Survey Protocol in Psychiatric Hospitals

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  • Topic: Psychiatry, Hospital, Medical record
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  • Published : March 13, 2013
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State Operations Manual
Appendix AA - Psychiatric Hospitals – Interpretative
Guidelines and Survey Procedures - (Rev 1, 05-21-04)
Part I – Investigative Procedures
Survey Protocol - Psychiatric Hospitals
I - Principal Focus of Surveys
II - Task 1 - Representative Sample of Patients - Selection Methodology A - Purpose of the Sample
B - Sample Size
C - Sample Selection
D - Program Audit Approach
III - Task 2 - Record Review of Individuals in the Sample
A - Introduction
B - Other Pertinent Information
IV - Task 3 - Other Record Reviews
A - Death Records
B - Discharge Records
C - Complaint Investigations
V - Task 4 - Direct Patient Observations
A - Purpose
B - Documentation
VI - Task 5 - Interviews
A - Patient Interviews
B - Purpose of Structured Interviews Related to Patient Staffing C - Documentation
D - Interviews with Major Department Directors
VII - Task 6 - Visit To Each Area of the Hospital Serving Certified Patients A - Purpose
B - Protocol
VIII - Task 7 - Team Assessment of Compliance

A - Pre-exit Meeting
B - Role of the Team Leader
C - General
D - Special Circumstances
IX - Completing Forms CMS-724 Through CMS-729 for Psychiatric Hospital Outcome Oriented Survey
Part II - Interpretive Guidelines - Psychiatric Hospitals
§482.60 Condition of Participation: Special Provisions Applying to Psychiatric Hospitals §482.61 Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals
§482.61(a) Standard: Development of Assessment/Diagnostic Data §482.61(b) Standard: Psychiatric Evaluation
§482.61(c) Standard: Treatment Plan
§482.61(d) Standard: Recording Progress
§482.61(e) Standard: Discharge Planning and Discharge Summary §482.62 Condition of Participation: Special Staff Requirements for Psychiatric Hospitals §482.62(a) Standard: Personnel
§482.62(b) Standard: Director of Inpatient Psychiatric Services; Medical Staff §482.62(c) Standard Availability of Medical Personnel
§482.62(d) Standard: Nursing Services
§482.62(e) Standard Psychological Services
§482.62(f) Standard: Social Services
§482.62(g) Standard: Therapeutic Activities

Part I – Investigative Procedures
Survey Protocol - Psychiatric Hospitals
I - Principal Focus of Surveys
The principal focus of the survey is on the “outcome” of the hospital’s implementation of requirements. Direct your principal attention to what actually happens to patients. The customer of the survey is the hospital, and/or the patient. What the hospital does is intended to reach the patient. The patient’s need, and whether desired outcomes are achieved determine compliance.

II - Task 1 - Representative Sample of Patients - Selection Methodology A - Purpose of the Sample
The purpose of drawing a sample of patients from the hospital is to reflect a proportionate representation from all certified program areas within the hospital. If the facility has a distinct part certified for participation in Medicare, care should be taken to assure that the patient sample is drawn only from program areas that participate in the distinct part certification.

While the patients in the sample are targeted for observation and interview, conduct each program audit of the patient within the context of the environments in that the patient lives, receives treatment and spends major leisure time. Although you may focus on the individual, the behavior and interactions of all other patients and staff within those environments also contribute to the total context and conditions for active treatment. Therefore, you may decide to include other patients in the overall sample. The sampling process results in survey team judgments, rather than quantitative, criteriabased projections. It is not designed to be a “statistically valid” sample. Use flexibility when applying this method.

As the sample is built, additional information about the hospital’s programs and services, as well as additional patient information may emerge. If you find a great...
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