Phase One

The critical components of this Phase are client observations including staff-to-client and client-to-client interactions, and staff/client/family interviews. These observations and interviews identify

the reporting records or investigation records that will be reviewed by the surveyor.

These records/reports are requested after the observations and interviews have been completed.

If the surveyor determines during Phase One that there is evidence of possible abuse, neglect and

mistreatment, then the surveyor should follow-up with associated interviews and record reviews.

The surveyor should contact his or her SA for a possible Immediate Jeopardy (IJ) call. If the CoP

for Client Protections at 42 CFR 483.420 is cited, then this concludes Task Two.

Additional review of Task Two is completed at the discretion of the SA or CMS RO.

If during Phase One, the surveyor does not observe any instances of possible abuse, neglect and

mistreatment, then Task Two may be ended.

1. Phase One Observations:

• Any signs of client injury (e.g., bruising, splints, bandages, scratches, limping or favoring a

limb, etc.);

• Client-to-client aggression;

• Inappropriate staff-to-client interactions (e.g., physical, verbal);

• Signs of fear in the presence of specific clients or staff;

• Signs of mistreatment or punishment by staff such as rudeness, rough handling,

restriction of rights, etc.; or

• Any clients currently in the hospital or experiencing recent hospitalizations or emergency

room visits

2. Phase One Interviews:

If Phase One observations identify any concerns with possible abuse, neglect and mistreatment, as

well as failure to resolve complaints, then specifically associated interviews must be conducted.

The client is interviewed first. Do not exclude clients who use alternate means of communication,

such as communication boards or gestures. Most clients are able to communicate in some manner.

Questions to the client may include, but are not be limited to:

a. Are the staff nice to you?

b. Do the staff yell, swear, or hit? Who?

c. Has anyone ever hurt you? Who? When?

d. Are you ever punished for anything? What was yourpunishment?

e. How did you get injured? (If the client has an obviousinjury)

Interview the family, legal guardian, advocates (if applicable) and close friends (if identified) of

each client for whom a concern was identified either during observations or client interviews.

Family members, legal guardians, advocates and close friends may be interviewed at the facility or

by telephone. Questions to the families, legal guardians, advocates and close friends may include,

but are not be limited to:

a. Have you noticed any bruises or injuries of an unknown source on (client’sname)?

b. If so, did you speak with thestaff?

c. What did they say?

d. How does the staff interact with (client’sname)?

e. Does (client name) complain of any mistreatment duringvisits?

Facility staff should be interviewed as indicated. This includes direct care staff from more than one

shift, the applicable Qualified Intellectual Disability Professional (QIDP) and medical personnel.

The goals of the interviews are to determine how often injuries/mistreatment are occurring, what

process the facility is using for reporting such instances, the timeliness of notifications, whether

clients are protected from harm during investigations and whether process changes are

implemented by the facility to prevent future injuries and/or mistreatment. The questions during

each interview should be tailored according to the observations made.

3. Phase One Record Reviews:

For any specific injury noted during observations (regardless of whether the client is in the sample

or not), the surveyor requests the documentation associated with the injury

(reporting/investigation/disposition). The goal of this documentation review is to verify the

information provided by the staff and to ensure the prompt reporting, investigation and protection

of clients with injuries and allegations of mistreatment.

If the observations, interviews or record reviews during Phase One confirm that the facility is

identifying injuries and mistreatment promptly, notifying the appropriate persons, doing

appropriate investigations, and doing appropriate interventions, then Task Two is concluded.

Deficiencies may be written at Phase One without proceeding to Phase Two.

B. Task Two Phase Two:

If the surveyor determines during Phase One that there is insufficient evidence to find that the

facility is in compliance with the Condition of Participation for client protections at 42 CFR

483.420, a more global review is indicated. Request the facility log of client incidents and reports

and select a sample of 5 percent of the incidents from the total client incidents occurring during

the last three (3) months (a minimum of 10 if available). Request the investigative reports for these

incidents. Look for any evidence that suggests that clients are being abused, neglected or

mistreated. Determine whether in each case the incident was reported promptly and investigated

thoroughly and that safeguards were put into place during the investigation and corrective

measures taken in order to prevent recurrences.

