Social Security Act §1861

(3)maintains clinicalrecords on all patients and maintains such records as the Secretaryfinds to be necessary to determine the degree and intensity of thetreatment provided to individuals entitled to hospital insurance benefitsunder part A; and(4)meets such staffingrequirements as the Secretary finds necessary for the institutionto carry out an active program of treatment for individuals who arefurnished services in the institution.In the case of an institution which satisfies paragraphs (1)and (2) of the preceding sentence and which contains a distinct partwhich also satisfies paragraphs (3) and (4) of such sentence, suchdistinct part shall be considered to be a psychiatric hospital.Outpatient Occupational Therapy Services(g)The term outpatient occupational therapyservices has the meaning given the term outpatientphysical therapy services in subsection (p), except that occupational shall be substituted for physical each place it appears therein.Extended Care Services(h)The term extended care services means the following items and services furnished to an inpatientof a skilled nursing facility and (except as provided in paragraphs(3), (6), and (7)) by such skilled nursing facility(1)nursing care providedby or under the supervision of a registered professional nurse;(2)bed and boardin connection with the furnishing of such nursing care;(3)physical or occupationaltherapy or speech-language pathology services furnished by the skillednursing facility or by others under arrangements with them made bythe facility;(4)medical socialservices;(5)such drugs, biologicals,supplies, appliances, and equipment, furnished for use in the skillednursing facility, as are ordinarily furnished by such facility forthe care and treatment of inpatients;(6)medical servicesprovided by an intern or resident-in-training of a hospital with whichthe facility has in effect a transfer agreement (meeting the requirementsof subsection (l)), under a teaching program of such hospital approvedas provided in the last sentence of subsection (b), and other diagnosticor therapeutic services provided by a hospital with which the facilityhas such an agreement in effect; and(7)such other servicesnecessary to the health of the patients as are generally providedby skilled nursing facilities, or by others under arrangements withthem made by the facility; able).excluding, however, any item or service if it would not be includedunder subsection (b) if furnished to an inpatient of a hospital.Post-Hospital Extended Care Services(i)The term post-hospital extended careservices means extended care services furnished an individualafter transfer from a hospital in which he was an inpatient for notless than 3 consecutive days before his discharge from the hospitalin connection with such transfer. For purposes of the preceding sentence,items and services shall be deemed to have been furnished to an individualafter transfer from a hospital, and he shall be deemed to have beenan inpatient in the hospital immediately before transfer therefrom,if he is admitted to the skilled nursing facility (A) within 30 daysafter discharge from such hospital, or (B) within such time as itwould be medically appropriate to begin an active course of treatment,in the case of an individual whose condition is such that skillednursing facility care would not be medically appropriate within 30days after discharge from a hospital; and an individual shall be deemednot to have been discharged from a skilled nursing facility if, within30 days after discharge therefrom, he is admitted to such facilityor any other skilled nursing facility.Skilled Nursing Facility(j)The term skilled nursing facility has the meaning given such term in section 1819(a).Utilization Review(k)A utilization review plan of a hospital orskilled nursing facility shall be considered sufficient if it is applicableto services furnished by the institution to individuals entitled toinsurance benefits under this title and if it provides(1)for the review,on a sample or other basis, of admissions to the institution, theduration of stays therein, and the professional services (includingdrugs and biologicals) furnished, (A) with respect to the medicalnecessity of the services, and (B) for the purpose of promoting themost efficient use of available health facilities and services;(2)for such reviewto be made by either (A) a staff committee of the institution composedof two or more physicians (of which at least two must be physiciansdescribed in subsection (r)(1) of this section), with or without participation of other professional personnel, or (B) a group outsidethe institution which is similarly composed and (i) which is establishedby the local medical society and some or all of the hospitals andskilled nursing facilities in the locality, or (ii) if (and for aslong as) there has not been established such a group which servessuch institution, which is established in such other manner as maybe approved by the Secretary;(3)for such review,in each case of inpatient hospital services or extended care servicesfurnished to such an individual during a continuous period of extendedduration, as of such days of such period (which may differ for differentclasses of cases) as may be specified in regulations, with such reviewto be made as promptly as possible, after each day so specified, andin no event later than one week following such day; and(4)for prompt notificationto the institution, the individual, and his attending physician ofany finding (made after opportunity for consultation to such attendingphysician) by the physician members of such committee or group thatany further stay in the institution is not medically necessary.The review committee must be composed as provided in clause(B) of paragraph (2) rather than as provided in clause (A) of suchparagraph in the case of any hospital or skilled nursing facilitywhere, because of the small size of the institution, or (in the caseof a skilled nursing facility) because of lack of an organized medicalstaff, or for such other reason or reasons as may be included in regulations,it is impracticable for the institution to have a properly functioningstaff committee for the purposes of this subsection. If the Secretarydetermines that the utilization review procedures established pursuantto title XIX are superior in their effectiveness to the proceduresrequired under this section, he may, to the extent that he deems itappropriate, require for purposes of this title that the proceduresestablished pursuant to title XIX be utilized instead of the proceduresrequired by this section.Agreements for Transfer Between Skilled Nursing Facilitiesand Hospitals(l)A hospital and a skilled nursing facility shallbe considered to have a transfer agreement in effect if, by reasonof a written agreement