Form CMS-360 CORF Survey Report

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.

(e) A physical therapist and a physical therapist
assistant must meet the qualifications set forth
in §484.4 of this chapter.

(1) Be licensed by the State in which practicing,
if applicable; and

(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.

(c) An occupational therapist and an occupational
therapy assistant must meet the qualifications set
forth in §484.4 of this chapter.

(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.

(d) An orthotist must—

(i) A rehabilitation counselor 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

(j) A respiratory therapist must—

-

(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.

(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.

(3) Be eligible to take that Board’s certification
examination in orthotics.

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

FACILITY NAME AND ADDRESS (City, State, Zip Code)

PROVIDER NUMBER

SURVEY DATE

Type of Survey
1.

Form CMS-360 (12/08)

❋ Initial Survey

2.

❋ Resurvey

2

Name of Facility
CODE

I-501

YES

NO

N/A

EXPLANATORY STATEMENT

§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.
(a) Standard: Licensure of facility.

I-502

If State or local law provides for licensing, the facility must
be currently licensed or approved as meeting the standards
established for licensure.
(b) Standard: Licensure of Personnel.

I-503

Personnel that provide service must be licensed, certified,
or registered in accordance with applicable State and local
laws.
I-504

I-505

State licensure, certification or registration is not required for:
(Check those applicable)
1

❋ Occupational Therapist

4

❋ Psychologist

2

❋ Speech Pathologist

5

❋ Rehabilitation Counselor

3

❋ Social Worker

6

❋ All of the Above

§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)

3

Name of Facility
CODE

I-507

YES

NO

N/A

EXPLANATORY STATEMENT

(b) Standard: Administrator.
The governing body must appoint an administrator who—

I-508

(1) Is responsible for the overall management of the
facility under the authority delegated by the
governing body;

I-509

(2) Implements and enforces the facility’s policies and
procedures;

I-510

(3) Designates, in writing, an individual who, in the
absence of the administrator, acts on behalf of the
administrator; and

I-511

(4) Retains professional and administrative responsibility
for all personnel providing facility services.

I-512

(c) Standard: Group of professional personnel.
The facility must have a group of professional personnel
associated with the facility that—

I-513

(1) Develops and periodically reviews policies to govern
the services provided by the facility; and

I-514

(2) Consists of at least one physician and one professional
representing each of the services provided by the
facility.

I-515

(d) Standard: Institutional budget plan.
The facility must have an institutional budget plan that
meets the following conditions:

I-516

(1) It is prepared, under the direction of the governing
body, by a committee consisting of representatives of
the governing body and the administrative staff.

I-517

(2) It provides for:
(i) An annual operating budget prepared according to
generally accepted accounting principles.
(ii) A 3-year capital expenditure plan if expenditures in
excess of $100,000 are anticipated, for that period,
for the acquisition of land; the improvement of land,
buildings and equipment; and the replacement,
modernization, and expansion of buildings and
equipment; and

Form CMS-360 (12/08)

4

Name of Facility
CODE

YES

NO

N/A

EXPLANATORY STATEMENT

(iii) Annual review and updating by the governing body.
I-518

I-519

(e) Standard: Patient care policies.
The facility must have written care policies that govern the
services it furnishes. The patient care policies must include
the following:
(1) A description of the services the facility furnishes
through employees and those furnished under
arrangements.

I-520

(2) Rules for and personnel responsibilities in handling
medical emergencies.

I-521

(3) Rules for the storage, handling, and administration of
drugs and biologicals.

I-522

(4) Criteria for patient admission, continuing care, and
discharge.

I-523

(5) Procedures for preparing and maintaining clinical
records on all patients.

I-524

(6) A procedure for explaining to the patient and the
patient’s family the extent and purpose of the services
to be provided.

I-525

(7) A procedure to assist the referring physician in
locating another level of care for patients whose
treatment has terminated and who are discharged.

