Form Cms-437- Psychiatric Unit Criteria Worksheet Page 7
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REGULATION
GUIDANCE
YES NO
EXPLANATORY STATEMENT
A1183
(3) Nursing Services. The unit must have a qualified
director of psychiatric nursing services. In addition to
the director of nursing, there must be adequate numbers
of registered nurses, licensed practical nurses, and
mental health workers to provide nursing care necessary
under each inpatient’s active treatment program and to
maintain progress notes on each inpatient.
A1184
(i) The director of psychiatric nursing services must
be a registered nurse who has a master’s degree
in psychiatric and mental health nursing, or its
equivalent, from a school of nursing accredited by
the National League of Nursing, or be qualified by
education and experience in the care of the mentally
ill. The director must demonstrate competence
to participate in interdisciplinary formulation of
individual treatment plans; to give skilled nursing
care and therapy; and to direct, monitor, and evaluate
the nursing care furnished.
A1185
(ii) The staffing pattern must ensure the availability of
a registered nurse 24 hours each day. There must
be adequate numbers of registered nurses, licensed
practical nurses, and mental health workers to
provide the nursing care necessary under each
inpatient’s active treatment program.
Number of Nursing Personnel Assigned to Unit (Full-Time Equivalents)
(A) R.N.S._________
(B) L.P.N.S. ___________(C) AIDES ________
Day of Survey-Number of Nursing Personnel (Full-Time Equivalents)
SHIFT
R.N.
L.P.N.
AIDES
OTHER
Day
Evening
Night
Average bed-size of adult patient ward _____ beds
R.N. Duty Roster (Full-time Equivalent) — For at least one complete week
SHIFT
SUN.
MON.
TUES.
WED.
THURS.
FRI.
SAT.
Day
Evening
Night
Relief
Form CMS-437 (04/06)
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Parent category: Medical