F825
(Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24)
§483.65 Specialized rehabilitative services.
§483.65(a) Provision of services.
If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident’s comprehensive plan of care, the facility must—
§483.65(a)(1) Provide the required services; or
§483.65(a)(2) In accordance with §483.70(f), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act.
INTENT §483.65(a)(1)-(2)
The intent of this regulation is to ensure that every resident receives specialized rehabilitative services as determined by their comprehensive plan of care to assist them to attain, maintain or restore their highest practicable level of physical, mental, functional and psycho-social well-being. The intent is also to ensure that residents with a Mental Disorder (MD), Intellectual Disability (ID) or a related condition receive services as determined by their Preadmission Screening and Resident Review (PASARR).
GUIDANCE §483.65(a)(1)-(2)
Regulations governing PASARR are found at 42 CFR §483.100-138. For any questions or concerns regarding PASARR do not cite here but refer to §483.20(e) and (k), F644, F645 and/or F646.
“Specialized Rehabilitative Services” includes but is not limited to physical therapy, speech-language pathology, occupational therapy, or respiratory therapy and are provided or arranged for by the nursing home. They are “specialized” in that they are provided based on each resident’s individual assessed rehabilitative needs based on their comprehensive plan of care and can only be performed by or under the supervision of qualified personnel.
These services must be provided by the facility or an outside resource and delivered by qualified personnel as defined below in the guidance under tag F826 and who are acting within the State’s scope of practice laws and regulations.
The facility must provide or arrange for the provision of specialized rehabilitative services to all residents that require these services for the appropriate length of time as assessed in their comprehensive plan of care. These services are considered a facility service provided to all residents who need them based on their comprehensive plan of care and are included within the scope of facility services.
Care provided by all facility staff must be coordinated and consistent with the specialized rehabilitative services provided by qualified personnel, which is defined under tag F826.
Restorative services are not considered Specialized Rehabilitative Service - As referenced in Section O of the MDS/RAI manual - Restorative services refers to nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A resident may be started on a restorative nursing program when he or she is admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy, or when restorative needs arise during the course of a longer-term stay, or in conjunction with
formalized rehabilitation therapy. Generally, restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy.
PROBES §483.65(a)(1)-(2)
Physical and occupational therapy:
• How did these services maintain, improve, or restore the individual’s muscle strength, balance, range of motion, functional mobility or prevent or slow decline or deterioration in the individual’s muscle strength?
• How are these services maintaining, improving or restoring the amount of activity the individual could do to maintain, improve or restore their independence?
• Do these services assist an individual in minimizing pain to enhance function and independence?
• How are these services maintaining, increasing or decreasing the amount of assistance needed by the individual to perform a task?
• How are these services maintaining, improving or restoring gross and fine motor coordination, including sensory awareness, visual-spatial awareness, and body integration?
• Do these services assist to maintain, improve or restore memory, problem solving, attention span, and the ability to recognize safety hazards?
Speech-language pathology:
• How are these services maintaining, improving or restoring auditory comprehension such as understanding common functional words, concepts of time and place, and conversation?
• How are these services maintaining, improving or restoring the functional abilities of individuals with moderate to severe hearing loss? For example, is the individual instructed how to effectively and independently use environmental controls to compensate for hearing loss such as eye contact, preferential seating, and use of the better ear or hearing aid?
• How are individuals who cannot speak or hear assessed for devices such as a communication board or an alternate means of communication?
• How are these services maintaining, improving or restoring the functional abilities of individuals with swallowing disorders? For example, are muscle re-education, swallowing, positioning, or food consistency modification techniques being employed to restore, improve, or maintain safe swallowing function?
• How are these services maintaining, improving or restoring the functional abilities of individuals with speech disorders? For example, are muscle re-education, positioning, breathing, or other techniques being employed to maintain, improve or restore the individual’s ability to communicate verbally?
Respiratory Therapy:
• How are residents assessed to determine which factor or factors may be involved in their underlying causes for ventilator dependence?
• How does the clinical team design and implement an individualized comprehensive pulmonary rehabilitation program to include resident assessment, exercise training, education, and psychosocial support?
• Are qualified personnel caring for mechanically ventilated residents aware of risk factors for ventilator-associated pneumonia (VAP) (e.g., nebulizer therapy, manual ventilation, and patient transport) and how do they practice prevention for these factors?
• How do facility staff implement practices to prevent VAP and other potential infections for residents on ventilator care? Refer to §483.80 (Infection Control).
• What precautions do facility staff take to avoid accidental drainage of condensate into the resident’s airway and to avoid contamination of caregivers during ventilator disconnection or during disposal of condensate? Refer to §483.80 (Infection Control).
• If the conditions that warranted placing the resident on the ventilator stabilize and begin to resolve, does the clinical team determine the patient’s readiness for subsequent discontinuation of ventilator support and, ultimately, extubation? Is a gradual process implemented according to the physician’s orders to wean the resident from the ventilator?
• How and to whom do facility staff report ventilator malfunction? Does the facility have a system in place to provide ventilator services for residents in the event of a malfunction of equipment?
• Does the facility have back-up power to assure ventilators and other respiratory devices are operable in the event of a power failure? Refer to §483.90 (Physical environment).
PROCEDURES §483.65(a)(1)-(2)
For each of the services noted above, surveyors should determine through information obtained by observations, interviews and record reviews, that the facility not only delivered these services, but that the services and interventions:
(1) Were monitored for their effectiveness; and
(2) Assisted residents to attain or maintain their highest practicable level of physical, mental, functional and psycho-social well-being or to prevent or slow a decline in condition.
If the facility did not provide or obtain the required services, cite that here under tag F825. However, if the services provided were not appropriately assessed or delivered in accordance with a resident’s plan of care, do not cite here but refer to the section below, Potential Requirements for Additional Investigation.
POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION §483.65(a)(1)-(2)
For residents with MI or ID, their assessment and comprehensive plan of care must be coordinated with their PASARR. If this coordination is not done, or where it is clear that the resident needs a service according to their comprehensive plan of care and facility staff failed to adequately assess the resident or has failed to care plan for the service, do not cite here but refer to §483.20 Resident Assessment and §483.21 Comprehensive person-centered care planning.
Regulations governing PASARR are found at 42 CFR §483.100-138. For any questions or concerns regarding PASARR do not cite here but refer to §483.20(e) and (k), F644, F645 and/or F646.
If noncompliance with F825, has been identified, the surveyor may have identified concerns with related structure, process, and/or outcome requirements. If an additional concerns have been identified, the surveyor must investigate the identified concern. Do not cite any related or associated requirements before first conducting an investigation to determine compliance or non-compliance with the related or associated requirement.
Other Potential Tags
• Use of Outside Resources,§483.70(f);
• Self-determination, §483.10;
• Quality of Life, §483.24;
• Quality of Care, §483.25;
• Resident Rights, §483.10 (for example if there are concerns regarding charges to the resident for any of these services refer to §483.10(f)(11));
• If an assistive device is needed for food and nutrition, refer to §483.60;
• Behavioral Health Services,§483.40;
• Infection Control,§483.80;
• Physical Environmental, §483.90
KEY ELEMENTS OF NONCOMPLIANCE
To cite deficient practice at F825, the surveyor's investigation will generally show that the facility failed to do any one or more of the following:
• Provide specialized rehabilitative services based on a resident’s comprehensive plan of care; OR
• Obtain specialized rehabilitative services from an outside resource that is a provider of specialized rehabilitation services that is NOT excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Social Security Act.