Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

§482.57(b)(2) - If blood gases or other clinical laboratory tests are performed in the respiratory care unit, the unit must meet the applicable requirements for laboratory services specified in §482.27.

Interpretive Guidelines §482.57(b)(2)

Refer to the guidelines under §482.27 for independent laboratory if blood gases and laboratory tests are performed in the respiratory care unit.

A-1163

(Rev. 137, Issued: 04-01-15, Effective: 03-27-15, Implementation: 03-27-15)

§482.57(b)(3) -Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital's medical staff to order the services in accordance with hospital policies and procedures and State laws.

## Interpretive Guidelines §482.57(b)(3)

Respiratory care services must be ordered by a qualified and licensed practitioner who is responsible for the care of the patient.  The practitioner must have medical staff privileges to write orders for these services or, for outpatient services, if hospital policy permits acceptance of orders from outside practitioners, the practitioner's order must meet the requirements at §482.54(c).

For practitioners who have medical staff privileges, such privileges must be granted in a manner consistent with the State's scope of practice law, as well as with hospital policies and procedures governing respiratory care services developed by the medical staff.

Practitioners who may be granted privileges to order respiratory care services include physicians, and may also, in accordance with hospital policy, include Nurse Practitioners, Physicians' Assistants, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Certified Nurse Midwives as long as they meet the parameters of this requirement.  Although the following licensed professionals are also considered practitioners, in accordance with Section 1842(b)(18)(C) of the Social Security Act, they generally would not be considered responsible for the care of the patient with regard to respiratory care services or qualified to order respiratory care services:  Clinical social worker (Section 1861(hh)(1) of the Act and as defined in 42 CFR 410.71);  Clinical psychologist (for purposes of Section 1861(ii) of the Act); or registered dietician or nutrition professional.

## Survey Procedures §482.57(b)(3)

- Review medical records of patients receiving respiratory care services.  Determine who wrote the orders for the respiratory care services.  Determine if the practitioner is responsible for the care of the patient and privileged to write orders for respiratory care services.  Verify the practitioner meets hospital medical staff policy criteria to order services as well as State law for ordering respiratory care services.

Does the hospital permit acceptance of orders from outside practitioners who do not practice at the hospital?  If so, evaluate for compliance with §482.54(c).

A-1164

(Rev. 72, Issued: 11-18-11, Effective: 11-18-11, Implementation: 11-18-11)

§482.57(b)(4)- All respiratory care services orders must be documented in the patient's medical record in accordance with the requirements at §482.24.

## Interpretive Guidelines §482.57(b)(4)

The patient's medical record must contain documentation of all respiratory care services ordered.  The medical record entries must comply with regulations at 42 CFR 482.24.

## Survey Procedures §482.57(b)(4)

Review a sample of patient medical records who received respiratory care services. Determine whether the respiratory care services orders are legible, complete, dated, timed, authenticated, and meet all other medical record requirements as specified at §484.24.

A-1500

(Rev.183, Issued: 10-12-18, Effective: 10-12-18, Implementation: 10-12-18)

## Condition of Participation: §482.58 Special requirements for hospital providers of long-term care services ('swing-beds')

A hospital that has a Medicare provider agreement must meet the following requirements in order to be granted an approval from CMS to provide post-hospital extended care services, as specified in §409.30 of this chapter, and be reimbursed as a swing-bed hospital, as specified in §413.114 of this chapter:

## Interpretive Guidelines §482.58

Swing-bed services are an optional service. The swing-bed concept allows a hospital to use their beds interchangeably for either acute-care or post-acute care. A 'swing-bed' is a change in reimbursement status. The patient swings from receiving acute-care hospital inpatient services and reimbursement to receiving post-acute care skilled nursing facility (SNF) services and reimbursement.  A psychiatric hospital is not allowed to have swingbed approval.

Allowing a hospital to operate swing-beds is done by issuing a 'swing-bed approval'.  If the hospital fails to meet the swing-bed requirements (not the same as the hospital conditions of participation (CoPs)), and the hospital does not implement a plan of correction, they lose the approval to operate swing-beds and receive swing-bed reimbursement. However, in such a situation, the hospital does not go on a termination track. If the hospital continues to meet all other applicable hospital CoPs, it continues to participate in Medicare, but loses its swing-bed approval.

Swing-beds do not have to be located in a special section of the hospital although a hospital may choose to do so. The patient does not have to change locations in the hospital merely because their admission status changes unless the hospital requires it. The change in status from acute care to swing-bed status can occur within the same part of the hospital or the patient can be moved to another part of the hospital for swing-bed admission. Likewise, a patient may be discharged from one hospital and admitted in swing bed status to another hospital that has swing bed approval.

Beds in a hospital IPPS-excluded rehabilitation or psychiatric unit, or a separately certified co-located Medicare participating entity (e.g., a distinct part SNF/NF, another hospital, or an inpatient hospice) cannot be used by the hospital for providing swing-bed services.

There must be discharge orders from acute care hospital inpatient services and subsequent admission orders for swing-bed services, the same as if the patient had been transferred to a separately certified skilled nursing facility.  The same clinical record may be used for a swing-bed patient, but it must include discharge orders from acute care hospital inpatient services and admission orders to swing-bed services, and the swing-bed services (which may be SNF or NF level services) must be clearly delineated within the clinical record.

There is no length of stay restriction for any hospital swing-bed patient. There is no Medicare requirement to place a swing-bed patient in a nursing home and there are no requirements for transfer agreements between hospitals and nursing homes. While there is no length of stay limit for patients in swing-bed status, the intended use for swing beds is for a transitional time period to allow the patient to fully recover to return home or while awaiting placement into a nursing facility.

The Medicare statute and regulations require that, in order to be eligible for Medicare coverage of post-hospital skilled nursing facility (SNF) or swing-bed care, a beneficiary must have a qualifying 3-day inpatient stay in a participating or qualified hospital or participating CAH prior to admission to a swing bed in a hospital, or admission to a SNF. This requirement applies only to patients who are Medicare beneficiaries who seek Medicare coverage of their SNF services. It is not evaluated or enforced through the survey and certification process, since it is a coverage requirement.

In accordance with SOM Section 2037 hospitals seeking swing-bed approval are screened prior to survey for their eligibility for swing beds. However, the CMS Regional Office makes the determination whether the hospital has satisfied the eligibility criteria, regardless of whether the State Survey Agency or Accrediting Organization, as applicable, recommends approval of swing bed status.

NOTE :  Swing-beds must not be confused with beds in a skilled nursing facility (SNF) or nursing facility (NF), including a distinct part SNF/NF, that shares the same building/campus as the hospital but is a separately certified provider with its own Medicare provider agreement.

An onsite survey must be conducted and the hospital must meet all the requirements of 42 CFR 482.58 before the hospital can obtain swing bed approval. Surveyors assess the manner and degree of non-compliance with the swing bed standards in determining whether there is condition-level compliance or standard-level non-compliance.

Structured rule (JSON):
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