DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICE OMB NO. 0938-0986 REHABILITATION UNIT CRITERIA WORK SHEET CMS-437A RELATED MEDICARE PROVIDER NUMBER ROOM NUMBERS IN THE UNIT FACILITY NAME AND ADDRESS (City, State, Zip Code) NUMBER OF BEDS IN THE UNIT SURVEY DATE REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD / / to / / MM DD YYYY MM DD YYYY VERIFIED BY ALL CRITERIA UNDER SUBPART B OF PART 412 OF THE REGULATIONS MUST BE MET FOR EXCLUSION FROM MEDICARE222S ACUTE CARE HOSPITAL PROSPECTIVE PAYMENT SYSTEM OR FROM THE PAYMENT SYSTEM USED TO PAY CRITICAL ACCESS HOSPITALS. TAG REGULATION GUIDANCE THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM YES NO N/A 225 Verification of hospital attestations may be done by CMS surveyors or MACs as applicable. The hospital representative is expected to answer all questions accurately. The representative should verify the answers with the director of rehabilitation, physician, medical records office, or any applicable department to ensure correct responses to this form. A 223yes224 response means the hospital is in compliance with the applicable regulation. 247412.25 Excluded hospital units: Common requirements. (a) Basis for exclusion. In order to be excluded from the prospective payment systems specified in 247412.1(a)(1), a rehabilitation unit must meet the following requirements in addition to the all criteria under Subpart B of Part 412 of the regulations: In the case of 247 412.25 and 247 412.29, as related to IRF units, the term hospital includes Critical Access Hospitals. Form CMS-437A (04/30/19) American LegalNet, Inc. www.FormsWorkFlow.com Form CMS - 437A (04/30/19 ) 2 TAG REGULATION GUIDANCE THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM YES NO N/A A3500 (1) Be part of an institution that has in effect an agreement under Part 489 to participate as a hospital, and is not excluded in its entirety from the prospective payment systems, and has enough beds that are not excluded to permit the provision of adequate cost. 225 The surveyor will verify, through the regional office (RO), that the hospital has an agreement to participate in the Medicare program, and the hospital is not already excluded in its entirety from IPPS, such as a rehabilitation hospital. In other words, the unit seeking exclusions cannot comprise the entire hospital 225 The hospital must be sufficiently staffed, maintained and IPPS beds utilized that are not part of the rehabilitation unit. 225 Verification of this information may be done by CMS surveyors or MACs. Representative to ensure the hospital has a Medicare provider agreement. A3501 (2) Have written admission criteria that are applied uniformly to both Medicare and non-Medicare patients. 225 Verify that the hospital has preadmission criteria for the rehabilitation unit. 225 Conduct an open and closed record review to determine whether the approved preadmission criteria is applied equally to all patients. Representative to verify the rehab unit has preadmission criteria. A3502 (3) Have admission & discharge records that are separately identified from those of the hospital in which it is located and are readily available. 225 Verify that rehabilitation unit medical records are separate and not commingled with other hospital records and are readily available for review. Representative to verify that the rehab unit houses only the records of the rehab patients. A3503 (4) Have policies specifying that necessary clinical information is transferred to the unit when a patient of the hospital is transferred to the unit. 225 Verify that the hospital has a policy detailing the prompt transfer of information, and that it is being followed. 225 Review rehabilitation unit clinical records to ensure that the clinical information that should be transferred with the record is actually in the medical record. Representative to verify the hospital has a policy regarding the transfer of information, and the hospital adheres to the policy. American LegalNet, Inc. www.FormsWorkFlow.com Form CMS - 437A (04/30/19 ) 3 TAG REGULATION GUIDANCE THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM YES NO N/A A3504 (5) Meet applicable State licensure laws. 225 Verify and document that all applicable State licensure laws are met. 225 Document all unmet State licensure requirements. 225 Verify the hospital has current licenses for its professional staff. 225 Are the licenses issued by the State in which the rehabilitation unit is located? 225 Does the unit meet special licensing requirements issued by the State? Representative to verify that all applicable State laws are being met and that all applicable licenses are current. A3505 (6) Have utilization review standards applicable for the type of care offered in the unit. 225 Verify that the hospital has a utilization review plan that includes the review of rehab services (No utilization review (UR) standards are required if the QIO is conducting review activities.) 225 Verify that the hospital has written UR standards that are applied to the care offered in the unit. Representative to verify that the hospital has a UR plan and that the UR standards are being applied to the care offered in the rehab unit. A3506 (7) Have beds physically separate from (that is, not commingled with) the hospital222s other beds. NOTE: 247412.25(a) (8)-(12) are verified by the FI. 225 Is the space containing the rehab beds physically separate from the beds in other units of the hospital? 225 There cannot be any beds that are located within the physical confines of the excluded rehab unit that are not excluded beds. 225 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. 225 If the unit doesn222t 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. Representative will verify that the beds on the rehab unit do not belong to medical/surgical patients but are dedicated to rehab patients only. American LegalNet, Inc. www.FormsWorkFlow.com Form CMS - 437A (04/30/19 ) 4 TAG REGULATION GUIDANCE THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM YES NO N/A A3507 (13) As part of the first day of the first cost reporting period for which all other exclusion requirements are met, the unit is fully equipped and staffed and is capable of providing hospital inpatient rehabilitation care regardless of whether there are any inpatients in the unit on that date. 225 Prior to scheduling the survey, verify with the FI that the unit is operational: fully staffed and equipped. 225 It is not required that the unit has inpatients on the day of the survey, but must demonstrate capability of caring for patients. A3508 (b) Changes in the size of excluded units. Except in the special cases noted at the end of this paragraph, changes in the number of beds or square footage considered to be part of an excluded unit under this section are allowed one time during a cost reporting period if the hospital notifies its Medicare contractor and the CMS RO in writing of the planned change at least 30 days before the date of the change. The hospital must maintain the information needed to accurately determine costs that are attributable to the excluded unit. A change in bed size or a change in square footage may occur at any time during a cost reporting period and must remain in effect for the rest of that cost reporting period. Changes in bed size or square footage may be made at any time if these changes are made necessary by relocation of a unit to permit construction or renovation necessary for compliance with changes in Federal, State, or local law affecting the physical facility or because of catastrophic events such as fires, floods, earthquakes, or tornadoes. 225 Verify that the request the IRF is making to add beds is the first and only request during the cost report year. 225 A decrease in the number of beds or square footage may occur at any time during the cost report period. In both cases, the change must remain in