Form CMS-360 COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY

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

Form Approved
OMB No. 0938-0267

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT
(CMS-360)
Name of Facility
PROVIDER NUMBER

SURVEY DATE

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

Type of Survey
1.

□Initial Survey

2.

□Resurvey

CODE

I-501

YES

NO

N/A

EXPLANATORY STATEMENT

§485.54 - Condition of Participation: Compliance with
State and local laws.
The facility and all personnel who provide services must
be in compliance with applicable State and local laws and
regulations.

I-502

(a) Standard: Licensure of facility.
If State or local law provides for licensing, the facility must
be currently licensed or approved as meeting the
standards established for licensure.

I-503

(b) Standard: Licensure of Personnel.
Personnel that provide service must be licensed, certified,
or registered in accordance with applicable State and local
laws.

Form CMS-360 (10/31/2019)

3

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

Form Approved
OMB No. 0938-0267

CODE

YES

NO

N/A

EXPLANATORY STATEMENT

State licensure, certification or registration is not required
for: (Check those applicable)

1 □Occupational Therapist

4

□Psychologist

2 □Speech Pathologist

5

□Rehabilitation

6

□All of the Above

Counselor
3
I-505

□Social Worker

§485.56 - Condition of Participation: Governing body and
administration.
The facility must have a governing body that assumes full
legal responsibility for establishing and implementing policies
regarding the management and operation of the facility.

I-506

(a) Standard: Disclosure of Ownership.
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.

I-507

(b) Standard: Administrator.
The governing body must appoint an administrator who—

I-508

(1) Is responsible for the overall management of the
facility under the authority delegated by the governing
body;

I-509

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

Form CMS-360 (10/31/2019)

4

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

YES

I-510

(3) Designates, in writing, an individual who, in the
absence of the administrator, acts on behalf of the
administrator; and

I-511

(4) Retains professional and administrative responsibility
for all personnel providing facility services.

I-512

Form Approved
OMB No. 0938-0267
NO

N/A

EXPLANATORY STATEMENT

(c) Standard: Group of professional personnel.
The facility must have a group of professional personnel
associated with the facility that—

I-513

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

I-514

(2) Consists of at least one physician and one professional
representing each of the services provided by the
facility.

I-515

(d) Standard: Institutional budget plan.
The facility must have an institutional budget plan that meets
the following conditions:

I-516

(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.

Form CMS-360 (10/31/2019)

5

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

I-517

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

(2) It provides for:
(i) An annual operating budget prepared according to
generally accepted accounting principles;
(ii) A 3-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.

I-518

(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:

I-519

(1) A description of the services the facility furnishes
through employees and those furnished under
arrangements.

I-520

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

I-521

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

I-522

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

I-523

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

Form CMS-360 (10/31/2019)

6

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

YES

I-524

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

I-525

(7) A procedure to assist the referring physician in locating
another level of care for patients whose treatment has
terminated and who are discharged.

I-526

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

I-527

(9) A requirement that there be a plan of treatment
established by a physician for each patient. and

I-528

(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.

I-529

Form Approved
OMB No. 0938-0267
NO

N/A

EXPLANATORY STATEMENT

(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.

Form CMS-360 (10/31/2019)

7

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

I-530

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

(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 procedures for
billing and accounting systems.
(iii) Assistance in the development of an operating
budget.
(iv) Purchase of supplies in bulk form.
(v) The preparation of financial statements.

I-531

(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.

Form CMS-360 (10/31/2019)

8

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

I-532

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

§485.58 Condition of Participation: Comprehensive
rehabilitation program
The facility must provide a coordinated rehabilitation
program that includes, at a minimum, physicians’ services,
physical therapy services and social or psychological
services. Services must be furnished by personnel that meet
the qualifications set forth in §485.70 and §484.115 of this
chapter and must be consistent with the plan of treatment
and the results of comprehensive patient assessments.

I-533

(a) Standard: Physician services.
(1) A facility physician must be present in the facility for a
sufficient time to—
(i) Provide, in accordance with accepted
principles of medical practice, medical
direction, medical care services, consultation
and medical supervision of non-physician staff;
(ii) Establish the plan of treatment in cases
where a plan has not been established by
the referring physician;
(iii) Assist in establishing and implementing
the facility’s patient care policies;
(iv) Participate in plan of treatment reviews,
patient case review conferences,
comprehensive patient assessment and
reassessments and utilization reviews.

