John Falcetano (john.falcetano@brooksrehab.org) is Director Corporate Compliance at Brooks Health System in Jacksonville, Florida.

A critical element of any effective compliance program is monitoring. As a service to our members, each month this column focuses on potential monitors for specific business lines.

To identify potential monitors, conduct a probe sample of your inpatient rehabilitation facility’s (IRF) required documentation and select monitors for missing documentation identified. Required documentation includes:

1. Documentation at the time of admission that the patient:

   1. Needs multiple active and ongoing therapies, one of which must be physical (PT) or occupational therapy (OT)

   2. Requires supervision by a rehabilitation physician to assess, modify treatment to maximize the benefit

   3. Is sufficiently stable to actively participate and benefit from an intensive rehabilitation therapy

2. Preadmission screening (PAS)

   1. Completed within 48 hours preceding admission

   2. Conducted by licensed or certified clinician within their scope of practice and training

   3. Signed and dated by a physician with specialized training and experience in rehabilitation

      Includes:

      1. Patient’s medical and functional status

      2. Prior level of function

      3. Expected level of improvement and expected time frame to achieve improvement

      4. Risk for clinical complications

      5. Conditions that caused need for rehab

      6. Prior and current medical and functional conditions and comorbidities

      7. Treatments needed e.g., (PT, OT, or speech therapy, prosthetics/orthotics)

      8. Expected frequency/duration of treatment

      9. Anticipated discharge destination

      10. Anticipated post-discharge treatment

      11. Findings of PAS reviewed by physician

3. Post-admission physician evaluation

   1. Conducted within first 24 hours of admission

      Includes:

      1. Changes or no changes since the preadmission screening

      2. History and physical exam

      3. Review of prior/current medical/functional conditions

      4. If IRF criteria are not met, was placement sought in another setting within 3 days?

4. Overall plan of care

   1. Conducted within first four days of admission

   2. Synthesized by a rehabilitation physician

      Includes:

      1. Prognosis, anticipated interventions, functional outcomes, and discharge destination

      2. Expected intensity (at least 180 minutes/day)

      3. Frequency of days/week (at least 5 days a week)

      4. Duration of therapy days/IRF stay

5. Interdisciplinary team approach

   1. First meeting within seven days, then every seven days

   2. Individuals present: MD, RN, social worker/case manager, therapist with designation

   3. Assessment or progress toward goals

   4. Rehab physician conducts face-to-face visits with patient at least three days/week

6. Multiple therapies

   1. More than one type therapy (e.g., PT, OT, speech therapy)

   2. Started within 36 hours from midnight on the day of admission