Fillable Form Cms-437- Psychiatric Unit Criteria Worksheet (Page 4 of 8) in pdf

Form Cms-437- Psychiatric Unit Criteria Worksheet Page 4

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TAG

REGULATION

GUIDANCE

YES NO

EXPLANATORY STATEMENT

A1145

(v) Describe attitudes and behavior;

Does the problem statement describe the

behavior(s) which require modification in order

for the patient to function in a less restrictive

environment?

A1146

(vi) Estimate intellectual functioning, memory

functioning, and orientation; and

A1147

(vii) Include an inventory of the inpatient’s assets in

For the purposes of this regulation, words such as

descriptive, not interpretative fashion.

“youth”, “pretty”, “social security income” and

“has a car” do not represent assets.

A1150

(3) Treatment Plan.

Is the treatment plan a result of collaboration

(i) Each inpatient must have an additional

between the patient and the treatment team?

comprehensive treatment plan that must be based

Is the treatment plan individualized?

on an inventory of the inpatient’s strengths and

Is there a primary diagnosis upon which the

disabilities. The written plan must include a

treatment interventions are based?

substantiated diagnosis; short-term and long-term

Are the treatment plan goals written in a manner

goals; the specific treatment modalities utilized; the

that allows for changes in the patient’s behavior to

responsibilities of each member of the treatment

be measured?

team; and adequate documentation to justify the

Are the treatment plan goals relevant to the

diagnosis and the treatment and rehabilitation

patient’s condition?

activities carried out; and

Does the treatment team encourage the patient’s

active participation and responsibility for engaging

in the treatment regimen?

For patients who have been secluded or restrained,

have less restrictive interventions been considered

prior to the use of seclusion or restraints?

What is the rationale for use of seclusion and/or

restraints?

If the use of seclusion and/or restraints is a frequent

occurrence, does the treatment plan document

alternative interventions to address and treat

negative patient behavior?

A1151

(ii) The treatment received by the inpatient must be

Does the patient require 24 hour specialized

documented in such a way as to assure that all active

psychiatric care?

therapeutic efforts are included.

Is the patient receiving all aspects of treatment to

which the unit has committed itself, based on the

assessment, evaluation, and plan of care?

Do the policies and procedures adequately direct

staff on alternatives or less restrictive interventions

prior to the use of seclusion and restraints?

Has the staff documented that less restrictive

therapeutic interventions have been reviewed and/

or attempted?

Form CMS-437 (04/06)

Form Cms-437- Psychiatric Unit Criteria Worksheet Page 4

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