DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0267 COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT §485.70 Personnel qualifications. This section sets forth the qualifications that must be met, as a condition of participation, under §485.58, and as a condition of coverage of services under §410.100 of this chapter. (a) A facility physician must be a doctor of medicine or osteopathy who-- (1) Is licensed under State law to practice medicine or surgery; and (2) Has had, subsequent to completing a 1-year hospital internship, at least 1 year of training in the medical management of patients requiring rehabilitation services; or (3) Has had at least 1 year of full-time or part-time experience in a rehabilitation setting providing physicians' services similar to those required in this subpart. (b) A licensed practical nurse must be licensed as a practical or vocational nurse by the State in which practicing, if applicable. (c) An occupational therapist and an occupational therapy assistant must meet the qualifications set forth in §484.4 of this chapter. (d) An orthotist must-- (1) Be licensed by the State in which practicing, if applicable; (2) Have successfully completed a training program in orthotics that is jointly recognized by the American Council on Education and the American Board for Certification in Orthotics and Prosthetics; and (3) Be eligible to take that Board's certification examination in orthotics. (e) A physical therapist and a physical therapist assistant must meet the qualifications set forth in §484.4 of this chapter. (f) A prosthetist must-- (1) Be licensed by the State in which practicing, if applicable; (2) Have successfully completed a training program in prosthetics that is jointly recognized by the American Council on Education and the American Board for Certification in Orthotics and Prosthetics; and (3) Be eligible to take the Board's certification examination in prosthetics. (g) A psychologist must be certified or licensed by the State in which he or she is practicing, if that State requires certification or licensing, and must hold a master's degree in psychology from an educational institution approved by the State in which the institution is located. (h) A registered nurse must be a graduate of an approved school of nursing and be licensed as a registered nurse by the State in which practicing, if applicable. (i) A rehabilitation counselor must-- (1) Be licensed by the State in which practicing, if applicable; (2) Hold at least a bachelor's degree; and (3) Be eligible to take the certification examination administered by the Commission on Rehabilitation Counselor Certification. (j) A respiratory therapist must-- (1) Be licensed by the State in which practicing, if applicable; and (2) Have successfully completed a nationallyaccredited educational program that confers eligibility for the National Board for Respiratory Care (NBRC) registry examina tion administered by the NBRC, or (3) Has equivalent training and experience as determined by the National Board for Respiratory Care (NBRC) and passed the registry examination administered by the NBRC. (k) A social worker must-- (1) Be licensed by the State in which practicing, if applicable; (2) Hold at least a bachelor's degree from a school accredited or approved by the Council on Social Work Education; and (3) Have 1 year of social work experience in a health care setting. (l) A speech-language pathologist must meet the qualifications set forth in this chapter. American LegalNet, Inc. www.FormsWorkFlow.com Form CMS-360 (12/08) 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0267 COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT PROVIDER NUMBER FACILITY NAME AND ADDRESS (City, State, Zip Code) SURVEY DATE Type of Survey 1. Initial Survey 2. Resurvey Form CMS-360 (12/08) American LegalNet, Inc. www.FormsWorkFlow.com 2 Name of Facility CODE YES NO N/A EXPLANATORY STATEMENT I-501 §485.54 Condition of Participation: Compliance with State and local laws. The facility and all personnel who provide services must be in compliance with applicable State and local laws and regulations. I-502 (a) Standard: Licensure of facility. If State or local law provides for licensing, the facility must be currently licensed or approved as meeting the standards established for licensure. I-503 (b) Standard: Licensure of Personnel. Personnel that provide service must be licensed, certified, or registered in accordance with applicable State and local laws. I-504 State licensure, certification or registration is not required for: (Check those applicable) 1 2 3 Occupational Therapist Speech Pathologist Social Worker 4 5 6 Psychologist Rehabilitation Counselor All of the Above I-505 §485.56 Condition of Participation: Governing body and administration. The facility must have a governing body that assumes full legal responsibility for establishing and implementing policies regarding the management and operation of the facility. I-506 (a) Standard: Disclosure of Ownership. The facility must comply with the provisions of part 420, subpart C of this chapter that require health care providers and fiscal agents to disclose certain information about ownership and control. Form CMS-360 (12/08) American LegalNet, Inc. www.FormsWorkFlow.com 3 Name of Facility CODE YES NO N/A EXPLANATORY STATEMENT I-507 I-508 (b) Standard: Administrator. The governing body must appoint an administrator who-- (1) Is responsible for the overall management of the facility under the authority delegated by the governing body; (2) Implements and enforces the facility's policies and procedures; (3) Designates, in writing, an individual who, in the absence of the administrator, acts on behalf of the administrator; and (4) Retains professional and administrative responsibility for all personnel providing facility services. (c) Standard: Group of professional personnel. The facility must have a group of professional personnel associated with the facility that-- I-509 I-510 I-511 I-512 I-513 I-514 (1) Develops and periodically reviews policies to govern the services provided by the facility; and (2) Consists of at least one physician and one professional representing each of the services provided by the facility. (d) Standard: Institutional budget plan. The facility must have an institutional budget plan that meets the f