If the facility has a system in place to prevent abuse, neglect and mistreatment and to resolve

complaints and takes the appropriate corrective measures, then, Task Two is complete.

If the 5 percent sample review is not determinative as to the compliance with the CoP for client

protections, or the surveyor identifies any patterns of possible abuse, mistreatment or neglect, or

the incident report logs for the past three (3) months indicate an extremely high incident rate, the

surveyor should proceed to a full review of the total number of incidents and reports for the past

three (3) months to identify any deficient practice by the facility.

If the surveyor believes that issues exist that rise to the level of an Immediate Jeopardy, investigate

and procedures in Appendix Q should be followed.

VI - Task Three – Focused Observation

(Rev. 178; Issued: 04-13-18; Effective: 04-13-18; Implementation: 04-13-18)

The majority of the time on an ICF/IID focused fundamental survey is spent doing observation,

associated interviews and associated targeted record review. It is critical that observations of

sufficient duration occur across the entire survey (i.e. early morning, afternoon, and evening) and

occur across the client’s various environments (home, recreation and day program). A minimum of

two meals must be observed and two medication pass observations must be conducted.

Once the client core sample is selected and copies of the Individual Program Plan for each

selected client have been obtained, the observations should begin. Do not delay beginning

observations awaiting the IPPs. Begin general observations until the IPPs are provided by the

facility.

Initially note and record the first general impressions of each area where the clients are observed

(i.e., the milieu). Conduct these observations, without intruding (unless it is necessary to alert a

staff member to a possible risk to a client) for at least an hour in each initial location. Note things

on the general milieu such as:

a. Are all the clients in the area dressed appropriately but individually according to

what appears to be their preferences?

b. What activities are taking place? Note the time of day. Are these activities appropriate

for the time of day?

c. How many staff are present?

d. Does the environment appear calm andpurposeful?

e. What is the staff doing? How is the staff interacting with the clients? How are clients

interacting with each other?

f. Are clients being encouraged by the staff to participate in activities or are things done for

them?

g. What types of adaptive equipment or assistive devices areused?

h. Do the staff use teachable moments with the clients?

i. How are behavioral episodes addressed?

j. Do clients appear well nourished? Do they appear sleepy (not early in themorning)?

k. Do any clients have signs of injury? (Note for subsequent staff interview and Task 2

review.)

The results of these initial observations are critical to the focused fundamental survey process on

two levels. The surveyor(s) may observe specific issues which would indicate further investigation

or additional clients may need to be added to the core sample. The SA may determine that, based

upon the overall initial observation findings, the facility will require an extended or full survey

rather than a focused fundamental.

Focused Observation Areas:

1. Active Treatment-

Each IPP must be appropriate for the client based upon a comprehensive assessment and revised

with changes in client program needs. The IPP must correspond to what treatments, programs or

services the client is actually receiving. Programs should be appropriate for the client (i.e., is the

client able to accomplish/complete the program too easily; have they already accomplished the

components of the program; or does the client have program needs that have not been addressed

by the IPP (e.g., ADL, behavioral, socialization))? If there are discrepancies with the IPP

programs after observing the client in several environments, the surveyor should speak with the

client and/or appropriate staff (QIDP, direct care staff, psychology staff) for additional

information on the identified concerns. Interviews with staff are not done routinely. If during

observations the surveyor(s) determine that the current objectives of the IPP match the strengths

and needs of the client, the staff is familiar with the methodology of accomplishing these programs,

and they are being carried out as written in the IPP, there is no need to conduct formal staff

interviews. The surveyor should ask the staff (direct care staff carrying out the program(s)) for

records documenting program(s). Generally, the client should be making steady progress and this

should be reflected in the program data. However, if there is no progress made or if there has been

a regression, there should be evidence that the QIDP/ID team is aware of the issue and is

addressing it. In this case or in the case where actual programs do not match IPP programs or do

not seem appropriate for the client based upon the client’s identified skills, it will be necessary for

the surveyors to interview appropriate staff.

