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qualified personnel and written agreements with each facility providing the service. Other ancillary services include physical health, pharmacy and dietary services.
(C) Standards for physical plant and environment.
(1) Physical environment. The buildings and grounds of the SUDRF shall be maintained so as to avoid health and safety hazards, be supportive of the services provided to patients, and promote patient comfort, dignity, privacy, personal hygiene, and personal safety.
(2) Physical plant safety. The SUDRF shall be maintained in a manner that protects the lives and ensures the physical safety of patients, staff, and visitors, including conformity with all applicable building, fire, health, and safety codes.
(3) Disaster planning. The SUDRF shall maintain and rehearse written plans for taking care of casualties and handling other consequences arising from internal or external disasters.
(D) Standards for evaluation system.
(1) Quality assessment and improvement. The SUDRF develop and implement a comprehensive quality assurance and quality improvement program that monitors the quality, efficiency, appropriateness, and effectiveness of the care, treatments, and services it provides for patients and their families, utilizing clinical indicators of effectiveness to contribute to an ongoing process of program improvement. The clinical director is responsible for developing and implementing quality assessment and improvement activities throughout the facility.
(2) Utilization review. The SUDRF shall implement a utilization review process, pursuant to a written plan approved by the professional staff, the administration, and the governing body, that assesses the appropriateness of admissions, continued stay, and timeliness of discharge as part of an effort to provide quality patient care in a costeffective manner. Findings of the utilization review process are used as a basis for revising the plan of operation, including a review of staff qualifications and staff composition.
(3) Patient records review. The center shall implement a process, including monthly reviews of a representative
sample of patient records, to determine the completeness and accuracy of the patient records and the timeliness and pertinence of record entries, particularly with regard to regular recording of progress/non-progress in treatment plan.
(4) Drug utilization review. An inpatient rehabilitation center and, when applicable, a partial hospitalization center, shall implement a comprehensive process for the monitoring and evaluating of the prophylactic, therapeutic, and empiric use of drugs to assure that medications are provided appropriately, safely, and effectively.
(5) Risk management. The SUDRF shall implement a comprehensive risk management program, fully coordinated with other aspects of the quality assurance and quality improvement program, to prevent and control risks to patients and staff and costs associated with clinical aspects of patient care and safety.
(6) Infection control. The SUDRF shall implement a comprehensive system for the surveillance, prevention, control, and reporting of infections acquired or brought into the facility.
(7) Safety. The SUDRF shall implement an effective program to assure a safe environment for patients, staff, and visitors.
(8) Facility evaluation. The SUDRF annually evaluates accomplishment of the goals and objectives of each clinical program and service of the SUDRF and reports findings and recommendations to the governing body.
(E) Participation agreement requirements. In addition to other requirements set forth in paragraph (b)(4)(xiv) of this section, in order for the services of an inpatient rehabilitation center or partial hospitalization center for the treatment of substance abuse disorders to be authorized, the center shall have entered into a Participation Agreement with OCHAMPUS. The period of a Participation Agreement shall be specified in the agreement, and will generally be for not more than five years. On October 1, 1995, the SUDRF shall not be considered to be a CHAMPUS authorized provider and CHAMPUS payments shall not be made for seryices provided by the SUDRF until the date the participation agreement is
signed by the Director, OCHAMPUS. In addition to review of the SUDRFS application and supporting documentation, an on-site visit by OCHAMPUS representatives may be part of the authorization process. In addition, such a Participation Agreement may not be signed until an SUDRF has been licensed and operational for at least six months. The Participation Agreement shall include at least the following requirements:
(1) Render applicable services to eligible CHAMPUS beneficiaries in need of such services, in accordance with the participation agreement and CHAMPUS regulation;
(2) Accept payment for its services based upon the methodology provided in $199.14, or such other method as determined by the Director, OCHAMPUS;
(3) Accept the CHAMPUS-determined rate as payment in full and collect from the CHAMPUS beneficiary or the family of the CHAMPUS beneficiary only those amounts that represent the beneficiary's liability, as defined in $199.4, and charges for services and supplies that
not benefit of CHAMPUS;
(4) Make all reasonable efforts acceptable to the Director, OCHAMPUS, to collect those amounts which represent the beneficiary's liability, as defined in $ 199.4;
(5) Comply with the provisions of $199.8, and submit claims first to all health insurance coverage to which the beneficiary is entitled that is primary to CHAMPUS;
(6) Furnish OCHAMPUS with cost data, as requested by OCHAMPUS, certified to by an independent accounting firm or other agency as authorized by the Director, OCHAMPUS;
(7) Certify that:
(i) It is and will remain in compliance with the provisions of paragraph (b)(4)(xiv) of the section establishing standards for substance use disorder rehabilitation facilities;
(ii) It has conducted a self assessment of the SUDRF'S compliance with the CHAMPUS Standards for Substance Use Disorder Rehabilitation Facilities, as issued by the Director, OCHAMPUS, and notified the Director, OCHAMPUS of any matter regarding which the fa
cility is not in compliance with such standards; and
(iii) It will maintain compliance with the CHAMPUS Standards for Substance Use Disorder Rehabilitation Facilities, as issued by the Director, OCHAMPUS, except for
any such standards regarding which the facility notifies the Director, OCHAMPUS that it is not in compliance.
