Form Cms-437b - Rehab Hospital Criteria Worksheet (Page 6 of 6) in pdf

THE HOSPITAL REPRESENTATIVE WHO

TAG

REGULATION

GUIDANCE

YES

N/A

COMPLETES THIS ENTIRE FORM

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(h) Have a plan of treatment for each

• Conduct a clinical record review to verify

The representative verifies that the rehabitation hospital

inpatient that is established, reviewed, and revised

that each IRF patient has a plan of treatment and

has patient plans of treatment.

as needed by a physician in consultation with other

that the plans are updated whenever there is a

professional personnel who provide services to the

change in the patient’s condition.

patient.

• The plan of treatment should include the patient’s

medical prognosis and the anticipated inteventions,

functional outcomes, and discharge destination from

the IRF stay.

• The anticipated interventions detailed in the overall

plan of care should include the expected intensity

(meaning number of hours per day), frequency

(meaning number of days per week), and duration

(meaning total number of days during the IRF stay)

of physical, occupational, speech-language pathology,

and prosthetic/orthotic therapies required by the

patient during the IRF stay.

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(i) Use a coordinated interdisciplinary team approach in

• Review clinical records to determine whether the

The representative will determine whether interdiciplinary

the rehabilitation of each inpatient,as documented by

interdisciplinary team is meeting once

teams are meeting once weekly to review patient

periodic clinical entries made in the patient’s medical

a week to review patient progress toward goal

progress and that documentation is in the medical

record to note the patient’s status in relationship to

attainment and discharge planning.

records.

goal attainment and discharge plans; and that team

• Determine if the documentation complies with the

conferences are held at least once per week to determine

regulatory requirement.

the appropriateness of treatment.

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Ul Retroactive adjustments. If a new IRF (or new beds

If the new IRF’s inpatient population doesn’t meet the

that are added to an existing IRF) are excluded from the

60% rule, the IRF will lose its IPPS exclusionary status.

prospective payment systems specified in§ 412.1(a)(1)

The RO will send notification to the facility prior to the

and paid under the prospective payment system specified

beginning of the next cost report period that the facility

in § 412.1(a)(3) for a cost reporting period under

has lost its IPPS excluded status and will revert to acute

paragraph (c) of this section, but the inpatient population

care hospital status.

actually treated during that period does not meet the

requirements of paragraph (b) of this section, we adjust

payments to the IRF retroactively in accordance with the

provisions in § 412.130.

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 0938-0986. The time

required to complete this information collection is estimated to average 15 minutes 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

COMMENTS

Form CMS-437B (06/12)

Form Cms-437b - Rehab Hospital Criteria Worksheet Page 6

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