CMS SOM App. A, Tag A-1572

§483.65 Specialized rehabilitative services

(a) Provision of services. If specialized rehabilitative services such as but

not limited to physical therapy, speech-language pathology,

occupational therapy, respiratory therapy, and rehabilitative services

for a mental disorder and intellectual disability or services of a lesser

intensity as set forth at § 483.120(c), are required in the resident's

comprehensive plan of care, the facility must—

(1) Provide the required services; or

(2) In accordance with § 483.70(f), obtain the required services

from an outside resource that is a provider of specialized

rehabilitative services and is not excluded from participating in

any Federal or State health care programs pursuant to section

1128 and 1156 of the Act.

(b) Qualifications. Specialized rehabilitative services must be provided

under the written order of a physician by qualified personnel.

Interpretive Guidelines §482.58(b)(6)

Refer to §483.65(a)(b) (Tags F-0825 and F-0826 ) in Appendix PP of the State

Operations Manual (SOM) for interpretive guidelines

Survey Procedures §482.58(b)(6)

Refer to §483.65(a)(b) (Tags F-0825 and F-0826) in Appendix PP of the SOM for survey

procedures

Psychiatric Hospital Survey Module

Introduction

Under section 1861(f)(1) of the Social Security Act (the Act), a psychiatric hospital is an

institution that is primarily engaged in providing, by or under the supervision of a

physician, psychiatric services for the diagnosis and treatment of mentally ill persons. A

psychiatric hospital is

a type of hospital, and is required to be in compliance with the

Federal requirements at 42 CFR part 482, including the special requirements for

psychiatric hospitals which are the following:

• 42 CFR 482.60 -- Special provisions applying to psychiatric hospitals;

• 42 CFR 482.61 -- Special medical record requirements for psychiatric hospitals;

and

• 42 CFR 482.62 -- Special staff requirements for psychiatric hospitals

The focus of the psychiatric hospital survey is on the “outcome” experienced by the

patient, and the overall process and implementation of care provided to achieve a

favorable outcome. The survey process includes seven (7) tasks. When these tasks are

viewed in total, they give a clear indication of how the provider is meeting or not meeting

the requirements. The seven tasks are:

• Task 1 - Representative sample of patients -- selection methodology;

• Task 2 - Record review of individuals in the sample;

• Task 3 - Other record reviews;

• Task 4 - Direct patient observation;

• Task 5 - Interviews;

• Task 6 - Visit to each area of the hospital serving certified patients; and

• Task 7 - Team assessment of compliance.

Psychiatric hospital requirements at 42 CFR §§482.60-482.62 do not apply in the

following settings:

Psychiatric Residential Treatment Facilities (PRTF) are not psychiatric hospitals. They

are non-hospital, inpatient settings that treat children, adolescents and individuals under

the age of 21 with psychiatric disorders. The psychiatric hospital requirements do not

apply in PRTFs.

Inpatient Prospective Payment System (IPPS)-excluded psychiatric distinct part units

located in hospitals or critical access hospitals (CAHs) are not psychiatric hospitals and

are not subject to the psychiatric hospital special conditions at §§482.60-62. Facilities

with inpatient psychiatric units must meet the payment requirements at 42 CFR part 412

and must attest to meeting the necessary requirements that make them exempt from

receiving payments under the IPPS. These units must submit Form CMS-437 to attest

that they meet the requirements for IPPS exempt status prior to being placed into

excluded status. CMS accepts this attestation and does not survey to the IPPS-excluded

psychiatric unit for compliance with the psychiatric hospital special conditions.

Rehabilitation Hospital Survey Module

When conducting a full survey of an accredited or non-accredited rehabilitation hospital,

conduct a survey of the hospital’s compliance with rehabilitation hospital excluded

requirements using the survey methods in this module.

Surveys of the PPS excluded rehabilitation hospital requirements utilizing these methods

will count as annual validation compliance surveys of the hospital’s self-attestation of

compliance with the excluded requirements.

