Criteria for Psychiatric and Rehabilitation Units

3106 - Criteria for Psychiatric and Rehabilitation Units (Rev. 1, 05-21-04) A PPS-excluded psychiatric unit must meet both the general criteria for units and the specific criteria for psychiatric units below. A PPS-excluded rehabilitation unit must also meet the general criteria for units and the specific criteria for rehabilitation units below. 3106A - General Criteria for Units (Rev. 1, 05-21-04) • The unit is a part of an institution that: o Has in effect a provider agreement to participate as a hospital; o Is not excluded in its entirety from PPS; and o Has enough beds not excluded from PPS to permit the provision of adequate cost information. • The unit has written admission criteria applied uniformly to both Medicare and non-Medicare patients; The unit has admission and discharge records that are identified separately from those of the hospital in which it is located, and that are readily retrievable. The medical records of the unit’s patients need not be physically separate from the records of patients in the acute care portion of the hospital. It is not necessary to create a second medical record when a patient is moved from the acute care portion of the hospital to the excluded unit or vice versa. The record, however, must indicate, for Medicare purposes, the dates of admission and discharge from the excluded unit. The unit’s policies provide that necessary clinical information accompany a patient upon transfer from the hospital to the unit; • If State law provides special licensing requirements for psychiatric or rehabilitation units, the unit is licensed in accordance with the applicable requirements; • The hospital’s UR plan includes specific standards for the type of care offered by the unit; • The beds assigned to the unit are physically separate from (not commingled with) beds not included in the unit; The unit must also meet the accounting requirements set forth in §§2803.B.1.g through j of the Provider Reimbursement Manual. These include requirements that: • The unit is treated as a separate cost center for cost finding and apportionment purposes; • The hospital’s accounting system properly allocates costs attributable to the unit and maintains statistical data that are adequate to support the basis of allocation of shared costs; • The cost report for the hospital includes the costs of the unit in the same fiscal period and uses a single method of cost apportionment; • As of the first day of the first reporting period for which all other exclusion requirements are met, the unit is fully equipped and staffed, and capable of providing inpatient psychiatric or rehabilitation care, regardless of whether there are any inpatients in the unit on that date; and • Each hospital may have only one unit of each type (psychiatric or rehabilitation) excluded from PPS. 3106B - Specific Criteria for Psychiatric Units (Rev. 121, Issued: 09-19-14, Effective: 09-19-14, Implementation; Upon Implementation of ICD-10) An SA onsite verification or reverification survey for PPS exclusion of a psychiatric unit is required for a hospital filing a first-time request for PPS exclusion for its psychiatric unit, a psychiatric unit that has been selected as part of a sample for an annual validation survey, and/or a complaint against a psychiatric unit. For cost reporting periods following the first cost reporting period, the hospital is to self-attest that its psychiatric unit is in compliance with the requirements at 42 CFR 412.27. 3106B1 - Patient Criteria The unit admits only patients requiring admission for active treatment, of an intensity that can be provided only in an inpatient hospital setting. The psychiatric principal diagnosis must be one contained in • the Fourth Edition of the American Psychiatric Association Diagnostic and Statistical Manual; • Chapter 5 (“Mental Disorders”) of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM); or Chapter 5 (“Mental and Behavioral Disorders”) of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM.), upon implementation of ICD-10. 3106B2 - Services Provided The unit furnishes, through the use of qualified personnel, psychological, social work, psychiatric nursing, occupational and recreational therapy services; and 3106B3 - Medical Records The unit maintains medical records that permit determination of the degree and intensity of treatment provided to individuals who are furnished services in the unit, and that meet the following requirements: a. Development of Assessment/Diagnostic Data The medical record stresses psychiatric findings in the history, physical examination findings and treatment plan. It also includes the doctor’s orders for the psychiatric condition for which the patient is treated. • The identification data includes the inpatient’s legal status (i.e., court commitment or voluntary admission); • A provisional or admitting diagnosis is made at the time of admission. The record also includes the diagnoses of intercurrent diseases as well as psychiatric diagnoses; • The reasons for admission are clearly documented as stated by the patient or others significantly involved, or both; • The social service record, including reports of interviews with patients, family members, and others provides an assessment of home plans and family attitudes, community resource contacts and a social history; and • When indicated, a complete neurological examination is recorded at the time of the