I-526

(8) A requirement that patients accepted by the facility
must be under the care of a physician.

I-527

(9) A requirement that there be a plan of treatment
established by a physician for each patient.

I-528

I-529

(10) A procedure to ensure that the group of professional
personnel reviews and takes appropriate action on
recommendations from the utilization review
committee regarding patient care policies.
(f) Standard: Delegation of authority.
The responsibility for overall administration, management
and operation must be retained by the facility itself and not
delegated to others.

Form CMS-360 (12/08)

5

Name of Facility
CODE

YES

I-530

(1) The facility may enter into a contract for purposes of
assistance in financial management and may
delegate to others the following and similar services:
(i) Bookkeeping.
(ii) Assistance in the development of procedures for
billing and accounting systems.
(iii) Assistance in the development of an operating
budget.
(iv) Purchase of supplies in bulk form.
(v) The preparation of financial statements.

I-531

(2) When the services listed in paragraph (f)(1) of this
section are delegated, a contract must be in effect
and:
(i) May not be a term of more than 5 years;
(ii) Must be subject to termination within 60 days of
written notice by either party;
(iii) Must contain a clause requiring renegotiation of any
provision that CMS finds to be in contravention to
any new, revised, or amended Federal regulation or
law;
(iv) Must state that only the facility may bill the Medicare
program; and
(v) May not include clauses that state or imply that the
contractor has power and authority to act on behalf
of the facility, or clauses that give the contractor
rights, duties, discretions, or responsibilities that
enable it to dictate the administration, management,
or operations of the facility.

I-532

NO

N/A

EXPLANATORY STATEMENT

§485.58 Condition of Participation: Comprehensive
rehabilitation program
The facility must provide a coordinated rehabilitation
program that includes, at a minimum, physicians’ services,
physical therapy services and social or psychological
services. Services must be furnished by personnel that
meet the qualifications set forth in §485.70 and 484.4 of this
chapter and must be consistent with the plan of treatment
and the results of comprehensive patient assessments.

Form CMS-360 (12/08)

6

Name of Facility
CODE

I-533

YES

NO

N/A

EXPLANATORY STATEMENT

(a) Standard: Physician services.
(1) A facility physician must be present in the facility for
a sufficient time to—
(i) Provide, in accordance with accepted principles of
medical practice, medical direction, medical care
services, consultation and medical supervision of
nonphysician staff.;
(ii) Establish the plan of treatment in cases where a
plan has not been established by the referring
physician;
(iii) Assist in establishing and implementing the
facility’s patient care policies; and

I-534
I-535

(iv) Participate in plan of treatment reviews, patient case
review conferences, comprehensive patient
assessment and reassessments and utilization
reviews.
(2) The facility must provide for emergency physician
services during the facility operating hours.
(b) Standard: Plan of treatment.
For each patient, a physician must establish a plan of
treatment before the facility initiates treatment. The plan of
treatment must meet the following requirements:

I-536

(1) It must delineate anticipated goals and specify the
type, amount, frequency and duration of services to
be provided.

I-537

(2) It must be promptly evaluated after changes in the
patient’s condition and revised when necessary.

I-538

(3) It must, if appropriate, be developed in consultation
with the facility physician and the appropriate facility
professional personnel.

I-539

(4) It must be reviewed at least every 60 days by a
facility physician who, when appropriate, consults
with the professional personnel providing services.
The results of this review must be communicated to
the patient’s referring physician for concurrence
before treatment is continued or discontinued.

