Form Cms-437a - Rehab Unit Criteria Worksheet Page 2
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9THE HOSPITAL REPRESENTATIVE WHO
TAG
REGULATION
GUIDANCE
YES
NO
N/A
COMPLETES THIS ENTIRE FORM
Representative to ensure the hospital has a
A3500
(1) Be part of an institution that has in effect an
• The surveyor will verify, through the regional
Medicare provider agreement.
agreement under Part 489 to participate as a
office (RO), that the hospital has an agreement
hospital, and is not excluded in its entirety from the
to partici p ate in the Medicare program, and the
prospective payment systems, and has enough beds
hospital is not already excluded in its entirety
that are not excluded to permit the provision of
from IPPS, such as a rehabilitation hospital. In
adequate cost.
other words, the unit seeking exclusions cannot
comprise the entire hospital
• The hospital must be sufficiently staffed,
maintained and IPPS beds utilized that are not
part of the rehabilitation unit.
• Verification of this information may be done by
CMS surveyors or MACs.
A3501
(2) Have written admission criteria that are applied
• Verify that the hospital has preadmission criteria
Representative to verify the rehab unit has
uniformly to both Medicare and non-Medicare
for the rehabilitation unit.
preadmission criteria.
patients.
• Conduct an open and closed record review to
determine whether the approved preadmission
criteria is applied equally to all patients.
A3502
(3) Have admission & discharge records that are
• Verify that rehabilitation unit medical records
Representative to verify that the rehab unit houses
separately identified from those of the hospital in
are separate and not commingled with other
only the records of the rehab patients.
which it is located and are readily available.
hospital records and are readily available for
review.
A3503
(4) Have policies specifying that necessary clinical
• Verify that the hospital has a policy detailing
Representative to verify the hospital has a policy
information is transferred to the unit when a patient
the prompt transfer of information, and that it is
regarding the transfer of information, and the
of the hospital is transferred to the unit.
being followed.
hospital adheres to the policy.
• Review rehabilitation unit clinical records to
ensure that the clinical information that should
be transferred with the record is actually in the
medical record.
Form CMS-437A (06/12)
2
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