Background

The term “exclusion” is a reimbursement term. Patient care in a PPS excluded

rehabilitation hospital is reimbursed at the PPS rehabilitation hospital excluded rate rather

than at the hospital PPS rate. In order for a hospital to receive the excluded rate for

rehabilitation care provided, the hospital must comply with the excluded requirements

found at 42 CFR 412.

A PPS excluded rehabilitation hospital is regulated by both the hospital CoP at 42 CFR

482 (also found in Appendix A of the SOM) and the PPS excluded rehabilitation hospital

requirements at 42 CFR 412.

Regulatory Authority and Requirements for PPS Excluded Rehabilitation Hospitals

• 42 CFR 482-Conditions of Participation for Hospitals;

• 42 CFR 412.22-Excluded hospitals and hospital units ; and

42 CFR 412.23-Excluded hospitals: Classifications.

Activities Conducted Prior to a Rehabilitation Hospital Survey

• Contact the CMS Location to determine if the hospital has approval for a PPS

excluded rehabilitation hospital.

• Contact the CMS Location to determine the hospital’s cost reporting period.

• Do not conduct the survey of the PPS excluded rehabilitation hospital

requirements within 90 days of the end of the hospital’s cost reporting period.

• Identify any satellite locations of the hospital.

• Verify with the CMS Location that the hospital is in compliance with the

inpatient population percent rule, and that each satellite, if any, is

independently in compliance with the inpatient population percent rule.

• Review the “Rehabilitation Hospital Criteria Worksheet,” Form CMS-437B.

Survey Tool

“Rehabilitation Hospital Criteria Worksheet,” Form CMS-437B.

Survey Procedures for Determining Compliance with the PPS Excluded

Rehabilitation Hospital Requirements

• Survey activities to determine hospital compliance with the PPS excluded

rehabilitation hospital requirements should be conducted concurrently with the

full survey of the hospital’s compliance with the hospital CoP.

• Using the “Rehabilitation Hospital Criteria Worksheet,” Form CMS-437B,

verify whether the requirements have been met by checking the appropriate

box marked “YES” or “NO.” Under the column “Explanatory Statement,”

document specifics about the findings. Additional findings can be documented

in a narrative note that should be attached to the worksheet.

• Select a minimum of two current inpatients for the patient sample.

• Select additional patients (open or closed records) as needed to determine

compliance with the excluded rehabilitation hospital requirements.

• The selected patients should be included in the patient sample used for the full

hospital survey.

• Identify if the rehabilitation hospital has remote locations, satellites, or other

provider based locations. Record the location, name, address and telephone

number for every remote location, satellite, or provider based location on the

Hospital/CAH Medicare Database Worksheet for updating the Medicare

database.

Exit Conference

• Inform the hospital of findings of noncompliance with the excluded

rehabilitation hospital requirements.

• Inform the hospital that the SA will forward the completed Form CMS-437B

to the hospital at the same time as the completed Form CMS-2567.

Post Survey Activities

• Do not include the survey findings for the PPS excluded rehabilitation

hospital requirements on the Form CMS-2567.

• If there are PPS excluded hospital requirements that have not been met, notify

the CMS Location. Document survey findings of the PPS excluded

rehabilitation hospital requirements on the CMS 437B. Submit the completed

Form CMS-437B to the CMS Location within the same time frame as the

completion of the Form CMS-2567 and at least 60 days prior to the end of the

hospital’s cost reporting period.

• Follow the requirements in the SOM for post-survey activities.

Inpatient Rehabilitation Unit Survey Module

When conducting a full survey of an accredited or non-accredited hospital that has a PPS

excluded rehabilitation unit, conduct a survey of the rehabilitation unit using the survey

methods in this module to assess the hospital’s compliance with the excluded

rehabilitation unit requirements.

