Evaluation of components of residential treatment by Medicaid ICF-MR surveys: a validity assessment.

We evaluated the proficiency of the federal Medicaid program's survey process for evaluating intermediate care facilities for the mentally retarded. In Study 1, an observational analysis of active treatment during leisure times in living units suggested that these surveys did not discriminate between certified and noncertified units. In Study 2, a reactivity analysis of a survey indicated that direct-care staff performed differently during the survey by increasing interactions with clients and decreasing nonwork behavior. Similarly, results of Study 3 showed increases in client access to leisure materials during a survey. In Study 4, questionnaire results indicated considerable variability among service providers' opinions on the consistency, accuracy, and objectivity with which survey teams determine agency standard compliance. Results are discussed regarding effects of the questionable proficiency of survey processes and the potential utility of behavioral assessment methodologies to improve such processes.