CMS SOM App. PP, Tag F826

Specialized rehabilitative services must be provided under the written order of a

physician by qualified personnel.

DEFINITIONS §483.65(b)

“Qualified Personnel” means a physical therapist, occupational therapist, respiratory

therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse

specialist, or physician’s assistant, who is licensed or certified by the state to furnish

therapy services. Qualified personnel may also include a physical therapist assistant

(PTA), or an occupational therapy assistant (OTA) when furnishing services under the

supervision of a qualified therapist.

GUIDANCE §483.65(b)

The facility must employ either directly or contract with an outside resource the

appropriate qualified personnel as defined above, and additional support staff to ensure

the needs of the residents are met in accordance with their comprehensive plan of care.

In addition to meeting the specific competency requirements as part of their license and

certification requirements defined under State law or regulations, these personnel must

have the training, competencies and skill sets to care for residents as identified through

resident assessments, and described in the plan of care.

NOTE: For residents receiving physical therapy (PT), occupational therapy (OT) and/or

speech-language pathology (SLP) services under the Medicare Part B benefit, an order is

not required An order from a physician may substitute for the required plan of care

(although orders from therapists are not recognized). Although §483.30(e)(3) allows a

resident’s attending physician to delegate the task of writing therapy orders to a qualified

therapist, Medicare Part B does not currently recognize an order written by a

therapist. Under current Part B requirements, when a therapy order is written by a

qualified therapist, for that therapy to be covered and paid under the Part B benefit, a

physician or recognized non-physician practitioner including a nurse practitioner, clinical

nurse specialist or physician assistant – not a therapist − must sign and date the PT, OT,

or SLP plan of care which may be established by the therapist.

In situations where there are differences between federal and state supervision

requirements, the requirement with the greater level of supervision will apply. Only

physical therapists may supervise physical therapy assistants, and only occupational

therapists may supervise occupational therapy assistants. All speech-language pathology

services must be provided by a licensed speech-language pathologist, or by a physician,

nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or

certified by the state to furnish therapy services.

PROCEDURES §483.65(b)

During the record review, determine that these services are provided under the written

order of a physician (or therapist as delegated by the physician in accordance with

§483.30(e)(3)) and provided by qualified personnel.

If individuals providing specialized rehabilitative services, i.e., physical, occupational,

speech or respiratory therapy are not qualified cite here. If a problem in a resident’s care

or services is related to the qualifications, competencies or training, of personnel (i.e.,

facility staff, contractors, temporary staff, etc.), also refer to:

• Nursing services not related to behavioral health care or dementia care, tag F725

or 726, §483.35(a),(c);

• Any staff caring for residents with dementia or a history of trauma and/or post-traumatic stress disorder, tag F741, §483.40;

• Administration, tag F839, §483.70(e).

If there are any problems in quality of care related to restoring, maintaining or improving

a resident’s functional abilities, determine if these problems are attributable in part to the

qualifications, competencies or training of specialized rehabilitative services staff. Also

refer to §483.25 (Quality of Care) and §483.24 (Quality of Life).

KEY ELEMENTS OF NONCOMPLIANCE

To cite deficient practice at F826, the surveyor's investigation will generally show that

the facility failed to do any one or more of the following:

• Obtain a written order from a physician (or therapist as delegated by the physician

in accordance with §483.30(e)(3)), except as otherwise permitted with regard to

residents receiving these services under the Medicare Part B benefit (as explained

above); OR,

• Ensure that services were provided by qualified personnel.