Program Certification FAQs

Preparing to Become Certified FAQs

Data Collection
Consent Forms
Staffing Questions
Changing Locations/Facility
Physician Supervision
Restrictions for Treating Patients
Physician Orders vs. Referrals
Applying for More Than One Program
Physician Feedback
Monitoring Specifics
CMS Regulations
Risk Stratification
Program Management
Equipment Cleaning
Billing & Payment

Application FAQs - Page-by-Page
Application Technical Issues
Staff Competencies – Cardiac & Pulmonary
Individualized Treatment Plans – Cardiac & Pulmonary
Medical Emergencies – Cardiac & Pulmonary
Emergency Preparedness – Cardiac & Pulmonary
Exercise Prescription – Cardiac & Pulmonary
Outcomes (General) - Cardiac & Pulmonary
Clinical Outcomes Assessment – Cardiac Only
Functional Status/Exercise Capacity - Pulmonary Only
Behavioral Outcome Assessment – Cardiac Only
Dyspnea Measurement - Pulmonary Only
Health Outcome Assessment – Cardiac Only
Quality of Life - Pulmonary Only
Service Outcomes Assessment – Cardiac & Pulmonary
Quality Improvement - Cardiac & Pulmonary

Clinical Questions? If you are an AACVPR member and have a question not addressed in the FAQ, please submit your question by email to certification@aacvpr.org to be forwarded to a clinical expert.


Preparing to Become Certified FAQs

Data Collection

Q: How I get access to the format for which you would like information submitted. For example, is there a specific table or excel in which you would like to receive the information we will be providing?
A: Each page of the application will specify what information to provide and the format it is to be provided in. Many of the pages request the information be uploaded electronically. This will be the only way to submit the requested information. Many of the pages of the application such as staff competencies, emergency in-services and program outcomes require a narrative section to be completed. Please read the application carefully for clear instructions on what and how to submit the narrative information.

Q: What is the data collection period for my program?
A: The data collection period is January 1 to December 31, of the year just preceding the application. Please see individual application pages for details.

Q: Our program is new – when can we certify?
A: To apply for certification, a cardiac or pulmonary rehabilitation program must have been in operation for a minimum of one full year prior to the date of application. 

Consent Forms

Q: We are using a separate document to address privacy and confidentiality (HIPAA requirements). Does the confidentiality component have to be included in the informed consent form itself, or would our second document be acceptable?
A: The AACVPR certification application does not currently require you to submit a consent form.

Staffing Questions

Q: If our program is only open 20 hours per week, and the staff works all 20 hours, do we list them as full- or part-time?
A: You would list them as part-time.

Q: For certification purposes, are we required to have an RD to teach nutrition for cardiac & pulmonary rehab, or could we use this MPH to teach nutrition?
A: You do not have to have an RD teach nutrition. Many programs use nurses or other staff. Anyone on the CR/PR staff could present for general nutrition education. Keep in mind that all programs should incorporate a multidisciplinary team. For specific nutrition plans, medical nutrition therapy or formal diabetes education, a registered dietitian would be appropriate since this is in their scope of practice. AACVPR requires a nutrition assessment (screening) and general nutrition education that can be performed by those who have met the Core Competencies in that area. Patients who screen positive for nutritional needs should be offered the advanced guidance that an RD can provide.

Q: I am having difficulty filling the psychosocial component of both my cardiac and pulmonary rehabilitation programs. How could an RN be utilized for this? What additional qualities/certifications would they need?
A: You do NOT need to have someone on staff like a psychologist or psychiatrist. You should have a multidisciplinary team that can be utilized as needed.  What you do need is a validated assessment tool that measures for psychosocial issues. There are several options (see the AACVPR Program Certification Application Resources page for a list of tools, costs, descriptions). You also need to have a medical-director-approved policy that addresses ‘cut-points’ for interventions and how you will deal with psychosocial issues that are discovered. This may include utilization of the primary care provider, or referral to contracted psychotherapy specialists, etc. All of the psychosocial Assessment, Interventions, Reassessments, and Follow-up/Discharge information must be included on the ITP.

Changing Locations/Facility

Q: We will be integrated into the area of physical therapy and employee gym. My question is – don’t AACVPR guidelines state we are to be a separate entity in our own area?
A: The separate area used to be a CMS regulation, although this is not addressed in the current regulatory statement. You need to address staffing for quality, patient care and safety – will you have adequate access to the necessary equipment at the time it is needed? Will you have the types of equipment necessary to meet the requirement established in each patient’s ITP? How will you address patient privacy issues in an area with mixed population? Are you able to safely monitor and address emergencies adequately? Will you have separate staff working only with the CRII patients?

Q: Our program is currently certified by AACVPR. We are moving to a new location and we are wondering if there are any steps to complete to maintain our current certification?
A: If you are moving to a new location and your policies and procedures will be remaining the same, you will need to complete the following two steps. First, you will need to report your new location information to AACVPR. You can submit new contact information to certification@aacvpr.org. This new information will be updated in the AACVPR program database. If you have had your Primary Contact for Certification change, please complete our New Primary Contact Form on our Certification Homepage. Second, to meet the requirements of program certification and maintain your certified status, you will need to email a copy of all nine required medical emergency policies as requested on the certification application. These policies would include:
     - Cardiac arrest
     - Angina/chest pain
     - Hyperglycemia
     - Hypoglycemia
     - Hypertension
     - Hypotension
     - Tachycardia
     - Bradycardia
     - Acute dyspnea

Remember, these policies will need to be department specific and if you reference any hospital-wide policies in your departmental policy, they will also need to be submitted. (example: Cardiac arrest policy refers to a hospital-wide “Code Blue” policy) Please email documentation to certification@aacvpr.org.

