CMS SOM App. A, Tag A-1124

The organization of the service must be appropriate to the scope of the services

offered.

Interpretive Guidelines §482.56(a)

The hospital must provide the appropriate equipment and types and numbers of qualified

personnel necessary to furnish the rehabilitation services offered by the hospital in

accordance with acceptable standards of practice.

The scope of rehabilitation services offered by the hospital should be defined in written

policies and procedures, and approved by the Medical staff.

Each service, whether provided through a single discipline department or within a multi-discipline department, must function with established lines of authority and responsibility

to ensure the health and safety of patients. There must be an adequate number of

qualified staff available when needed to evaluate each patient, initiate the plan of

treatment, and supervise supportive personnel when they furnish rehabilitation services.

The number of qualified staff is based on the type of patients treated and the frequency,

duration, and complexity of the treatment required.

Survey Procedures §482.56(a)

• Review the hospital’s policies and procedures to verify that the scope of

rehabilitation services offered is defined in writing.

• If services are provided under an arrangement, review policies and contracts.

• For each service, determine that adequate types and numbers of qualified staff are

available to ensure safe and efficient provision of treatment.

• Review medical records to verify that a qualified professional evaluates the

patient and initiates each treatment episode.

• Review a sample of personnel files to verify current licensure, certifications and

ongoing training, consistent with applicable State laws.