AACVPR Program Certification Application Frequently Asked Questions

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

Application FAQs - Page-by-Page

Staff Competencies – Cardiac & Pulmonary
Individualized Treatment Plans – Cardiac & Pulmonary
Emergency Preparedness – Cardiac & Pulmonary
Policies and Procedures – Cardiac & Pulmonary
Exercise Prescription – Cardiac & Pulmonary
Medical Emergencies – Cardiac & Pulmonary
Clinical Outcomes Assessment – Cardiac Only
Behavioral Outcome Assessment – Cardiac Only
Health Outcome Assessment – Cardiac Only
Service Outcomes Assessment – Cardiac & Pulmonary

Preparing to Become Certified FAQs

Data Collection

*NEW* 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.  If a specific table or format is required, there will be a link that will take you to a sample of the format/table for your use. Many of the pages request the information be uploaded electronically. For the 2014 cycle, 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 refer to the AACVPR website Certification application resource page to see the applications there it will inform you what to submit.

Q: What is the data collection period for my program?
A: The data collection period is January 1 to December 31, 2013. 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 year.  For the 2014 application cycle, your program should be open to patients from January through December of 2013.

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 requirements are that the consent has an explanation of the program, that you explain the risks and benefits, a confidentiality statement (usually found in the general hospital consent) signed and witnessed. (NOTE: It is very important that all components of the informed consent are addressed with the patient and their family, whether it is covered in one document or multiple documents.)

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. As long as it is their scope of practice, anyone can teach. Keep in mind that all programs should incorporate a multidisciplinary team.

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 Outcomes Matrix on the AACVPR website 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?

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 physician, cardiologist, PA/ANRP (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. 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 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 law or requirement 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 certification pertaining to monitoring specifics.

CMS Regulations

Q: Where would I attain a copy of CMS rules?
A: AACVPR website - members only section - Medicare regulations. 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.

Program Management

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 changes in location relative to crash cart location, emergency response of MD, etc.

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.

Application FAQs – Page-by-Page

Staff Competencies – Cardiac & Pulmonary

*NEW* 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. 

*NEW* 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 you are not using?  4) Are dates listed for all the staff with marked checkboxes?

*NEW* 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: A narrative description of what occurred for the competency.  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 2007.  Staff competency can be assessed by peer review, return demonstration, post-tests, etc. 

Q: Where should we list ACLS/BLS on the Staff Competencies page?
A: ACLS/BLS  can be included under two competency areas, e.g. Patient Assessment (“Appropriate emergency responses to changing signs and symptoms”), OR Exercise Training Evaluation (“Recognition of life-threatening cardiac arrhythmias, myocardial ischemia or infarction, hypoxemia, hypotension, hypoglycemia, and other signs and symptoms of exercise intolerance”).

Q: Since ACLS/BLS certification is valid for two years, can a 2012 certification be listed as a competency completed in 2013?
A.  No.  ACLS for staff competency is not related to the 2 year regulation of the ACLS.  If a staff member completed the ACLS in 2013, they can use it; if they completed it in 2012, they cannot.

*NEW* Q:  For the competency of ACLS/ BLS, is it acceptable if some staff are proficient in only one or the other?
A:  Yes.

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.  We are going to apply in January-February of 2014 using 2013 data.  Are we required to meet the 2014 Staff Competencies requirement?
A.  Yes, programs will be held accountable to this requirement.  It has been the decision of Cert Leadership along with Barb Fagan (Board President) and the AACVPR BOD, that if programs have been training for the nine medical emergencies and keeping up with the competency training (that we have been reminding them to do for at least the last two years), they should have MORE than four competencies to report on.  Even if they only had two ‘documented’ as of October, they would still have two+ months to document the other two…that could be accomplished at staff meetings, a mini skills fair, a reading assignment with post-test, etc.  With the first CCRP exam coming in 2014, the BOD is in support of moving programs to improved staff competency training.

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 Guidelines for Pulmonary Rehabilitation Professionals (2007).

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.

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. After a focused review, additional 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 Guidelines for Pulmonary Rehabilitation Professionals (2007).  Staff competency can be assessed by peer review, return demonstrations, 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: Either a nurse or an EP can administer the 6-MWT as long as everyone performing this test follows the same competency process…ATS 6-min walk test competency is best reference.  The 6-MWT is a great test for exercise assessment and for outcomes.

Q: Our Cardiac Rehab department will be applying for certification and we have a question about the Staff Competencies. Do the PRN RNs, who are only working in our area when one of our direct staff is out, have to do the staff competencies for our cardiac rehab department?
A: Yes. They staff your department, assess and counsel your patients, and at times have sole decision making responsibility for patient care. All full-time and part-time staff should be listed on your roster and should be included in staff competency assessment.

