CMS-1893 Outpatient Physical Therapy -- Speech Pathology Survey R

OUTPATIENT PHYSICAL THERAPY — SPEECH PATHOLOGY SURVEY REPORT

42 CFR 485.703 Definitions
(a) Clinic. A facility that is established primarily to furnish outpatient physician
services and that meets the following tests of physician involvement:
(1) The medical services are furnished by a group of three or more
physicians practicing medicine together.
(2) A physician is present during all hours of operation of the clinic to
furnish medical services, as distinguished from purely administrative services.
(b) Organization. A clinic, rehabilitation agency, or public health agency.
(c) Public health agency. An official agency established by a State or local
government, the primary function of which is to maintain the health of the
population served by performing environmental health services, preventive
medical services, and in certain cases, therapeutic services.
(d) Rehabilitation agency. An agency that provides an integrated multidisciplinary
rehabilitation program designed to upgrade the physical functioning of
handicapped disabled individuals by bringing specialized rehabilitation staff
together to perform as a team; and provides at least the following services:
physical therapy or speech-language pathology services; social or vocational
adjustment services.
(e) Supervision. Authoritative procedural guidance that is for the accomplishment
of a function or activity and that includes initial direction and periodic observation
of the actual performance of the function or activity; and is furnished by a qualified
person whose sphere of competence encompasses the particular function or
activity; and who (unless otherwise provided in this subpart) is on the premises if
the person performing the function or activity does not meet the assistant level
practitioner qualifications specified in 485.705.
42 CFR 485.705 Personnel qualifications.
(a) General qualification requirements. Except as specified in paragraphs (b) and
(c) of this section, all personnel who are involved in the furnishing of outpatient
physical therapy, occupational therapy, and speech-language pathology services
directly by or under arrangements with an organization must be legally authorized
(licensed or, if applicable, certified or registered) to practice by the State in which
they perform the functions or actions, and must act only within the scope of their
State license or State certification or registration.
(b) Exception for federally defined qualifications. The following federally defined
qualifications must be met:
(1) For a physician, the qualifications and conditions as defined in section
1861(r) of the Act and the requirements in part 484 of this chapter.
(2) For a speech-language pathologist, the qualifications specified in section
1861(ll)(1) of the Act and the requirements in part 484 of this chapter.

Form CMS-1893 (10/99)

(c) Exceptions when no State Licensing laws or State certification or
registration requirements exist. If no State licensing laws or State certification
or registration requirements exist for the profession, the following requirements
must be met—
(1) Administrator. A person who has a bachelor’s degree and:
(i) Has experience or specialized training in the administration of health
institutions or agencies; or
(ii) Is qualified and has experience in one of the professional health
disciplines.
(2) Occupational Therapist. A person who:
(i) Is a graduate of an occupational therapy curriculum accredited jointly by
the Committee on Allied Health Education and Accreditation of the
American Medical Association and the American Occupational Therapy
Association; or
(ii) Is eligible for the National Registration Examination of the American
Occupational Therapy Association; or
(iii) Has 2 years of appropriate experience as an occupational therapist, and
has achieved a satisfactory grade on a proficiency examination
conducted, approved, or sponsored by the U.S. Public Health Service,
except that such determinations of proficiency do not apply with respect to
persons initially licensed by a State or seeking initial qualification as an
occupational therapist after December 31, 1977.
(3) Occupational Therapy Assistant. A person who:
(i) Meets the requirements for certification as an occupational therapy
assistant established by the American Occupational Therapy Association; or
(ii) Has 2 years of appropriate experience as an occupational therapy
assistant, and has achieved a satisfactory grade on a proficiency
examination conducted, approved, or sponsored by the U.S. Public Health
Service, except that such determinations of proficiency do not apply with
respect to persons initially licensed by a State or seeking initial
qualification as an occupational therapy assistant after December 31, 1977.
(4) Physical Therapist. A person who is licensed as a physical therapist by the
State in which he or she is practicing, and
(i) Has graduated from a physical therapy curriculum approved by:
(a) The American Physical Therapy Association, or
(b) The Committee on Allied Health Education and Accreditation of the
American Medical Association, or
(c) The Council on Medical Education of the American Medical Association
and the American Physical Therapy Association; or
(ii) Prior to January 1, 1966,
(a) Was admitted to membership by the American Physical Therapy
Association, or
(b) Was admitted to registration by the American Registry of