I-534

(2) The facility must provide for emergency physician
services during the facility operating hours.

Form CMS-360 (10/31/2019)

9

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

I-535

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

(b) Standard: Plan of treatment.
For each patient, a physician must establish a plan of
treatment before the facility initiates treatment. The plan of
treatment must meet the following requirements:

I-536

(1) It must delineate anticipated goals and specify the
type, amount, frequency and duration of services to be
provided.

I-537

(2) It must be promptly evaluated after changes in the
patient’s condition and revised when necessary.

I-538

(3) It must, if appropriate, be developed in consultation
with the facility physician and the appropriate facility
professional personnel.

I-539

(4) It must be reviewed at least every 60 days by a facility
physician who, when appropriate, consults with the
professional personnel providing services. The results
of this review must be communicated to the patient’s
referring physician for concurrence before treatment is
continued or discontinued.

I-540

(5) It must be revised if the comprehensive reassessment
of the patient’s status or the results of the patient case
review conference indicate the need for revision.

I-541

(c) Standard: Coordination of services.
The facility must designate, in writing, a qualified professional to
ensure that professional personnel coordinate their related
activities and exchange information about each patient under
their care. Mechanisms to assist in the coordination of services
must include—

Form CMS-360 (10/31/2019)

1

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

YES

I-542

(1) Providing to all personnel associated with the facility, a
schedule indicating the frequency and type of services
provided at the facility;

I-543

(2) A procedure for communicating to all patient care
personnel pertinent information concerning significant
changes in the patient’s status;

I-544

(3) Periodic clinical record entries, noting at least the
patient’s status in relationship to goal attainment; and

I-545

(4) Scheduling patient case review conferences for purposes
of determining appropriateness of treatment, when
indicated by the results of the initial comprehensive
patient assessment, reassessment(s), the
recommendation of the facility physician (or other
physician who established the plan of treatment), or upon
recommendation of one of the professionals providing
services.

I-546

Form Approved
OMB No. 0938-0267
NO

N/A

EXPLANATORY STATEMENT

(d) Standard: Provision of services.
(1) All patient’s must be referred to the facility by a
physician who provides the following information to the
facility before treatment is initiated:
(i) The patient’s significant medical history.
(ii) Current medical findings.
(iii) Diagnosis(es) and contraindications to any
treatment modality.
(iv) Rehabilitation goals, if determined.

Form CMS-360 (10/31/2019)

1

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

Form Approved
OMB No. 0938-0267

YES

I-547

(2) Services may be provided by facility employees or by
others under arrangements made by the facility.

I-548

(3) The facility must have on its premises the necessary
equipment to implement the plan of treatment and
sufficient space to allow adequate care.

I-549

(4) The services must be furnished by personnel that meet
the qualifications of §485.70 and the number of qualified
personnel must be adequate for the volume and diversity
of services offered.

NO

N/A

EXPLANATORY STATEMENT

Personnel that do not meet the qualifications specified in
§485.70 may be used by the facility in assisting qualified
staff. When a qualified individual is assisted by these
personnel, the qualified individual must be on the
premises, and must instruct these personnel in
appropriate patient care service techniques and retain
responsibility for their activities.
I-550

(5) A qualified professional must initiate and coordinate
the appropriate portions of the plan of treatment,
monitor the patient’s progress, and recommend
changes in the plan, if necessary.

I-551

(6) A qualified professional representing each service
made available at the facility must be either on the
premises of the facility or must be available through
direct telecommunication for consultation and
assistance during the facility’s operating hours. At
least one qualified professional must be on the
premises during the facility’s operating hours.

I-552

(7) All services must be provided consistent with accepted
professional standards and practice.

I-553

(e) Standard: Scope and site of services.