Q: Our program is currently certified by AACVPR. Our hospital is merging with another hospital and our name will be changing but our policies and procedures and location will remain the same. Are there any steps to complete to maintain our current certification?
A: As long as your policies and procedures and location remain the same, the only step you will need to complete would be to update your contact information with AACVPR. You can submit new program information to certification@aacvpr.org. This new information will be updated in the AACVPR program database.

Q: Our program is currently certified by AACVPR. Our hospital has been bought out by another hospital system and they also have a currently certified cardiac and pulmonary rehab program. In order to streamline both programs, we will be adopting all of the policies and procedures of new hospital system. They are already AACVPR-certified so should we assume that their policies are approved for our program? What steps do we need complete to maintain our current certification?
A: You are correct in assuming that the new policies for your program should be acceptable if the new hospital system already has a currently certified program. For the purposes of AACVPR Program Certification, it is important that there are emergency policies in place to address the treatment of NINE of the most commonly seen clinical situations that are or could lead to a medical emergency in your program. These policies need to be specific to your department in your hospital. Policies and procedures that are adopted from another hospital system may address medical emergencies in general but may not be specific to how you would care for a patient in your program. To maintain your current certification status, you will need to submit a copy of all NINE medical emergency policies in place as a result of adopting the policies from the new hospital system. Send these policies to certification@aacvpr.org. Also, please make sure your contact information is up-to-date with AACVPR by completing our New Primary Contact Form on our Certification Homepage

Q: We are building a new facility. Everything will remain the same. (Forms will be changed to reflect the new name but the mission statement, plan of care, ITPs, referrals, etc. will stay in their current form. The staff is planning to return. They will be working in the cardiology dept. during the completion of the building. The current medical directors will be the directors at the new location. We are expecting the same patient population.) What if anything will we need to adjust to recertify? 
A: You will need to adjust your policies, including emergency procedures, because of the new physical layout of your department and emergency response of MD, etc. Also, please make sure your program information is up to date with AACVPR by emailing certification@aacvpr.org.

Physician Supervision

Q: On page 109 of the “Guidelines to Pulmonary Rehabilitation”, physician supervision is defined as “close physical proximity to the rehabilitation area” – what defines close proximity?
A: Medicare requires direct physician supervision. The physician does not need to be in the rehab suite but must be immediately available and interruptible.

Restrictions for Treating Patients

Q: I would like to know if there are any restrictions to treating cardiac, pulmonary and perhaps maintenance patients at the same time. Are there any problems with "mixing" rehab patients?
A: There are no restrictions on exercising patients with different co-morbidities. Also there are no restrictions for mixing any population of patients.

Q: We have both traditional cardiac rehab and intensive cardiac rehab patients. Are the ICR patients to be included in the application data?
A: The certification is for early outpatient, which ICR falls into unless you have a different situation. If you think about it, Phase II patients do not always have the same number of visits – they are different. The intervention for each patient is different, individualized. Therefore if both programs are early outpatient, you may keep them together.

Physician Orders vs. Referrals

Q: When speaking to referrals is that the same as a physician order?
A: Yes, a referral to cardiac/pulmonary rehab is an order from a primary care physician, pulmonologist, cardiologist, PA/NP (if allowed based on scope of practice in your region of the country).

Applying for More Than One Program

Q: We have both a cardiac and pulmonary program, do we need to apply for each separately or can we enter them together as one combined unit?
A: Cardiac and pulmonary programs must submit separate applications because they would have different policies and procedures. Similarly, multi-location “sister” programs within a larger hospital system would need to submit separate applications because they would have different policies and procedures based on having a different physical layout and emergency response processes, possibly different staff, and different providers. Each application would be reviewed independently and so would have its own payment. Please note, however, that related or “SISTER” programs (whether a cardiac and a pulmonary within the same physical building, or multiple cardiac or pulmonary programs within a larger hospital system) MUST identify all sister programs when completing the program demographics section prior to beginning the application process.

Q. My hospital system has multiple certified programs due for recertification in different years. Is my program allowed to recertify a year early so that next time we will be due in the same year?
A. Yes, you are welcome to recertify early at the recertification rate. However, if a program chose to delay recertification for this same reason, their certification would lapse, and they would need to submit an initial certification application with a full certification fee to become certified again.

State Requirements

Q: Guideline 10.3 discusses general facility considerations and only mentions a water source to be immediately available to the exercise area. We have bathrooms; do we need a shower as well?
A: There is no requirement related to water source for AACVPR Program Certification. There may be a law/requirement in your state.

Physician Feedback

Q: Does our physician feedback have to include exercise, clinical and risk factor modification recommendations? We have a cardiologist review and sign the reports daily, but all three factors are not included daily. Feedback is provided when necessary for that patient. A medical director reviews care plans and discusses each patient’s status, progress, and any pertinent information on a monthly basis. Does this meet AACVPR’s requirements?
A: If you have a well-designed ITP that contains all components, it should meet all of the feedback requirements. The ITP should be signed at initial assessment, at least every 30 calendar days thereafter, and at discharge, and it should provide an area for MD changes/comments/suggestions.

Monitoring Specifics

Q: Is it required for each tele session to have the tele strips analyzed for PR, QRS, and QT intervals?
A: There are no requirements for the purpose of AACVPR Program certification pertaining to monitoring specifics.

CMS Regulations

Q: Where would I attain a copy of CMS rules?
A: Log on to the AACVPR website page. Choose the "Advocacy tab" and select "Regulatory and Legislative Action." Then choose "Final Medicare Rules for CR and PR." This brief guide is easy to read and understand. You would also be able to get a copy of the CMS regulations specific to cardiac and/or pulmonary rehab from the billing specialist at your facility.