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Physical Therapists; or
(c) Has graduated from a physical therapy curriculum in a 4-year college or
university approved by a State department of education; or
(i) Has 2 years of appropriate experience as a physical therapist, and
has achieved a satisfactory grade on a proficiency examination
conducted, approved, or sponsored by the U.S. Public Health Service
except that such determinations of proficiency do not apply with
respect to persons initially licensed by a State or seeking qualification
as a physical therapist after December 31, 1977; or
(ii) Was licensed or registered prior to January 1, 1966, and prior to
January 1, 1970 had 15 years of full-time experience in the treatment
of illness or injury through the practice of physical therapy in which
services were rendered under the order and direction of attending and
referring doctors of medicine or osteopathy; or
(iii)If trained outside the United States,
(a) Was graduated since 1928 from a physical therapy curriculum
approved in the country in which the curriculum was located and
in which there is a member organization of the World
Confederation for Physical Therapy.
(b) Meets the requirements for membership in a member
organization of the World Confederation for Physical Therapy.
(5) Physical Therapy Assistant. A person who is licensed as a physical
therapy assistant, if applicable, by the State in which practicing, and
(i) Has graduated from a 2-year college-level program approved by the
American Physical Therapy Association; or
(ii) Has 2 years of appropriate experience as a physical therapy assistant,
and has achieved a satisfactory grade on a proficiency examination
conducted, approved, or sponsored by the U.S. Public Health Service,
except that these determinations of proficiency do not apply with respect
to persons initially licensed by a State or seeking initial qualification as a
physical therapy assistant after December 31, 1977.
(6) Psychologist. A person who:
(i) Holds a doctoral degree in psychology from a training program approved
by the American Psychological Association; or
(ii) Has attained certification or licensing by the State, or non-statutory
certification by the State psychological association.
(7) Social Worker. A person who has a master’s degree from a school of social
work accredited by the Council on Social Work Education, and has 1 year of
social work experience in a health care setting.
(8) Speech-language pathologist. A person who:
(i) Meets the education and experience requirements for a Certificate of
Clinical Competence in (speech pathology or audiology) granted by the
American Speech-Language-Hearing Association; or
Form CMS-1893 (10/99)

(ii) Meets the educational requirements for certification and is in the process
of accumulating the supervised experience required for certification.
(9) Vocational specialist. A person who has a baccalaureate degree and—
(i) Two years experience in vocational counseling in a rehabilitation setting
such as a sheltered workshop, State employment service agency, etc.; or
(ii) At least 18 semester hours in vocational rehabilitation educational or
vocational guidance, psychology, social work, special education or
personnel administration, and 1 year of experience in vocational
counseling in a rehabilitation setting; or
(iii) A master’s degree in vocational counseling.
(9) Nurse practitioner. A person who must:
(i)Possess a master’s degree in nursing;
(ii) Be a registered professional nurse who is authorized by the State in which
the services are furnished, to practice as a nurse practitioner in
accordance with State law; and
(iii) Be certified as a nurse practitioner by the American Nurses
Credentialing Center.
(10) Clinical nurse specialist. A person who must:
(i) Be a registered nurse who is currently licensed to practice in the State
where he or she practices and be authorized to perform the services of a
clinical nurse specialist in accordance with State law;
(ii) Have a master’s degree in a defined clinical area of nursing from an
accredited educational institution; or
(iii) Be certified as a clinical nurse specialist by the American Nurses
Credentialing Center.
(11) Physician Assistant. A person who:
(i) Has graduated from a physician assistant educational program that is
accredited by the National Commission on Accreditation of Allied Health
Education Programs; and
(ii) Has passed the national certification examination that is certified by the
National Commission on Certification of Physician Assistants; and
(iii) Is licensed by the State as a physician assistant to practice as a
physician assistant.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB NO. 0938-0065

I1 SURVEY DATE
I2

PROVIDER NUMBER

OUTPATIENT PHYSICAL THERAPY — SPEECH PATHOLOGY SURVEY REPORT
NAME OF ORGANIZATION

SURVEYED BY

STREET NUMBER

I3

TYPE OF SURVEY

■
■
SURVEYOR’S PROFESSIONAL TITLE

I7

I4

STATE

ZIP CODE

LIST ADDITIONAL PHYSICAL THERAPISTS
NAME

INITIAL SURVEY

I.D. NUMBER

TITLE

RESURVEY

■
■
■

CLINIC
REHABILITATION AGENCY
PUBLIC HEALTH AGENCY

STANDARDS

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

§485.707 Compliance with Federal, State and Local Laws
The organization and its staff are in compliance with all
applicable Federal, State, and local laws and regulations.