Form CMS-360 (10/31/2019)

1

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

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

(1) Basic Requirements: The facility must provide all the
CORF services required in the plan of treatment and,
except as provided in paragraph (e) (2) of this section,
must provide the services on its premises.
(2) Exceptions. Physical therapy, occupational therapy, and
speech-language pathology services may be furnished
away from the premises of the CORF including the
individual's home when payment is not otherwise made
under Title XVIII of the Act. In addition, a single home
environment evaluation is covered if there is a need to
evaluate the potential impact of the home environment
on the rehabilitation goals. The single home environment
evaluation requires the presence of the patient and the
physical therapist, occupational therapist, or speechlanguage pathologist, as appropriate. The single home
environment evaluation requires the presence of the
patient and the physical therapist, occupational
therapist, or speech-language pathologist as
appropriate.
I-554

(f) Standard: Patient assessment.
Each qualified professional involved in the patient’s care, as
specified in the plan of treatment, must—

I-555

(1) Carry out an initial patient assessment; and

I-556

(2) In order to identify whether or not the current plan of
treatment is appropriate, perform a patient
reassessment after significant changes in the patient’s
status.

Form CMS-360 (10/31/2019)

1

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

I-557

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

(i) Standard: Laboratory services
(1) If the facility provides its own laboratory services, the
services must meet the applicable requirements for
laboratories specified in part 493 of this chapter.

I-558

I-559

(2) If the facility chooses to refer specimens for laboratory
testing, the referral laboratory must be certified in the
appropriate specialties and subspecialties of services in
accordance with the requirements of part 493 of this
chapter.

§485.60 - Condition of Participation: Clinical records.
The facility must maintain clinical records on all patients in
accordance with accepted professional standards and
practice. The clinical records must be completely, promptly,
and accurately documented, readily accessible, and
systematically organized to facilitate retrieval and compilation
of information.

I-560

(a) Standard: Content.
Each clinical record must contain sufficient information to
identify the patient clearly and to justify the diagnosis and
treatment. Entries in the clinical record must be made as
frequently as is necessary to insure effective treatment, and
must be signed by personnel providing services. All entries
made by assistant level personnel must be countersigned by
the corresponding professional. Documentation on each
patient must be consolidated into one clinical record that must
contain—

I-561

(1) The initial assessment and subsequent reassessments
of the patient’s needs;

Form CMS-360 (10/31/2019)

1

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

YES

I-562

(2) Current plan of treatment;

I-563

(3) Identification data and consent or authorization forms;

I-564

(4) Pertinent medical history, past and present;

I-565

(5) A report of pertinent physical examinations if any;

I-566

(6) Progress notes or other documentation that reflect
patient reaction to treatment, tests, or injury, or the
need to change the established plan of treatment; and

I-567

(7) Upon discharge, a discharge summary including
patient status relative to goal achievement, prognosis,
and future treatment considerations.

I-568

Form Approved
OMB No. 0938-0267
NO

N/A

EXPLANATORY STATEMENT

(b) Standard: Protection of clinical record information.
The facility must safeguard clinical record information against
loss, destruction, or unauthorized use. The facility must have
procedures that govern the use and removal of records and
the conditions for release of information. The facility must
obtain the patient’s written consent before releasing
information not required to be released by law.

Form CMS-360 (10/31/2019)

1

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

I-569

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

(c) Standard: Retention and preservation
The facility must retain clinical record information for 5 years
after patient discharge and must make provision for the
maintenance of such records in the event that it is no longer
able to treat patients.

I-570

§485.62 Condition of Participation: Physical environment.
The facility must provide a physical environment that protects
the health and safety of patients, personnel, and the public.

I-571

(a) Standard: Safety and comfort of patients.
The physical premises of the facility and those areas of its
surrounding physical structure that are used by the patients
(including at least all stairwells, corridors and passageways)
must meet the following requirements:

I-572

(1) Applicable Federal, State, and local building, fire and
safety codes must be met.

I-573

(2) Fire extinguishers must be easily accessible and fire
regulations must be prominently posted.

I-574

(3) A fire alarm system with local (in-house) capability
must be functional, and where power is generated by
electricity, an alternate power source with automatic
triggering must be present.

I-575

(4) Lights, supported by an emergency power source,
must be placed at all exits.

Form CMS-360 (10/31/2019)

1

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

YES

I-576

(5) A sufficient number of staff to evacuate patients during
a disaster must be on the premises of the facility
whenever patients are being treated.

I-577

(6) Lighting must be sufficient to carry out services safely;
room temperature must be maintained at comfortable
levels; and ventilation through windows, mechanical
means, or a combination of both must be provided.

I-578

(7) Safe and sufficient space must be available for the
scope of services offered.