(8) Grant the Director, OCHAMPUS, or designee, the right to conduct quality assurance audits or accounting audits with full access to patients and records (including records relating to patients who are not CHAMPUS beneficiaries) to determine the quality and cost effectiveness of care rendered. The audits may be conducted on a scheduled or unscheduled (unannounced) basis. This right to audit/review included, but is not limited to:
(i) Examination of fiscal and all other records of the center which would confirm compliance with the participation agreement and designation as an authorized CHAMPUS provider;
(ii) Conducting such audits of center records including clinical, financial, and census records, as may be necessary to determine the nature of the services being provided, and the basis for charges and claims against the United States for services provided CHAMPUS beneficiaries;
(iii) Examining reports of evaluations and inspection conducted by federal, state and local government, and private agencies and organizations;
(iv) Conducting on-site aspections of the facilities of the SUDRF and interviewing employees, members of the staff, contractors, board members, volunteers, and patients, as required.
(v) Audits conducted by the United States General Accounting Office.
(F) Other requirements applicable to substance use disorder rehabilitation facilities.
(1) Even though a SUDRF may qualify as a CHAMPUS-authorized provider and may have entered into a participation agreement with CHAMPUS, payment by CHAMPUS for particular services provided is contingent upon the SUDRF also meeting all conditions set forth in $199.4.
(2) The center shall provide inpatient services to CHAMPUS beneficiaries in the same manner it provides services to all other patients. The center may not discriminate against CHAMPUS beneficiaries in any manner, including admission practices, placement in special or separate wings or rooms, or provisions of special or limited treatment.
(3) The substance use disorder facility shall assure that all certifications and information provided to the Director, OCHAMPUS incident to the process of obtaining and retaining authorized provider status is accurate and that it has no material errors or omissions. In the case of any misrepresentations, whether by inaccurate information being provided or material facts withheld, authorized provider status will be denied or terminated, and the facility will be ineligible for consideration for authorized provider status for a two year period.
(c) Individual professional providers of care—(1) General-i) Purpose. This individual professional provider class is established to accommodate individuals who are recognized by 10 U.S.C. 1079(a) as authorized to assess or diagnose illness, injury, or bodily malfunction as a prerequisite for CHAMPUS cost-share of otherwise allowable related preventive or treatment services or supplies, and to accommodate such other qualified individuals who the Director, OCHAMPUS, or designee, may authorize to render otherwise allowable services essential to the efficient implementation of a plan-of-care established and managed by a 10 U.S.C. 1079(a) authorized professional. (ii) Professional corporation affiliation
association membership permitted. Paragraph (c) of this section applies to those individual health care professionals who have formed a professional corporation or association pursuant to applicable state laws. Such a professional corporation or association may file claims on behalf of a CHAMPUSauthorized individual professional provider and be the payee for any payment resulting from such claims when the CHAMPUS-authorized individual certifies to the Director, OCHAMPUS, or designee, in writing that the professional corporation or association is acting on the authorized individual's behalf.
