Form CMS-437A Rehabilitiation Unit Criteria Worksheet

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

FORM APPROVED

OMB NO. 0938-0986

REHABILITATION UNIT CRITERIA WORK SHEET

RELATED MEDICARE PROVIDER NUMBER

ROOM NUMBERS IN THE UNIT

NUMBER OF BEDS IN THE UNIT

SURVEY DATE

REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD:

FACILITY NAME AND ADDRESS (City, State, Zip Code)

/ /
to
/ /
VERIFIED BY
MM DD YYYY MM DD YYYY

ALL CRITERIA UNDER SUBPART B OF PART 412 OF THE REGULATIONS MUST BE MET FOR EXCLUSION FROM

MEDICARE'S ACUTE CARE HOSPITAL PROSPECTIVE PAYMENT SYSTEM OR FROM THE PAYMENT SYSTEM USED TO PAY CRITICAL ACCESS HOSPITALS.

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YES NO

EXPLANATORY STATEMENT

§412.25 Excluded hospital units:
Common requirements
(a) Basis for exclusion. In order to be excluded
from the prospective payment systems specified
in §412.1(a)(1), a rehabilitation unit must meet
the following requirements in addition to the
all criteria under Subpart B of Part 412 of the
regulations:
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(1) Be part of an institution that — has in
effect an agreement under Part 489 to
participate as a hospital and is not
excluded in its entirety from the
prospective payment systems and has
enough beds that are not excluded to
permit the provision of adequate cost.

• Verify through the RO that the rehab unit meets
the classification criteria compliance percentage
threshold (commonly known as the 75 percent
rule).
• The surveyor should check State Agency (SA)
records and/or verify with the Regional Office
(RO) to ensure the hospital has an agreement to
participate in the Medicare program and to
ensure that the hospital is not already excluded
in its entirety from IPPS, such as a rehabilitation
hospital. In other words, the unit seeking
exclusion cannot comprise the entire hospital.

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(2) Have written admission criteria that are
applied uniformly to both Medicare and
non-Medicare patients.

Verify that the hospital has admission criteria and
review same. Verify through open and closed
record review that the approved admission criteria
is being followed for all patients.

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(3) Have admission & discharge records that
are separately identified from those of the
hospital in which it is located and are
readily available.

Verify that medical records are separate and not
commingled with other hospital records and are
readily available for review.

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(4) Have policies specifying that necessary
clinical information is transferred to the
unit when a patient of the hospital is
transferred to the unit.

Verify that the hospital has a policy detailing the
prompt transfer of information and that it is being
followed. Review records to ensure that the clinical
information that should be transferred with the
record is actually in the medical record.

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(5) Meet applicable State licensure laws.

• Verify and document that all applicable State
licensure laws are met.
• Document all unmet State licensure requirements.
• Verify the hospital has current licenses for its
professional staff.
• Are the licenses issued by the State in which the
hospital is located?
• Does the unit meet special licensing requirements
issued by the State?

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(6) Have utilization review standards applicable
for the type of care offered in the unit.

Verify that the hospital has a utilization review
plan that includes the review of rehab services
(No utilization review (UR) standards are required
if the QIO is conducting review activities.)

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(7) Have beds physically separate from (that
is, not commingled with) the hospital’s
other beds.
NOTE: §412.25(a) (8)-(12) are verified by
the FI.
(13) As part of the first day of the first cost
reporting period for which all other
exclusion requirements are met, the unit is
fully equipped and staffed and is capable
of providing hospital inpatient rehabilitation
care regardless of whether there are any
inpatients in the unit on that date.

YES NO

EXPLANATORY STATEMENT

Is the space containing the rehab beds separate
from the beds in other units of the hospital?

Prior to scheduling the survey, verify with the
FI that the unit is operational: fully staffed and
equipped. (It is not required that the unit has
inpatients on the day of the survey, but must
demonstrate capability of caring for patients.)

§412.29 Excluded rehabilitation units:
Additional requirements. In order to be excluded
from the prospective payment systems described in
§412.1(a)(1) and to be paid under the prospective
payment stystem in §412.1(a)(2), a rehabilitation
unit must meet the following requirements:
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(a) Have met either the requirements for:
(1) New units under §412.30(a); or
(2) Converted units under §412.30(c).

Form CMS-437A (03/06) EF 06/2006

The SA will check these provisions with the RO
prior to the survey.

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(b) Have in effect a pre-admission screening
procedure under which each prospective
patient’s condition and medical history are
reviewed to determine whether the patient is
likely to benefit significantly from an intensive
inpatient program or assessment.

Review the pre-admission screening protocol.

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(c) Ensure that the patients receive close medical
supervision and furnish, through the use of
qualified personnel, rehabilitation nursing,
physical therapy, and occupational therapy,
plus, as needed, speech therapy, social services
or psychological services, and orthotic and
prosthetic services.

• Verify that every patient is under the care of
a physician and has authenticated orders in
the chart.
• If the State issues licenses, verify that all licenses
are current & are issued by the State in which
qualified personnel are providing services.
• Determine that the hospital has a means of ensuring
that its personnel remain qualified/competent.
• Refer to State laws and hospital policies to
determine the qualifications of personnel
providing rehabilitation services.
• Review medical charts if patients have been
admitted.

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(d) Have a plan of treatment (POT) for each
inpatient that is established, reviewed, and
revised as needed by a physician in consultation
with other professional personnel who provide
services to the patient.

Ensure that all patients have a POT in their medical
record. Verify the physician and other professional
personnel participate in the establishment, review,
and revision of the POT. (This could be a signature,
a record of a conference, or record of consultation.)

