2001 CMS ICF/MR Surveyor Training Update

October, 2001

Information Bulletin 01-25

2001 CMS ICF/MR Surveyor Training Update


This Information Bulletin provides information and regulatory clarification following the Centers for Medicare and Medicaid Services (CMS formerly HCFA) Advanced Surveyor Training for ICF for Persons with MR : New Directions for the New Millennium held in Kansas City, Missouri, June 4-6, 2001, and information received from the Federal Monitoring and Oversight Contract team surveys. This bulletin also contains a web site address for Person-Centered Supports, a contemporary concept referring to a family of approaches to organizing and guiding community change in alliance with people with disabilities and their families and friends.

1. Regulatory Clarifications

Additional information regarding regulation clarification is available at the ICF/MR web site titled Questions and Answers:

http://www.cms.hhs.gov/medicaid/icfmr/ [expired link]

This site is updated periodically by CMS.

Q1.  Do all medications which have dual purpose, e.g., Tegretol for epilepsy and/or mood disorders, require approval by the specially constitutes committee (SCC) regardless of the diagnosis for which it is prescribed?

R1.  No. If the medication is used to control seizures, it would not need to be incorporated into a plan and reviewed/approved by the SCC. However, if it is used for a mental illness or behavior, then it is part of the active treatment plan and requires review of the active treatment plan and requires review and approval by the committee.


Q2.  Do all clients in ICF/MR have the same rights as very other US citizen?

R2.  Yes. CFR 483.42(a), W122, states: "Condition of Participation: Client Protections. (a) Standard: Protection of client's rights. The facility must ensure the rights of all clients."

Guidelines:  Ensure means that the facility actively asserts the individual's rights and does not wait for him or her to claim a right. This obligation exists even when the individual is less than fully competent and requires that the facility is actively engaged in activities which result in the proactive assertion of the individual's rights, e.g., guardianship, advocacy, training programs, use of specially constituted committee, etc.


Q3.  Are locked doors or alarms on doors an infringement on the client's rights?

R3.  Yes. CFR 483. 420(f)(3), W125 states: "The facility must ensure the rights of all clients. Therefore, the facility must allow and encourage individual clients to exercise their rights as clients of the facility and as citizens of the United States, including the right to file complaints and the right to due process."

Probes:  How are individuals prepared to exercise their rights? Are provisions made for all individuals to assert their rights including those with mobility, sensory and communication impairments? Can staff explain individual rights and how they facilitate individual exercise of their rights? Are rights that are modified or limited specific, general or blanket? Are they reviewed to ensure continued appropriateness to the individual?

Example:  The client's rights could be compromised when the facility implements alarms or locks on a facility-wide or individual basis without an accurate assessment. The comprehensive individual assessment should clearly address the behavior or disability of the client which requires a lock or alarms. Have alternatives which are less intrusive or less restrictive been explored? Have they been attempted? What active treatment programs have been designed for this individual to reduce the target behavior and the risks of living in a home without locks and alarms? What are the needs of other clients living in the facility? How is their right to privacy, free association, choice, and self-determination impacted by the use of alarms or locks for another individual? Reality check: Does your home have alarms on doors or locks on closets, dressers, refrigerators, etc?


Q4.  Following an accurate, comprehensive assessment of each individual client's needs, do locked doors, wander-guards, and "alert" buzzers on doors need to be approved by a committee before implementation?

R4.  Yes. CFR 483. 420(f)(3), W262 states: "The facility must designate and use a specially constituted committee or 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 (I)Review, approve, and monitor individual programs designed to manage inappropriate behavior and other programs that, in the opinion of the committee, involve risks to client protections and rights."

Facility Practices:  Any programs which incorporate restrictive techniques (e.g., restraints, medication to manage behavior, restrictions on community access, etc.) have been reviewed and approved by the committee prior to implementation. The committee periodically monitors restrictive programs to determine if the restriction of rights or risk to protections remains justified.

Guidelines:  The committee should consider factors such as whether less intrusive methods have been attempted and whether the severity of behavior outweighs the risk of the proposed program.


Q5.  Must the facility investigate all injuries of unknown origin?

R5.  Yes. CFR 483.420(D)(2-4), W153 states:  "The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures."

