March, 1999

Information Bulletin 99-3
ICF/MR - 5

Survey Procedures For Intermediate Care Facilities
For Persons With Mental Retardation

The survey procedures for Appendix J, Survey Procedures for Intermediate Care Facilities for Persons with Mental Retardation (ICF/MR) have been revised. These changed procedures update and provide further clarification on survey issues based on recent recommendations by State survey agencies, HCFA regional office, and other interested parties.

Below is a summary of the changes in Appendix J that surveyors will be using when surveying your facility at your next survey.

Three additional tags have been added to the Fundamental survey, increasing the number of Fundamental Tags from 52 to 55. Surveyors will review these 55 fundamental tags in the first stage of the survey process.

  1. W120 483.410(d)(3):    The facility must assure that outside service meet the needs of each client.

  2. W448 483.470(I)(4):    Investigate all problems with evacuation drills, including accidents,

  3. W449 483.470(I)(4):    And take corrective action.
  4. (See replaced pages J-3)

The number of interview with Individual/Family have been changed in the following categories:

  1. 51 - 100 individuals residing in the facility-- changed from 7 to 5

  2. 101 - 500 individual residing in the facility-- changed from 10 to 50 [percent of sample (max.: 15)]
  3. (See replaced pages J-7)

The following sentence replaces the first sentence of the fourth paragraph on page J-8 under the heading Sampling on Follow-up Survey:

    "If the last survey found multiple standard-level deficiencies that are not limited to a specific area or issue, follow the procedure described in paragraphs A through D above to select a new sample and use the same sample size specified in paragraph B."

The next paragraph on J-8 is changed to:

    "When Conditions of Participation have been found not met in the annual survey and the types of deficiencies are limited to a specific need or service area, then the follow-up sample may be drawn from the specific universe of individuals who have that specific need. To select the sample, start with the total number of individuals affected by the specific need, than choose the sample size. The sample universe will be the total number of individuals who have that specific need."

Page J-11 is the same text as Rev. 278.

The following sentence is added on page J-12 under Task 4.A.:

    Purpose: "Only interviews with the individuals, their family members/guardians, advocates, and direct care staff count toward the total number of required interviews (as reflected in the sample chart shown in Section 5B - Sample Size)."

On page J-15 the word "immediately" has been removed and the sentence now reads:

    "If possible, interview staff following the interval in which the individual was observed with the particular staff member."

To request a copy of the revised pages in Appendix J, contact the Facility and Provider Compliance Division at (651) 201-4101.

If there are any questions concerning the changes, please feel free to contact Peggy Durham-Lien, Unit Supervisor, (218) 739-1393.

Updated Thursday, 17-Mar-2011 12:53:15 CDT