admission physical examination. b. Psychiatric Evaluation Each patient receives a psychiatric evaluation that: • Is completed within 60 hours of admission; • Includes a medical history; • Contains a record of mental status; • Notes the onset of illness and the circumstances leading to admission; • Describes attitudes and behavior; • Estimates intellectual functioning, memory functioning, and orientation; and • Includes an inventory of the patient’s assets in descriptive, not interpretive, fashion. c. Treatment Plan • Each patient has a comprehensive treatment plan based on an inventory of his/her strengths and disabilities; and • The written plan includes: o A substantiated diagnosis; o Short-term and long-term goals; o The specific treatment modalities; o The responsibilities of each member of the treatment team; and o Documentation that justifies the diagnosis and treatment and all active therapeutic efforts. d. Progress Notes Physician progress notes must be documented by a Doctor of Medicine or Osteopathy responsible for the care of the patient, a nurse, a social worker and, when appropriate, others significantly involved in active treatment modalities. Progress notes’ frequency is based on the condition of the patient, but they must be recorded at least weekly for the first 2 months, and at least monthly thereafter. They should contain recommendations for revisions in the treatment plan as indicated, as well as a precise assessment of the inpatient’s progress in accordance with the original or revised treatment plan. e. Discharge Planning and Discharge Summary The record of each discharged patient has a discharge summary that must include a recapitulation of the patient’s hospitalization in the unit, recommendations from appropriate services concerning follow-up or aftercare, and a brief summary of the patient’s condition on discharge. 3106B4 - Staffing The unit meets special staff requirements and has 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: a. Personnel The unit employs or undertakes to provide adequate numbers of qualified professional, technical, and consultative personnel to: • Evaluate patients; • Formulate written individualized comprehensive treatment plans; • Provide active treatment measures; and • Engage in discharge planning. b. Director of Inpatient Psychiatric Services and Medical Staff The number and qualifications of Doctors of Medicine and Osteopathy are adequate to provide essential psychiatric services. Inpatient psychiatric services are under the supervision of a clinical director, service chief, or equivalent who is qualified to provide the leadership required for an intensive treatment program and who: ● Meets the training and experience requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry, and ● Monitors and evaluates the quality and appropriateness of services and treatment provided by the medical staff. In verifying the training and experience requirements of the clinical director, the SA follows the Hospital Interpretive Guidelines and survey procedures specified in Appendix A. (See 42 CFR 482.62(b)(1).) A director is qualified to take the examination for board certification upon successful completion of a psychiatric residency program approved by either of the two boards. c. Nursing Services The unit has a qualified director of psychiatric nursing services. There are also adequate numbers of RNs, LPNs, and mental health workers to provide care necessary under each patient’s active treatment program and to maintain progress notes on each patient. The director of psychiatric nursing services is an RN who has a master’s degree in psychiatric or mental health nursing, or its equivalent, from a school of nursing accredited by the National League for Nursing, or is qualified by education and experience in the care of the mentally ill. The director demonstrates competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished. The staffing pattern ensures the availability of a registered nurse 24 hours each day. There are adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each inpatient’s active treatment program. d. Psychological Services The unit provides or has available psychological services to meet the needs of the patients. The services are furnished in accordance with accepted standards of practice and established policies and procedures. e. Social Services There is a director of social services who monitors and evaluates the quality and appropriateness of social services furnished. The services are furnished in accordance with accepted standards of practice and established policies and procedures. Social service staff responsibilities include, but are not limited to, participating in discharge planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital. f. Therapeutic Activities The unit provides a therapeutic activities program. The program is appropriate to the needs and interest of patients and is directed toward restoring and maintaining optimal levels of physical and psychosocial functioning. The number of qualified therapists, support personnel, and consultants are adequate to provide comprehensive therapeutic activities consistent with each patient’s active treatment program. 