Soon after 2010 regulations were released, clinicians began assessing workflow and practices to ensure each detailed item listed to be completed was covered.
Initially, there was much debate as to when it was necessary to define exact levels of treatment by discipline (duration and frequency) for each therapy. Although the pre-admission screen asks for expected frequency and duration of ”treatment in the IRF,” it does not say “by discipline” that early on. Instead, this early assessment must validate that the patient can tolerate therapy intensity. Overall, this means no less than three hours, five days per week on a rolling week; starting with the admission date, or a varied schedule of 15 hours over seven days. It’s not expected that detail is prescribed in the pre-admission or post admission assessments. Clarification documents posted to discuss the November 12, pre-2010 on-line education session, created clearer definitions of when detailed therapy must be outlined. Remember these clarification documents are written for MACs and RACs, outlining how to interpret regulation statements (see series 1, page 11, numbers 9 and 10 here).
In clarification and within the rule, a detailed prescription for therapy,by discipline, is outlined and must appear by day four, when the plan of care is due.
This makes perfect sense, since the pre-admission must define appropriateness to tolerate a rigorous schedule. The post admission evaluation, required within 24 hours of admission, is an attestation by the physician that the patient is as appropriate as they suspected within the clinical documentation/issues present on the pre-admission screen. By the time therapy disciplines begin to assess and provide detailed impairments/needs; the physician, who has the sole responsibility to integrate the information presented, can match resource needs with expected levels of care and then can detail the therapy care expected per day by discipline to meet those needs.
Although there is nothing keeping a physician from defining this level earlier, it is required by day four when the Plan of Care document is due.