2. Staff

Generally, an inadequate number of staff will result in concerns with client programming and

client protection. During observations, note how the on duty staffing ratios either promote or

prevent a safe and productive active treatment environment. In some instances surveyors will see

the effects of inadequate staffing early (during the first impression observation). These effects may

include chaotic environment, client-to-client abuse, self-abuse by clients, clients sitting unengaged

for long periods of time with little or no staff presence, clients not given the opportunity to assist in

ADLs or participate in the rhythms of life due to the need to “get things done” (such as assisting

with mal preparation), or programs not being carried out due to inadequate on-duty staffing.

3. Qualified Intellectual Disabilities Professional (QIDP)

The increased time devoted to observations during the survey provides more of an opportunity to

also observe the QIDP in action. Observe interactions between the QIDP and the staff and the

QIDP and the clients. Is the QIDP familiar with client programs and client progress? How much

direct interaction is occurring among the QIDP, the staff and the clients? Is the QIDP intervening

when necessary and facilitating revisions to IPP as indicated? If the surveyor has unresolved

discrepancies, any concerns should be discussed with the QIDP.

4. Health Care Services

The surveyor should determine from observations whether or not the sampled clients are receiving

medical care as indicated. NOTE:

a. Do any of the clients have acute or chronic medical issues? How are these issues

being addressed by the medical staff at the facility?

b. Do the clients seem alert and energetic?

c. Are clients at a healthy weight?

d. Do the clients have good oral health? Have any dental problems been dealt

with promptly and appropriately?

e. Are the staff trained on first aid and reporting of medical issues?

If during observation there is concern about the health of a client, the nurse surveyor should talk

with the client and/or the nurse about the issues observed. In the event that there is not a nurse

surveyor, the non-clinical surveyor will need to consult with a clinician at the SA. Determine what

interaction is occurring between the client and the medical staff and whether the situation is

improving or deteriorating? Review the pertinent portions of the client record and discuss with the

medical staff as necessary.

If there are clients on a self-administration of medications program, the evaluation of the program

should be part of the active treatment observations.

5. Physical Environment

During observations, the surveyor should observe the facility for cleanliness, comfortable

temperature and any safety hazards (i.e. obstructed walkways, resilient, nonabrasive, and slip-resistant floors).

Client Record Review:

Review of the client record during the focused fundamental survey is kept to a minimum. No

routine record review is done. All record reviews are focused on obtaining additional information

to clarify or completely document areas of question or concern identified during observation.

VII - Task Four - Required Interviews with Individuals and/or Family/Advocate

Direct Care Staff

(Rev. 178; Issued: 04-13-18; Effective: 04-13-18; Implementation: 04-13-18)

A – Purpose

Individuals living in the facility, their families/guardians and advocates, and direct care staff are

important sources of information about the receipt of active treatment on a daily basis.

Interviews are conducted for two purposes: to determine how the individual perceives the services

delivered by the facility, and to clarify information gathered during observations.

B - Interview Procedure

Start with the individual in the sample and the people most closely associated with the individual’s

daily program implementation. Use the following hierarchy of sources, to the maximum extent

possible, in the order shown:

Individual;

Families, legal guardian, or advocate;

Direct care staff;

Qualified intellectual disabilities professional (QIDP) and/or professional staff; and

Managers, administrators, or department heads.

Determine from your observations and from the staff how the individual communicates with others.

Also determine from the staff the extent of involvement of family members, guardians or advocates

with the individuals in the sample. Based on this information, select the individuals from the sample

with whom you will conduct more in-depth interviews. Select those individuals who will be able to

communicate at least some basic information or those who have actively involved family members,

guardians or advocates. Do not exclude from interviews individuals who use alternate means of

communication, such as communication boards, sign language, and gestures. Most individuals are

able to communicate in some manner.