I8

(a) Licensure of organization. In any State in which State or
applicable local law provides for the licensing of
organizations, a clinic, rehabilitation agency, or public health
agency is licensed in accordance with applicable laws.

I9

(b) Licensure or registration of personnel. Staff of the
organization are licensed or registered in accordance with
applicable laws.

I11

COUNTY

ORGANIZATION MEETS DEFINITION OF:

I6

CODE

CITY

EXPIRATION DATE OF LICENSURE, IF APPLICABLE __________________________

§485.709 Administrative Management
The clinic or rehabilitation agency has an effective governing
body that is legally responsible for the conduct of the clinic or
rehabilitation agency. The governing body designates an
administrator, and establishes administrative policies.

I12

(a) Governing body. There is a governing body (or designated
person(s) so functioning) which assumes full legal
responsibility for the overall conduct of the clinic or
rehabilitation agency and for compliance with applicable
laws and regulations. The name of the owner(s) of the clinic
or rehabilitation agency is fully disclosed to the State agency.
In the case of corporations, the names of the corporate
officers are made known.

Form CMS-1893 (10/99)

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NAME

CODE
I15

STANDARDS

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(b) Administrator. The governing body —
(1) Appoints a qualified full time administrator;
(2) Delegates to the administrator the internal operation of
the clinic or rehabilitation agency in accordance with
written policies;
(3) Defines clearly the administrator’s responsibilities for
procurement and direction of personnel; and
(4) Designates a competent individual to act in the
temporary absence of the administrator.

I19

(c) Personnel policies. Personnel practices are supported by
appropriate written personnel policies that are kept current.
Personnel records include the qualifications of all
professional and assistant level personnel, as well as
evidence of State licensure if applicable.

I22

(d) Patient care policies. Patient care practices and
procedures are supported by written policies established by
a group of professional personnel including one or more
physicians associated with the clinic or rehabilitation
agency, one or more qualified physical therapists (if
physical therapy services are provided), and one or more
qualified speech pathologists (if speech pathology services
are provided). The policies govern the outpatient physical
therapy and/or speech pathology services and related
services that are provided. These policies are evaluated at
least annually by the group of professional personnel, and
revised as necessary based upon this evaluation.

I47

§485.711 Plan of care and physician involvement
For each patient in need of outpatient physical therapy or
speech pathology services there is a written plan of care
established and periodically reviewed by a physician, or by a
physical therapist or speech pathologist respectively. The
organization has a physician available to furnish necessary
medical care in case of emergency.

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NAME

CODE

STANDARDS

I49

(a) Medical history and prior treatment. The following are
obtained by the organization before or at the time of
initiation of treatment:

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(1) The patient’s significant past history.
(2) Current medical findings, if any.
(3) Diagnosis(es), if established.
(4) Physician’s orders, if any.
(5) Rehabilitation goals, if determined.
(6) Contraindications, if any.
(7) The extent to which the patient is aware of the
diagnosis(es) and prognosis.
(8) If appropriate, the summary of treatment furnished and
results achieved during previous periods of
rehabilitation services or institutionalization.
I50

(b) Plan of care.
(1) For each patient there is a written plan of care
established by the physician; or
(i) by the physical therapist; or
(ii) by the speech-language pathologist who furnishes
the services.
(2) The plan of care for physical therapy or speech
pathology services indicates anticipated goals and
specifies for those services the —
(i) Type;

(iii) Frequency; and

(ii) Amount;

(iv) Duration.

(3) The plan of care and results of treatment are reviewed
by the physician or by the individual who established
the plan at least as often as the patient’s condition
requires, and the indicated action taken. (For Medicare
patients, the plan must be reviewed by a physician,
nurse practitioner, clinical nurse specialist, or physician
assistant at least every 30 days, in accordance with
§410.61 (e) of this chapter.)
(4) Changes in the plan of care are noted in the clinical
record. If the patient has an attending physician, the
Form CMS-1893 (10/99)

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NAME

CODE

STANDARDS

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

therapist or speech-language pathologist who furnishes
the services promptly notifies him or her of any change
in the patient’s condition or in the plan of care.
I54

I55

(c) Emergency care. The organization provides for one or
more doctors of medicine or osteopathy to be available on
call to furnish necessary medical care in the case of
emergency. The established procedures to be followed by
personnel in an emergency cover immediate care of the
patient, persons to be notified, and reports to be prepared.
§485.713 Physical Therapy Services
If the organization offers physical therapy services, it provides
an adequate program of physical therapy and has an adequate
number of qualified personnel and the equipment necessary to
carry out its program and to fulfill its objectives.