I-579

Form Approved
OMB No. 0938-0267
NO

N/A

EXPLANATORY STATEMENT

(b) Standard: Sanitary environment.
The facility must maintain a sanitary environment and
establish a program to identify, investigate, prevent, and
control the cause of patient infections

I-580

(1) The facility must establish written policies and
procedures designed to control and prevent infection
in the facility and to investigate and identify possible
causes of infection.

I-581

(2) The facility must monitor the infection control program
to ensure that the staff implement the policies and
procedures and that the policies and procedures are
consistent with current practices in the field.

Form CMS-360 (10/31/2019)

1

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

YES

I-582

(3) The facility must make available at all times a quantity
of laundered linen adequate for proper care and
comfort of patients. Linens must be handled, stored,
and processed in a manner that prevents the spread of
infection.

I-583

(4) Provisions must be in effect to ensure that the facility’s
premises are maintained free of rodent and insect
infestation.

I-584

Form Approved
OMB No. 0938-0267
NO

N/A

EXPLANATORY STATEMENT

(c) Standard: Maintenance of equipment, physical
location, and grounds.
The facility must establish a written preventive
maintenance program to ensure that—

I-585

(1) All equipment is properly maintained and equipment
needing periodic calibration is calibrated consistent
with the manufacturer’s recommendations; and

I-586

(2) The interior of the facility, the exterior of the physical
structure housing the facility, and the exterior
walkways and parking areas are clean and orderly and
maintained free of any defects that are a hazard to
patients, personnel, and the public.

I-587

(d) Standard: Access for the physically impaired.
The facility must ensure the following:

Form CMS-360 (10/31/2019)

1

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

I-588

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

(1) Doorways, stairwells, corridors, and passageways
used by patients are—
(i) Of adequate width to allow for easy movement of
all patients (including those on stretchers or in
wheelchairs); and
(ii) In the case of stairwells, equipped with firmly
attached handrails on at least one side.

I-589

(2) At least one toilet facility is accessible and constructed
to allow utilization by ambulatory and non-ambulatory
individuals;

I-590

(3) At least one entrance is usable by individuals in
wheelchairs;

I-591

(4) In multi-story buildings, elevators are accessible to and
usable by the physically impaired on the level that they
use to enter the building and all levels normally used
by the patients of the facility.

I-592

(5) Parking spaces are large enough and close enough to
the facility to allow safe access by the physically
impaired.

I-602

§485.66 - Conditions of Participation: Utilization Review
Plan
The facility must have in effect a written utilization review plan
that is implemented annually, to assess the necessity of
services and promotes the most efficient use of services
provided by the facility.

Form CMS-360 (10/31/2019)

1

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

I-603

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

(a) Standard: Utilization Review Committee.
The utilization review committee, consisting of the group of
professional personnel specified in §485.56(c), a committee of
this group, or a group of similar composition, comprised by
professional personnel not associated with the facility, must
carry out the utilization review plan.

I-604

(b) Standard: Utilization review plan.
The utilization review plan must contain written procedures for
evaluating—

I-605

(1) Admissions, continued care, and discharges using, at
a minimum, the criteria established in the patient care
policies;

I-606

(2) The applicability of the plan of treatment to established
goals; and

I-607

(3) The adequacy of clinical records with regards to -–
(i) Assessing the quality of services provided; and
(ii) Determining whether the facility’s policies and
clinical practices are compatible and promote
appropriate and efficient utilization of services.

I-610

§485.70 - Personnel qualifications.
This section sets forth the qualifications that must be met, as
a condition of participation, under §485.58, and as a condition
of coverage of services under §410.100 of this chapter.

Form CMS-360 (10/31/2019)

2

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

I-611

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

(a) A facility physician must be a doctor of medicine or
osteopathy who—
(1) Is licensed under State law to practice medicine or
surgery; and

I-612

(2) Has had, subsequent to completing a 1-year hospital
internship, at least 1 year of training in the medical
management of patients requiring rehabilitation
services; or
(3) Has had at least 1 year of full-time or part-time
experience in a rehabilitation setting providing
physicians’ services similar to those required in this
subpart.

I-613

(b) A licensed practical nurse must be licensed as a practical
or vocational nurse by the State in which practicing, if
applicable;

I-614

(c) An occupational therapist and an occupational therapy
assistant must meet the qualifications (as also set forth in
§484.115(f) and §484.115(g) of this chapter.