Individualized Treatment Plans – Cardiac & Pulmonary

Q.  How have the ITP requirements changed for the 2014 application?
A.  For the 2014 Program Cert Application, the 12 Components listed below are required.  Just label them wherever they appear on your treatment plan.  With the increase in EMRs (and all programs moving that way eventually) the Program Certification requirements are not encouraging use of a specific template.

The other Core Components/Measures are optional this year, but will be required for 2015 application…so if your program doesn’t have any of the others like hypertension, diabetes management, or tobacco use, then you don’t have to include or label them on the ITP.  If your patient does use tobacco or has other issues that would not be included under Exercise/Nutrition/Psychosocial,  you could include those and label the components (including Assessment, Plan [Goals, Interventions, Education], Reassessment, and Discharge/Follow-Up) and you would be doing great!

So, here are the 12 REQUIRED Components for 2014:
1.         Exercise Assessment **
2.         Exercise Plan (including Goals, Interventions [Exercise Prescription including Mode, Frequency, Duration, Intensity, Progression **], and Education)
3.         Exercise Reassessment **
4.         Exercise Discharge/Follow-Up **
                        **For Pulmonary Rehabilitation Only these areas must include Oxygen Use and Titration information

5.         Nutrition Assessment
6.         Nutrition Plan (including Goals, Interventions, Education)
7.         Nutrition Reassessment
8.         Nutrition Discharge/Follow-Up

9.         Psychosocial Assessment
10.       Psychosocial Plan (including Goals, Intervention, Education)
11.       Psychosocial Reassessment
12.       Psychosocial Discharge/Follow-Up

Other OPTIONAL Core Components/Measures for 2014 [like tobacco use, blood pressure management, etc] as appropriate for the individual patient can be included and might look like:
13.       Tobacco Assessment
14.       Tobacco Plan (including Goals, Intervention, Education)
15.       Tobacco Reassessment
16.       Tobacco Discharge/Follow-Up

17.       Diabetes Assessment
18.       Diabetes Plan (including Goals, Intervention, Education)
19.       Diabetes Reassessment
20.       Diabetes Discharge/Follow-Up

Q: Do the components need to specifically be those four categories in that arrangement or just used/found in the ITP?
A: The 12 REQUIRED Components are the SAME ones that were required for the past few years and you just have to make SURE to LABEL them wherever they appear in the ITP.

Q: Is this new format for 2014 or 2015 Program Certification cycle?
A: This is for 2014 since these components are NOT NEW.  We are making the process easier for programs with an EMR.  To meet the requirements for certification, programs just need to add LABELS to whatever EMR or PAPER format they have, rather than trying to adapt some new template into an EMR that doesn’t easily allow for specific formats.

Q: Do all the changes in the 5th Edition of the Guidelines apply to the 2014 application?
A: No.  We are NOT holding the 2014 program certification applications accountable for the 5th Edition of the Guidelines.  These will take effect for the 2015 application.

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 application is requesting the ITP showing a treatment plan for the areas of exercise, nutrition, psychosocial, and other core components as appropriate for each individual patient. There should be evidence of an initial assessment, plan, re-assessment, and follow-up/discharge. It should be complete for a patient with initial plan, and 30 day, 60 day, and final/FU/Discharge, with MD signature for each at least every 30 calendar day.

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 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 measureable and valid tools should be used to assess patient baseline and improvement. Refer to the Outcomes Matrix and Pulmonary Rehab Outcomes Toolkit and other resources provided on the AACVPR certification website.

Q: Can we use our ITP as our monthly progress note and just add addendums 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.

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: That would meet the requirements for AACVPR certification.

Additional ITP Resource:

View this Webcast: "Individualized Treatment Plan: Sensible Documentation in your ITP"

This vendor session was sponsored by Quinton and presented at the AACVPR 28th Annual Meeting in Nashville, TN.

Emergency Preparedness – Cardiac & Pulmonary

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, the following medical emergency equipment and supplies must be immediately available to the Cardiac rehabilitation unit and documentation must be maintained of verification of readiness every day the rehab program is in operation:

•         Portable oxygen and tubing with cannulas and face mask defibrillator
•         AED
•         Intubation equipment and advanced airways
•         Crash cart with emergency equipment and
•         ACLS medications 

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 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. This is defined as “the facility or office has available for immediate use all the necessary cardiopulmonary emergency diagnostic and therapeutic life saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator; The program is staffed by personnel necessary to conduct the program safely and effectively, who are trained in both basic and advanced life support techniques and in exercise therapy for heart disease…

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.