Attempt to obtain the required number of interviews first from individuals and then from family

members, guardians or advocates. In the absence of individuals who are able to communicate and

active significant others, interview the direct care staff person who works most closely with the

individual in order to obtain the required number of in-depth interviews.

The questions and communication method will vary from person to person. For individuals who use

a specialized communication method, attempt to begin the interview on a one to one basis. If you

find you are unable to communicate with the individual, ask someone familiar with the person to

assist you (e.g., a family member or a staff person.) For this individual, pay close attention to how

the staff communicates with him or her. If the person uses sign language or a communication board,

does staff understand and interact with the individual using the same method? If the person uses

gestures, does staff take time to determine his or her needs?

Family members, guardians or advocates may be interviewed at the facility, at a location convenient

to both the surveyor and the interviewee, or by telephone. All interviews should be conducted in

private locations and scheduled at mutually agreed upon times in order to minimize disruptions to

individual, family, or staff activities.

C - Content of In-depth Interviews

Determine what the facility does to provide individualized services and supports; and how

individuals and families participate in service planning and in making choices about matters

important to them.

Are individuals treated with respect and dignity?

Does the facility attempt to help the person set and attain individual goals?

Are there consistent opportunities for making choices?

When a choice is not an option, how is the individual assisted to understand?

For example, if a planned activity is to go to a restaurant for dinner, who chooses

the restaurant?

Is it staff or the individuals living in the facility?

If one group of people does not want to go, how is this choice accommodated?

Is the accommodation based on individual choice, staff convenience, or a

reasonable justification if a choice is not an option?

See section D for suggested interview questions. Unless designated that certain questions be directed

to a certain person, questions are relevant to whoever is being interviewed (individual, family

member, advocate or staff person.) Modify the wording of the questions based on the person being

interviewed (individual, family member, or staff) and on the communication skills of that individual.

For example, you may discover that the person responds better to questions that can be answered

“yes” or “no” than to open-ended questions. Be sensitive to signs that the

individual is tiring or becoming uncomfortable and either end the interview or continue it at a later

time if this occurs. It is not necessary to ask every question in the guide, but do try to ask at least one

question from each topic area.

D - Suggested Interview Questions

If you have not met the person before, begin the interview by explaining who you are and what your

role is. To put the person at ease you may want to begin with some general conversation, e.g., about

the weather or a special event coming up. At the end of the interview, if you think you may need to

discuss or confirm personal information with staff or family, ask the person if it is OK to share that

information.

Questions Related to Choice and Community Participation (W136, W147, W247):

What sorts of things do you like to do for fun?

Do you go out to activities or events in the community (like shopping, movies or

church)?

How often do you do this?

How do you get there?

Who chooses where you go?

Do you go to visit family members or take vacations?

Is there something you would like to do more often?

Questions Related to Personal Finances and Possessions (W126, W137):

Do you earn money on your job (at your day program)?

What do you like to buy with your money?

Do you have enough money to buy the things you want or need?

Does someone help you with spending or saving your money?

When you go to the store, do you pay for items or does a staff person pay for them?

Do you have enough clothes and shoes?

Do you always have enough deodorant and toothpaste, etc.?

What do you do if you need to buy something?

Questions Related to Personal Relationships and Privacy (W129-W130, W133, W143 - W148):

Do you have family or friends who visit you?

Does your family write to you or telephone you?

Does someone help you read their letters/ call them on the phone?

If you feel like being alone or spending private time with a friend or family where do you

go?

Does staff knock on your door before they come into the room?

For family member/advocate:

How do you learn about things like the services your family member receives, an

illness or a change in medication?

Are there any restrictions on when you visit your family member or where you can go

within the home?

Questions Related to Individual’s and Family’s Participation in the IPP Process (W209, W247):

Do you go to (team) meetings with the staff where they talk about the services you get?

Does your family/advocate come to these meetings?

Were you asked if the date and time of the meeting were OK with you?

What would you like to learn to do for yourself?

Does the staff ask you what you want?

