Health Facility Licensing, Certification and Resident Assessment
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Description of the Survey and Certification Process

Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) are specialized long-term residential care for persons who are mentally retarded and/or developmentally disabled. Most residents qualify for Medicaid to reimburse for their care due to their disability. ICFs/MR that are approved to be reimbursed for care given to Medicaid consumers are required to meet minimum standards set by federal regulations. The process of approving ICFs/MR for participation in the Medicaid program is known as the survey and certification process. The regulations/standards that are used during the survey/certification process are the way federal and state governments make sure that ICFs/MR receiving public monies provide care of acceptable quality to residents.

The standards used for survey/certification are developed by the federal Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Service (DHHS). The Bureau of Health Facility Licensing, Certification and Resident Assessment at least annually inspects/surveys ICFs/MR in Utah using these standards to ensure they meet active treatment, health, safety and quality standards. The surveyors are state employees who use federal forms and standards. The Federal government pays Utah for this survey activity and our state pays a share of the cost for surveying the facilities. Nationally, information from these surveys are stored in a centralized computer system in Baltimore, Maryland. The information published in this report was adapted from this system, although many changes were made to make the data easier to use.

Overview of Utah's ICF/MR Certification/Licensure Programs

Certification of ICFs/MR to participate in the Medicaid program is performed by the Bureau of Health Facility Licensing, Certification and Resident Assessment. The Bureau of Health Facility Licensing, Certification and Resident Assessment performs annual on-site inspections of ICFs/MR to see that they comply with Medicaid standards. During these inspections, Bureau staff also determine that state licensure rules and federal and state fire safety rules are met. These latter duties are performed under memoranda of agreement with the Bureau of Licensing and with the office of the State Fire Marshal.

Licensure of ICFs/MR is performed by the Bureau of Health Facility Licensing, Certification and Resident Assessment. The Bureau writes and publishes state licensure rules; reviews and approves architectural plans of proposed new and remodeled facilities; and performs initial physical environment inspections of new programs.

The Bureau of Health Facility Licensing, Certification and Resident Assessment is required to survey/certify all ICFs/MR at least once a year and report the findings to other state and federal officials. During a survey, a team of surveyors tours an ICF/MR, observes the provision of the active treatment programming and reviews all areas of the facility that affect the quality of care and services that residents receive. The specialized inspection team of the Bureau of Health Facility Licensing, Certification and Resident Assessment consist of health care professionals including Qualified Mental Retardation Professionals (Q.M.R.P), Registered Nurses, Dieticians, Social Workers and Sanitarians/Life Safety surveyors. The size and composition of survey team varies upon the size of the facility and any specialized services that may need to be reviewed.

During the survey/certification process, State surveyors observe how medical care and active treatment programming are actually given to residents. Some examples of what surveyors do when they inspect an ICF/MR include; interviewing a sample of the residents and review their medical and programming records; evaluate the preparation of meals and eating assistance techniques; check whether residents get prescribed medications in the proper dosage at the correct times; review the records required of the ICF/MR provider; interview facility staff, including direct care staff; and, observe the facility for a home-like atmosphere, cleanliness, comfort and safety.

If non-life threatening problems/deficiencies that are not severe enough or sufficiently widespread to be a threat to care or safety of the residents are found by the surveyors during the survey, the ICF/MR must submit a written Plan of Correction. The Plan of Correction describes how the provider plans to correct the problems that were found. The Bureau of Medicare/Medicaid Program Certification and Resident Assessment performs a follow-up survey on every certified ICF/MR with identified deficiencies in order to ensure that deficiencies are corrected. These follow-ups generally occur forty-five to sixty days after the annual survey was completed.

State/Federal Adverse or Compliance Actions

If the problems are serious enough to threaten the health and safety of the residents and/or the ICF/MR fails to correct the problems for which they submitted the Plan of Correction, the facility will not be allowed to continue to participate in the Medicaid program. Short of this action, State officials can also use an array of other actions to bring about compliance with State and Federal requirements. Examples of possible actions include bans on new admissions, transfer of residents to other facilities, or temporary government ordered monitoring management. Additionally, the Bureau of Licensing has an array of actions they may take in conjunction with or separate from the Bureau of Medicare/Medicaid Program Certification and Resident Assessment as a result of the survey/certification findings. All certification survey results are shared with the Bureau of Licensing.

If you wish to determine if a specific ICF/MR was given an adverse or compliance action, please refer to the individual ICF/MR in the "ICF/MR Profiles" section of this report. If an ICF/MR was subjected to some form of action, it will appear under the headings of "Compliance Actions" and/or "Sanctions".