Even in the best-managed facility, Survey is a stressful process. A tremendous amount of energy goes into preparing all the in-house departments, making sure all charts is up to date and all documentation done correctly. The last thing a facility needs is to be dealing with outside service providers who are not up to date on their documentation, or worse, have documentation that contradicts  other sections of the residents’ charts.

In addition to the programs and policies discussed below which are in place at all times, ITS makes an extra effort to be present and available during Survey for any questions or issues that may come up. Our Clinical Director comes on-site  prior to and during Survey to provide additional review and support, and is available 24/7 during the Survey for any urgent questions that may arise.

Here are some of the more common issues that we have seen come up relating to psychological services, and the programs/policies we have developed to reduce these. Our goal is always to ensure that not only do ITS psychology notes not cause the facility problems, but that they actively enhance the survey process and clinically support  all relevant sections of the resident’s chart.



One of the main things Surveyors look for in a chart is that all medical orders are in place, and that they are being followed correctly. Psychological services must be appropriately medically-ordered, and the order must be adhered to in duration, frequency, and purpose. Often, this process is overlooked: the initial order can be omitted or forgotten, or, more commonly, the original reasons for treatment can no longer be relevant or the ordered frequency/duration have been altered significantly.

At ITS we have an in-house program to self-audit the charts of our patients to make sure they are being treated as per their medical order. We have a form-tracking system to ensure that the correct order is requested and obtained when treatment is initiated, and we audit all charts quarterly to ensure that treatment has not deviated from this. If treatment needs have changed (as they often do) we have an administrative process to ensure that a modification to the original order is made , and that this is placed in the patient’s chart. this way, when the Surveyor looks at the psychological services order, it is in place, and the actual treatment rendered matches the order.



We believe that psychotherapy is most valuable when it is integrated into the patient’s care plan , and the entire treatment team is able to be updated as to progress and strategies to help our patients. Therefore, it is our policy that all clinical documentation must be completed within 24 hours of seeing the patient; it is then reviewed administratively by a senior clinical supervisor for content and corrections, and it is then released for placement in the chart. All clinical notes are given to the facility within 48 hours of clinical services being provided. This way the most up to date treatment data can always be in the staff’s hands and the psychological treatment can be relevant to the daily care residents get from their entire treatment team.

Additionally, our rigor in terms of getting the notes into the charts in a timely manner ensures that when a survey is in progress all notes are in place in the charts, and there is no need to start scrambling for missing notes at the last moment.



One of the most common pitfalls occurs when psychotherapy services operate in a vacuum, with no coordination between disciplines as to clinical content, symptoms, and treatment strategy. At ITS we always make a strong effort to interface with all relevant disciplines, including psychiatry and other medical specialties. Aside from the obvious clinical benefits of treatment team members being on the same page, this has an added benefit in that it makes the patient’s chart consistent.

It reflects very poorly  on the facility when the same patient is assigned conflicting diagnoses by different disciplines, and worse, when the clinical information from one discipline contradicts another. We always make an effort to coordinate psychiatric diagnosis with the medical and psychiatric team, and our close interaction with the facility staff ensures that clinical information is being shared in a way that is useful and collaborative. This reflects positively when a reviewer sees that recommendations made by the psychologist are, for example, integrated into the behavioral section of the Care Plan .



A question that often comes up during Survey is whether or not a particular resident is capable of benefitting from psychotherapy. Especially when there is severe medical impairment and/or dementia, the question needs to be asked whether the resident is truly appropriate for psychotherapy services, and that decision must be justified strongly and clearly in the clinical documentation. At ITS we recognize that this is one of the most serious decisions  psychologists in a long-term care setting must make.

The official Medicare policy about this issue is:

“Patients with dementia represent a very vulnerable population in which co-morbid psychiatric conditions are common. However, for such a patient to benefit from psychotherapy services requires that their dementia to be [sic] mild and that they retain the capacity to recall the therapeutic encounter from one session, individual or group, to another. This capacity to meaningfully benefit from psychotherapy must be documented in the medical record.  Psychotherapy services are not covered when documentation indicates that dementia has produced a severe enough cognitive defect to prevent psychotherapy from being effective.”

Our policy at ITS is to take a very conservative approach when making this decision. What this means is that when there is any question of cognitive ability to benefit from psychotherapy we provide thorough cognitive assessment and regular follow-ups to determine level of cognitive impairment. When there is sufficient impairment to reasonably believe a patient might not benefit from services, psychotherapy is discontinued. All of the testing results, rationale for treatment, and if necessary reason for termination, are fully documented  and supported in the clinical record. This way when the question of clinical appropriateness comes up during Survey, the answer is already fully prepared and documented as to why a particular resident is or is not appropriate for psychological treatment.



The treatment our psychologists provide is based on two general principles: it needs to be helpful, and it needs to make sense . The treatment plan is the central document upon which our clinical documentation is built; it contains the patient’s diagnosis, symptoms that are present, and specific goals to work towards in alleviating and improving those symptoms.

Everything follows a logical treatment pathway:

  1. The diagnosis needs to be justified by specific symptoms.
  2. The goals on the treatment plan need to be related directly to those symptoms.
  3. The objectives in the plan need to be related to the goals.
  4. The interventions used need to make sense for the objectives chosen.
  5. And finally, the actual session note is an extension of this documentation process:

The psychotherapy session note concisely describes the specific interventions used in that specific session to address a specific objective on the plan, and describes how this relates to the overall treatment goals of the patient.

This entire clinical chain is monitored by senior clinical supervisors to ensure consistency and that it all makes sense. 

The end goal is that when someone looks at a psychotherapy session note written by an ITS psychologist, it should be consistent  with the rest of the patient’s chart, should reflect accurate clinical information that is consistent with the patient’s current level of functioning, should make a clear and persuasive case  for the clinical necessity of treatment, and should demonstrate in a clear and logical manner exactly what is being done to improve the patient’s symptoms.