between them or (in case the two institutionsare under common control) by reason of a written undertaking by theperson or body which controls them, there is reasonable assurancethat(1)transfer of patientswill be effected between the hospital and the skilled nursing facilitywhenever such transfer is medically appropriate as determined by theattending physician; and(2)there will beinterchange of medical and other information necessary or useful inthe care and treatment of individuals transferred between the institutions,or in determining whether such individuals can be adequately caredfor otherwise than in either of such institutions.Any skilled nursing facility which does not have such an agreementin effect, but which is found by a State agency (of the State in whichsuch facility is situated) with which an agreement under section 1864 is in effect (or,in the case of a State in which no such agency has an agreement undersection 1864,by the Secretary) to have attempted in good faith to enter into suchan agreement with a hospital sufficiently close to the facility tomake feasible the transfer between them of patients and the informationreferred to in paragraph (2), shall be considered to have such anagreement in effect if and for so long as such agency (or the Secretary,as the case may be) finds that to do so is in the public interestand essential to assuring extended care services for persons in thecommunity who are eligible for payments with respect to such servicesunder this title.Home Health Services(m)The term home health services means the following items and services furnished to an individual,who is under the care of a physician, by a home health agency or byothers under arrangements with them made by such agency, under a plan(for furnishing such items and services to such individual) establishedand periodically reviewed by a physician, which items and servicesare, except as provided in paragraph (7), provided on a visiting basisin a place of residence used as such individuals home(1)part-time or intermittentnursing care provided by or under the supervision of a registeredprofessional nurse;(2)physical or occupationaltherapy or speech-language pathology services;(3)medical socialservices under the direction of a physician;(4)to the extentpermitted in regulations, part-time or intermittent services of ahome health aide who has successfully completed a training programapproved by the Secretary;(5)medical supplies(including catheters, catheter supplies, ostomy bags, and suppliesrelated to ostomy care, and a covered osteoporosis drug (as definedin subsection (kk)), but excluding other drugs and biologicals) anddurable medical equipment and applicable disposable devices (as definedin section 1834(s)(2)) while under such a plan;[496](6)in the case ofa home health agency which is affiliated or under common control witha hospital, medical services provided by an intern or resident-in-trainingof such hospital, under a teaching program of such hospital approvedas provided in the last sentence of subsection (b); and(7)any of the foregoingitems and services which are provided on an outpatient basis, underarrangements made by the home health agency, at a hospital or skillednursing facility, or at a rehabilitation center which meets such standardsas may be prescribed in regulations, and(A)the furnishingof which involves the use of equipment of such a nature that the itemsand services cannot readily be made available to the individual insuch place of residence, or(B)which arefurnished at such facility while he is there to receive any such itemor service described in clause (A),but not including transportation of the individual in connectionwith any such item or service;excluding, however, any item or service if it would not be includedunder subsection (b) if furnished to an inpatient of a hospital andhome infusion therapy (as defined in subsection (iii)(i)). For purposesof paragraphs (1) and (4), the term parttime or intermittentservices means skilled nursing and home health aide servicesfurnished any number of days per week as long as they are furnished(combined) less than 8 hours each day and 28 or fewer hours each week(or, subject to review on a case-by-case basis as to the need forcare, less than 8 hours each day and 35 or fewer hours per week).For purposes of sections 1814(a)(2)(C) and 1835(a)(2)(A), intermittent means skilled nursing care that is either providedor needed on fewer than 7 days each week, or less than 8 hours ofeach day for periods of 21 days or less (with extensions in exceptionalcircumstances when the need for additional care is finite and predictable).[497]Durable Medical Equipment(n)The term durable medical equipment includes iron lungs, oxygen tents, hospital beds, and wheelchairs(which may include a power-operated vehicle that may be appropriatelyused as a wheelchair, but only where the use of such a vehicle isdetermined to be necessary on the basis of the individualsmedical and physical condition and the vehicle meets such safety requirementsas the Secretary may prescribe) used in the patients home (includingan institution used as his home other than an institution that meetsthe requirements of subsection (e)(1) of this section or section 1819(a)(1)), whetherfurnished on a rental basis or purchased, and includes blood-testingstrips and blood glucose monitors for individuals with diabetes withoutregard to whether the individual has Type I or Type II diabetes orto the individuals use of insulin (as determined under standardsestablished by the Secretary in consultation with the appropriateorganizations) and eye tracking and gaze interaction accessories forspeech generating devices furnished to individuals with a demonstratedmedical need for such accessories; except that such term does notinclude such equipment furnished by a supplier who has used, for thedemonstration and use of specific equipment, an individual who hasnot met such minimum training standards as the Secretary may establishwith respect to the demonstration and use of such specific equipment.With respect to a seat-lift chair, such term includes only the seat-liftmechanism and does not include the chair[498].Home Health Agency(o)The term home health agency meansa public agency or private organization, or a subdivision of suchan agency or organization, which(1)is primarily engagedin providing skilled nursing services and other therapeutic services;(2)has policies,established by a group of professional personnel (associated withthe agency or organization), including one or more physicians andone or more registered professional nurses, to govern the services(referred to in paragraph (1)) which it provides, and provides forsupervision of such services by a physician or registered professionalnurse;(3)maintains clinicalrecords on all patients;