Form CMS-360 (12/08)

7

Name of Facility
CODE

I-540

I-541

YES

NO

N/A

EXPLANATORY STATEMENT

(5) It must be revised if the comprehensive reassessment
of the patient’s status or the results of the patient case
review conference indicate the need for revision.
(c) Standard: Coordination of services.
The facility must designate, in writing, a qualified professional
to ensure that professional personnel coordinate their related
activities and exchange information about each patient under
their care. Mechanisms to assist in the coordination of servic­
es must include—

I-542

(1) Providing to all personnel associated with the facility,
a schedule indicating the frequency and type of serv­
ices provided at the facility;

I-543

(2) A procedure for communicating to all patient care
personnel pertinent information concerning significant
changes in the patient’s status;

I-544

(3) Periodic clinical record entries, noting at least the
patient’s status in relationship to goal attainment; and

I-545

(4) Scheduling patient case review conferences for purpos­
es of determining appropriateness of treatment, when
indicated by the results of the initial comprehensive
patient assessment, reassessment(s), the recommen­
dation of the facility physician (or other physician who
established the plan of treatment), or upon recommen­
dation of one of the professionals providing services.

I-546

(d) Standard: Provision of services.
(1) All patient’s must be referred to the facility by a
physician who provides the following information to
the facility before treatment is initiated:
(i) The patient’s significant medical history.
(ii) Current medical findings.
(iii) Diagnosis(es) and contraindications to any
treatment modality.
(iv) Rehabilitation goals, if determined.

I-547
I-548

(2) Services may be provided by facility employees or by
others under arrangements made by the facility.
(3) The facility must have on its premises the necessary
equipment to implement the plan of treatment and
sufficient space to allow adequate care.

Form CMS-360 (12/08)

8

Name of Facility
CODE

YES

I-549

(4) The services must be furnished by personnel that meet the
qualifications of §485.70 and §484.4 and the number of
qualified personnel must be adequate for the volume and
diversity of services offered. Personnel that do not meet
the qualifications specified in §485.70 and §484.4 may be
used by the facility in assisting qualified staff. When a
qualified individual is assisted by these personnel, the
qualified individual must be on the premises, and must
instruct these personnel in appropriate patient care service
techniques and retain responsibility for their activities.

I-550

(5) A qualified professional must initiate and coordinate
the appropriate portions of the plan of treatment,
monitor the patient’s progress, and recommend
changes in the plan, if necessary.

I-551

(6) A qualified professional representing each service
made available at the facility must be either on the
premises of the facility or must be available through
direct telecommunication for consultation and
assistance during the facility’s operating hours. At
least one qualified professional must be on the
premises during the facility’s operating hours.

I-552

(7) All services must be provided consistent with
accepted professional standards and practice.

I-553

NO

N/A

EXPLANATORY STATEMENT

(e) Standard: Scope and site of services.
(1) Basic Requirements: The facility must provide all the
CORF services required in the plan of treatment and,
except as provided in paragraph (e) (2) of this section,
must provide the services on its premises.
(2) Exceptions: Physical therapy, occupational therapy
and speech pathology services may be furnished
away from the premises of the CORF including the
individual’s home when payment is not otherwise
made under Title XVIII of the Act. In addition, a single
home environment evaluation is covered if there is
need to evaluate the potential impact of the home
environment on the rehabilitation goals.
(3) The single home environment evaluation requires the
presence of the patient and the physical therapist,
occupational therapist, or speech-language patholo­
gist, as appropriate.

Form CMS-360 (12/08)

9

Name of Facility
CODE

I-554

YES

NO

N/A

EXPLANATORY STATEMENT

(f) Standard: Patient assessment.
Each qualified professional involved in the patient’s care, as
specified in the plan of treatment, must—

I-555

(1) Carry out an initial patient assessment; and

I-556

(2) In order to identify whether or not the current plan of
treatment is appropriate, perform a patient
reassessment after significant changes in the
patient’s status.

I-557

(g) Standard: Laboratory services
(1) If the facility provides its own laboratory services, the
services must meet the applicable requirements for
laboratories specified in part 493 of this chapter.

