CMS Pub. 100-02, ch. 1, § 110.1.1

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).