Risk Stratification

Q: Does Risk Stratification (Risk of Untoward Events), refer to the risk stratification that we do on each patient to determine the risk for exercise events and approximate length of treatment using the tool on page 63 of the manual? Alternately, does it refer to risk stratification for the individual risk factors such as smoking, dyslipidemia, DM, obesity, HTN, sedentary lifestyle, and depression?
A: Risk Stratification is not a requirement that you submit documentation for this on your application. That does not mean that you should not be doing it in your program. You need to be risk stratifying your patients for both event and risk factors as outlined in the AACVPR Guidelines.

Equipment Cleaning

Q: Are there guidelines regarding the cleaning of exercise equipment?
A: The certification process does not have a requirement for equipment cleaning (although we know it is a very important procedure!) Consult your Infection Prevention Specialist at your facility for advice on State and Facility guidelines regarding equipment cleaning, hand washing, and other infection prevention standards that you may need to follow.

Billing & Payment

Q: How do I pay for my application? Can I pay by check, credit card, and/or purchase order?
A: AACVPR does not accept Purchase Orders.  AACVPR Program Certification does allow check payments and credit card payments. To pay for your application by credit card or print off an invoice to pay by check, please visit the Payment page of your application. The payment page of your application has a printable invoice that you will need to send along with your check payment. Please note: If you would like to pay by credit card after you have already selected paying by check, please contact certification@aacvpr.org. We will then change your payment method to credit card and notify you by email.

Q: Can I submit my application before payment has been applied?
A: Yes. We strongly recommend verifying with your accounting department that payment has been postmarked by no later than February 29th. All payments must be postmarked by no later than February 29th.

Q: How can I check if my payment has been applied to my application?
A: In your Program Certification Dashboard, click on View Application. Then click on the second to last page of your application—this page is titled ‘Payment’. On that page, you can see if your program still owes money. If your application still has a balance left, we have not received your payment yet. If you would like to contact us about this payment, please call us at (312) 321-5146 with the check number & the date the payment was cashed.


Application FAQs – Page-by-Page

Application Technical Issues

Q: How do I submit my forms and documentation for my program's application? Do I scan and fax them to AACVPR?
A: All documentation for AACVPR Program Certification must be uploaded to the application digitally. If your program's records are not digital, you will need to scan all necessary documentation into your computer and upload it to your application from your computer. AACVPR no longer accepts emailed or faxed documentation for applications.

NEW Q: I'm trying to update my program's information but when I click the "My Profile" button, nothing happens. What should I do?
A: If this happens, simply log out and then log back in. If after doing this you are still unable to access the "My Profile" link of your profile, log out again then proceed to login again, but before logging in click the "Remember Login" button.

Q. No matter what I do, I can’t get any of the informational videos about the application to load, what should I do?
A. AACVPR has created extensive video formats that should play across any web browser. If none of the links to different video formats work for you, please contact your hospital’s IT department. Hospitals frequently block JavaScript, Adobe Flash, and Quicktime video players. Please make sure they have access to these unlocked. Some hospitals also use old versions of Internet Explorer that don’t support our videos. Please try to see if your hospital will allow you to download Google Chrome and/or Mozilla Firefox as a web browser for you to use for viewing the informational videos.

Q. What types of files can be uploaded to the application?
A. Word, Excel, and PDF documents are the most frequently submitted types. Documents with the following extensions are accepted: .doc, .docx, .jpg, .gif, .pdf, .xls, .xlsx, .png, .jpeg, & .txt

Q: Why can’t I change the contact information (e.g. email address, phone number, address) of anyone on my roster?
A: Since individual contact information in our database is personal information, we restrict Certification Primary Contacts and Certification Secondary Contacts from changing any of this information for their staff. If you would like to have this information updated, there are two ways to do this. The best option is to have your staff member that needs to update their information log onto their account on www.aacvpr.org and click My Profile. The second way to update this information is to have each individual wishing to change contact information send an email to aacvpr@aacvpr.org with the contact information they would like to update.

Q: I’d like to change the Professional Titles of staff members on my roster - why can’t I do this?
A: Similar to the above question, all personal information must be updated by the individual. However, rather than focusing on professional titles, our review process assesses rosters based on the listed roles of each staff member, whether they report to the director, and whether they are involved in direct patient care to determine whether competencies must be submitted.

Q: I can’t proceed past the Program Profile Review / Edit option of my application.  When I try to click on another page of the application, nothing happens.
A: This issue is related to your web browser and Internet Explorer. This means that your web browser is working in Compatibility View. This will need to be disabled in order for you to work on the other pages of our application. Please email certification@aacvpr.org for detailed instructions on how to resolve this issue or disable Compatbility view on your application by clicking the broken page icon next to the website’s address bar (this is where you will see https://www.aacvpr.org/ written).

Staff Competencies – Cardiac & Pulmonary

Q: Do primary and secondary contacts need to be listed twice in the roster – once in their contact role and once in their organizational role?
A: Yes. Please list the appropriate staff role as well the contact role. 

Q: I finished the Staff Competencies section, but the page is not being marked as complete – am I doing something wrong?
A. Please double check to make sure that all of the following are complete: 1) Are you missing any required roles in your roster? 2) Are True/False responses listed for the “reports to director” and “provides direct patient care” questions for ALL staff on the roster? 3) Did you enter “NA” or “Not Applicable” in the text boxes of any competencies you are not using? 4) Are dates listed for all the staff with marked check boxes?

Q: I am the Program Director for my program, but I also provide direct patient care. Should I indicate that I "report to the director" in our application roster (even though I am the director), so that I am listed on the Staff Competencies page?
A: Yes - if you provide direct patient care, please mark yourself as reporting to the director. Only staff who are marked as "reporting to the director" and "providing direct patient care" will appear in the check box lists under the various competency areas.

Q: Do I need to complete staff competencies for people who were on staff for only part of the data collection year?
A: Any staff member who is active at the time of applying for certification should be included in the staff competency list and should have a competency record. Staff who are no longer working in the program should not be listed.

