Centers for Medicare & Medicaid Services' proposed rule on Conditions of Participation for Community Mental Health Centers

American Psychiatric Nurses Association Comments and Proposed Changes

General Comments:

Under the section of current rules (1) The CMHC meets each of the following core requirements identified at 42 CFR 410.0....should include broader language by replacing the term "physician" with "provider."

Section Review:

Section II. Provision of the Proposed Regulations (p. 35686)

A. Proposed Requirements
We support an implementation window of 12 months to allow CMHC time to prepare to meet new requirements.

CMHC CoP: Personnel Qualifications (Proposed § 485.904 (b) ) (p. 35687)

The current definition in "Standard: Personnel qualifications for certain disciplines," does not include the scope of practice, advanced degrees, training and licensure of Advanced Practice Registered Nurses (APRNs) in addition to the Psychiatric Mental Health Registered Nurse.

“Advanced Practice Psychiatric Nurse” would mean an individual who specializes in assessing and treating persons having psychiatric disorders; is certified by a national certifying body as a Psychiatric Clinical Nurse Specialist (CNS) or Nurse Practitioner (NP) and licensed in the state as an advanced practice registered nurse or has documented equivalent education, training or experience, and is fully licensed to practice advanced psychiatric nursing in the State in which he or she practices.

For additional information about Advanced Practice Nurses, see the “Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education” (

CMHC CoP: Client Rights (Proposed § 485.910) (p. 35687)

The proposed rights follow current practice. APNA strongly supports the current wording and intent related to Seclusion and Restraint (below).

"Based on discussions with the CMHC industry and The Joint Commission, we believe restraints or seclusion are rarely, if ever, used in a CMHC setting and that there are very few deaths (if any) that occur due to restraints or seclusion in CMHCs. However, there are no data available regarding this issue. The use of restraint or seclusion would be considered contrary to targeted client outcomes and therefore we would consider the use of restraint or seclusion an adverse client event that would be tracked as part of the QAPI program (Quality assessment and performance improvement: proposed § 485.917)." (Page 35688, 3rd column)

CMHC CoP: Admission, Initial Evaluation, Comprehensive Assessment and Discharge or Transfer of the Client (Proposed § 485.914) (p. 35689)

APNA suggests that consideration to change the term "physician-led" to "provider-led." This request in change in language should be recommended for the entire document. Even if "physician" is required by current federal and state law, the change to the register from "physician" to "provider" would continue to follow the law but allow for future changes in the law to include other providers without having to change the register language.

CMHC CoP: Treatment Team, Client-Centered Active Treatment Plan, and Coordination of Services (Proposed § 485.916) (p. 35690-91)

§ 485.916(a), ‘‘Standard: Delivery of services’’

As stated above, PMH APRNs are omitted from the Interdisciplinary Team list. Limiting delivery of services to physicians creates a huge access and quality issue in that any physician (without any psychiatric training) can perform a psychiatric evaluation while the omission would suggest that a specialty-trained PMH NP/CNS would not be allowed.

APNA’s recommendation is that the term "physician-led" should be changed to "provider-led." This enables all providers who are legally within their scope of practice to deliver these services actually to provide the evaluation/care needed.

Given that the definition of “psychiatric registered nurse” does not reflect the training or scope of practice of PMH APRNs, APNA strongly recommends specific inclusion of PMH APRN within the personnel qualifications.

There is a growing emphasis on the Recovery Model in the care of people with psychiatric disorders. Within this model there is a therapeutic place for the inclusion of Peer Counselors to be part of the Interdisciplinary Team, the APNA would like to see their inclusion.

It is currently listed as:

The interdisciplinary team would include, but would not be limited to the following:

  • A doctor of medicine, osteopathy or psychiatry.
  • A psychiatric registered nurse.
  • A clinical social worker.
  • A clinical psychologist.
  • An occupational therapist.
  • Other licensed mental health professionals, as necessary.

We suggest that the wording be changed to:

The interdisciplinary team would include, but would not be limited to the following:

  • A doctor of medicine, osteopathy or psychiatry
  • An advanced practice psychiatric nurse (NP or CNS)
  • A psychiatric registered nurse (RN)
  • A clinical social worker
  • A clinical psychologist
  • An occupational therapist
  • A peer counselor
  • Other licensed mental health professionals, as necessary

§ 485.916(b), ‘‘Standard: Active treatment plan’’

Active treatment plan includes diagnosing, treating, individual, family and group psychotherapy and medication management. Inclusion of PMH APRNs as an integral part of the interdisciplinary treatment team is strongly recommended. It is also recommended that peer specialists are considered as a part of the interdisciplinary team as well.

§ 485.914 Condition of participation: Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client. (Page 35708)

The PMH APRN is educated and qualified to perform psychiatric evaluations without “supervision” and/or oversight in many states.

We suggest the following wording below to indicate the inclusion of advanced practice nurses and the psychological evaluation as a component of the psychiatric assessment (edited text in red).

(4) The comprehensive assessment, minimum, must include the following: (i) The reasons for the admission. (ii) A psychiatric evaluation, completed by a psychiatrist or advanced practice psychiatric nurse, that includes the medical history and severity of symptoms. (iii) A Psychological Evaluation by a clinical psychologist iv) Information concerning previous and current mental status, including but not limited to, previous therapeutic interventions and hospitalizations. (v) Information regarding the onset of symptoms of the illness and circumstances leading to the admission....


August 12, 2011


The American Psychiatric Nurses Association is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.