Surveys of the PPS excluded rehabilitation unit requirements utilizing these methods will

count as annual validation compliance surveys of the hospital’s self-attestation of

compliance with the excluded requirements.

Background

The PPS excluded rehabilitation unit is part of the hospital and is included as part of the

overall hospital survey. The term “exclusion” is a reimbursement term. Patient care in a

PPS excluded rehabilitation unit is reimbursed at the PPS excluded rehabilitation unit rate

rather than the hospital PPS rate. In order for a hospital to receive the excluded rate for

rehabilitation care provided in its excluded unit, the unit must comply with the excluded

rehabilitation unit requirements found at 42 CFR 412.

A PPS excluded rehabilitation unit is regulated by both the hospital CoP at 42 CFR 482

(also found in Appendix A of the SOM) and the PPS excluded rehabilitation unit

requirements at 42 CFR 412.

Requirements for PPS Excluded Rehabilitation Units

• 42 CFR 482-Conditions of Participation for Hospitals;

• 42 CFR 412.25-Excluded hospital units: Common Requirements;

• 42 CFR 412.29-Excluded rehabilitation units: Additional Requirements; and

• State Operations Manual, Chapter 3, §3100.

Activities Conducted Prior to Rehabilitation Unit Survey

• Contact the CMS Location to determine if the hospital has approval for a PPS

excluded rehabilitation unit.

• Contact the CMS Location to determine the unit’s cost-reporting period.

• Do not conduct the survey of the PPS excluded rehabilitation unit

requirements within 90 days of the end of the hospital’s cost reporting period.

• Verify with the CMS Location that the hospital is in compliance with the

inpatient population percent rule for the unit and that each rehabilitation unit

satellite, if any, is independently in compliance with the inpatient population

percent rule.

• If possible, establish the location or locations of the rehabilitation unit.

Determine if the unit has a satellite or satellites in other locations.

Determination or verification of this information may have to wait until the

survey team is onsite.

• Review the “Rehabilitation Unit Criteria Worksheet,” Form CMS-437A.

Survey Tool

The “Rehabilitation Unit Criteria Worksheet,” Form CMS-437A.

Survey Procedures for Determining Compliance with the PPS Excluded

Rehabilitation Unit Requirements

• Survey activities to determine hospital compliance with the PPS excluded

rehabilitation unit requirements should be conducted concurrently with the

full survey of the hospital’s compliance with the hospital CoP.

• Using the “Rehabilitation Hospital Criteria Worksheet,” Form CMS-437A,

verify whether the requirements have been met by checking the appropriate

box marked “YES” or “NO.” Under the column “Explanatory Statement,”

document specifics about the findings. Additional findings can be documented

in a narrative note that should be attached to the worksheet.

• Select 10 percent of the unit’s average daily census or a minimum of two

current patients for the patient sample.

• The selected patients should be included in the patient sample used for the full

hospital survey.

• Select additional patients (open or closed records) as needed to determine

compliance with the excluded rehabilitation unit requirements.

• If there are no patients on the unit at the time the survey is conducted, review

closed patient records of unit patients treated within six months of the survey.

• Identify if the rehabilitation unit has a satellite or satellites. Record the

location, name, address and telephone number for every satellite on the

Hospital/CAH Medicare Database Worksheet for updating the Medicare

database.

Exit Conference

• Inform the hospital of findings of noncompliance with the excluded

rehabilitation unit requirements.

• Inform the hospital that the SA will forward the completed Form CMS-437A

to the hospital at the same time as the completed Form CMS-2567.

Post Survey Activities

• Do not include the survey findings for the PPS excluded rehabilitation unit

requirements on the Form CMS-2567.

• If there are PPS excluded unit requirements that have not been met, notify the

CMS Location. Document survey finding of the PPS rehabilitation unit

requirements on the CMS-437A. Submit the completed Form CMS-437A to

the CMS Location within the same time frame as the completion of the Form

CMS-2567 and at least 60 days prior to the end of the hospital’s cost reporting

period.