Q: How do I upload the staff competency table?
A: An upload is no longer required for the Staff Competencies section of the application. You may now enter all the required information directly into the online application.

Q: What information do I need to enter in the text boxes in the Staff Competencies section of the application?
A: For each submitted competency, describe in detail how you determined staff is competent in this area. This description must include the following:  1) Objectives; and 2) The specific tool or method used for assessment. Note: Simply stating "return demonstration/check-off station" is not sufficient. Staff competencies are technical, interpersonal, and critical thinking skills required to fulfill organization, department and work-setting requirements. Please review: Core Competencies for Cardiac Rehabilitation Secondary Prevention Professionals: 2010 Update and Clinical Competency for Guidelines for Pulmonary Rehabilitation Professionals. Staff competency can be assessed by peer review, return demonstration with a description, post-tests, etc.  

Q: Is ACLS/BLS accepted on the Staff Competencies page?
A: ACLS/BLS no longer qualifies as a competency due to the variation in state and practice guidelines.

Q: Do we need to submit Staff Competencies for employees who worked in our program during 2016 but who are no longer on staff at the time of application?
A: No. Submission of Staff Competencies is only required for staff who worked in your program during the data collection period and remain on staff at the time of application. Anyone who started working at your program during 1/1/2016 – 12/31/2016 and is still working at your program must be included in the staff roster.

Q: How should we handle part-time staff? We have ‘cover’ staff that help out if one of us is sick or on vacation, but otherwise they do not work in Phase II. 
A: If they do direct patient care, have independent decision making for those patients (i.e. would need to adjust exercise based on medication changes, identify and treat rhythm or other hemodynamic changes, etc.), and are responsible for immediate triage and emergency management of patients, they should be included and have the necessary competencies.  Even if they work only occasionally, they still need to know what they are doing and how to assess, monitor, and effectively care for CR patients. All staff need to complete 4 different competencies regardless of their role, FTE status, or educational background. 

Q: Should I include all our Phase 1 and Phase III staff when listing staff in our ‘Program Staff and Competencies’ section of the application?
A: We only certify Phase II programs at this time, so including Phase I and III staff really only complicates the application process for you and for the review team. Only include the staff that do actual hands on or education, etc. with the Phase II population.

Q: How does AACVPR define staff competency skills?
A: AACVPR defines staff competency skills as technical, interpersonal, and critical thinking skills required to fulfill organizational, departmental, and work-setting requirements. Suggested references: Core Competencies for Cardiac Rehabilitation/Secondary Prevention Professionals: 2010 Update and Clinical Competency for Guidelines for Pulmonary Rehabilitation Professionals.

Q: If I purchase the AACVPR Staff Competencies for Core Components and have my staff complete those, will that meet the staff competencies requirements for program certification?
A: The AACVPR Staff Competencies for Core Components is a great way to meet the staff competencies requirements for program certification. The Staff Competencies for Core Components contains seven modules: 1.) Cardiac Exercise Training, 2.) Pulmonary Exercise Training, 3.) Patient Assessment, 4.) Diabetes Management, 5.) Psychosocial Management, 6.) Tobacco Cessation, and 7.) Weight Management. These seven components can be purchased as a complete series; "2014 and 2016 Staff Competencies for Core Components: Full Series", or they can be purchased individually. Also, please remember that there are many competency areas in both cardiac and pulmonary in which staff should be proficient. 

Q: Are we still required to differentiate between direct and indirect staff?
A: No, that is not required, however it is important that you understand this concept due to staff competencies. You are only required to submit staff competencies for those individuals who directly report to the cardiac or pulmonary rehab director/coordinator/manager and who provide hands-on care to your cardiac and/or pulmonary patients. If the director/coordinator/manager works within the department, they would also be required to complete the competencies. You do not need to submit competencies for any staff that consults (but is not employed by your department) with your department, such as the medical director, psychiatrist, smoking cessation specialist, pharmacist or dietitian, etc. Competencies for part-time and PRN staff that work in the department should be included.

Q: Is it the manager verifying that the direct staff competencies have been completed?
A: It doesn’t have to be the manager depending on your organizational structure. It should be someone in a supervisory/managerial role who signs off on all competencies. It might be a hospital education coordinator who sets up a skills fair, one or a number of MDs/Cardiologist/Pulmonologists, or a combination of people depending on the specific competency.

Q: Does the certification require that pulmonary rehabilitation programs employ a respiratory therapist in addition to other clinical specialists?
A: A respiratory therapist does not have to be part of a program to be certified. However, remember that each program must be able to show evidence of a multidisciplinary team approach.

Q: Is it a requirement with AACVPR that a respiratory therapist run the pulmonary rehab?
A: It is not required that you have a respiratory therapist to run pulmonary rehab, but it is highly recommended. The team should be interdisciplinary. Please see the Guidelines for Pulmonary Rehabilitation Programs, 4th Edition, Chapter 8 on Program Management.

Q: I understand that all employees must be CPR and AED certified. Does this certification have to be through the American Heart association or Red Cross? Does it matter what organization certifies them?
A: AHA and Red Cross are the main organizations that are recognized for CPR training, and either is acceptable. Other agencies may be considered if their requirements are substantially equivalent to those of AHA and Red Cross.

Q: With regards to staff roles and responsibilities, how in depth do we need to be? Would a job description be sufficient? What would be an example of staff competencies?
A: A job description would not be necessary. There is a drop down box in the roster that gives you the options of the staff role, i.e. program director, medical director, primary certification contact, staff, etc. Staff Competencies are technical, interpersonal, and critical thinking skills required to fulfill organizational, departmental and work-setting requirements. Please review: Core Competencies for Cardiac Rehabilitation/Secondary Prevention Professionals: 2010 Update and Clinical Competency for Guidelines for Pulmonary Rehabilitation Professionals.  Staff competency can be assessed by peer review, return demonstrations with a description, post- tests, etc.