Form CMS-360 (10/31/2019)

2

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

I-615

Form Approved
OMB No. 0938-0267

YES

NO

N/A

EXPLANATORY STATEMENT

(d) An orthotist must—
(1) Be licensed by the State in which practicing, if
applicable;
(2) Have successfully completed a training program in
orthotics that is jointly recognized by the American
Council on Education and the American Board for
Certification in Orthotics and Prosthetics; and
(3) Be eligible to take that Board’s certification
examination in orthotics.

I-616

(e) A physical therapist and a physical therapist assistant
must meet the qualifications of §484.115(i) of this chapter.

I-617

(f) A prosthetist must—
(1) Be licensed by the State in which practicing, if
applicable;
(2) Have successfully completed a training program in
prosthetics that is jointly recognized by the American
Council on Education and the American Board for
Certification in Orthotics and Prosthetics; and
(3) Be eligible to take the Board’s certification
examination in prosthetics.

Form CMS-360 (10/31/2019)

2

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

Form Approved
OMB No. 0938-0267
YES

I-618

(g) A psychologist must be certified or licensed by the State
in which he or she is practicing, if that State requires
certification or licensing, and must hold a master’s degree
in psychology from an educational institution approved by
the State in which the institution is located.

I-619

(h) A registered nurse must be a graduate of an approved
school of nursing and be licensed as a registered nurse
by the State in which practicing, if applicable.

I-620

(i) A rehabilitation counselor must—

NO

N/A

EXPLANATORY STATEMENT

(1) Be licensed by the State in which practicing, if
applicable;

(2) Hold at least a bachelor’s degree; and
(3) Be eligible to take the certification examination
administered by the Commission on Rehabilitation
Counselor Certification
I-621

(j) A respiratory therapist must complete one of the following
criteria:
(1) Criterion 1. All of the following must be completed:
(i) Be licensed by the State in which practicing, if
applicable;
(ii) Have successfully completed a nationallyaccredited educational program;
(iii) (A) Be eligible to take the registry examination
administered by the National Board for
Respiratory Care for respiratory therapists; or
(B) Have passed the registry examination
administered by the National Board for
Respiratory Care for respiratory therapists.

Form CMS-360 (10/31/2019)

2

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

I-622

Form Approved
OMB No. 0938-0267
YES

NO

N/A

EXPLANATORY STATEMENT

(2) Criterion 2: All of the following must be completed:
(i) Be licensed by the State in which practicing, if
applicable.
(ii) Have equivalent training and experience as
determined by the National Board for Respiratory
Care.

I-623

(k) A respiratory therapy technician must(1) Be licensed by the State in which practicing, if
applicable;
(2) Have successfully completed a training program
accredited by the Committees on Allied Health
Education and Accreditation (CAHEA) in collaboration
with the Joint Review Committee for Respiratory
Therapy Education, Inc.; and

I-624

(3) Either –
(i) Be eligible to take the certification examination for
respiratory therapy technicians administered by the
National Board for Respiratory Therapy, Inc.; or
(ii) Have equivalent training and experience as
determined by the National Board for Respiratory
Therapy, Inc.

Form CMS-360 (10/31/2019)

2

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

I-625

Form Approved
OMB No. 0938-0267
YES

NO

N/A

EXPLANATORY STATEMENT

(l) A social worker must—
(1) A person who has a master’s or doctoral 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.
(2) Hold at least a bachelor's degree from a school

accredited or approved by the Council on Social Work
Education; and
(3) Have 1 year of social work experience in a health care

setting.
I-626

(m) A speech-language pathologist must meet the
qualifications set forth in part §484.115(n) of this chapter,
§484.115(n) requires the following:
A person who has a master’s or doctoral degree in
speech-language pathology, and who meets either of the
following requirements:
(1) Is licensed as a speech-language pathologist by the
state in which the individual furnishes such services; or

I-627

(2) In the case of an individual who furnishes services in a
state which does not license speech-language
pathologists:
(i) Has successfully completed 350 clock hours of
supervised clinical practicum (or is in the process of
accumulating supervised clinical experience);
(ii) Performed not less than 9 months of supervised
full-time speech-language pathology services after
obtaining a master’s or doctoral degree in speechlanguage pathology or a related field; and
(iii) Successfully completed a national examination in
speech-language pathology approved by the
Secretary.