I56

(a) Adequate program.
(1) The organization is considered to have an adequate
outpatient physical therapy program if it can:
(i) Provide services using therapeutic exercise and
the modalities of heat, cold, water, and electricity;
(ii) Conduct patient evaluations; and
(iii) Administer tests and measurements of strength,
balance, endurance, range of motion, and
activities of daily living.
(2) A qualified physical therapist is present or readily
available to offer supervision when a physical therapist
assistant furnishes services.
(i) If a qualified physical therapist is not on the
premises during all hours of operation, patients
are scheduled so as to ensure that the therapist is
present when special skills are needed, for
example, evaluation and reevaluation.
(ii) When a physical therapist assistant furnishes
services off the organization's premises, those
services are supervised by a qualified physical
therapist who makes an onsite supervisory visit at
least once every 30 days.

Form CMS-1893 (10/99)

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NAME

CODE

STANDARDS

I57

(b) Facilities and equipment. The organization has the
equipment and facilities required to provide the range of
services necessary in the treatment of the types of
disabilities it accepts for service.

I58

(c) Personnel qualified to provide physical therapy
services. Physical therapy services are provided by, or
under the supervision of, a qualified physical therapist. The
number of qualified physical therapists and qualified
physical therapist assistants is adequate for the volume
and diversity of physical therapy services offered. A
qualified physical therapist is on the premises or readily
available during the operating hours of the organization.

I63

(d) Supportive personnel. If personnel are available to assist
qualified physical therapists by performing services incident
to physical therapy that do not require professional
knowledge and skill, these personnel are instructed in
appropriate patient care services by qualified physical
therapists who retain responsibility for the treatment
prescribed by the attending physician.

I150

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

§485.715 Speech pathology services
If speech pathology services are offered, the organization
provides an adequate program of speech pathology and has an
adequate number of qualified personnel and the equipment
necessary to carry out its program and to fulfill its objectives.

I151

(a) Adequate program. The organization is considered to
have an adequate outpatient speech pathology program if it
can provide the diagnostic and treatment services to
effectively treat speech disorders.

I152

(b) Facilities and equipment. The organization has the
equipment and facilities required to provide the range of
services necessary in the treatment of the types of speech
disorders it accepts for service.

I153

(c) Personnel qualified to provide speech pathology
services. Speech pathology services are given or
supervised by a qualified speech pathologist and the
number of qualified speech pathologists is adequate for the
volume and diversity of speech pathology services offered.

Form CMS-1893 (10/99)

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NAME

CODE

STANDARDS

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

At least one qualified speech pathologist is present at all
times when speech pathology services are furnished.
I67

§485.717 Rehabilitation program
This condition and its standards apply only to a rehabilitation
agency's own patients, not to patients of hospitals, skilled
nursing facilities (SNFs), or Medicaid nursing facilities (NFs) to
whom the agency furnishes services. (The hospital, SNF, or NF
is responsible for ensuring that qualified staff furnish services
for which they arrange or contract for their patients.) The
rehabilitation agency provides, in addition to physical therapy
and speech-language pathology services, social or
vocational adjustment services to all of its patients who need
them. The agency provides for special qualified staff to
evaluate the social and vocational factors, to counsel and
advise on the social or vocational problems that arise from the
patient's illness or injury, and to make appropriate referrals for
needed services.

I68

(a) Qualification of staff. The agency’s social or vocational
adjustment services are furnished as appropriate, by
qualified psychologists, qualified social workers, or qualified
vocational specialists. Social or vocational adjustment
services may be performed by a qualified psychologist or
qualified social worker. Vocational adjustment services may
be furnished by a qualified vocational specialist.

I72

(b) Arrangements for social or vocational adjustment
services.
(1) If a rehabilitation agency does not provide social or
vocational adjustment services through salaried employees,
it may provide those services through a written contract with
others who meet the requirements and responsibilities set
forth in this subpart for salaried
personnel.
(2) The contract must specify the term of the contract and
the manner of termination or renewal, and provide that the
agency retains responsibility for the control and supervision
of the services.