Q: Can a cardiac rehab nurse and/or exercise physiologist perform the 6 minute walk test? We are considering changing over to a 6 min walk test for pre-post evaluation.
A: A nurse, respiratory therapist, exercise physiologist, physical therapist can administer the 6 MWT as long as everyone performing this test follows the same process and competency in the administration of the test.  Please refer to The American Thoracic Society (ATS) guidelines on specific competencies for the administration of the 6 MWT. The 6-MWT is a great test for exercise assessment and for patient and program outcomes.

Q:Some of our staff nurses hold current Cardio-Vascular Nurse Certifications through ANCC. Does this certification apply as evidence of professional competency?  This certification was recognized by the AACVPR and in place before the recently available CCRP certification.
A: No, the Cardio-Vascular Nurse Certifications do NOT apply as evidence of professional competency in Cardiac Rehabilitation for Cardiac Program Certification. The ANCC examination developed specifically for RNs practicing in cardiac rehabilitation was retired a number of years ago. While the current ANCC examination for cardiovascular nurses includes some questions regarding cardiac rehabilitation, the focus for this exam is for RNs practicing in a cardiovascular setting such as hospital unit or physician practice. It is not based on the published core competencies for cardiac rehabilitation and, therefore, does not adequately reflect the comprehensiveness of knowledge and skills required of a practitioner in a cardiac rehabilitation outpatient setting. The CCRP Exam is the ONLY credential that addresses Cardiac Rehabilitation Core Competencies specifically. CCRP is the only certification that will be accepted in lieu of other competency requirements for our Cardiac Program Certification applications and only for staff who have passed the exam.


Individualized Treatment Plans – Cardiac & Pulmonary

Q: How Have the ITP requirements changed? Where can I find a template based on the current requirements?
A: With the increase in EMRs (and all programs moving that way eventually) the Program Certification requirements are not encouraging use of a specific template. Rather, please reference the draft applications posted on our Program Certification Application Resources webpage to make sure that your program's ITP includes all required components. In addition, the required components are conveniently listed in the ITP Checklist documents, which are also posted on the Resources page.

Q: Can you tell me if the application is requesting the session report which identifies the vital signs and specific exercises done, along with the assessment of the patient, or if it is requesting the ITP which identifies the monthly progress of the patient, or the written form given to the patient?
A: The cardiac application is requesting an ITP showing a treatment plan for the areas of exercise, nutrition, psychosocial, and other core components/risk factors as appropriate for each individual patient.
The pulmonary application is requesting an ITP showing a treatment plan for the areas of exercise, nutrition, psychosocial, other core components/risk factors, as appropriate for each individual AND an assessment of oxygen usage and titration. There should be evidence of an initial assessment, plan, reassessments, and follow-up/discharge. The ITP must be signed by a physician and dated at initial assessment and at least every 30 calendar days thru completion of the program. Daily exercise session notes, assessment tools, letters to physicians, etc. will not be accepted as a part of the ITP and will result in denial of the page.

Q: Is the physician still required to sign and date the initial ITP and sign again with each update?
A: It is still a CMS requirement that the physician reviews, signs and dates the initial ITP (and ExRx) at initial assessment and at least every 30 calendar days thereafter, including discharge.   

Q: For re-assessments of patients’ ITPs can we do them at session 12, 24 and 36 or do they need to be done every 30, 60, 90 days? We do have our Medical Director come every 30 days and sign off on patient’s progress.
A: You can do your reassessments at any time, but per CMS you need to have the ITP signed and dated at least every 30 days.

Q: Can a mid-level (APRN or PA) associated with the cardiologist sign our ITP? How often does a physician and or mid-level need to review and sign the ITP?
A: It needs to be signed every 30 days and per CMS can only be signed by the physician.

Q: For the nutrition assessment portion of the ITP, do you have to use a diet survey with a score to show a pre and post assessment? Would nurse/pt. discussion of pt. knowledge qualify? Would pre and post weights and lipids help to qualify the completion of the goals set?
A: The requirements for nutrition are that you need an assessment, plan, reassessment, and follow-up. Remember that outcomes should be measurable and valid tools should be used to assess patient baseline and improvement. Refer to the AACVPR Registry supported data sets, Cardiac Outcomes Matrix and Pulmonary Rehab Outcomes Resource Guide and other resources provided on the AACVPR certification website.

Q: Can we use our ITP as our monthly progress note and just add an addendum for any documentation needed for incidents or issues not recorded in the ITP?
A: Your ITP just needs to meet the requirements: assessment, plan, reassessment, and discharge for exercise, nutrition, psychosocial, and other core components, and they need to be labeled as such. However, with the various EMRs, the format you choose to use for the ITP is up to you.

Q: We have our physicians electronically sign our ITP. Does that meet CMS and AACVPR guidelines or does it have to be a hand written signature?
A: An electronic signature and date would meet the requirements for AACVPR program certification if your ITP is part of an EMR.
If you are using an ITP that has been provided by a telemetry vendor, for program certification, you must provide evidence of the hand written signature and date for the initial assessment, reassessments and discharge. In this case, if you have typed in the physician signatures and dates on the ITP after the physician has physically signed the document, we will need a copy of the ITP that has the hand written signature and date.
We would advise you to check with your regional CMS MAC Representative for further information regarding the electronic physician signature on your ITP. CMS requirements can vary in certain parts of the country.

NEW Q: I see that progression is no longer a requirement on the Exercise Prescription for AACVPR Program Certification. Should I not be documenting progression? Why is it no longer required?
A: Yes, we strongly recommend continuing to include progression on your Exercise Prescription. If you have progression included in your Exercise Prescription you will not be penalized. Progression is simply not required within our application for 2017 but may be required in future applications. AACVPR understands that patient progression is important to CMS but we need to foster more research around the topic. Doing this will allow us to adequately promote the writing/publishing of documents that can help programs operationalize the concept of progression.  


