CMS SOM App. K, Tag I-506

The facility must comply with the provisions at 42 CFR Part 420, Subpart C that require

health care providers and fiscal agents to disclose certain information about ownership

and control.

The facility must disclose certain information about its ownership and control in complying

with 42 CFR Part 420, Subpart C. Fiscal Intermediaries will review and verify the

information provided on the Form CMS—855A (Application for Health Care Providers that

will Bill Medicare Fiscal Intermediaries), prior to the state’s survey of a new CORF or when

a CORF makes a change (e.g., change of ownership (CHOW) or change of address).

Review ownership documents for signature and completeness.

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I-507, I-508, I-509, I-510, I-511

(Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05)

§485.56(b) Standard: Administrator

The governing body must appoint an administrator who:

(1) Is responsible for the overall management of the facility under the authority

delegated by the governing body;

(2) Implements and enforces the facility’s policies and procedures;

(3) Designates, in writing, an individual who, in the absence of the administrator,

acts on behalf of the administrator; and

(4) Retains professional and administrative responsibility for all personnel

providing facility services.

The qualifications of an administrator may vary among facilities, i.e., some administrators

may be health professionals while others may be business managers. The administrator's

basic responsibility regardless of the field of expertise is to assure that services are rendered

in accordance with CORF policies and that there is efficient utilization of resources and

coordination of services. The administrator should have a thorough working knowledge of

the overall operation of the facility, including the scope of services provided, policies

governing these services, budgetary and fiscal matters and the utilization and qualification of

personnel.

Discussion with the administrator will assist in determining depth of facility knowledge.

An administrator, especially of a large facility, generally functions on a full- time basis.

However, a small facility may have a part-time administrator, e.g., one who also provides

services as one of the professional personnel.

Determine if services are being provided in accordance with facility policies, that policies are

current and reflect an acceptable standard of care, that care is coordinated among the

professional staff and that there is efficient use of resources. If system problems are identified

in any of these areas, consider a citation under governing body.

Facility policies must designate in writing an individual who acts on behalf of the

administrator during a period of absence.

Review facility policies to ensure the facility has named an individual who will serve as

administrator in the administrator’s absence.

I-512, I-513, I-514

(Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05)

§485.56(c) Standard: Group of Professional Personnel

The facility must have a group of professional personnel associated with the facility that:

(1) Develops and periodically reviews policies to govern the services provided by

the facility; and

(2) Consists of at least one physician and one professional representing each of the

services provided by the facility.

The group of professional personnel serves a very specific facility function, that is, to

make certain that policies relating to patient care are realistic and best meet the needs of

the facility and patients alike. Effective facility operation is dependent, in part, on

workable policies especially those relating to: limitation of service capability, criteria for

patient admission, etc. These policies must be developed and periodically reviewed by the

group of professional personnel. The facility should be able to show that the group of

professional personnel is carrying out its policy formulation and review function. The

group must consist of at least one physician and one professional representing each of the

services provided by the facility. The names of all group members must be available and

evidence must confirm their participation in policy development and review.

All or part of the group of professional personnel, or a group of similar composition, can

serve as the facility's utilization review committee. Although a similarly comprised group

not associated with the facility can perform the utilization review function, it cannot

develop and periodically review the facility's policies

Review facility policies and/or procedures or other documentation that reflects this

function is being carried out (i.e., minutes of meetings, etc).

I-515, I-516, I-517

(Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05)

§485.56(d) Standard: Institutional Budget Plan

The facility must have an institutional budget plan that meets the following conditions:

(1) It is prepared, under the direction of the governing body, by a committee

consisting of representatives of the governing body and the administrative staff;

(2) It provides for:

(i) An annual operating budget prepared according to generally accepted

accounting principles;

(ii) A three year capital expenditure plan if expenditures in excess of $100,000

are anticipated, for that period, for the acquisition of land; the

improvement of land, buildings and equipment; and the replacement,

modernization, and expansion of buildings and equipment; and

(iii) Annual review and updating by the governing body.

In reviewing the facility's institutional budget plan, there must be evidence the plan has been

prepared under the direction of the governing body (a committee composed of at least one

member of the governing body and at least one member of the administrative staff). The

CORF may have a 3-year capital expenditure plan if expenditures, in excess of $100,000 are

anticipated for that period of time (i.e., acquisition or improvement of land, replacement or

modernization of equipment, buildings, etc.).

Review the Institutional Budget Plan for evidence that the governing body annually reviews

and updates the institutional budget plan. If the administrator states that there is no capital

expenditure plan because no capital expenditure in excess of $100,000 is anticipated, note on

the Survey Report Form CMS -360.

