Cms-360 Comprehensive Outpatient Rehabilitation Facility Survey

Department of Health & Human Services
Centers For Medicare & Medicaid Services

Form Approved
OMB No. 0938-0267

Comprehensive Outpatient Rehabilitation Facility Survey Report
CMS-360
Facility Name:

Facility CCN:

Facility Street Address:

City:

State:

Zip Code:

Telephone Number:

Survey Start Date:

Survey End Date:

Type of Survey:
Initial Survey

Code

Description

I-501

§485.54 - Condition of Participation: Compliance
with State and local laws.

I-502

(a) Standard: Licensure of facility.

I-503

Yes

No

Other: (Specify):

N/A

Recertification Survey

Complaint

Explanatory Statement

The facility and all personnel who provide services
must be in compliance with applicable State and
local laws and regulations.
If State or local law provides for licensing, the facility
must be currently licensed or approved as meeting
the standards established for licensure.

(b) Standard: Licensure of Personnel.

Personnel that provide service must be licensed,
certified, or registered in accordance with applicable
St ate and local laws.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

State licensure, certification or registration is not
required for: (Check those applicable):
1. Occupational Therapist
2. Speech Pathologist
3. Social Workers
4. Psychologist

5. Rehabilitation Counselor
6. All of the above

I-505

§485.56 - Condition of Participation: Governing body
and administration.

I-506

(a) Standard: Disclosure of Ownership.

I-507

(b) Standard: Administrator.

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.
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.

The governing body must appoint an administrator
who—

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Centers For Medicare & Medicaid Services
Code

Description

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;

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

I-513

Form Approved
OMB No. 0938-0267
Yes

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

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Description

Code

I-514
I-515

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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

(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.

I-517

(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.

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Centers For Medicare & Medicaid Services
Code

I-518

Description

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

(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;

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Centers For Medicare & Medicaid Services
Code

Description

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
Yes

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.

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Centers For Medicare & Medicaid Services
Code

Description

I-530

(1) The facility may enter into a contract for purposes

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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.
I-531

(v) The preparation of financial statements.

(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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

I-532

§485.58 Condition of Participation: Comprehensive
rehabilitation program

I-533

(a) Standard: Physician services.

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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.

(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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

I-534

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

I-535

(b) Standard: Plan of treatment.

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

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

I-541

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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

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;

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Centers For Medicare & Medicaid Services
Code

Description

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
Yes

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.

I-547

(iv) Rehabilitation goals, if determined.

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

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Centers For Medicare & Medicaid Services
Code

Description

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.

Form Approved
OMB No. 0938-0267
Yes

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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Description

Code

I-552

Yes

No

N/A

Explanatory Statement

(7) All services must be provided consistent with
accepted professional standards and practice.
(e) Standard: Scope & Site of Services

I-553

Basic Requirements: The facility must provide all the
CORF services required in the plan of treatment and,
except as provided in paragraph € (2) of this section,
must provide the services on its premises.

)

I-554

Form Approved
OMB No. 0938-0267

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

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Centers For Medicare & Medicaid Services
Code

Description

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.

I-557

I-558

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

(g) 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
(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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

I-559

§485.60 - Condition of Participation: Clinical records.

I-560

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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.
(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;

I-562

(2) Current plan of treatment;

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Centers For Medicare & Medicaid Services
Code

Description

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.

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Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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Centers For Medicare & Medicaid Services
Code

Description

I-568

(b) Standard: Protection of clinical record
information.

I-569

(c) Standard: Retention and preservation

I-570

§485.62 Condition of Participation: Physical
environment.

I-571

(a) Standard: Safety and comfort of patients.

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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.

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.

The facility must provide a physical environment that
protects the health and safety of patients, personnel, and
the public.

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:

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

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.

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.

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Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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Code

Description

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

I-580

I-581

Form Approved
OMB No. 0938-0267
Yes

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
(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.
(3) 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.

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Code

I-582

I-583

Description

Yes

No

N/A

Explanatory Statement

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

I-584

(c) Standard: Maintenance of equipment, physical
location, and grounds.

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

Form Approved
OMB No. 0938-0267

The facility must establish a written preventive
maintenance program to ensure that—

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

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

I-588

(1) Doorways, stairwells, corridors, and passageways
used by patients are—

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

(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.

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Description

I-602

§485.66 - Conditions of Participation: Utilization
Review Plan

I-603

(a) Standard: Utilization Review Committee.

I-604

(b) Standard: Utilization review plan.

I-605

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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.

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.

The utilization review plan must contain written
procedures for evaluating—

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

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Description

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 -–

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

(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.

I-611

(a) A facility physician must be a doctor of medicine or
osteopathy who—

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.

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

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Centers For Medicare & Medicaid Services
Code

I-612

Description

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

(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.

I-615

(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.

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Description

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—

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

(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.

I-618

(g) A psychologist must be certified or licensed by the

I-619

(h) A registered nurse must be a graduate of an

State in which he or she is practicing, if that State
requires certification or licensing, and must hold a
master’sdegree in psychology from an educational
institution approved by the State in which the
institution is located.

approved school of nursing and be licensed as a
registered nurse by the State in which practicing, if
applicable.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Description

Code

I-620

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

(i) A rehabilitation counselor must—

(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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Description

Code

I-622

I-623

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.

(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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Description

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
I-626

care setting.

(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:

Is licensed as a speech-language pathologist by the
state in which the individual furnishes such
services; or

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

I-627

(2) In the case of an individual who furnishes services

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

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 speech- language
pathology or a related field; and

(iii) Successfully completed a national
E-0001

examination in speech-language pathology
approved by the Secretary.

§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:

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Page 29

Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

E-0004

E-0006

Description

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

§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:

§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, facilitybased and community-based risk assessment,
utilizing an all- hazards approach; and
(2) Include strategies for addressing emergency
events identified by the risk assessment.

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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

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.

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 Approved
OMB No. 0938-0267
Yes

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:

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Description

Code

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.

Form Approved
OMB No. 0938-0267
Yes

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
(iv) Other [facilities].
(v) Volunteers

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

I-0031

Description

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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Description

Code

E-0036

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

§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.

E-0037

§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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

E-0039

§485.68(d)(2) – Testing. The CORF must conduct
exercises to test the emergency plan annually. The CORF
must do all of the following:

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

(i) Participate in a full-scale exercise that is
community- based 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 man-

made 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 Jasmine Burleson
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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

E-0042

Description

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

§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
iscapable 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 mustalso be based on
and include the following:

(i) A documented community-based risk

assessment, utilizing an all-hazards approach.

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Page 36

Department of Health & Human Services
Centers For Medicare & Medicaid Services
Code

Description

Form Approved
OMB No. 0938-0267
Yes

No

N/A

Explanatory Statement

(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.

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Department of Health & Human Services
Centers For Medicare & Medicaid Services

Form Approved
OMB No. 0938-0267

Comprehensive Outpatient Rehabilitation Facility Survey Report
CMS-360
PRA Disclosure Statement
According to the Paperwork Reduction Act 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 0938-0267 (Expires XX/XX/20XX). This
is a required to retain or obtain a benefit information collection. The time required to complete this information collection is
estimated to average 8 hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C426-05, Baltimore, Maryland 21244-1850.

****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA
Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns
regarding where to submit your documents, please contact Joy Webb at 410-786-1667.

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