Who chooses what you do?

Does the staff listen to you and make changes based on what you want?

For staff:

How do you communicate with this individual?

What does (s) he like and dislike? How do you know that?

Questions Related to Service Delivery (W242, W249, W436):

What help do you need from staff to dress, eat, bathe, etc?

Do you get any special therapy (e.g., speech or physical therapy)?

What new things are you learning to do?

What chores do you help with around the house?

Who helps you when you do not know how to do something?

What special equipment do you use?

Questions Related to Individual’s Rights and Protections: W124-W125, W127, W153 - W157,

W127-W128, W263:

Who do you tell if you do not like something, or something is wrong?

Are there rules that everyone who lives here must follow?

What sorts of things are you allowed to do or not do?

How does the staff treat you?

Are staff loud?

Does staff yell, swear or hit?

Do you ever do things you are not supposed to do? What happens then?

Were you ever asked to give consent for any treatments or services?

Were you told the benefits, risks and alternatives?

Questions Related to Health Status (W322, W356):

How often do you see a doctor? A dentist?

Do you have any health problems?

Do you take any medicines? Do you know what they are for?

Wrap-up Questions:

Is there anything you especially like about living here? Anything you especially dislike?

Is there anything else you think I should know about what it is like to live here?

E - Interviews to Clarify Observations

In the absence of finding appropriate interaction between staff and individuals during observations,

it may be necessary to judge whether or not staff is knowledgeable about individual objectives and

techniques for implementation of programs. If possible, interview staff following the interval in

which the individual was observed with the particular staff member. (For example, if you have just

observed Individual A engaging in stereotypical behaviors, ask: “Can you tell me what, if anything,

you do when he rocks back and forth?”) Ask questions that elicit information about how staff learns

what to do with individuals across the spectrum of support and programming activities they are

expected to perform. Ask professional staff questions to see if they know how to implement

programs for an individual other than their professional discipline (e.g., how to carry through with a

behavior program in the midst of communications training).

Ascertain whether the staff is competent to carry out the individual’s choices and skill development

activity. Is there evidence that programs are in fact being carried out throughout the individual’s

waking hours? Are interventions revised based on changes in the individual’s progress toward

goals? If staff cannot demonstrate the skills necessary to implement the individual’s programs and

choices, if interventions are not being carried out consistently, or if revisions to interventions do not

occur, you have findings that active treatment is not being delivered.

F - Documentation

Record each interview you conduct with individuals, staff, consultants, off-site day program staff,

legal guardians, etc., in your personal notes or on the optional observation worksheet (Form CMS-

3070I). Include the following information in your notes for each interview:

Date and time of interview;

Job title and assignment at the ICF/IID;

Relationship to the individual or reason for the interview; and

Summary of the information obtained.

VIII - Task Five - Drug Pass Observation

(Rev. 178; Issued: 04-13-18; Effective: 04-13-18; Implementation: 04-13-18)

Observe the preparation and administration of medications to individuals. With this approach, there

is no doubt that the errors detected, if any, are errors in drug administration, not documentation.

Follow the procedure in the interpretive guidelines at W369 for conducting the drug pass

observation. Notes on observations of the drug pass may be recorded on Form CMS- 677 (LTC

Medication Pass Worksheet) or in the surveyor’s personal notes. The purpose of the review is to

direct the facility’s attention to assuring an error free drug distribution system and away from the

paper processes that often do not represent actual errors in medication administration. For the

purposes of this task, a “small” facility is one that houses 16 or fewer residents.

IX - Task Six - Visit to Each Area of Facility Serving Certified Individuals

(Rev. 178; Issued: 04-13-18; Effective: 04-13-18; Implementation: 04-13-18)

A - Purpose

By the end of the survey, visit each area of the facility serving certified individuals in order to:

Ensure that all areas of the facility (including those that are not represented by individuals

in the sample) are providing services in the manner required by the regulations.

Assess generally the physical safety of the environment.

Assess that individual rights are proactively asserted and protected.

