ICF/IID Regulations Compliance Worksheet
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This document is intended as a simplified worksheet to assist the ICF/IID provider in evaluating compliance with the federal regulations. Each Condition of Participation (CoP) is in its own section and the “fundamental” CoPs and tags are highlighted so that the provider may more easily prepare for an upcoming survey or perform internal quality assurance focused on the survey tasks. Each tag may be checked as compliant or non-compliant and an area for notes is provided that may serve as the basis for QA actions or a plan of correction.
In 1996, CMS introduced a three-tier approach to the ICF/IID surveys. Rather than doing a full survey of all eight conditions of participation and all 389 “TAGS” or regulations for all ICF/IID providers each year, surveyors can now do either a full, fundamental or extended survey.
Most annual re-certification surveys start as a “fundamental” survey to determine compliance with the fundamental requirements of the Conditions of Participation (CoP) for ICFs/IID. The fundamental survey is called that because it reviews four CoPs and 55 regulations deemed “fundamental” which focus on outcomes for individuals, as opposed to processes.
These regulations fall under the following four conditions of participation:
1. Client Protections
2. Active Treatment
3. Client Behavior and Facility Practices
4. Health Care
Each of the eight CoPs has its own section within this document. These fundamental CoPs are highlighted in bright red text within the worksheet sections.
The 55 Fundamental Tags are highlighted in italics and dark red text within the worksheet sections If surveyors find enough evidence to question whether the provider is in compliance with these fundamental requirements, surveyors are then required to conduct an “extended” survey.
Surveyors can “extend” the survey within any of the four fundamental conditions of participation and may extend the survey in one, two, three or all four of the Conditions of Participation (CoPs). When a surveyor extends the survey, they look at all of the regulations under the CoP(s) that is in question, as opposed to reviewing only the fundamental regulations that are covered by the CoP.
If a provider is opening a new home, had a condition of participation out of compliance on the last survey, or has had a significant problem maintaining the regulations in the recent past, the state survey agency will conduct a full survey or “review” of all eight conditions of participation and all 389 regulations.
This toolbox provides a quick checklist for preparation and maintenance of compliance with the federal regulations. It will assist the ICF/IID provider in identifying and concentrating on areas that may be non-compliant in whatever level survey is anticipated.