Required Individualized Overall Plan of Care

110.1.3 - Required Individualized Overall Plan of Care (Rev. 10892; Issued: 08-06-21; Effective: 11-08-21; Implementation: 11-08-21) In accordance with 42 CFR § 412.622(a)(4)(ii), information from the preadmission screening and other information garnered from the assessments of all therapy disciplines involved in treating the patient and other pertinent clinicians, must be synthesized by a rehabilitation physician to support a documented overall plan of care. The overall plan of care should generally detail the patient’s medical prognosis and the anticipated interventions, functional outcomes, and discharge destination from the IRF stay, thereby supporting the medical necessity of the admission. The anticipated interventions detailed in the overall plan of care should generally include the expected intensity (meaning number of hours per day), frequency (meaning number of days per week), and duration (meaning the total number of days during the IRF stay) of physical, occupational, speech- language pathology, and prosthetic/orthotic therapies required by the patient during the IRF stay. These expectations for the patient’s course of treatment should generally be based on consideration of the patient’s impairments, functional status, complicating conditions, and any other contributing factors. Whereas the individual assessments of appropriate clinical staff will contribute to the information contained in the overall plan of care, the rehabilitation physician is responsible (in accordance with 42 CFR § 412.622(a)(4)(ii)) for developing the overall plan of care with input from the interdisciplinary team. In accordance with 42 CFR § 412.622(a)(4)(ii), in order for the IRF admission to be considered reasonable and necessary, the overall plan of care must be completed within the first 4 days of the IRF admission; it must support the determination that the IRF admission is reasonable and necessary; and it must be retained in the patient’s medical record at the IRF. While CMS believes that it may be good practice to conduct the first interdisciplinary team meeting within the first 4 days of admission to develop the overall individualized plan of care, CMS believes that there may be other ways of developing the overall individualized plan of care. Thus, IRFs may develop this required documentation using whatever internal processes they believe are most appropriate, provided that the documentation fulfills all relevant regulatory requirements.