3106C - Specific Criteria for Rehabilitation Units (Rev. 1, 05-21-04) An SA onsite verification or reverification survey for PPS exclusion for a rehabilitation unit is to be performed for a hospital’s first-time request for PPS exclusion for its rehabilitation unit, a rehabilitation unit that is selected as part of a sample for an annual validation compliance survey, and/or a complaint against a rehabilitation unit. For cost reporting periods following the first cost reporting period, the hospital will self-attest that its rehabilitation unit is in compliance with the requirements in 42 CFR 412.29. The unit meets the requirement in §3104.B, except as provided below, with respect to patients treated in the unit during the hospital’s most recent 12-month cost reporting period, i.e., the period immediately preceding the period for which the exclusion would be effective. This finding is based on the medical conditions of all (i.e., Medicare and non-Medicare) patients who occupy the beds assigned to the physically separate unit. The medical condition of all patients treated in the unit is considered. If a hospital has not previously sought exclusion for any rehabilitation unit, and has both increased its bed capacity under Medicare certification and obtained approval for added bed capacity under State licensure, it may identify the new beds as a new rehabilitation unit for the first full 12-month cost-reporting period during which the unit is in service. For purposes of these provisions, “new beds” are defined as ones for which the hospital has obtained approval by increasing its bed capacity under both State licensure and Medicare certification. Note that there is no net increase if the hospital adds 20 new beds and deletes 20 beds previously licensed and certified for conversion. A unit that is comprised of some beds that were previously licensed and certified, and some new beds, will be recognized as a new rehabilitation unit only if over half of the beds are new. Beds are considered “new” only for the first full 12-month cost reporting period in which a hospital seeks exclusion of a new rehabilitation unit. The hospital may provide written certification that the inpatient population it intends the unit to serve meets the 75 percent rule instead of showing that it has treated such a population during its most recent 12- month cost reporting period. The hospital that has an excluded rehabilitation unit must obtain approval for added bed capacity under State licensure requirements. If the hospital seeks to add the new beds to its existing excluded unit for the first full 12-month cost reporting period during which the new beds are used to furnish inpatient care, it must provide written certification that the new beds are intended to meet the inpatient population percent rule (see §3104.B) instead of showing that those beds were used to treat such a population during the unit’s most recent 12-month cost reporting period. The written certification described above is effective for any cost reporting period of not less than one month and not more than 11 months occurring between the dates the hospital began participating in Medicare and the start of the hospital’s regular 12-month cost reporting period. For purposes of this exclusion, a hospital that has undergone a change of ownership or leasing (see §3210) is not considered to have participated previously in the Medicare program. If a hospital has a new rehabilitation unit excluded from PPS for a cost reporting period, or expands an existing PPS-excluded rehabilitation unit through the addition of new beds as defined above, but the inpatient population treated in the new unit of added beds during the period does not actually meet the inpatient population percent rule, a retroactive adjustment of payments to the hospital for the period is needed. Where this occurs, the FI advises the RO of the identity of the hospital and the dates of the cost reporting period involved. If a hospital that has not previously participated in the Medicare program seeks exclusion of a rehabilitation unit, it may designate certain beds as a new rehabilitation unit for the first full 12-month cost reporting period that occurs after it becomes a Medicare participating hospital. The written certification described above also is effective for any cost reporting period of not less than one month and not more than 11 months occurring between the dates the hospital began participating in Medicare and the start of the hospital’s regular 12-month cost reporting period. For purposes of this exclusion, a hospital that has undergone a change of ownership or leasing (see §3210) is not considered to have participated previously in the Medicare program. • The unit meets the requirements for a rehabilitation hospital in §3104. (The intermediary verifies the 75 percent rule.) • The unit has a director of rehabilitation who: o Is a Doctor of Medicine or Osteopathy licensed under State law to practice medicine or surgery; o Has had, after completing a 1-year hospital internship, at least two years of training or experience in the medical management of inpatients requiring rehabilitation services; and o Provides services to the unit and its inpatients for at least 20 hours per week. If the rehabilitation unit serves both inpatients and outpatients through a single, integrated unit, the time spent by the director in performing administrative duties for the entire unit counts toward the time requirement. The SA does not prorate this administrative time between inpatients and outpatients. However, time devoted to performing direct patient care can count toward the time requirement only if furnished to inpatients of the unit.