Medical Emergencies – Cardiac & Pulmonary


Q: Our policies are reviewed every other year, is this acceptable for certification?

A: For the purposes of AACVPR Program Certification, you do not need to demonstrate that your policies have been reviewed, however other regulatory agencies have requirements that you will need to follow. Your Compliance Officer should be able to assist you.

Q: We have Medical Emergencies in our Policy and Procedures but at times we refer to ACLS protocol. Is this okay, or does it need to be spelled out? I looked at the AACVPR book and it says ACLS protocol.
A: We all follow or should follow ACLS protocol. The policy or protocol for rehab MUST be department specific. The policy should give a step by step procedure on how your staff handles the patient in an emergency from the time symptoms begin to resolution of the symptoms. For example, stop exercise, lay patient on floor, the secretary takes the other patients to the waiting room to cool down, etc. then you can incorporate specific ACLS steps that you use. However, it is not acceptable to just state that you follow ACLS protocol.

Q: Our program does a quarterly review of the contents of the crash cart. We would like to use this review as one of the 4 medical emergency in-services required for certification. In the drop down box for emergency in-services, we see all 9 of the required medical emergencies but we do not see a drop down option for using the crash cart. Can we use the crash cart review as one of our emergency in-services?
A: It is very important to review the contents of the crash cart as a part of your department's readiness for an emergency. With many types of emergencies that can occur during a rehab session, the crash cart may have to be utilized. We have found it helpful to create an emergency scenario within the required 9 medical emergencies that includes the use of the crash cart. Not only are you addressing the specific medical emergency (example: bradycardia) and steps to be taken to effectively manage the situation, you are also incorporating the use of the crash cart for this emergency.

Q: What is required for the Emergency Preparedness regarding the crash cart component for cardiac rehab? We are an outpatient center not able to call codes so therefore we do not have a crash cart as staff is not up to date on training to push medications. We do have an AED and oxygen but our policy is to call 911, not to intubate or provide ACLS meds?
A: For the purpose of AACVPR Program Certification, medical emergency equipment and supplies must be immediately available to the cardiac and pulmonary rehab program. Documentation must be maintained for daily verification of readiness performed every day the rehab program is in operation. On the application, we are asking for daily verification of the Defibrillator/AED and Portable Oxygen only.

AACVPR Program Certification requirements are the minimum necessary to assure appropriate patient safety and care. In addition to the Program Certification requirements, you should also be compliant with the CMS requirements related to this issue. CMS requirements for administering cardiac and pulmonary rehab programs include all services being provided under the supervision of a physician. There are specific statements by CMS regarding “Facilities” where services are provided. 

For Program Certification, your program must clearly answer the question of “If your policy is to call 911 in the event of an emergency, what would your staff do and what equipment would be available to care for the patient until emergency assistance arrives?” This answer must comply with the guidelines for program certification for this page to be approved.



Emergency Preparedness – Cardiac & Pulmonary

Q: Can CPR recertification be used as a Medical Emergency In-service? Our staff is due for CPR recertification in October, and we will be doing it as a group.
A: CPR is no longer an acceptable core competency and CPR by itself is not one of the 9 medical emergency diagnoses to be used for in-services. However, many of the 9 medical emergencies may need to incorporate CPR in the care of the patient. We have found it helpful to create an emergency scenario, within the 9 medical emergencies, that includes the use of CPR. In this case, not only are you addressing a specific medical emergency, such as bradycardia, and steps to be taken to effectively manage the situation, but you are also incorporating the use of CPR.  

Q: If an application was submitted by an experienced In-Hospital based cardiac rehab for accreditation, would it be approved with the following staffing?:  All full time and part-time exercise physiologists that are BLS certified with Master Degree’s. The coordinator also has ACSM credentials in exercise specialty, and has critical care competencies in EKGs. The Medical Director is ACLS, board certified cardiologist, etc. There is also a registered License RCP who is BLS certified with critical care competencies in EKGs. There is no full time RN running this program; only RN per-diems who are part of the patient care sessions as needed.
A: There are no staffing requirements as far as AACVPR program certification is concerned. The issue is safety of the patient, and if you feel you meet the guidelines for all emergency equipment. You must have adequate medical emergency policies in place, which is the important factor. Be certain that you also: 1) meet CMS requirements, like ACLS training and appropriate cardiac/pulmonary exercise training; 2) that your staffing is approved by your Medical Staff; and 3) that everyone is practicing within their scope of practice.

Q: We have had multiple medical emergency in-services, but they repeat themselves. For example: we offer multiple code blue classes throughout the year, a yearly Cardiac Rehab skills lab, and two mock codes. Would each of these medical emergencies count as one?

A: Your medical emergency in-services meet the criteria for the portion of the certification; as long as you are actively offering and documenting emergency education (a minimum of 4 per year) from the nine required medical emergencies. Each of these can only be used once per year.

Q: For emergency in-services - are you required to have a mock code or will an actual called code be OK?

A: Emergency In- services can be variable. They can be walking through an emergency in your center, review of your emergency policies, or a mock code as long as it applies to one of the nine required medical emergencies. It must be planned or scheduled, and incorporate emergency situations. You could do a mock hypertensive situation or hypoglycemic situation etc. Debriefing or review of an actual code would also be acceptable.

Q: We are looking at retiring our defibrillator and are in need of assistance to determine if a defibrillator is absolutely needed. We do have 2 AED’s. In the AACVPR Resource Manual I am aware that a guideline lists a defibrillator that can monitor, print, cardiovert and act as an external pacemaker – but again is this absolutely needed since EMS would immediately be activated?
A: For the purposes of certification, you are required to have a Defibrillator/AED, so an AED would be acceptable. You will want to make sure that the AED meets your facility requirements, CMS requirements for your part of the country, and any other regulatory stipulations.

