CMS SOM App. H, Tag V555

address, but not be limited to, the following: (8) Rehabilitation status. The interdisciplinary

team must assist the patient in achieving and sustaining an appropriate level of productive

activity, as desired by the patient, including the educational needs of pediatric patients

(patients under the age of 18 years), and make rehabilitation and vocational rehabilitation

referrals as appropriate.

Interpretive Guidance § 494.90(a)(8):

The patient plan of care must reflect the information from the interdisciplinary patient

evaluation/assessment for rehabilitation status required at V515. The goals for the plan of care

in this area must be individualized for the patient (e.g., returning to a former occupation,

obtaining an educational certificate or diploma, resuming normal household activities, etc.) and

reflect the patient’s preferences.

Pediatric patient services should address normal growth and development needs, educational

needs, and age-appropriate activities, especially if dialysis treatments occur during hours when

the child would normally be in school. The social worker should be aware of the availability of

community referral options for physical and vocational rehabilitation services for all patients, as

well as educational resources for pediatric patients, if applicable for this facility. The IDT

should have a plan and procedure for making referrals for rehabilitation.

The IDT must provide and document assistance (e.g., education, encouragement) and referrals,

if indicated, which were aimed at enabling patients to maintain or return to their desired level of

functioning at work, school, home and in their community.