130 CMR, § 435.410 - Level-of-Care Criteria for Rehabilitation Hospitals

(A) Introduction. A member is considered appropriate for rehabilitation hospital placement only when a medical need exists for an intensive rehabilitation program that includes a multidisciplinary approach to improve the member's ability to function to his or her maximum potential. Factors must be present in the member's condition that indicate the potential for functional movement or freedom from pain. A member who requires therapy solely to maintain function is not considered an appropriate rehabilitation hospital patient.

(B) Level-of-Care Criteria. The Medicare rehabilitation hospital level-of-care criteria and the criteria below are used by the Division or its agent to determine the medical necessity of rehabilitation hospital placement. The hospital must provide a rehabilitation program that:

(1) includes specialized skilled nursing services, physical therapy, occupational therapy, and any other services that are necessary for the rehabilitative program (such as speech therapy, prosthetic, or orthotic services);

(2) is organized and directed by a physician who is board-certified in rehabilitation medicine; and

(3) is designed to achieve specified goals within a given time frame.

(C) Team Conferences. The rehabilitation hospital must conduct team conferences for each member. The first team conference must occur within seven calendar days of the member's admission; successive team conferences must occur at least every 14 calendar days thereafter. All team members must be present during the team conferences. These conferences must assess the member's progress and rehabilitation goals, and adjust them when necessary, or terminate the rehabilitation program when the expected outcome is reached. A record must be maintained of:

(1) each team member's goals and progress notes from each conference;

(2) all decisions reached during each team conference; and

(3) the reason for any lack of progress on the part of the member in reaching specific goals.

Notes

130 CMR, § 435.410

Amended by Mass Register Issue 1302, eff. 12/18/2015.