Cms-1893 Outpatient Physical Therapy — Speech Pathology Survey Re

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.

(e)

Extension location. A location or site from which a rehabilitation agency provides
services within a portion of the total geographic area served by the primary site.
The extension location is part of the rehabilitation agency. The extension location
is located sufficiently close to share administration, supervision, and services in a
manner that renders it unnecessary for the extension location to independently
meet the conditions of participation as a rehabilitation agency.

(f)

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.

Form CMS-1893 (01/13)

(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.
(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. An occupational therapist must meet the
qualifications set forth in § 484.4 of this chapter.
(3) Occupational Therapy Assistant. An occupational therapy assistant must
meet the qualifications set forth in § 484.4 of this chapter.

(4) Physical Therapist. A physical therapist must meet the qualifications set forth
in § 484.4 of this chapter.

(5) Physical Therapist Assistant. A physical therapist assistant must meet the
qualifications set forth in § 484.4 of this chapter.
(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) Speech-language pathologist. A person who meets either of the following
requirements:

(i) The education and experience requirements for a Certificate of Clinical
Competence in speech-language pathology granted by the American
Speech-Language-Hearing Association.

(ii) The educational requirements for certification and is in the process of
accumulating the supervised experience required for certification.

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 (8) 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.
(9) 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.
(10) 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.

Form CMS-1893 (01/13)

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

OUTPATIENT PHYSICAL THERAPY — SPEECH PATHOLOGY SURVEY REPORT
NAME OF ORGANIZATION
SURVEYED BY

STREET NUMBER
I3

CITY

I6

I7

I9
I11

I12

ZIP CODE

LIST ADDITIONAL PHYSICAL THERAPISTS
I.D. NUMBER

TITLE

■ CLINIC
■ REHABILITATION AGENCY
■ PUBLIC HEALTH AGENCY

STANDARDS
§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

NAME

STATE

ORGANIZATION MEETS DEFINITION OF:

CODE

COUNTY

I4
TYPE OF SURVEY

■ INITIAL SURVEY
■ RESURVEY
SURVEYOR’S PROFESSIONAL TITLE

PROVIDER NUMBER

FORM APPROVED
OMB NO. 0938-0065
I1 SURVEY DATE
I2

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

EXPIRATION DATE OF LICENSURE, IF APPLICABLE _________­­­­­­­_________________

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

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STANDARDS
(b) Administrator. The governing body —

NOT
N/A
MET

EXPLANATORY STATEMENT

(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

MET

§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.

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STANDARDS

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(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)
(2)
(3)
(4)
(5)
(6)
(7)

I50

The patient’s significant past history.
Current medical findings, if any.
Diagnosis(es), if established.
Physician’s orders, if any.
Rehabilitation goals, if determined.
Contraindications, if any.
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.

(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.
(4) Changes in the plan of care are noted in the clinical
record. If the patient has an attending physician, the

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.

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I55

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STANDARDS
(c) Emergency care. 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.

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

§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.
(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.
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.

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STANDARDS

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(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

I151

I152

I153

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

Form CMS-1893 (01/13)

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CODE
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STANDARDS
§485.717 Rehabilitation program

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

This condition and 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, physical therapy and speech
language pathology services, to all of its patients who
need them.

I68
I69

(a) Qualification of staff. The agency’s services are furnished,
by qual­ified individuals as direct services and services provided under contract.
(b) Arrangements for services.
If services are provided under contract, the contract must
specify all of the following:

I79

(1) Term of the contract.
(2) The manner of termination or renewal.
(3) Provisions stating that the agency retains responsibility
for the control and supervision of the services.

§485.719 Arrangements for physical therapy and speech
pathology services to be performed by other than
salaried organization personnel

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CODE

STANDARDS

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§485.719(a) Conditions.
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.

I81

(b) Contract provisions. The contract:
(1) Specifies the term of the contract and the manner of
termination or renewal;

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(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.
I90

§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.

I91

(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.

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CODE
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STANDARDS
(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:

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(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.
I95

I96

(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.
(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.
I97

(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.

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CODE

STANDARDS

I99

(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

I118

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.
(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.
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CODE
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STANDARDS
(b) Maintenance of equipment, building, and grounds. The
organization establishes a written preventive-maintenance
program to ensure that:

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(1) The equipment is operative and is properly calibrated,
and

I123

(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.
(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.

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I161

(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.
§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.
(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.

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STANDARDS

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(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.

I165

(c) Housekeeping.

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.

I167

(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.

I169

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

I170

MET

§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.

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STANDARDS
(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:

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(1) Transfer of casualties and records;

(2) The location and use of alarm systems and signals;
(3) Methods of containing fire;

(4) Notification of appropriate persons; and
(5) Evacuation routes and procedures.
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I180

(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.

I181

(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.

I183

(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 (01/13)

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