Q: Are cardiac drugs in the facility a requirement for certification, even pulmonary programs?
A: Please refer to the application for specific information on medications and other emergency supplies and equipment required for your cardiac or pulmonary program.

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: I would document a review with your staff of what they should do during an emergency. It doesn't need to be complicated, just informative and practical. This will be considered an in-service as long as: 1) it is done in a group; 2) it is department specific related to either cardiac or pulmonary patients, and 3) it outlines all the specific tasks that your staff will carry out in a specific emergency situation (i.e. apply Oxygen at ‘__’ LPM, stop exercise, place patient supine, call family, call PCP, start CPR, remove patient or remove other patients, etc. as appropriate for the specific situation).

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 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), doing regular mock codes, and actively working on your skills lab. Be sure to list the specific content, relative to either cardiac or pulmonary, that was covered in each in-service.

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, review of crash cart, and competency set up of 02, or…. a mock code. 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, it is always mentioned as either or Defibrillator/AED. You will want to make sure that it meets your facility requirements 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 emergency equipment and medications.

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.

Policies and Procedures – Cardiac & Pulmonary

Q: Who must review the policies and procedures that we have in place for our Cardiac/Pulmonary Program? Could it be a Medical Director, Director, or Chief Nursing Officer reviewing the policy?

A: For the purposes of AACVPR Program Certification, a program must have written policies and procedures specific to Cardiac/Pulmonary Rehabilitation that are reviewed at least every three years by the program medical director and program director/coordinator/manager. You may have administrative signatures as well, however they aren’t required.

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.

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 application is requesting the ITP showing a monthly treatment plan for the areas of exercise, nutrition, psychosocial, and other core components as appropriate for each individual patient . There should be evidence of an initial assessment, plan, re-assessment, and follow-up/discharge. It should be complete for a patient with initial plan, and 30 day, 60 day, and final/FU/Discharge, with MD signature for each at least every 30 calendar days.

Be sure that you include these 12-16 labels:

  Nutrition Exercise Psychosocial Other Core Components
Assessment (required) (required) (required) (optional)
Plan (required) (required) (required) (optional)
Reassessment (required) (required) (required) (optional)
Follow-up - Discharge (required) (required) (required) (optional)

Q: My exercise prescription is included as part of my ITP, do I need to submit it separately?
A: The submitted exercise prescription can be a component of the Individualized Treatment Plan, but it must be submitted for both the ITP page AND the Exercise Prescription page.

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. The details of exercise prescription can be found in the AACVPR Guidelines for Pulmonary Rehabilitation Programs, 4th Edition and ACSM’s Guidelines for Exercise Testing and Prescription.

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: Here are recommended resources to help you with exercise prescription or either cardiac or pulmonary rehabilitation: AACVPR Guidelines for Pulmonary Rehabilitation Programs, 4th Edition and ACSM’s Guidelines for Exercise Testing and Prescription.

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. You need an exercise assessment at the initial visit and need to reassess prior to discharge. Test-Retest validity would require you to use the same assessment tool or process.

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 will need all of your policies reviewed and every three years.

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 out 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.

Clinical Outcomes Assessment – Cardiac Only

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.)

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: 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. 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.

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 AAVCPR Outcomes Matrix or in the Registry listing.

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. Also 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: We would like to use the "Health-related quality of life" outcome. We used the SF-36 through our WiCORE membership until mid-1st quarter of the year. We then switched to Ferran’s and Powers Quality of Life Index Cardiac Version-IV for the remainder of the year due to the SF-36 no longer bring included in the membership. Do we use the SF-36 scores in addition to the QLI scores? If we are to use the SF-36 scores, which score do we use, MCS or PCS? Or do we average both of these scores? We chose this "Health" outcome to measure as we are a small rural program & our Morbidity & Mortality numbers were very low.

A: Since you used the FP QOL for over ¾ of the year, I would recommend that you use that data (and only that data) for your analysis. Please explain briefly in the narrative why you switched. Since you are a small program, you may need to include 100% of all patients that used the FP index, unless your “N” (total number of patients) is 30 or greater. Programs should NOT report on Morbidity or Mortality data since it is very unlikely that they would be able to collect that data during the very short collection period.

Q: Are SOBQ scores a valid tool to report for Health Outcome Assessment for the certification process?
A: The SOBQ is an outcome for pulmonary symptoms, not Quality of Life.

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

Service Outcomes Assessment – Cardiac & Pulmonary

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

A: As long it is on the Outcomes Matrix under the “Service” category, you can use it. Please review the 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.

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