Conditions of Participation Simplified

As a new or experienced QIDP, the regulations that mandate the services provided in ICF-DD\H facilities can be confusing and frustrating. This outline is designed to minimize the confusion and concentrate on the federal guidelines with occasional notes.

There are eight Conditions of Participation. During a survey, any ONE of these
Conditions of Participation is "out of compliance" the facility will go into the de-certification process.

De-certification means that licensing will return for a repeat visit within 30 days and if the problems are not corrected the de-certification process will be filed and the facility is in jeopardy of losing its funding.

In order for a Condition of Participation to be "out of compliance" one or more standards under that Condition of Participation must also be "out of compliance". In some cases it may be just one or two key standards or it may be several standards that show a pattern of sub-standard services.

Just as the Conditions of Participation are broken down into standards. Each standard has subsections that are designated by "tag numbers". This presentation will not discuss the Conditions of Participation, the Standards and the Tag Numbers.

The following is a general outline of the 8 Conditions of Participation

I. GOVERNING BODY AND MANAGEMENT

  1. Governing Body
  2. Compliance with Federal, State and Local Laws
  3. Client Records
  4. Services provided Under Agreements with Outside Sources

II.CLIENT PROTECTION

  1. Protection of Client's Rights
  2. Client Finances
  3. Communication with Clients, Parents, and Guardians
  4. Staff Treatment of Clients

III. FACILITY STAFFING

  1. Qualified Intellectually Disabilities Professional
  2. Professional Program Services
  3. Facility Staffing
  4. Direct Care (Residential Living Unit) Staff
  5. Staff Training Program

IV. ACTIVE TREATMENT SERVICES

  1. Active Treatment
  2. Admissions, Transfers, and Discharges
  3. Individual Program Plan
  4. Program Implementation
  5. Program Documentation
  6. Program Monitoring and Change

V. CLIENT BEHAVIOR AND FACILITY PRACTICES

  1. Facility Practices and Conduct Toward Clients
  2. Management of Inappropriate Client Behavior
  3. Time-Out Rooms
  4. Physical Restraints
  5. Drug Usage

VI. HEALTH CARE SERVICES

  1. Physician Services
  2. Physician Participation in the Individual Program Plan
  3. Nursing Services
  4. Nursing Staff
  5. Dental Services
  6. Comprehensive Dental Diagnostic Services
  7. Comprehensive Dental Treatment
  8. Documentation of Dental Services
  9. Pharmacy Services
  10. Drug Regimen Review
  11. Drug Administration
  12. Drug Storage and Record keeping
  13. Drug Labeling
  14. Laboratory Services

VII. PHYSICAL ENVIRONMENT

  1. Client Living Environment
  2. Client Bedrooms
  3. Storage Space in Bedrooms
  4. Client Bathrooms
  5. Heating and Ventilation
  6. Floors
  7. Space and Equipment
  8. Emergency Plan and Procedures
  9. Evacuation Drills
  10. Fire Protection
  11. Paint
  12. Infection Control

VIII. DIETETIC SERVICES

  1. Food and Nutrition Services
  2. Meal Services
  3. Menus
  4. Dining Areas and Service