Required Preadmission Screening

110.1.1 - Required Preadmission Screening (Rev. 10892; Issued: 08-06-21; Effective: 11-08-21; Implementation: 11-08-21) In accordance with 42 CFR § 412.622(a)(4)(i) a preadmission screening is an evaluation of the patient’s condition and need for rehabilitation therapy and medical treatment that must be conducted by licensed or certified clinician(s) within the 48 hours immediately preceding the IRF admission. A preadmission screening that includes all of the required elements, but that is conducted more than 48 hours immediately preceding the IRF admission, will be accepted as long as an update is conducted in person or by telephone to document the patient’s medical and functional status within the 48 hours immediately preceding the IRF admission in the patient’s medical record at the IRF. The preadmission screening in the patient’s IRF medical record serves as the primary documentation by the IRF clinical staff of the patient’s status prior to admission and of the specific reasons that led the IRF clinical staff to conclude that the IRF admission would be reasonable and necessary. As such, IRFs must make this documentation detailed and comprehensive. In accordance with 42 CFR § 412.622(a)(4)(i)(B) the preadmission screening documentation must indicate the patient’s prior level of function (prior to the event or condition that led to the patient’s need for intensive rehabilitation therapy), expected level of improvement, and the expected length of time necessary to achieve that level of improvement. It must also include an evaluation of the patient’s risk for clinical complications, the conditions that caused the need for rehabilitation, the treatments needed (i.e., physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), and anticipated discharge destination. If the patient is being transferred from a referring hospital, the preadmission screening could either be done in person or through a review of the patient’s medical records from the referring hospital (either paper or electronic format), as long as those medical records contain the necessary assessments to make a reasonable determination. However, a preadmission screening conducted entirely by telephone should generally include transmission of the patient’s medical records from the referring hospital to the IRF and a review of those records by licensed or certified clinical staff member in the IRF to ensure it includes a detailed and comprehensive review of the patient’s condition and medical history in accordance with 42 CFR § 412.622(a)(4)(i)(B). The IRF should develop a thorough preadmission screening process for patients admitted to the IRF from the home or community-based environment, which should ensure that patient preadmission screenings include all of the required elements described in 42 CFR § 412.622(a)(3), (4), and (5). However, such admissions may not necessarily involve the use of medical records from a prior hospital stay in another inpatient hospital setting unless such records are pertinent to the individual patient’s situation. Individual elements of the preadmission screening may be evaluated by any clinician or group of clinicians designated by a rehabilitation physician, as long as the clinicians are licensed or certified to perform the evaluation. Although clinical personnel are required to evaluate the preadmission screening information in accordance with 42 CFR § 412.622(a)(4)(i), each IRF may determine its own processes for collecting and compiling the preadmission screening information. The focus of the review of the preadmission screening information will be on its completeness, accuracy, and the extent to which it supports the appropriateness of the IRF admission decision, not on how the process is organized. The “rehabilitation physician” need not be a salaried employee of the IRF, but must be a licensed physician who is determined by the IRF to have specialized training and experience in inpatient rehabilitation, in accordance with 42 CFR § 412.622(c). For ease of exposition throughout this document, this physician will be referred to as a “rehabilitation physician”. All findings of the preadmission screening should be conveyed to a rehabilitation physician prior to the IRF admission. Additionally, in accordance with 42 CFR § 412.622(a)(4)(i), the rehabilitation physician must document that he or she has reviewed and concurs with the findings and results of the preadmission screening prior to the IRF admission. All preadmission screening documentation (including documents transmitted from the referring hospital or other prior inpatient hospital stay, if applicable) must be retained in the patient’s medical record at the IRF per the regulation at 42 CFR § 412.622(a)(4)(i).