Survey Protocol in Psychiatric Hospitals

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