B – Protocol

After individuals in the sample have been assigned to team members, review the facility’s map or

building layout. Assign members to visit each remaining residential and on-campus day program

site prior to completing the survey. Insure that each area of the facility that is utilized by individuals

has been visited. This visit may be done with or without facility staff accompanying you, as you

prefer, and subject to their availability. Record your observations in your notes.

Converse with individuals, family members/significant others (if present), and staff. Ask open-ended questions in order to confirm observations, obtain additional information, or corroborate

information, e.g., accidents, odors, apparent inappropriate dress, adequacy and appropriateness of

training activities. Observe staff interactions with other staff members as well as with individuals for

insight into matters such as individual rights and staff responsibilities.

X - Task Seven - Record Review of Individuals in the Sample

(Rev. 178; Issued: 04-13-18; Effective: 04-13-18; Implementation: 04-13-18)

A - Introduction

Do not spend an excessive amount of time looking at fine details in the record review of the

selected sample. The purposes are to:

• Verify the applicable information obtained from your observations and

interviews;

• Review revisions that have been made to the objectives; and

• Verify that needed health and safety supports are in place.

Do not review in detail the written training programs that are developed for each individual

unless you discover serious differences between the record and your observations and

interviews. Review those parts of the record most relevant to your purposes as described

below.

B - The Individual Program Plan (IPP)

Identify the developmental, behavioral, and health objectives the facility has committed itself

to accomplish during the current IPP period. Identify what, if any, behavioral strategies (e.g.,

behavior modification programs, use of psychotropics) are being used with individuals in your

sample. Determine what, if any, health or other problems might interfere with participation in

program services.

C - Program Monitoring and Change

Skim the most recent interdisciplinary team review notes to identify what revisions were made

to the IPP. Determine whether revisions were based on objective measures of the individual’s

progress, regression, or lack of progress toward his/her objectives.

D - Health and Safety Supports

Verify, either through the interdisciplinary team review notes or through the most recent

nursing notes, that the individual has received follow-up services for any health or dental

needs identified in the IPP and check the person’s current drug regimen. For individuals with

whom restrictive or intrusive techniques are used, verify that the necessary consents and

approvals have been obtained.

If this information is consistent with your observations and interviews, conclude the record

review. If discrepancies are found, conduct further observations or interviews as needed to

verify your findings.

XI - Exit Conference

(Rev. 178; Issued: 04-13-18; Effective: 04-13-18; Implementation: 04-13-18)

During the pre-exit conference, the survey team records on the Form CMS-3070H

(“Intermediate Care Facilities for Individuals with Intellectual Disabilities Deficiencies

Report”) those requirements that are determined to be deficient and the findings that

support that determination. Write the deficiency statement in terms specific enough to

allow a reasonably knowledgeable person to understand the aspect(s) of the

requirement(s) that is (are) not met. Indicate on the Form CMS-3070H the data prefix

tag, followed by a summary of the deficient facility practice(s). Briefly identify the

supporting findings for each deficiency (i.e., transfer to the Form CMS-3070H the

identifier numbers of all clients to whom the deficient practice applies.) It is not necessary

to write a full description of the findings on the Form CMS- 3070H since they will be

described in more detail on the completed Statement of Deficiencies (Form CMS-2567).

It is necessary to complete the Form CMS-3070H for each survey because the Form

CMS-3070H is the only document in which the survey team’s recommendations for

deficiencies are recorded (which may be changed later on the final Form CMS-2567 as a

result of supervisory review) and because not all client examples may be used on the

Form CMS-2567. During the exit conference, provide the facility administrator with all

regulations determined to not be met during the survey. Provide examples as necessary,

allow the facility to provide additional information if it chooses, inform the facility that

the findings are preliminary and final compliance determinations will be made by the

survey office.

Part II- Interpretive Guidelines-Responsibilities of Intermediate

Care Facilities for Individuals with Intellectual Disabilities

§440.150 Intermediate Care Facility Services, Other Than

in Institutions for Mental Diseases