Guidelines:  The facility is responsible for reporting any injuries of unknown origin and allegations of mistreatment to an individual residing in the facility regardless of who is the perpetrator (e.g., facility staff, parents, legal guardians, volunteer staff from outside agencies serving the individual, neighbors or other individuals, etc.).

W154  "The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress".

W156 (4)  "The results of all investigations must be reported to the administrator or designated representative or to other officials in accordance with State law within five working days of the incident and, if the alleged violation is verified, appropriate corrective action must be taken".


Q6.  Must the facility actually evacuate clients from the building during emergency drills?

R6.  Yes. CFR 483.470(I)(2)(I), W445 states:  "The facility must actually evacuate clients during at least one fire drill each year on each shift."

Facility Practices:  All individuals totally evacuate the building at least once per year per shift regardless of the occupancy chapter under which the building falls.

Guidelines:  All facilities, regardless of their size require actual evacuation. "Actually evacuate", as used in this standard, applies to all individuals. The drills are conducted not only to rehearse the individuals and staff for fire, but for other disasters such as hurricanes, tornadoes, floods, etc. Such disasters would require the entire occupancy to be evacuated, and therefore the actual evacuation must be practiced, as required. Individuals with physical disabilities can be evacuated.

According to the CMS's web page, ICF/MR Questions and Answers:  "Surveyors should check the fire drill log as part of the record review. If surveyors find that fire drills have not been conducted, they can ask the facility to conduct a fire drill in order to determine whether or not clients can effectively evacuate the facility. Tags W448 and W449 have been added as fundamental tags to ensure attention is focused on whether or not a facility is investigating all problems with evacuation drills, including accidents, and taking corrective action."


Q7.  Does every ICF/MR client need to be assessed for the ability to monitor one's own health status and self-administer medications regardless of the medical diagnosis or cognitive disability?

R7.  Yes. CFR 483.440(c)(3)(iii-v), W216, states:  "The Comprehensive Functional Assessment must identify the client's specific developmental and behavioral management needs, needs for services without regard to the actual availability of the services needed, and include physical development and health."

Family Practices:  Findings are recorded in terms that facilitate clear communication across disciplines. Diagnoses or imprecise terms and phrases in the absence of specific terms are not acceptable. Identification of needed services is based on the comprehensive functional assessment. Recommendations are present to address areas of deficits. Physical development includes the individual's developmental history, results of the physical examination conducted by a licensed physician, physician assistance, or nurse practitioner, health assessment data which may be compiled by a nurse, and skills normally associated with the monitoring and supervision of one's own health status, and administration and/or scheduling of one's own medical treatments.

Example:  In performing the functional assessment for self-administration of medications, the IDT should evaluate whether the client can perform any of the tasks of med administration. For example, is she able to push the pill out of the "blister pack" or take the pill(s) out of another container such as a "daily pill reminder"? Can he remove the cover from the tube of topical cream? Can he apply the cream to the prescribed site? Is she able to shake the canister of a Metered Dose Inhaler? Hold the inhaler to her lips independently? Self-administer insulin? What skills need to be learned to that the client can more fully participate in his health care? Remember that the client is not held to the same standards of knowledge about his/her medications as the staff whose responsibility includes medication administration.


2. Person-Centered Support

Information about Person-Centered-Supports can be found at the web site established by National Association of State Directors of Developmental Disabilities Services, Inc. following the completion of the Reinventing Quality project begun October, 1999.

The web address is:  Quality Mall

Click on Personal Centered Principles.

The publication, Person-Centered Supports--They're for everyone! is available for download in either Adobe Acrobat or Microsoft Word format from the web site:

http://www.hsri.org/new.html [expired link]

Scroll down to Person-Centered Supports.

Please Note:  CMS web site addresses are subject to change. As MDH becomes aware of these changes, we will update the CMS address on this bulletin.

If you have any questions regarding this Information Bulletin, please contact in writing:

Minnesota Department of Health
Health Regulation Division
Licensing and Certification Program
85 East Seventh Place, Suite 300
PO Box 64900
St. Paul, Minnesota 55164-0900
Telephone: (651) 201-4200

Tuesday, April 13, 2021 at 11:12AM