I-558

I-559

(2) If the facility chooses to refer specimens for laboratory
testing, the referral laboratory must be certified in the
appropriate specialties and subspecialties of services
in accordance with the requirements of part 493 of
this chapter.
§485.60 Condition of Participation: Clinical records.
The facility must maintain clinical records on all patients in
accordance with accepted professional standards and
practice. The clinical records must be completely, promptly,
and accurately documented, readily accessible, and
systematically organized to facilitate retrieval and
compilation of information.

I-560

(a) Standard: Content.
Each clinical record must contain sufficient information to
identify the patient clearly and to justify the diagnosis and
treatment. Entries in the clinical record must be made as
frequently as is necessary to insure effective treatment, and
must be signed by personnel providing services. All entries
made by assistant level personnel must be countersigned
by the corresponding professional. Documentation on each
patient must be consolidated into one clinical record that
must contain—

Form CMS-360 (12/08)

10

Name of Facility
CODE

YES

I-561

(1) The initial assessment and subsequent reassessments
of the patient’s needs;

I-562

(2) Current plan of treatment;

I-563

(3) Identification data and consent or authorization forms;

I-564

(4) Pertinent medical history, past and present;

I-565

(5) A report of pertinent physical examinations if any;

I-566

(6) Progress notes or other documentation that reflect
patient reaction to treatment, tests, or injury, or the
need to change the established plan of treatment;
and

I-567

(7) Upon discharge, a discharge summary including
patient status relative to goal achievement, prognosis,
and future treatment considerations.

I-568

NO

N/A

EXPLANATORY STATEMENT

(b) Standard: Protection of clinical record information.
The facility must safeguard clinical record information
against loss, destruction, or unauthorized use. The facility
must have procedures that govern the use and removal of
records and the conditions for release of information. The
facility must obtain the patient’s written consent before
releasing information not required to be released by law.

I-569

(c) Standard: Retention and preservation.
The facility must retain clinical record information for 5
years after patient discharge and must make provision for
the maintenance of such records in the event that it is no
longer able to treat patients.

I-570

§485.62 Condition of Participation: Physical environment.
The facility must provide a physical environment that
protects the health and safety of patients, personnel, and
the public.

I-571

(a) Standard: Safety and comfort of patients.
The physical premises of the facility and those areas of its
surrounding physical structure that are used by the patients
(including at least all stairwells, corridors and passageways)
must meet the following requirements:

Form CMS-360 (12/08)

11

Name of Facility
CODE

YES

I-572

(1) Applicable Federal, State, and local building, fire and
safety codes must be met.

I-573

(2) Fire extinguishers must be easily accessible and fire
regulations must be prominently posted.

I-574

(3) A fire alarm system with local (in-house) capability
must be functional, and where power is generated by
electricity, an alternate power source with automatic
triggering must be present.

I-575

(4) Lights, supported by an emergency power source,
must be placed at exits.

I-576

(5) A sufficient number of staff to evacuate patients
during a disaster must be on the premises of the
facility whenever patients are being treated.

I-577

(6) Lighting must be sufficient to carry out services
safely; room temperature must be maintained at
comfortable levels; and ventilation through windows,
mechanical means, or a combination of both must be
provided.

I-578

(7) Safe and sufficient space must be available for the
scope of services offered.

I-579

NO

N/A

EXPLANATORY STATEMENT

(b) Standard: Sanitary environment.
The facility must maintain a sanitary environment and
establish a program to identify, investigate, prevent, and
control the cause of patient infections.

I-580

(1) The facility must establish written policies and
procedures designed to control and prevent infection
in the facility and to investigate and identify possible
causes of infection.

I-581

(2) The facility must monitor the infection control program
to ensure that the staff implement the policies and
procedures and that the policies and procedures are
consistent with current practices in the field.

Form CMS-360 (12/08)

12

Name of Facility
CODE

YES

I-582

(3) The facility must make available at all times a
quantity of laundered linen adequate for proper care
and comfort of patients. Linens must be handled,
stored, and processed in a manner that prevents the
spread of infection.

