Next up in CMS Compliance Group’s “Ftag of the Week” series on the CMSCG Blog is F826 Rehab Services – Physician Order/ Qualified Person. F826 is the companion tag to F825 Provide/Obtain Specialized Rehab Services.
F826 requires that specialized rehabilitative services must have a written physician order* and be provided by qualified personnel. Providers are required to either employ – or use an appropriate outside resource – to provide these services, and also must ensure that additional “support staff” are available to ensure resident needs are met per their plan of care.
Qualified personnel are those who have the appropriate licensure or certification by their State to provide therapy services. These individuals must:
- Meet the specific competency requirements that are part of their license/ certification requirements as defined by State law/regulation
- Have the appropriate training, competencies and skill sets to care for the facility’s residents
Provision of Supervision and Services
When there are differences between the Federal and State supervision requirements, the requirement for the greater level of supervision will apply. This means:
- Only physical therapists can supervise PA assistants
- Only occupational therapists can supervise OT assistants
Speech-language pathology (SLP) services may only be provided by:
- Licensed speech-language pathologist
- Physician
- Nurse Practitioner
- Clinical Nurse Specialist
- Physician’s Assistant who is licensed or certified by the State
How It’s Cited
This is not a highly cited regulation by any means, but it’s always a good reminder to double check that orders are in place for therapy. It’s also important to note that the majority of times F826 has been cited on survey, it has been when a surveyor has observed a resident with contractures.
Standard Survey Citation – F826 S/S: D
During the initial tour of the facility, one resident was observed in the activity room with left hand contractures and a second resident with both hands in a fist and right hand contractures. The residents were observed again multiple times to not have devices in place to prevent further contractures. The facility provided physician’s orders for both residents to have splints applied, but the Restorative Aide did not have them on her list of splints. Additionally, upon review of the residents’ care plans, contractures were not addressed.
Per the IG, it would be appropriate to cite F826 if:
- The facility did not obtain a written order from a physician (or therapist delegated by a physician where permissible (*also see below regarding Part B)
- Services were not provided by qualified personnel
Definition: Per the SOM, “Qualified Personnel” is a physical therapist, occupational therapist, respiratory therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist or physician’s assistant who is licensed or certified by the State to provide these services. If services are being furnished under the care of a qualified therapist, then this may also include physical or occupational therapy assistants.
*For residents receiving PT/ OT/ SLP under the Medicare Part B benefit, the requirements differ and are included in the Interpretive Guidance (IG):
- Medicare Part B benefits do not require an order.
- A physician’s order may substitute for a plan of care.
- Orders written by a therapist are not recognized by Part B.
- When a therapy order is written by a qualified therapist, per the IG, a physician or recognized non-physician practitioner must sign and date the plan of care that has been established by the therapist.
