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CMS Regulations for CAHs with Swing Beds

CMS Regulations for CAHs with Swing Beds


Please review CMS regulations for Critical Access Hospitals that have swing beds?


Critical Access Hospital (CAH) swing-bed care is regulated by both the CAH requirements and the swing-bed requirements at 42 CFR Part 485.  The actual swing-bed survey requirements are referenced in the Medicare Nursing Homes requirements at 42 CFR Part 483. Section 18883 of the Act authorizes payment under Medicare for post-hospital SNF services provided by any CAH that meets certain requirements.

The following requirements can be found at 42 CFR 485.645.

  • The CAH has a Medicare provider agreement
  • The total number of beds that may be used at any time for furnishing swing-bed services or acute inpatient services does not exceed 25 beds
  • The CAH has not had a swing-bed approval terminated within two years previous to application; and
  • The CAH meets the swing-bed CoP on:
    • Resident Rights
    • Admission, Transfer, and Discharge Rights
    • Resident Behavior and Facility Practices
    • Patients Activities
    • Social Services
    • Discharge Planning
    • Specialized Rehabilitative Services; and
    • Dental Services.

Swing bed certification is limited to the CAH itself and does not include any distinct part rehabilitation or psychiatric units. Swing bed services may not be provided in CAH distinct part units

Swing-bed requirements apply to any patient discharged from a hospital or CAH and admitted to a swing-bed for skilled nursing services. The requirements for acute-care CAHs also apply to swing-bed patients.

C-0350 §485.645 Special Requirements for CAH Providers of Long-Term Care Services (“Swing-Beds”)

485.645 – A CAH must meet the following requirements in order to be granted an approval from CMS to provide post-CAH SNF care, as specified in §409.30 and to be paid for SNF-level services.

  • Interpretive Guidelines §485.645:
    • The swing-bed concept allows a CAH 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 services and reimbursement to receiving skilled nursing (SNF) services and reimbursement.
    • Medicare allows a CAH to operate swing-beds through the issuance of a “swing-bed approval.” If the facility fails to meet the swing-bed requirements, and the facility does not develop and implement an accepted plan of correction, the facility loses the approval to operate swing-beds and receive swing-bed reimbursement. The facility does not go on a termination track. If the CAH continues to meet the CoP for the provider type, it continues to operate but loses swing-bed approval.
    • Swing-beds need not be located in a special section of the CAH. The patient need not change locations in the facility merely because his/her status changes unless the facility requires it. The change in status from acute care to swing-bed status can occur within one facility or the patient can be transferred from another facility for swing-bed admission.
    • There must be discharge orders from acute care services, appropriate progress notes, discharge summary, and subsequent admission orders to swing-bed status regardless of whether the patient stays in the same facility or transfers to another facility.
    • If the patient does not change facilities, the same chart can be utilized but the swing-bed section of the chart must be separate with appropriate admission orders, progress notes, and supporting documents.
    • There is no length of stay restriction for any CAH 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 CAHs and nursing homes.
    • Medicare reimbursement requires a 3-day qualifying stay in any CAH or CAH prior to admission to a swing-bed. The swing-bed stay must fall within the same spell of illness as the qualifying stay. This requirement does not apply to patients who are not receiving Medicare reimbursement.
    • There is no requirement for a CAH to use the MDS form for recording the patient assessment or for nursing care planning.
    • Swing-bed patients receive a SNF level of care, and the CAH is reimbursed for providing a SNF level of care, however swing-bed patients are not SNF patients. Swing-bed patients in CAHs are considered to be patients of the CAH.

485.645(a) Eligibility

  • A CAH must meet the following eligibility requirements:
    • The facility has been certified as a CAH by CMS under §485.606(b); and
    • The facility provides not more than 25 inpatient beds, and the number of beds used at any time for acute care inpatient services does not exceed 15 beds. Any bed of a unit of the facility that is licensed as a distinct-part SNF at the time the facility applies to the State for designation as a CAH is not counted under this section.

Related Products from MCN:

Administrative Manual for Critical Access Hospitals


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