DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0358 PSYCHIATRIC UNIT CRITERIA WORK SHEET RELATED MEDICARE PROVIDER NUMBER: NUMBER OF BEDS IN THE UNIT: ROOM NUMBERS IN THE UNIT: SURVEY DATE: // to // MM DD YY MM DD YY FACILITY NAME AND ADDRESS (City, State, Zip Code) REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD: VERIFIED BY: ALL CRITERIA MUST BE MET FOR EXCLUSION FROM MEDICARE'S HOSPITAL PROSPECTIVE PAYMENT SYSTEM YES NO EXPLANATORY STATEMENT �412.25 Excluded distinct part hospital units: Common requirements. (a) Basis for exclusion. In order to be excluded from the prospective payment system, a distinct part psychiatric unit must meet the following requirements: (1) Have written admission criteria that are applied uniformly to both Medicare and non-Medicare patients. (2) Have admission and discharge records that are separately identified from those of the hospital in which it is located and are readily available. (3) Have policies specifying that necessary clinical information is transferred to the unit when a patient of the hospital is transferred to the unit. (4) Meet applicable State licensure laws. (5) Have utilization review standards applicable for the type of care offered in the unit. (6) Have beds physically separate from (that is, not commingled with) the hospital's other beds. �412.27 Distinct part psychiatric units: Additional requirements. A distinct part psychiatric unit must also meet the following requirements: (a) Admit only patients whose admission to the unit is required for active treatment, of an intensity that can be provided appropriately only in an inpatient hospital setting, of a Form CMS-437 (04/90) American LegalNet, Inc. www.USCourtForms.com YES NO EXPLANATORY STATEMENT 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. (b) Furnish, through the use of qualified personnel, psychological services, social work services, psychiatric nursing, occupational therapy, and recreational therapy. (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: (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. (i) The identification data must include the inpatient's legal status. (ii) A provisional or admitting diagnosis must be made on every inpatient at the time of admission, and must include the diagnoses of intercurrent diseases as well as the psychiatric diagnoses. (iii) The reasons for admission must be clearly documented as stated by the inpatient or others significantly involved, or both. (iv) The social service records, including reports of interviews with inpatients, family members, and others must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history. (v) When indicated, a complete neurological examination must be recorded at the time of the admission physical examination. (2) Psychiatric evaluation. Each inpatient must receive a psychiatric evaluation that must-- Form CMS-437 (04/90) American LegalNet, Inc. www.USCourtForms.com Page 2 YES NO EXPLANATORY STATEMENT (i) Be completed within 60 hours of admission; (ii) Include a medical history; (iii) Contain a record of mental status; (iv) Note the onset of illness and the circumstances leading to admission; (v) Describe attitudes and behavior; (vi) Estimate intellectual functioning, memory functioning, and orientation; and (vii) Include an inventory of the inpatient's assets in descriptive, not interpretative fashion. (3) Treatment Plan. (i) Each inpatient must have an individual comprehensive treatment plan that must be based on an inventory of the inpatient's strengths and disabilities. The written plan must include a substantiated diagnosis; short-term and longterm goals; the specific treatment modalities utilized; the responsibilities of each member of the treatment team; and adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out; and (ii) The treatment received by the inpatient must be documented in such a way as to assure that all active therapeutic efforts are included. (4) Recording progress. Progress notes must be recorded by the doctor of medicine or osteopathy responsible for the care of the inpatient, a nurse, social worker and, when appropriate, others significantly involved in active treatment modalities. The frequency of progress notes is determined by the condition of the inpatient and must be recorded at least weekly for the first two months and at least once a month thereafter and must contain recommendations for revisions in the treatment plan as indicated as well as precise assessment of the inpatient's progress in accordance with the original or revised treatment plan. Form CMS-437 (04/90) American LegalNet, Inc. www.USCourtForms.com Page 3 YES NO EXPLANATORY STATEMENT (5) Discharge planning and discharge summary. The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the inpatient's hospitalization in the unit and recommendations from appropriate services concerning follow-up or after care as well as a brief summary of the patient's condition on discharge. (d) Meet special staff requirements in that the unit must have adequate numbers of qualified professional and supportive staff to evaluate inpatients, formulate written, individualized, comprehensive treatment plans, provide active treatment measures and engage in discharge planning, as follows: (1) Personnel. The unit must employ or undertake to provide adequate numbers of qualified professional, technical, and consultative personnel to-- (i) Evaluate inpatients; (ii) Formulate written, individualized, comprehensive treatment plans; (iii) Provide active treatment measures; and (iv) Engage in discharge planning. (2) Director of inpatient psychiatric services; Medical staff. Inpatient psychiatric services must be under the supervision of a cli