42 C.F.R. Subpart I—Inspections of Care in Intermediate Care Facilities and Institutions for Mental Diseases
Title 42 - Public Health
This subpart prescribes requirements for periodic inspections of care and services intermediate care facilities (ICF's), and institutions for mental diseases (IMD's). [43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996] For purposes of this subpart— Facility means an institution for mental diseases, or an intermediate care facility. Intermediate care facility includes institutions for the mentally retarded or persons with related conditions but excludes religious nonmedical institutions as defined in §440.170(b) of this chapter. Institution for mental diseases includes a mental hospital, a psychiatric facility, and an intermediate care facility that primarily cares for mental patients. Psychiatric facility includes a facility or program that provides inpatient psychiatric services for individuals under 21, as specified in §441.151 of this chapter, but does not include psychiatric wards in acute care hospitals. [44 FR 56337, Oct. 1, 1979, as amended at 61 FR 38399, July 24, 1996; 64 FR 67052, Nov. 30, 1999] (a) A team, as described in this section and §456.603 must periodically inspect the care and services provided to recipients in each facility. (b) Each team conducting periodic inspections must have a least one member who is at physician or registered nurse and other appropriate health and social service personnel. (c) For an IMD other than an ICF, each team must have a psychiatrist or physician knowledgeable about mental institutions and other appropriate mental health and social service personnel. (d) For an ICF that primarily cares for mental patients, each team must have at least one member who knows the problems and needs of mentally retarded individuals. (e) For an institution for the mentally retarded or persons with related conditions, each team must have at least one member who knows the problems and needs of mentally retarded individuals. (f) For ICFs primarily serving individuals 65 years of age or older, each team must have at least one member who knows the problems and needs of those individuals. (g) If there is no physician on the team, the Medicaid agency must insure that a physician is available to provide consultation to the team. (h) If a team has one or more physicians, it must be supervised by a physician. (a) Except as provided in paragraph (b) of this section— (1) [Reserved] (2) No member of a team that reviews care in an ICF may have a financial interest in or be employed by any ICF. (b) A member of a team that reviews care in an IMD or an institution for the mentally retarded or persons with related conditions— (1) May not have a financial interest in any institution of that same type but may have a financial interest in other facilities or institutions; and (2) May not review care in an institution where he is employed but may review care in any other facility or institution. [43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996] No physician member of a team may inspect the care of a recipient for whom he is the attending physician. There must be a sufficient number of teams so located within the State that onsite inspections can be made at appropriate intervals in each facility caring for recipients. The team and the agency must determine, based on the quality of care and services being provided in a facility and the condition of recipients in the facility, at what intervals inspections will be made. However, the team must inspect the care and services provided to each recipient in the facility at least annually. No facility may be notified of the time of inspection more than 48 hours before the scheduled arrival of the team. (a) For recipients under age 21 in psychiatric facilities and recipients in ICFs, other than those described in paragraph (b) of this section, the team's inspection must include— (1) Personal contact with and observation of each recipient; and (2) Review of each recipient's medical record. (b) For recipients age 65 or older in IMDs, the team's inspection must include— (1) Review of each recipient's medical record; and (2) If the record does not contain complete reports of periodic assessments required by §441.102 of this subchapter or, if such reports are inadequate, personal contact with and observation of each recipient [43 FR 45266, Sept. 29, 1978, as amended at 44 FR 17940, Mar. 23, 1979; 61 FR 38399, July 24, 1996] The team must determine in its inspection whether— (a) The services available in the facility are adequate to— (1) Meet the health needs of each recipient, and the rehabilitative and social needs of each recipient in an ICF; and (2) Promote his maximum physical, mental, and psychosocial functioning. (b) It is necessary and desirable for the recipient to remain in the facility; (c) It is feasible to meet the recipient's health needs and, in an ICF, the recipient's rehabilitative needs, through alternative institutional or noninstitutional services; and (d) Each recipient under age 21 in a psychiatric facility and each recipient in an institution for the mentally retarded or persons with related conditions is receiving active treatment as defined in §441.154 of this subchapter. In making the determinations on adequacy of services and related matters under §456.609 for each recipient, the team may consider such items as whether— (a) The medical evaluation, any required social and psychological evaluations, and the plan of care are complete and current; the plan of care and, where required, the plan of rehabilitation are followed; and all ordered services, including dietary orders, are provided and properly recorded; (b) The attending physician reviews prescribed medications— (1) At least every 30 days in psychiatric facilities, and mental hospitals; and (2) At least quarterly in ICFs; (c) Tests or observations of each recipient indicated by his medication regimen are made at appropriate times and properly recorded; (d) Physician, nurse, and other professional progress notes are made as required and appear to be consistent with the observed condition of the recipient; (e) The recipient receives adequate services, based on such observations as— (1) Cleanliness; (2) Absence of bedsores; (3) Absence of signs of malnutrition or dehydration; and (4) Apparent maintenance of maximum physical, mental, and psychosocial funtion; (f) In an ICF, the recipient receives adequate rehabilitative services, as evidenced by— (1) A planned program of activities to prevent regression; and (2) Progress toward meeting objectives of the plan of care; (g) The recipient needs any service that is not furnished by the facility or through arrangements with others; and (h) The recipient needs continued placement in the facility or there is an appropriate plan to transfer the recipient to an alternate method of care. [43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996] (a) The team must submit a report promptly to the agency on each inspection. (b) The report must contain the observations, conclusions, and recommendations of the team concerning— (1) The adequacy, appropriateness, and quality of all services provided in the facility or through other arrangements, including physician services to recipients; and (2) Specific findings about individual recipients in the facility. (c) The report must include the dates of the inspection and the names and qualifications of the members of the team. [43 FR 45266, Sept. 29, 1978, as amended at 44 FR 56337, Oct. 1, 1979] The agency must send a copy of each inspection report to— (a) The facility inspected; (b) The facility's utilization review committee; (c) The agency responsible for licensing, certification, or approval of the facility for purposes of Medicare and Medicaid; and (d) Other State agencies that use the information in the reports to perform their official function, including, if inspection reports concern IMD's, the appropriate State mental health authorities. The agency must take corrective action as needed based on the report and recommendations of the team submitted under this subpart. A utilization review committee under subparts C through F of this part may conduct the periodic inspections required by this subpart if— (a) The committee is not based in the facility being reviewed; and (b) The composition of the committee meets the requirements of this subpart.
Title 42: Public Health
PART 456—UTILIZATION CONTROL
Subpart I—Inspections of Care in Intermediate Care Facilities and Institutions for Mental Diseases
§ 456.600 Purpose.
§ 456.601 Definitions.
§ 456.602 Inspection team.
§ 456.603 Financial interests and employment of team members.
§ 456.604 Physician team member inspecting care of recipients.
§ 456.605 Number and location of teams.
§ 456.606 Frequency of inspections.
§ 456.607 Notification before inspection.
§ 456.608 Personal contact with and observation of recipients and review of records.
§ 456.609 Determinations by team.
§ 456.610 Basis for determinations.
§ 456.611 Reports on inspections.
§ 456.612 Copies of reports.
§ 456.613 Action on reports.
§ 456.614 Inspections by utilization review committee.