Form CMS-1893 (10/99)

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NAME

CODE
I79

STANDARDS

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

§485.719 Arrangements for physical therapy and speech
pathology services to be performed by other than
salaried organization personnel
If an organization provides outpatient physical therapy or
speech pathology services under an arrangement with others,
the services are to be furnished in accordance with the terms of
a written contract, which provides that the organization retains
professional and administrative responsibility for, and control
and supervision of, the services.

I80

(a) Contract provisions. The contract:
(1) Specifies the term of the contract and the manner of
termination or renewal;
(2) Requires that personnel who furnish the services meet
the requirements that are set forth in this subpart for
salaried personnel; and
(3) Provides that the contracting outside resource may not
bill the patient or Medicare for the services. This
limitation is based on section 1861(w)(1) of the Act,
which provides that —
(i) Only the provider may bill the beneficiary for covered
services furnished under arrangements; and
(ii) Receipt of Medicare payment by the provider, on
behalf of an entitled individual, discharges the liability
of the individual or any other person to pay for
those services.

I96

§485.721 Clinical records
The organization maintains clinical records on all patients in
accordance with accepted professional standards and
practices. The clinical records are completely and accurately
documented, readily accessible, and systematically organized
to facilitate retrieving and compiling information.

I154

(a) Protection of clinical record information. The
organization recognizes the confidentiality of clinical record
information and provides safeguards against loss,
destruction, or unauthorized use. Written procedures
govern the use and removal of records and the conditions
for release of information. The patient’s written consent is
required for release of information not authorized by law.

Form CMS-1893 (10/99)

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NAME

CODE
I97

STANDARDS

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(b) Content. The clinical record contains sufficient information
to identify the patient clearly, to justify the diagnosis(es) and
treatment, and to document the results accurately. All
clinical records contain the following general categories of
data:
(1) Documented evidence of the assessment of the needs
of the patient, of an appropriate plan of care, and of the
care and services furnished.
(2) Identification data and consent forms.
(3) Medical history.
(4) Report of physical examinations, if any.
(5) Observations and progress notes.
(6) Reports of treatments and clinical findings.
(7) Discharge summary including final diagnosis(es) and
prognosis.

I155

(c) Completion of records and centralization of reports.
Current clinical records and those of discharged patients are
completed promptly. All clinical information pertaining to a
patient is centralized in the patient’s clinical record. Each
physician signs the entries that he or she makes in the
clinical record.

I108

(d) Retention and preservation. Clinical records are retained
for at least:
(1) The period determined by the respective State statute,
or the statute of limitations in the State, or
(2) In the absence of a State statute:
(i) Five years after the date of discharge, or
(ii) In the case of a minor, 3 years after the patient
becomes of age under State law or 5 years after
the date of discharge, whichever is longer.

I156

(e) Indexes. Clinical records are indexed at least according to
name of patient to facilitate acquisition of statistical medical
information and retrieval of records for research or
administrative action.

Form CMS-1893 (10/99)

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NAME

CODE

STANDARDS

I157

(f) Location and facilities. The organization maintains
adequate facilities and equipment, conveniently located, to
provide efficient processing of clinical records (reviewing,
indexing, filing, and prompt retrieval).

I117

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

§485.723 Physical Environment
The building housing the organization is constructed, equipped,
and maintained to protect the health and safety of patients,
personnel, and the public and provides a functional, sanitary,
and comfortable environment.

I118

(a) Safety of patients. The organization satisfies the following
requirements:
(1) It complies with all applicable State and local building,
fire, and safety codes.
(2) Permanently attached automatic fire-extinguishing
systems of adequate capacity are installed in all areas of
the premises considered to have special fire hazards.
Fire extinguishers are conveniently located on each floor
of the premises. Fire regulations are prominently posted.
(3) Doorways, passageways and stairwells negotiated by
patients are:
(i) Of adequate width to allow for easy movement of
all patients (including those on stretchers or in
wheelchairs),
(ii) free from obstruction at all times, and
(iii) in the case of stairwells, equipped with firmly
attached handrails on at least one side.
(4) Lights are placed at exits and in corridors used by
patients and are supported by an emergency power
source.
(5) A fire alarm system with local alarm capability and, where
applicable, an emergency power source is functional.
(6) At least two persons are on duty on the premises of the
organization whenever a patient is being treated.
(7) No occupancies or activities undesirable or injurious to
the health and safety of patients are located in the
building.