(iii) Scope of practice limitation. For CHAMPUS cost-sharing to be authorized, otherwise allowable services provided by a CHAMPUS-authorized individual professional provider shall be within the scope of the individual's license as regulated by the applicable state practice act of the state where the individual rendered the service to the CHAMPUS beneficiary or shall be within the scope of the test which was the basis for the individual's qualifying certification.
(iv) Employee status exclusion. An individual employed directly, or indirectly by contract, by an individual or entity to render professional services otherwise allowable by this part is excluded from provider status as established by this paragraph (c) for the duration of each employment.
(V) Training status exclusion. Individual health care professionals who are allowed to render health care seryices only under direct and ongoing supervision as training to be credited towards earning a clinical academic degree or other clinical credential required for the individual to practice independently are excluded from provider status as established by this paragraph (c) for the duration of such training.
(2) Conditions of authorization–(i) Professional license requirement. The individual must be currently licensed to render professional health care services in each state in which the individual renders services to CHAMPUS beneficiaries. Such license is required when a specific state provides, but does not require, license for a specific category of individual professional provider. The license must be at full clinical practice level to meet this requirement. A temporary license at the full clinical practice level is acceptable.
(ii) Professional certification requirement. When a state does not license a specific category of individual professional, certification by a Qualified Accreditation Organization, as defined in $199.2, is required. Certification must be at full clinical practice level. A temporary certification at the full clinical practice level is acceptable.
(iii) Education, training and experience requirement. The Director, OCHAMPUS,
or designee, may establish for each category or type of provider allowed by this paragraph (c) specific education, training, and experience requirements as necessary to promote the delivery of services by fully qualified individuals.
(iv) Physician referral and supervision. When physician referral and supervision is a prerequisite for CHAMPUS cost-sharing of the services of a provider authorized under this paragraph (c), such referral and supervision means that the physicians must actually see the patient to evaluate and diagnose the condition to be treated prior to referring the beneficiary to another provider and that the referring physician provides ongoing oversight of the course of referral related treatment throughout the period during which the beneficiary is being treated in response to the referral. Written contemporaneous documentation of the referring physician's basis for referral and ongoing communication between the referring and treating provider regarding the oversight of the treatment rendered as a result of the referral must meet all requirements for medical records established by this part. Referring physician supervision does not require physical location on the premises of the treating provider or at the site of treatment.
(3) Types of providers. Subject to the standards of participation provisions of this part, the following individual professional providers of medical care are authorized to provide services to CHAMPUS beneficiaries:
(i) Physicians. (A) Doctors of Medicine (M.D.).
(B) Doctors of Osteopathy (D.O.).
(ii) Dentists. Except for covered oral surgery as specified in $199.4(e) of this part, all otherwise covered services rendered by dentists require preauthorization.
(A) Doctors of Dental Medicine (D.M.D.).
(B) Doctors of Dental Surgery (D.D.S.).
(iii) Other allied health professionals. The services of the following individual professional providers of care coverable on a fee-for-service basis provided such services are otherwise authorized in this or other sections of this part.
(A) Clinical psychologist. For purposes of CHAMPUS, a clinical psychologist is an individual who is licensed or certified by the state for the independent practice of psychology and:
(1) Possesses a doctoral degree in psychology from a regionally accredited university; and
(2) Has has 2 years of supervised clinical experience in psychological health services of which at least 1 year is post-doctoral and 1 year (may be the post-doctoral year) is in an organized psychological health service training program; or
(3) As an alternative to paragraphs (c)(3)(iii)(A)(1) and (2) of this section is listed in the National Register of Health Service Providers in Psychology
(B) Doctors of Optometry.
(C) Doctors of Podiatry or Surgical Chiropody.
(D) Certified nurse midwives.
(1) A certified nurse midwife may provide covered care independent of physician referral and supervision, provided the nurse midwife is:
(i) Licensed, when required, by the local licensing agency for the jurisdiction in which the care is provided; and
(ii) Certified by the American College of Nurse Midwives. To receive certification, a candidate must be a registered nurse who has completed successfully an educational program approved by the American College of Nurse Midwives, and passed the American College of Nurse Midwives National Certification Examination.