Q: If there is an ACLS certified EP present, is an RN also required to be present during monitored outpatient cardiac rehabilitation classes?
A: No RN is required; however there should be a multidisciplinary team immediately available along with the emergency support.

Q: Does a glucometer have to be in the cardiac or pulmonary rehab area or is a stat call for someone from lab to bring one and do a finger stick sufficient to cover this requirement?
A: Each facility has their unique circumstance, i.e. how long will it take someone to come from lab, etc. therefore has to be taken into consideration for your decision. For the purposes of certification, we do not specifically require you to have a glucometer in your department. However, you are required to have policies in place for hypoglycemia and hyperglycemia management. How you would determine this (glucometer) and the time required to acquire the device should be part of that policy.

Q: How close must the crash cart be to where the Pulmonary Rehabilitation classes are held? I know on the forms for certification you have to say where it’s located but is there any specific distance?
A: For the purposes of certification there are no exact distance figures. Each facility will have specific needs. However, the stated requirement is “immediately available.”

Q: In regards to our emergency cart (Code Blue), we do not include Combitubes or LMAs anywhere throughout the hospital. Will this be an issue? Also, on holidays and weekends we are closed. Does it meet criteria if we write CLOSED on our emergency cart daily check off? One other question in regard to equipment maintenance, is the requirement specific to emergency equipment or exercise equipment for 6 month check?
A: No, you do not have to have Combitubes or LMAs, just some type of advanced airway. Writing CLOSED on the daily check is sufficient. The daily equipment readiness is just for your Defibrillator/AED and portable oxygen.

Q: Our cardiac rehab is located on the 5th floor of the hospital. Would an emergency evacuation drill fulfill one of the required emergency medical in-services?

A: No. An emergency evacuation drill would not be a clinical emergency drill. Please review the 9 medical emergencies and choose from that list for your required in-services. You may do mock codes, policy reviews, crash cart hands-on review, an assessment of an actual code, etc. The emergency in-service needs to be specific to cardiac or pulmonary rehab.


Exercise Prescription – Cardiac & Pulmonary

Q: Our cardiac rehab program utilizes the Karvonen Heart Rate Calculator to determine heart rate progression for their patients. It is based on the procedure they had done. Can the Karvonen calculation be utilized for pulmonary patients as well?
A: Karvonen is used for calculating target heart rate (intensity). It is not appropriate for all patients so you should have an alternative method outlined in your policy for those situations when Karvonen is not appropriate. I am not sure how you are using it for progression or what “procedure” you are referring to. You may find information in the Guidelines for Pulmonary Rehabilitation Programs, 4th Edition a good source for more on exercise intensity for pulmonary patients.

Q: My exercise prescription is included as part of my ITP, do I need to submit it separately?
A: The submitted exercise prescription should be a component of the planned interventions in the Exercise area of the Individualized Treatment Plan.

Q: Our program is in need of additional information on acceptable target heart rate configurations for our cardiac rehab patients. Is it possible for someone to let us know acceptable exercise intensity without a preliminary exercise stress test?
A: There are several methods for determining target heart rate for various populations. Please utilize the wide variety of resources available on the AACVPR website, the webcasts, and workshops to assist you in developing a comprehensive policy. For example, there are specifics in these resources regarding beta blockade. You need to have these guidelines in your policy on how you will set THR on patients with beta blockers.

Q: Is it acceptable to identify exercise intensity as "Borg rating 3-5/10", or do we need to specify intensity on each modality?
A: Remember that the exercise intensity must be individualized for each patient and must be based on multiple factors. Please refer to the AACVPR Program Certification Resources for additional guidance. There are multiple chapters in various resources that will provide detailed information.

Q: Is a 6 minute walk test a requirement for cardiac? We do a pre walk to assess function, but we do not do one at the end; we use MET levels to assess changes. Is this okay or do we need to start doing a test at the end as well?

A: 6 minute walk is not a requirement, but is an excellent, valid tool if administered appropriately. Please refer to the ATS guidelines for information regarding this as one valid methodology. You need to perform an exercise assessment at the initial visit and also need to reassess an exercise assessment prior to discharge. Test-Retest validity would require you to use the same assessment tool or process for entry and exit data collection.  If you use METs as an exit measure, you will also have to record METs as an entry measure for physical assessment


Outcomes (General) - Cardiac & Pulmonary


Q: Our sample size is 25 patients; are we qualified to apply, or would that result in automatic denial?
A: You may qualify for certification even if less than 30 patients completed your program. As noted in the outcomes sections of the application, the requirement is that if less than 30 patients completed your program during the data collection period, then you must submit data for 100% of the patients who did complete outcomes in your program during the data collection period. 

Q: How many sessions constitute program completion? 12? 18? 36? (Number of patients that completed your Early Outpatient Cardiovascular Rehabilitation (Phase II))
A: To be considered a completion, they have to go from initial assessment through discharge. The number of sessions does not factor into this. (The definition of program completion for the REGISTRY is more specific...must have completed the discharge process and final reassessments.)

Q: If we have a Phase II patient paying out of pocket like a Phase III patient due to high co-pay, no insurance or poor coverage, do they still count in our data we collect for certification?

A: You are certifying your Phase II, early outpatient program. No matter how you get reimbursement from the patient, if they are going through that Phase II program from assessment to discharge, they need to be in the collection data.

Q: Is using different tools than those suggested in the resource guide an automatic reason for denial of certification?  For example: using the RAND-36 instead of the SF-36?
A: The recommendation is to verify that the tool you plan to use is valid, reliable, and has been studied in the population that you will be using it for. For the 2017 application, you will be able to use the tools of your choice (within reason of course), but more recommendations and information will be provided by AACVPR in the coming year to provide additional guidelines and direction on both appropriate outcomes and the appropriate tools to measure those outcomes. Please stay tuned for more information.