• Follow the requirements in the SOM for post-survey activities.

Hospital Swing-Bed Survey Module

When conducting a full survey of an accredited or unaccredited hospital that has swing-bed approval, conduct a survey of the hospital swing-bed requirements found at 42 CFR

482.66.

Background

Swing-bed patients are hospital patients who are situated in the hospital but for whom the

hospital is receiving reimbursement for skilled nursing services, as opposed to acute-care

reimbursement. The reference to swing-bed is a patient care and reimbursement status

and has no relationship to geographic location in the facility. The patient may be in acute-care status one day and change to swing-bed status the next day. The patient doesn't need

to change location in the hospital when the reimbursement status changes, but moving to

a different location is allowed. A 3-day qualifying stay for the same spell of illness in any

hospital or critical access hospital (CAH) is required prior to admission to swing-bed

status. The 3-day qualifying stay does not need to be from the same facility as the swing-bed admission.

Regulatory Authority and Requirements for Hospital Providers of Extended Care

Services (“Swing-beds”)

Hospital swing-bed care is regulated by the hospital swing-bed requirements at 42 CFR

482.66. The swing-bed survey requirements are referenced in the Medicare Nursing

Home requirements at 42 CFR Part 483.

Section 1883 of the Act authorizes payment under Medicare for post-hospital SNF

services provided by any hospital that meets certain requirements. By regulation, the

Secretary has specified these requirements at 42 CFR 482.66:

• The hospital has a Medicare provider agreement;

• The facility has fewer than 100 hospital beds, excluding beds for newborns and

beds in intensive care type inpatient units;

• The hospital is located in a rural area. This includes all areas not delineated as

“urbanized” areas by the Census Bureau, based on the most recent census;

• The hospital does not have in effect a 24-hour nursing waiver granted under 42

CFR §488.54(c);

• The hospital has not had a swing-bed approval terminated within the two years

previous to application; and

• The hospital meets the swing-bed CoP on Resident Rights; Admission, Transfer,

and Discharge Rights; Resident Behavior and Facility Practices; Social Services;

Discharge Planning; Specialized Rehabilitative Services; and Dental Services.

Activities Conducted Prior to Swing-Bed Survey

Prior to conducting the swing-bed survey, verify the following:

• The hospital continues to be located in a rural census tract;

• The hospital does not have a 24-hour nursing waiver in place; and

• The hospital’s swing-bed approval is in effect and has not been terminated

within the two previous years.

Survey Procedures

In conducting the survey, verify that the hospital has fewer than 100 hospital beds,

excluding beds for newborns and beds in intensive care units. A hospital licensed for

more than 100 beds may be eligible for swing-bed approval if it utilizes and staffs for

fewer than 100 beds. Count the staffed beds in each nursing unit. Do not count beds in

recovery rooms, intensive care units, operating rooms, newborn nurseries or stretchers in

emergency departments.

Assess the hospital’s compliance with the swing-bed requirements at 42 CFR 482.66.

Swing-bed requirements apply to any patient discharged from the hospital and admitted

to a swing-bed for skilled nursing services. The requirements for acute-care hospitals also

apply.

If swing-bed patients are present during the on-site inspection, conduct an open record

review and an environmental assessment. Include patient interviews and observations of

care and services. However, if no swing-bed patients are present during the on-site

inspection, review two closed records for compliance with swing-bed requirements. In all

cases, review policies, procedures, and contracted services to assure that the hospital has

the capability to provide the services needed.

It is important for surveyors to maintain on-going documentation of their findings during

the course of the survey for later reference.

Exit Conference

Any findings of noncompliance may be discussed during the time of the hospital exit

conference.

Post-Survey Activities

The findings for swing-bed deficiencies must be documented on the same Form CMS-

2567 as the hospital survey.