(2) The services of a registered nurse who is not a certified nurse midwife may be authorized only when the patient has been referred for care by a licensed physician and licensed physican provides continuing supervision of the course of care. A lay midwife who is neither a certified nurse midwife nor a registered nurse is not a CHAMPUS-authorized provider, regardless of whether the services rendered may otherwise be covered.
(E) Certified nurse practitioner. Within the scope of applicable licensure or certification requirements, a certified nurse practitioner may provide covered care independent of physician referral and supervision, provided the nurse practitioner is:
(1) A licensed, registered nurse; and of clinical specialists in psychiatric
(2) Specifically licensed or certified and mental health nursing. as a nurse practitioner by the state in (H) Certified physician assistant. A which the care was provided, if the physician assistant may provide care state offers such specific licensure or under general supervision of a physicertification; or
cian (see $199.14(g)(1)(iii) of this part (3) Certified as a nurse practitioner for limitations on reimbursement). For (certified nurse) by a professional orga- purposes of CHAMPUS, a physician asnization offering certification in the sistant must meet the applicable state speciality of practice, if the state does requirements governing the qualificanot offer specific licensure or certifi- tions of physician assistants and at cation for nurse practitioners.
least one of the following conditions: (F) Certified Clinical Social Worker. A (1) Is currently certified by the Naclinical social worker may provide cov- tional Commission on Certification of ered services independent of physician Physician Assistants to assist primary referral and supervision, provided the care physicians, or clinical social worker:
(2) Has satisfactorily completed a (1) Is licensed or certified as a clin
program for preparing physician assistical social worker by the jurisdiction ants that: where practicing; or, if the jurisdiction (i) Was at least 1 academic year in does not provide for licensure or cer
length; tification of clinical social workers, is
(ii) Consisted of supervised clinical certified by a national professional or
practice and at least 4 months (in the ganization offering certification of
aggregate) of classroom instruction diclinical social workers; and
rected toward preparing students to de(2) Has at least a master's degree in
liver health care; and social work from a graduate school of
(iii) Was accredited by the American social work accredited by the Council
Medical Association's Committee on on Social Work Education; and
Allied Health Education and Accredita(3) Has had a minimum of 2 years or
tion; or 3,000 hours of post-master's degree supervised clinical social work practice
(3) Has satisfactorily completed a
formal educational program for preunder the supervision of a master's level social worker in an appropriate
paring program physician assistants
that does not meet the requirement of clinical setting, as determined by the
paragraph (c)(3)(iii)(H)(2) of this secDirector, OCHAMPUS, or a designee.
tion and had been assisting primary NOTE: Patients' organic medical problems must receive appropriate concurrent man
care physicians for a minimum of 12 agement by a physician.
months during the 18-month period im(G) Certified psychiatric nurse spe
mediately preceding January 1, 1987. cialist. A certified psychiatric nurse
(I) Other individual paramedical prospecialist may provide covered care
viders. The services of the following inindependent of physician referral and
dividual professional providers of care supervision. For purposes of
to be considered for benefits on a feeCHAMPUS, certified psychiatric
for-service basis may be provided only nurse specialist is an individual who: if the beneficiary is referred by a physi(1) Is a licensed, registered nurse; and
cian for the treatment of a medically(2) Has at least a master's degree in
diagnosed condition and a physician nursing from a regionally accredited
must also provide continuing and ongoinstitution with a specialization in
ing oversight and supervision of the psychiatric and mental health nursing; program or episode of treatment proand
vided by these individual para-medical (3) Has had at least 2 years of post- providers. master's degree practice in the field of
(1) Licensed registered nurses. psychiatric and mental health nursing, (2) Licensed registered physical including an average of 8 hours of di- therapists and occupational therapists. rect patient contact per week; or
(3) Licensed registered physical (4) Is listed in a CHAMPUS-recog- therapists. nized, professionally sanctioned listing (4) Audiologists.