Form CMS-360 (10/31/2019)

2

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

E-0001

Form Approved
OMB No. 0938-0267
YES

NO

N/A

EXPLANATORY STATEMENT

§485.68 - Condition of Participation: Emergency
Preparedness
The Comprehensive Outpatient Rehabilitation Facility (CORF)
must comply with all applicable Federal, State and local
emergency preparedness requirements. The CORF must
establish and maintain a [comprehensive] emergency
preparedness program that meets the requirements of this
section.
The emergency preparedness program must include, but not
be limited to, the following elements:

E-0004

§485.68(a) - Emergency Plan.
The Comprehensive Outpatient Rehabilitation Facility (CORF)
must develop and maintain an emergency preparedness plan
that must be [reviewed], and updated at least every 2 years.
The plan must do all of the following:

E-0006

§485.68(a)(1)-(2) - Condition of participation: Emergency
preparedness.
(a) The Comprehensive Outpatient Rehabilitation Facility
(CORF) must comply with all applicable Federal, State,
and local emergency preparedness requirements. The
CORF must establish and maintain an emergency
preparedness program that meets the requirements of
this section.
The emergency preparedness program must include, but
not be limited to, the following elements:
(1) Be based on and include a documented, facility-based
and community-based risk assessment, utilizing an allhazards approach; and
(2) Include strategies for addressing emergency events
identified by the risk assessment

Form CMS-360 (10/31/2019)

2

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

Form Approved
OMB No. 0938-0267
YES

E-0007

§485.68(a)(3) - Address [patient/client] population, including,
but not limited to, persons at-risk; the type of services the
CORF has the ability to provide in an emergency; and
continuity of operations, including delegations of authority and
succession plans.

E-0009

§485.68(a)(4) - Include a process for cooperation and
collaboration with local, tribal, regional, State, and Federal
emergency preparedness officials' efforts to maintain an
integrated response during a disaster or emergency situation.

E-0011

§485.68(a)(5) - Be developed and maintained with assistance
from fire, safety, and other appropriate experts.

E-0013

§485.68(b) - Policies and procedures.

NO

N/A

EXPLANATORY STATEMENT

CORFs must develop and implement emergency
preparedness policies and procedures, based on the
emergency plan set forth in paragraph (a) of this section, risk
assessment at paragraph (a)(1) of this section, and the
communication plan at paragraph (c) of this section. The
policies and procedures must be reviewed and updated at
least every 2 years. At a minimum, the policies and
procedures must address the following:
E-0020

§485.68(b)(1) - Safe evacuation from the CORF, which
includes staff responsibilities and needs of the patients.

E-0022

§485.68(b)(2) - A means to shelter in place for patients, staff,
and volunteers who remain in the CORF.

Form CMS-360 (10/31/2019)

2

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

Form Approved
OMB No. 0938-0267
YES

E-0023

§485.68(b)(3) - A system of medical documentation that
preserves patient information, protects confidentiality of
patient information, and secures and maintains availability of
records.

E-0024

§485.68(b)(4) - The use of volunteers in an emergency or
other emergency staffing strategies, including the process and
role for integration of State and Federally designated health
care professionals to address surge needs during an
emergency.

E-0029

§485.68(c) - The CORF must develop and maintain an
emergency preparedness communication plan that
complies with Federal, State and local laws and must be
reviewed and updated at least every 2 years.

NO

N/A

EXPLANATORY STATEMENT

The communication plan must include all of the following:

E-0030

§485.68(c)(1) - Names and contact information for the
following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iii) Other [facilities].
(iv) Volunteers

Form CMS-360 (10/31/2019)

2

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

E-0031

Form Approved
OMB No. 0938-0267
YES

NO

N/A

EXPLANATORY STATEMENT

§485.68(c)(2) - Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency
preparedness staff.
(ii) Other sources of assistance.

E-0032

§485.68(c)(3) - Primary and alternate means for
communicating with the following:
(i) CORF [facility] staff.
(ii) Federal, State, tribal, regional, and local emergency
management agencies.

E-0033

§485.68(c)(4) - A method for sharing information and medical
documentation for patients under the CORFs care, as
necessary, with other health providers to maintain the
continuity of care.