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(e) Use a coordinated multidisciplinary team
Review hospital policy regarding multidisciplinary
approach in the rehabilitation of each inpatient, team meetings, frequency, and medical record
as documented by periodic clinical entries
documentation.
made in the patient’s medical record to note
the patient’s status in relationship to goal
attainment, and that team conferences are held
at least every 2 weeks to determine the
appropriateness of treatment.

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(f) Have a director of rehabilitation who —

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(1) Provides services to the unit and to its
inpatients for at least 20 hours per week;

Form CMS-437A (03/06) EF 06/2006

GUIDANCE

YES NO

EXPLANATORY STATEMENT

Verify the rehab unit has a director of rehab.
The 20 hours may be any combination of patient
services and administration. Hours cannot be
substituted by a Physician Assistant or by any other
qualified professional. Verify the 20 hours through
review of personnel time cards/logs, etc.

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(2) Is a doctor of medicine or osteopathy;

Ensure license is current and issued by the State in
which the service is being provided.

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(3) Is licensed under State law to practice
medicine or surgery; and

Ensure license is current and issued by the State in
which the service is being provided.

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(4) Has had, after completing a 1 year
hospital internship, at least 2 years of
training or experience in the medical
management of inpatients requiring
rehabilitation services.

Review personnel files.

YES NO

EXPLANATORY STATEMENT

§412.30 Exclusion of new distinct part
rehabilitation units and expansion of units
already excluded.
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(a) Bed capacity in units.
A decrease in bed capacity must remain in
effect for at least a full 12-month cost reporting
period before an equal or lesser number of
beds can be added to the hospital’s licensure
and certification and considered “new” under
§412.30(b) below.

The SA must verify a previous decrease in State
licensed hospital beds. The RO will verify any
corresponding reduction in the number of beds
for Medicare certification purposes.

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(b) New units.
A hospital unit is considered a new unit if the
hospital has not previously sought exclusion
for any rehabilitation unit; and has obtained
approval under State licensure and Medicare
certification, for an increase in its hospital bed
capacity that is greater than 50 percent of the
number of beds in the unit. For a hospital
seeking exclusion of a new rehabilitation unit,
the hospital may provide a written certification
that the inpatient population it intends the unit
to serve will require intensive rehabilitation
services for treatment of one or more of the
following conditions instead of showing that it
has treated such a population during its most
recent 12-month cost reporting period:
(A) Stroke.
(B) Spinal cord injury.
(C) Congenital deformity.
(D) Amputation.
(E) Major multiple trauma.

• SA/RO to verify that the hospital has not
previously sought exclusion.
• SA to verify that hospital received approval
for unit under State licensure.
• SA to verify that the hospital has provided
written certification to the RO/FI.
• The regulations at §412.30 state that a hospital
unit is considered a converted unit if it doesn’t
qualify as a new unit. Therefore, existing
excluded units are treated as converted units
for purposes of reverification of the classification
criteria compliance percentage threshold.

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EXPLANATORY STATEMENT

(F) Fracture of femur (hip fracture).
(G) Brain injury.
(H) Neurological disorders, including
multiple sclerosis, motor neuron
diseases, polyneuropathy, muscular
distrophy, and Parkinson’s disease.
(I) Burns.
(J) Active, polyarticular rheumatoid
arthritis, psoriatic arthritis, and
seronegative arthropathies.
(K) Systemic vasculidities with joint
inflammation.
(L) Severe or advanced osteoarthritis
(osteoarthrosis or degenerative joint
disease).
(M) Knee or hip joint replacement, or both.
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(c) Converted units
A hospital unit is considered a converted unit if
it does not qualify as a new unit under paragraph
(a) of this section. A converted unit must have
treated, for the hospital’s most recent, consecutive,
and appropriate 12-month time period (as defined
by CMS or the fiscal intermediary), an inpatient
population meeting the requirements of
§412.23(b)(2).

Form CMS-437A (03/06) EF 06/2006

Verify through the RO that the hospital unit
provided intensive rehab services to the current
classification criteria compliance percentage
threshold of the unit’s population for the most
recent 12-month cost reporting period. (The FI is
responsible for verifying this criteria.)

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YES NO

EXPLANATORY STATEMENT

(d) Expansion of Excluded Rehabilitation Units • Verify the hospital obtained State approval for an
(1) The beds that a hospital seeks to add to its
increase in its bed capacity.
excluded rehabilitation unit are considered • FI to verify hospital has met the current
new only if the State-licensed & Medicare
classification criteria compliance percentage
certified bed capacity increases at the start
threshold for all of the most recent cost reporting
of the cost reporting period (for which the
period.
hospital seeks to increase the size of its
excluded rehabilitation unit) or at any time
after the start of the preceding cost report
period; and the hospital has obtained
approval, under State licensure and
Medicare certification, for an increase in its
hospital bed capacity that is greater than 50
percent of the number of beds it seeks to
add to the unit.
(2) (i) For cost reporting periods beginning on
or after July 1, 2004 and before July 1,
2005, the hospital intends to serve an
inpatient population of whom at least
50 percent, and for cost reporting periods
beginning on or after July 1, 2005 and
before July 1, 2006, the hospital intends
to serve an inpatient population of whom
at least 60 percent, and for cost reporting
periods beginning on or after July 1, 2006
and before July 1, 2007, the hospital
intends to serve an inpatient population
of whom at least 65 percent meet the
requirements of §412.23(b)(2).
(ii) A hospital may increase the size of its
excluded rehabilitation unit through the
conversion of existing bed capacity only
if it shows that, for all of the hospital’s
most recent, consecutive, and appropriate
12-month time period (as defined by CMS
or the fiscal intermediary), the beds have
been used to treat an inpatient population
meeting the requirements of §412.23(b)(2).

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Form CMS-437A (03/06)

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