Q: Which outcomes and tools can we expect to see for the 2018 Certification Cycle that will be more heavily based on Outcomes? 
A: The AACVPR Quality of Care Committee, the Expert Panels, and the Program Certification Team are researching both outcomes and acceptable tools at this time. The final recommendations for Program Certification will be provided well in advance of the 2018 certification cycle (application submission dates of Dec, 2017 until Feb, 2018), when the new outcomes and tools will be required. This information will be posted on the AACVPR website as soon as the final decisions have been made. In addition, education will be available to help programs transition to the new outcomes and tools. The currently available list of tools will be accepted for the 2017 cycle (submission dates of Dec, 2016 until Feb, 2017). Please continue to monitor the AACVPR certification website for updates and information as it becomes available.

Clinical Outcomes Assessment – Cardiac Only

Q: Do we list/collect data for all outcomes or just one per each of the 4 domains? In the clinical domain, what is the most frequently used outcome?
A: You can collect data on as many outcomes as you would like, but for the purposes of cardiac certification, you need to report on one clinical, one behavioral, one health, and one service outcome. There are a wide variety of clinical outcomes reported, and you can use any of the valid tools listed in the Outcome Matrix or on the Registry list.

Functional Status/Exercise Capacity Pulmonary Only

Q: Is it required that each pulmonary rehab patient have a graded exercise test to determine functional status and exercise capacity?
A: The 6 minute walk test and shuttle walk test are the most commonly used assessment tools for determining functional status and exercise capacity in pulmonary patients. Please review the PR Outcomes Resource Guide and the Guidelines for Pulmonary Rehabilitation Programs, 4th Edition for more information on appropriate tools. 


Behavioral Outcome Assessment – Cardiac Only

Q. What are some examples of acceptable tools to show for the Behavioral Outcome Assessment?

A. You may use any of the valid tools listed on the AACVPR Cardiac Outcomes Matrix or in the Registry listing.


Dyspnea Measurement Pulmonary Only

Q: Are SOBQ scores a valid tool to report for Health or Quality of Life Outcome assessment for the certification process? (MOVED from HEALTH-CARDIAC and revised)
A: The SOBQ is an outcome for the dyspnea measurement outcome, not Health or Quality of Life.

Q: We are considering the use of a new tool for assessing shortness of breath. How would we know what tool might be the most appropriate to use for our patients?
A: Whereas, there are many assessment tools that can be used to assess dyspnea, AACVPR does suggest numerous tools that have been tested as valid and reliable. They are listed on the Program Certification Application Resource page or on the PR Outcomes Resource Guide.


Health Outcome Assessment – Cardiac Only


Q: We use the SF-36 form for our Health outcomes. For recertification, we are asked to submit the pre- and post-program score and the % change. However, the SF-36 has numerous categories (8). Do we need to take the average pre and post scores for all categories combined? Or do we pick one of the categories to report that data?

A: You will chose one area that you are looking at specifically, select the SF-36 score that tests for that area, and report those numbers on the application. Please be very specific when selecting the SF-36 score to make sure you are testing the desired outcome. You can use the composite mental and/or physical score on the SF-36 for your data. The application will ask for your plan for improvement based on your outcome change found. Be sure that you chose an area to report on that requires you to perform a quality improvement process. Do not report on any outcomes where everything is perfect and no QI is needed. That does NOT meet the requirement for application submission, where you are asked to report on the QI process and the improvement that resulted from your change.

Q: Can I use the depression domain from PHQ as our Health Outcome measurement?
A: Depression outcome is clinical, not health. Please review the Cardiac Outcomes Matrix and the 5th Edition Guidelines for more information on appropriate tools in each of the categories.  


Quality of Life Pulmonary Only

Q: Are there certain Quality of Life tools that are specific to pulmonary rehab? We use the SF-36 with our cardiac rehab patients and we are wondering if it is appropriate to use with our pulmonary rehab patients?
A: The SF-36 is a tool that has been studied with both the heart disease and lung disease populations. It has been found to be acceptable for both type of patients. For more information on pulmonary rehab- specific quality of life tools, please review the PR Outcomes Resource Guide, Guidelines for Pulmonary Rehabilitation Programs, 4th Edition, or access the Program Certification Application Resource page.


Service Outcomes Assessment – Cardiac & Pulmonary


Q: I wanted to clarify the requirements for the service outcome. Do we need to do a satisfaction survey or can we track another outcome listed on the Outcomes Matrix?

A: As long it is listed in the Cardiac Outcomes Matrix under the “Service” category, both cardiac and pulmonary programs can use it. Please review the Cardiac Outcomes Matrix for more information on appropriate tools.  

Q: We are thinking about changing the survey process and wanted to know if it is okay to use the Press Ganey Survey as a measure of patient satisfaction and program effectiveness in the following years.
A: Press Ganey is used by a lot of institutes and meets requirements for the service outcome.


Quality Improvement - Cardiac & Pulmonary

Q: Is the information that programs submit for the new Quality Improvement page different from the four required Outcomes pages?  Doesn’t each of the Outcomes pages also ask for quality improvement?
A: The Quality Improvement page of the application was developed to give programs a “road map” for making quality improvements to their programs. Many past applicants have submitted outcomes with little to no data on what they did with their outcomes. The goal of this page is to guide programs in applying outcome data to improve every day practices. Also, we are encouraging programs to share negative outcomes as well as positive results, because part of quality improvement is reassessing both the good and the bad to make process changes for the betterment of the program, and ultimately patient outcomes. So even if all four of your outcomes pages had great results and you determine that there are no quality improvements necessary, we are asking you to select SOME area of your program that could be improved and then to record the steps that you would take to implement change toward that improvement.

Q: What if I have never done a Quality Improvement in my program?
  
A: That is all right. You can take your current data collected and create a quality improvement process.