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Treatment Modalities and the Patient’s Treatment Plan

MCN Question of the Week

Treatment Modalities and the Patient’s Treatment Plan

QUESTION

What is the CMS regulation that requires treatment modalities to be included in the patient treatment plan?

ANSWER

CMS §482.61(c) requires that each patient must have an individual comprehensive treatment plan. The written plan must include [§482.61(c)(1)]:

  • A substantiated diagnosis [§482.61(c)(1)(i)]
  • Short-term and long range goals [§482.61(c)(1)(ii)]
  • The specific treatment modalities utilized [§482.61(c)(1)(iii)]
  • The responsibilities of each member of the treatment team [§482.61(c)(1)(iv)]; and
  • Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out [§482.61(c)(1)(v)]

Interpretive Guidance for §482.61(c)(1)(iii):

  • This requirement refers to all of the planned treatment modalities used to treat the patient during hospitalization.
  • Modalities include all of the active treatment measures provided to the patient. It describes the treatment that will be provided to the patient. It describes the treatment that will be provided by various staff.
  • A daily schedule of unit activities does not, in itself, constitute planned modalities of treatment. It is expected that when a patient attends various treatment modalities/activities, it is a part of individualized planning with a specific purpose and focus for that patient.
  • Simply “naming” modalities (i.e., individual therapy, group therapy, occupational therapy, medication education) is not acceptable. The focus of the treatment must be included. Simply “stating” modality approaches (i.e., “set limits,” “encourage socialization,” “discharge planning as needed”) is not acceptable.
  • Modality approaches must be specifically described in order to assure consistency of approach. Observation of staff implementing treatment, both in structured and non-structured settings, is a major criterion to determine whether active treatment is being provided in accordance with planned treatment. It must be clear to you that the active treatment received by the patient is internally consistent and not simply a series of disconnected specific modalities delivered within certain scheduled intervals.

Effective April 4, 2016, The Joint Commission revised Provision of Care, Treatment, and Services (PC) Standard PC.01.03.01, Element of Performance (EP) 6, for psychiatric hospitals that use Joint Commission accreditation for deemed-status purposes.  The revision was made to align this Joint Commission standard with §482.61(c)(1)(iii).

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