Form Cms-437a - Rehab Unit Criteria Worksheet Page 3
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9THE HOSPITAL REPRESENTATIVE WHO
TAG
REGULATION
GUIDANCE
YES
NO
N/A
COMPLETES THIS ENTIRE FORM
A3504
(5) Meet applicable State licensure laws.
• Verify and document that all applicable State
Representative to verify that all applicable State
licensure laws are met.
laws are being met and that all applicable licenses
are current.
• Document all unmet State licensure
requirements.
• Verify the hospital has current licenses for its
professional staff.
• Are the licenses issued by the State in which the
rehabilitation unit is located?
• Does the unit meet special licensing
requirements issued by the State?
A3505
(6) Have utilization review standards applicable for
• Verify that the hospital has a utilization
Representative to verify that the hospital has a UR
the type of care offered in the unit.
review plan that includes the review of rehab
plan and that the UR standards are being applied to
services (No utilization review (UR) standards
the care offered in the rehab unit.
are required if the QIO is conducting review
activities.)
• Verify that the hospital has written UR standards
that are applied to the care offered in the unit.
A3506
(7) Have beds physically separate from (that is, not
• Is the space containing the rehab beds physically
Representative will verify that the beds on the rehab
commingled with) the hospital’s other beds.
separate from the beds in other units of the
unit do not belong to medical/surgical patients but
NOTE: §412.25(a) (8)-(12) are verified by the FI.
hospital?
are dedicated to rehab patients only.
• There cannot be any beds that are located
within the physical confines of the excluded
rehab unit that are not excluded beds.
• The IRF unit cannot use its beds for medical
/surgical patients or any other type of
patient. Those beds are solely for the use of IRF
patients.
• If the unit doesn’t have enough patients to fill
those beds, the beds must be left empty or the
unit can decrease the number of beds in the
unit after the hospital has notified CMS of its
intent.
Form CMS-437A (06/12)
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