Official Federal Forms > Centers For Medicare And Medicaid Services
Rehab Unit Criteria Worksheet - Official Federal Forms
| Rehab Unit Criteria Worksheet Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0986 REHABILITATION UNIT CRITERIA WORK SHEET RELATED MEDICARE PROVIDER NUMBER ROOM NUMBERS IN THE UNIT FACILITY NAME AND ADDRESS (City, State, Zip Code) NUMBER OF BEDS IN THE UNIT SURVEY DATE REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD / / to / / MM DD YYYY MM DD YYYY VERIFIED BY ALL CRITERIA UNDER SUBPART B OF PART 412 OF THE REGULATIONS MUST BE MET FOR EXCLUSION FROM MEDICARE'S ACUTE CARE HOSPITAL PROSPECTIVE PAYMENT SYSTEM OR FROM THE PAYMENT SYSTEM USED TO PAY CRITICAL ACCESS HOSPITALS. TAG REGULATION GUIDANCE THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM YES NO N/A · Verificationofhospitalattestationsmaybedone Thehospitalrepresentativeisexpectedtoanswerall byCMSsurveyorsorMACsasapplicable. questionsaccurately. Therepresentativeshouldverifytheanswerswith thedirectorofrehabilitation,physician,medical recordsoffice,oranyapplicabledepartmentto ensurecorrectresponsestothisform. A"yes"responsemeansthehospitalisin compliancewiththeapplicableregulation. §412.25Excludedhospitalunits:Common requirements. (a)Basisforexclusion.Inordertobeexcluded fromtheprospectivepaymentsystemsspecifiedin §412.1(a)(1),arehabilitationunitmustmeetthe followingrequirementsinadditiontotheallcriteria underSubpartBofPart412oftheregulations: Inthecaseof§412.25and§412.29,asrelatedto IRFunits,thetermhospitalincludesCriticalAccess Hospitals. Form CMS-437A (06/12) American LegalNet, Inc. www.FormsWorkFlow.com TAG A3500 REGULATION (1)Bepartofaninstitutionthathasineffectan agreementunderPart489toparticipateasa hospital,andisnotexcludedinitsentiretyfromthe prospectivepaymentsystems,andhasenoughbeds thatarenotexcludedtopermittheprovisionof adequatecost. GUIDANCE · Thesurveyorwillverify,throughtheregional office(RO),thatthehospitalhasanagreement topartici ateintheMedicareprogram,andthe p hospitalisnotalreadyexcludedinitsentirety fromIPPS,suchasarehabilitationhospital.In otherwords,theunitseekingexclusionscannot comprisetheentirehospital · Thehospitalmustbesufficientlystaffed, maintainedandIPPSbedsutilizedthatarenot partoftherehabilitationunit. · Verificationofthisinformationmaybedoneby CMSsurveyorsorMACs. THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM Representative to ensure the hospital has a Medicare provider agreement. YES NO N/A A3501 (2)Havewrittenadmissioncriteriathatareapplied uniformlytobothMedicareandnon-Medicare patients. · Verifythatthehospitalhaspreadmissioncriteria Representativetoverifytherehabunithas fortherehabilitationunit. preadmissioncriteria. · Conductanopenandclosedrecordreviewto determinewhethertheapprovedpreadmission criteriaisappliedequallytoallpatients. A3502 (3)Haveadmission&dischargerecordsthatare separatelyidentifiedfromthoseofthehospitalin whichitislocatedandarereadilyavailable. · Verifythatrehabilitationunitmedicalrecords areseparateandnotcommingledwithother hospitalrecordsandarereadilyavailablefor review. Representativetoverifythattherehabunithouses onlytherecordsoftherehabpatients. A3503 (4)Havepoliciesspecifyingthatnecessaryclinical informationistransferredtotheunitwhenapatient ofthehospitalistransferredtotheunit. · Verifythatthehospitalhasapolicydetailing Representativetoverifythehospitalhasapolicy theprompttransferofinformation,andthatitis regardingthetransferofinformation,andthe beingfollowed. hospitaladherestothepolicy. · Reviewrehabilitationunitclinicalrecordsto ensurethattheclinicalinformationthatshould betransferredwiththerecordisactuallyinthe medicalrecord. Form CMS-437A (06/12) American LegalNet, Inc. www.FormsWorkFlow.com 2 TAG A3504 REGULATION (5)MeetapplicableStatelicensurelaws. GUIDANCE · VerifyanddocumentthatallapplicableState licensurelawsaremet. · DocumentallunmetStatelicensure requirements. · Verifythehospitalhascurrentlicensesforits professionalstaff. · ArethelicensesissuedbytheStateinwhichthe rehabilitationunitislocated? · Doestheunitmeetspeciallicensing requirementsissuedbytheState? THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM RepresentativetoverifythatallapplicableState lawsarebeingmetandthatallapplicablelicenses arecurrent. YES NO N/A A3505 (6)Haveutilizationreviewstandardsapplicablefor thetypeofcareofferedintheunit. · Verifythatthehospitalhasautilization reviewplanthatincludesthereviewofrehab services(Noutilizationreview(UR)standards arerequirediftheQIOisconductingreview activities.) · VerifythatthehospitalhaswrittenURstandards thatareappliedtothecareofferedintheunit. RepresentativetoverifythatthehospitalhasaUR planandthattheURstandardsarebeingappliedto thecareofferedintherehabunit. A3506 (7)Havebedsphysicallyseparatefrom(thatis,not commingledwith)thehospital'sotherbeds. NOTE:§412.25(a)(8)-(12)areverifiedbytheFI. · Isthespacecontainingtherehabbedsphysically Representativewillverifythatthebedsontherehab separatefromthebedsinotherunitsofthe unitdonotbelongtomedical/surgicalpatientsbut hospital? arededicatedtorehabpatientsonly. · Therecannotbeanybedsthatarelocated withinthephysicalconfinesoftheexcluded rehabunitthatarenotexcludedbeds. · TheIRFunitcannotuseitsbedsformedical /surgicalpatientsoranyothertypeof patient.ThosebedsaresolelyfortheuseofIRF patients. · Iftheunitdoesn'thaveenoughpatientstofill thosebeds,thebedsmustbeleftemptyorthe unitcandecreasethenumberofbedsinthe unitafterthehospitalhasnotifiedCMSofits intent. Form CMS-437A (06/12) American LegalNet, Inc. www.FormsWorkFlow.com 3 TAG A3507 REGULATION (13)Aspartofthefirstdayofthefirstcostreporting periodforwhichallotherexclusionrequirements aremet,theunitisfullyequippedandstaffedandis capableofprovidinghospitalinpatientrehabilitation careregardlessofwhetherthereareanyinpatients intheunitonthatdate. (b)Changesinthesizeofexcludedunits.Exceptin thespecialcasesnotedattheendofthisparagraph, changesinthenumberofbedsorsquarefootage consideredtobepartofanexcludedunitunderthis sectionareallowedonetimeduringacostreporting periodifthehospitalnotifiesitsMedicarecontractor andtheCMSROinwritingoftheplannedchange atleast30daysbeforethedateofthechange. Thehospitalmustmaintaintheinformationneeded toaccuratelydeterminecoststhatareattributableto theexcludedunit.Achangeinbedsizeorachange insquarefootagemayoccuratanytimeduringa costreportingperiodandmustremainineffectfor therestofthatcostreportingperiod.Changesin bedsizeorsquarefootagemaybemadeatanytime ifthesechangesaremadenecessarybyrelocation ofaunittopermitconstructionorrenovation necessaryforcompliancewithchangesinFederal
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