I-583

(4) Provisions must be in effect to ensure that the facility’s
premises are maintained free of rodent and insect
infestation.

I-584

NO

N/A

EXPLANATORY STATEMENT

(c) Standard: Maintenance of equipment, physical
location, and grounds.
The facility must establish a written preventive maintenance
program to ensure that—

I-585

(1) All equipment is properly maintained and equipment
needing periodic calibration is calibrated consistent
with the manufacturer’s recommendations; and

I-586

(2) The interior of the facility, the exterior of the physical
structure housing the facility, and the exterior
walkways and parking areas are clean and orderly
and maintained free of any defects that are a hazard
to patients, personnel, and the public.

I-587

(d) Standard: Access for the physically impaired.
The facility must ensure the following:

I-588

(1) Doorways, stairwells, corridors, and passageways
used by patients are—
(i) Of adequate width to allow for easy movement of all
patients (including those on stretchers or in
wheelchairs); and
(ii) In the case of stairwells, equipped with firmly
attached handrails on at least one side.

I-589

(2) At least one toilet facility is accessible and constructed
to allow utilization by ambulatory and nonambulatory
individuals.

I-590

(3) At least one entrance is usable by individuals in
wheelchairs.

Form CMS-360 (12/08)

13

Name of Facility
CODE

YES

I-591

(4) In multi-story buildings, elevators are accessible to
and usable by the physically impaired on the level
that they use to enter the building and all levels
normally used by the patients of the facility.

I-592

(5) Parking spaces are large enough and close enough
to the facility to allow safe access by the physically
impaired.

I-593

NO

N/A

EXPLANATORY STATEMENT

§485.64 Condition of Participation: Disaster procedures.
The facility must have written policies and procedures that
specifically define the handling of patients, personnel,
records, and the public during disasters. All personnel
associated with the facility must be knowledgeable with
respect to these procedures, be trained in their application,
and be assigned specific responsibilities.

I-594

(a) Standard: Disaster plan.
The facility’s written disaster plan must be developed and
maintained with assistance of qualified fire, safety, and
other appropriate experts. The plan must include—

I-595

(1) Procedures for prompt transfer of casualties and
records;

I-596

(2) Procedures for notifying community emergency
personnel (for example, fire department, ambulance,
etc.);

I-597

(3) Instructions regarding the location and use of alarm
systems and signals and fire fighting equipment; and

I-598

(4) Specification of evacuation routes and procedures for
leaving the facility.

I-599

(b) Standard: Drills and staff training.

I-600

(1) The facility must provide ongoing training and drills
for all personnel associated with the facility in all
aspects of disaster preparedness.

I-601

(2) All new personnel must be oriented and assigned
specific responsibilities regarding the facility’s
disaster plan within 2 weeks of their first workday.

Form CMS-360 (12/08)

14

Name of Facility
CODE

I-602

YES

NO

N/A

EXPLANATORY STATEMENT

§485.66 Condition of Participation: Utilization review plan.
The facility must have in effect a written utilization review
plan that is implemented at least each quarter, to assess
the necessity of services and promotes the most efficient
use of services provided by the facility.

I-603

(a) Standard: Utilization review committee.
The utilization review committee, consisting of the group of
professional personnel specified in §485.56(c), a committee
of this group, or a group of similar composition, comprised
by professional personnel not associated with the facility,
must carry out the utilization review plan.

I-604

(b) Standard: Utilization review plan
The utilization review plan must contain written procedures
for evaluating—

I-605

(1) Admissions, continued care, and discharges using, at
a minimum, the criteria established in the patient
care policies;

I-606

(2) The applicability of the plan of treatment to
established goals; and

I-607

(3) The adequacy of clinical records with regard to—
(i) Assessing the quality of services provided;
(ii) Determining whether the facility’s policies and
clinical practices are compatible and promote
appropriate and efficient utilization of services.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for
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Form CMS-360 (12/08)

15