Form CMS-1893 (10/99)

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NAME

CODE
I158

STANDARDS

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(b) Maintenance of equipment, building, and grounds. The
organization establishes a written preventive-maintenance
program to ensure that:
(1) The equipment is operative and is properly calibrated,
and
(2) The interior and exterior of the building are clean and
orderly and maintained free of any defects that are a
potential hazard to patients, personnel, and the public.

I130

(c) Other environmental considerations. The organization
provides a functional, sanitary, and comfortable environment
for patients, personnel, and the public.
(1) Provision is made for adequate and comfortable lighting
levels in all areas; limitation of sounds at comfort levels;
a comfortable room temperature; and adequate
ventilation through windows, mechanical means, or a
combination of both.
(2) Toilet rooms, toilet stalls, and lavatories are accessible
and constructed so as to allow use by nonambulatory
and semiambulatory individuals.
(3) Whatever the size of the building, there is an adequate
amount of space for the services provided and
disabilities treated, including reception area, staff space,
examining room, treatment areas, and storage.

I159

§485.725 Infection Control
The organization that provides outpatient physical therapy
services establishes an infection-control committee of
representative professional staff with responsibility for overall
infection control. All necessary housekeeping and maintenance
services are provided to maintain a sanitary and comfortable
environment and to help prevent the development and
transmission of infection.

I160

(a) Infection-control committee. The infection-control
committee establishes policies and procedures for
investigating, controlling, and preventing infections in the
organization and monitors staff performance to ensure that
the policies and procedures are executed.

Form CMS-1893 (10/99)

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CODE

STANDARDS

I161

(b) Aseptic and isolation techniques. All personnel follow
written procedures for effective aseptic techniques. The
procedures are reviewed annually and revised if necessary
to improve them.

I162

(c) Housekeeping.

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(1) The organization employs sufficient housekeeping
personnel and provides all necessary equipment to
maintain a safe, clean, and orderly interior. A full-time
employee is designated as the one responsible for the
housekeeping services and for supervision and training
of housekeeping personnel.
(2) An organization that has a contract with an outside
resource for housekeeping services may be found to be
in compliance with this standard provided the
organization or outside resource or both meet the
requirements of the standard.
I163

(d) Linen. The organization has available at all times a quantity
of linen essential for proper care and comfort of patients.
Linens are handled, stored, processed, and transported in
such a manner as to prevent the spread of infection.

I164

(e) Pest control. The organization premises are maintained
free from insects and rodents through operation of a
pest-control program.

I165

§485.727 Disaster preparedness
The organization has a written plan, periodically rehearsed with
procedures to be followed in the event of an internal or external
disaster and for the care of casualties (patients and personnel)
arising from a disaster.

I166

(a) Disaster plan. The organization has a written plan in
operation, with procedures to be followed in the event of fire,
explosion, or other disaster. The plan is developed and
maintained with the assistance of qualified fire, safety, and
other appropriate experts, and includes:
(1) Transfer of casualties and records;
(2) The location and use of alarm systems and signals;
(3) Methods of containing fire;

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CODE

STANDARDS

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(4) Notification of appropriate persons; and
(5) Evacuation routes and procedures.
I167

I168

(b) Staff training and drills. All employees are trained, as part
of their employment orientation, in all aspects of
preparedness for any disaster. The disaster program
includes orientation and ongoing training and drills for all
personnel in all procedures so that each employee promptly
and correctly carries out his assigned role in case of a
disaster.
§485.729 Program evaluation
The organization has procedures that provide for a systematic
evaluation of its total program to ensure appropriate utilization of
services and to determine whether the organization’s policies
are followed in providing services to patients through employees
or under arrangements with others.

I169

(a) Clinical record review. A sample of active and closed
clinical records is reviewed quarterly by the appropriate
health professionals to ensure that established policies are
followed in providing services.

I170

(b) Annual statistical evaluation. An evaluation is conducted
annually of statistical data such as number of different
patients treated, number of patient visits, condition on
admission and discharge, number of new patients, number
of patients by diagnosis(es), sources of referral, number and
cost of units of service by treatment given, and total staff
days or work hours by discipline.

According to the Paperwork Reduction of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0065.
The time required to complete this information collection is estimated to average 1.75 hours per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the time estimates(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850.
Form CMS-1893 (10/99)

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