I-518, I-519, I-520, I-521, I-522, I-523, I-524, I-525, I-526, I-527, I-528

(Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05)

§485.56(e) Standard: Patient Care Policies

The facility must have written care policies that govern the services it furnishes. The

patient care policies must include the following:

(1) A description of the services the facility furnishes through employees and

those furnished under arrangements;

(2) Rules for and personnel responsibilities in handling medical emergencies;

(3) Rules for the storage, handling, and administration of drugs and biologicals;

(4) Criteria for patient admission, continuing care, and discharge;

(5) Procedures for preparing and maintaining clinical records on all patients;

(6) A procedure for explaining to the patient’s family the extent and purpose of

the services to be provided;

(7) A procedure to assist the referring physician in locating another level of care

for patients whose treatment has terminated and who are discharged;

(8) A requirement that patients accepted by the facility must be under the care of

a physician;

(9) A requirement that there be a plan of care established by a physician for each

patient; and

(10) A procedure to ensure that the group of professional personnel reviews and

takes appropriate action on recommendations from the utilization review

committee regarding patient care policies.

These policies comprise the basic operating framework of the CORF and are critical to its

effective operation. All policies must be in writing and documentation must verify the

input of the group of professional personnel in policy development and review. The

policies should be current, compatible with the CORF's provision of services and be

responsive to the needs of the patients.

Copies of all patient care policies should be reviewed.

In brief, patient care policies must reflect the following:

All services rendered by the CORF including those which are rendered by employees or by

others furnished under an arrangement;

A description of personnel tasks during medical emergencies and specific responsibilities,

where assigned;

The types of drugs and biologicals usually kept on the premises, their use, their manner of

storage, who has access to these materials and a procedure for periodic review to determine

the expiration date of the drugs and biologicals.

All criteria governing patient admission, continuing care and discharge. These criteria

should coincide with professional staffing and must be as specific as possible. Factors

governing admission may include geographic areas, ambulatory status of patients, specific

diagnoses, patient ability to carry through on a home program, etc. Criteria developed for

discharge may follow along the lines of specific levels of progress (attainment of goals), need

for higher level of care etc;

The manner in which clinical record documentation is to be prepared and maintained. At a

minimum, policies should state that all personnel performing services (i.e., those defined in

the conditions of participation) must authenticate any entry they place in the patient's clinical

record regardless of whether such personnel are employees of the facility or others. Clinical

records must be maintained so that easy access is afforded all CORF personnel.

The policy must require that documentation in the clinical records be sufficient to support

reasons for admission, care and treatment and discharge/transfer status;

A procedure for explaining a patient's treatment program to the patient and to the patient's

family. In most cases this procedure would include a discussion of the diagnosis (es), the

type and reasons for treatment, the treatment goal and the type of home program, where

applicable, which will be developed. In general, unless the referring physician specifically

notes that certain information is not to be revealed to the patient or family, the treatment

program is to be discussed in detail and procedures are to be in effect for continuing

discussions as they are warranted;

A policy that requires all patients to be under the care of a physician and that a plan of

treatment for each patient must be in effect;

A procedure to assist the referring physician in locating another level of care for patients

whose treatment has terminated and who are discharged; and

A procedure to ensure that the group of professional personnel reviews and takes appropriate

action on recommendations from the utilization review committee regarding patient care

policies.

Review clinical records and utilization review committee minutes, to determine if policies

have been developed for all aspects of care. Interview members of the professional staff to

determine if they have a working knowledge of the policies.

I-529, I-530, I-531

(Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05)

§485.56 (f) Standard: Delegation of Authority

The responsibility for overall administration, management and operation must be retained

by the facility itself and not delegated to others:

(1) The facility may enter into a contract for purposes of assistance in financial

management and may delegate to others the following and similar services:

(i) Bookkeeping;

(ii) Assistance in the development of an operating budget;

(iii) Purchase of supplies in bulk form; and

(iv) The preparation of financial instruments.

(2) When the services listed in paragraph (f)(1) of this section are delegated, a

contract must be in effect and:

(i) May not be a term of more than 5 years;

(ii) Must be subject to termination within 60 days of written notice by either

party;

(iii) Must contain a clause requiring renegotiation of any provision that CMS

finds to be in contravention to any new, revised, or amended Federal

regulation or law;

(iv) Must state that only the facility may bill the Medicare program; and

(v) May not include clauses that state or imply that the contractor has power and

authority to act on behalf of the facility, or clauses that give the contractor

rights, duties, discretions, or responsibilities that enable it to dictate the

administration, management, or operations of the facility.

A CORF may obtain assistance in financial management and delegate certain services,

including bookkeeping, billing procedure and accounting system development, budget

development, supply purchasing, and financial statement preparation. Where a CORF

does obtain services from another entity, the CORF must have a contract for a term of not

more than 5 years in effect. Such a contract must provide a 60 day right of termination,,

permit renegotiation of any term which CMS determines as contravening a Federal law or

regulation, and not permit the contractor to act on behalf of the facility or to bill the

Medicare program.

Review CORF contracts for adherence to this Standard.