In our continuing series on the technical requirements of the Jan. 1, 2010 updates to the regulations for inpatient rehabilitation facilities (IRFs), this article will address the requirements for the individualized plan of care (IPOC). While care planning is nothing new to IRFs, the specific time and content requirements have presented some challenges for the industry and warrant some clarification.
Time Frame for Completion
The IPOC must be completed within the first four days of an IRF admission. This means that a patient admitted on a Monday must have the IPOC completed and documented in the medical record no later than the Thursday of the same week. With the exception of interrupted stays and significant disasters, there are no extenuating circumstances in which a delay will be accepted.
Effect of an Interrupted Stay
When a patient has an “interrupted stay” during the initial four days of an IRF admission, the days in which the patient is out of the IRF will not count when calculating compliance with the time requirement for the IPOC.
Responsibility for Completing the IPOC
In the Medicare Benefit Policy Manual, Chapter 1, Section 110.1.3, Medicare indicates that “it is the sole responsibility of a rehabilitation physician to integrate the information that is required in the overall plan of care and to document it in the patient’s medical record at the IRF.” Additional clarifications, however, offer the IRF a fair amount of flexibility in how this requirement is met. There is no specific requirement that the rehabilitation physician write out or dictate the IPOC himself or herself. All disciplines can provide input, and the physician can reference or bring together the individual plans of care from all disciplines and modify, expand, or adjust these plans. We caution IRFs, however, that the IPOC is meant to provide a more general direction for the patient’s care, outlining broad and overarching goals for the treatment plan. Each discipline then can have more specific goals and objectives falling under their individual areas of expertise. For this reason, we recommend a document that pulls this information together and is clearly labeled as the “individualized plan of care”.
There are many ways in which the IRF can meet this requirement. Some of the more common ways are listed here, but the IRF may determine its own best way to meet the requirement.
- The rehabilitation physician can dictate or write the IPOC completely based on review of all assessments and discussions with the care team.
- The team can jointly develop the IPOC and the rehabilitation physician can expand, modify, adjust, and/or document his or her approval.
- The team can jointly develop and document the IPOC at the initial team meeting – if that meeting occurs by day four of the stay – and the rehabilitation physician can expand, modify, adjust, and document his or her approval.
- An integrated IPOC could be developed within the EMR and approved by the rehabilitation physician.
Our interpretation has been that, regardless of the method used to establish the IPOC, the rehabilitation physician is responsible for ensuring documentation of this information no later than day four of the stay – and that this requires the physician either to document a progress note approving the IPOC or to sign, date, and time the document. If your process does not include this signature, we recommend you seek guidance from your healthcare attorney to ensure that your processes meet the requirements of the rule.
Regulations require that the IPOC include the following information:
- The patient’s medical prognosis. There has been no clarification about what “prognosis” means just yet, but we believe that the prognosis should include a statement that identifies the potential for the patient to achieve his or her rehabilitation goals, as well as the prospects for resolution of any medical issues impacting the rehabilitation stay.
- Anticipated interventions – therapy, rehab nursing, other ancillary and medical services, etc..
- Anticipated functional outcomes.
- Expected overall length of stay in the IRF (even though this has been addressed in the preadmission assessment and the post-admission physician evaluation).
- Expected DC destination from the IRF.
Anticipated interventions must include key criteria above and beyond the information listed above. For each therapy intervention, specifically, the IPOC must include the following:
- Expected intensity – the number of hours per day.
- Frequency – the total number of days per week.
- Duration – the total number of days during the IRF stay. This is different from the total length of stay in that the patient may not receive therapy services on every day of the week.
For example, the intervention for physical therapy might read: “Physical therapy services for 90 minutes per day, 5 times per week, with additional therapy services as needed based on patient progress for a total of 18 visits during the admission.” Interventions need to be described this specifically in order to demonstrate that the rehabilitation physician and the team are creating an individualized plan of care for the patient.
IPOC Versus Interdisciplinary Team Meeting Requirements
While Medicare does not require a team meeting by day four of the stay, the organization may find that such a meeting presents an excellent forum for synthesis of all evaluation data and finalization of the plan of care, with the full care team present to establish the overall goals. An interdisciplinary team meeting must be held weekly and can be combined with an IPOC planning meeting if desired. Any organization, however, can use any effective method to complete the IPOC.
In our experience, we find that organizations have difficulty in two primary areas of compliance with the IPOC requirements:
- Time frame for completion: In this area, each organization needs to establish good mechanisms for monitoring admissions and IPOC due dates. Often the case manager can manage this process effectively.
- Individualization of therapy plan of care items: Therapy plan of care often includes ranges (60-90 minutes) that are not considered individualized. The IPOC should be established with clear expectations of therapy minutes that can be adjusted at team meetings or via progress notes and physician orders that are revised as the patient progresses or has status changes.
By focusing on these areas, IRFs can improve overall compliance and reduce risk of denial of Medicare payment in the event of an audit.
Coming next: The Interdisciplinary Team Meeting Requirements
About the Author
Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has more than 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting inpatient rehabilitation facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.
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 The Interdisciplinary Team Meeting will be the subject of our next article.