E-0034

§485.68(c)(5) - A means of providing information about the
CORFs occupancy, needs, and its ability to provide
assistance, to the authority having jurisdiction, the Incident
Command Center, or designee.

E-0036

§485.68(d) - Training and testing.
The CORF must develop and maintain an emergency
preparedness training and testing program that is based on
the emergency plan set forth in paragraph (a) of this section,
risk assessment at paragraph (a)(1) of this section, policies
and procedures at paragraph (b) of this section, and the
communication plan at paragraph (c) of this section.
The training and testing program must be reviewed and
updated at least every 2 years.

Form CMS-360 (10/31/2019)

2

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

E-0037

Form Approved
OMB No. 0938-0267
YES

NO

N/A

EXPLANATORY STATEMENT

§485.68(d)(1) - Training program.
The CORF must do all of the following:
(i) Initial training in emergency preparedness policies and
procedures to all new and existing staff, individuals
providing services under arrangement, and volunteers,
consistent with their expected roles;
(ii) Provide emergency preparedness training at least
every 2 years;
(iii) Maintain documentation of all emergency
preparedness training;
(iv) Demonstrate staff knowledge of emergency
procedures;
(v) If the emergency preparedness policies and
procedures are significantly updated, the CORF must
conduct training on the updated policies and
procedures.

Form CMS-360 (10/31/2019)

3

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

E-0039

Form Approved
OMB No. 0938-0267
YES

NO

N/A

EXPLANATORY STATEMENT

§485.68(d)(2) - Testing. The CORF must conduct exercises to test
the emergency plan annually. The CORF must do all of the
following:
(i) Participate in a full-scale exercise that is communitybased every 2 years; or
(A) When a community-based exercise is not accessible,
conduct a facility-based functional exercise every 2
years; or
(B) If the [facility] experiences an actual natural or manmade emergency that requires activation of the
emergency plan, the CORF is exempt from engaging
in its next required community-based or individual,
facility-based functional exercise following the onset of
the actual event.
(ii) Conduct an additional exercise at least every 2 years,
opposite the year the full-scale or functional exercise
under paragraph (d)(2)(i) of this section is conducted, that
may include, but is not limited to the following:
(A) A second full-scale exercise that is communitybased or individual, facility-based functional
exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a
facilitator and includes a group discussion using a
narrated, clinically-relevant emergency scenario, and
a set of problem statements, directed messages, or
prepared questions designed to challenge an
emergency plan.
(iii) Analyze the [facility's] response to and maintain
documentation of all drills, tabletop exercises, and
emergency events, and revise the [facility's] emergency
plan, as needed.

CODE
Form CMS-360 (10/31/2019)

YES NO N/A

EXPLANATORY STATEMENT
3

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

E-0042

Form Approved
OMB No. 0938-0267

§485.68(e) - Integrated healthcare systems. If a facility is part of a
healthcare system consisting of multiple separately certified
healthcare facilities that elects to have a unified and integrated
emergency preparedness program, the CORF may choose to
participate in the healthcare system's coordinated emergency
preparedness program. If elected, the unified and integrated
emergency preparedness program must- [do all of the following:]
(1) Demonstrate that each separately certified facility within the
system actively participated in the development of the unified
and integrated emergency preparedness program;
(2) Be developed and maintained in a manner that takes into
account each separately certified facility's unique
circumstances, patient populations, and services offered;
(3) Demonstrate that each separately certified facility is capable
of actively using the unified and integrated emergency
preparedness program and is in compliance [with the
program]; ;
(4) Include a unified and integrated emergency plan that meets
the requirements of paragraphs (a)(2), (3), and (4) of this
section. The unified and integrated emergency plan must also
be based on and include the following:
(i) A documented community-based risk assessment, utilizing
an all-hazards approach;
(ii) A documented individual facility-based risk assessment
for each separately certified facility within the health
system, utilizing an all-hazards approach.
(5) Include integrated policies and procedures that meet the
requirements set forth in paragraph (b) of this section, a
coordinated communication plan, and training and testing
programs that meet the requirements of paragraphs (c) and
(d) of this section, respectively.

Form CMS-360 (10/31/2019)

3

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

Form Approved
OMB No. 0938-0267

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Form CMS-360 (10/31/2019)

3