Form Cms-437- Psychiatric Unit Criteria Worksheet Page 2
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REGULATION
GUIDANCE
YES NO
EXPLANATORY STATEMENT
A1111
(6) Have utilization review standards applicable for the
Does the hospital have a utilization review plan
type of care offered in the unit.
that includes psychiatric services?
A1112
(7) Have beds physically separate from (that is, not
Is the area containing the psychiatric unit beds
commingled with) the hospital’s other beds.
separate from the beds in the other units of the
hospital?
§412.27 Excluded Psychiatric Units: Additional
Requirements:
A1120
(a) Admit only patients whose admission to the unit is
required for active treatment, of an intensity that can be
provided appropriately on in an inpatient hospital setting,
of a psychiatric principal diagnosis that is listed in the
Third Edition of the American Psychiatric Association’s
Diagnostic and Statistical Manual or in Chapter Five
(“Mental Disorders”) of the International Classification
of Diseases, Ninth Revision, Clinical Modification.
A1121
(b) Furnish, through the use of qualified personnel,
psychological services, social work, psychiatric nursing,
occupational therapy, and recreational therapy.
A1122
(c) Maintain medical records that permit determination of
the degree and intensity of the treatment provided to
individuals who are furnished services in the unit, and
that meet the following requirements:
A1130
(1) Development of Assessment/Diagnostic Data.
Medical records must stress the psychiatric components
of the record, including history of findings and
treatment provided for the psychiatric condition for
which the inpatient is treated in the unit.
A1131
(i) The identification data must include the inpatient’s
Legal status is defined by state statutes and dictates
legal status.
the circumstances under which the patient was
admitted and/or is being treated (i.e. voluntary,
involuntary, committed by court)
A1132
(ii) A provisional or admitting diagnosis must be made
Is the diagnosis written in DSM nomenclature?
on every inpatient at the time of admission, and
If the diagnosis is absent, is there written
must include the diagnoses of intercurrent diseases
justification for the omission? (for example,
as well as the psychiatric diagnoses.
the patient was psychotic on admission and not
accompanied by family)
Is treatment provided for physical illnesses
requiring immediate attention?
Is there an evaluation and treatment plan for
identified physical illnesses that may impact the
patient’s psychiatric outcome?
Form CMS-437 (04/06)
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