Intermediate Care Facilities, Long Term Care & Rehabilitation Records. HIM 2000. Intermediate care facilities. Mentally retarded Developmentally disabled individuals ICF/MR funded by Title XIX (Medicaid) and must meet the standards in the Conditions of Participation for ICFs/MR. ICF/MR.
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ICF/MR funded by Title XIX (Medicaid) and must meet the standards in the Conditions of Participation for ICFs/MR.
Surveys performed by the state’s department of health.
Coding: ICD-9-CM and some DSM-IV coding for psychology/psychiatry services
-Optional survey for LTC
-Minimum Data Set (MDS)
-Resident Assessment Protocols(RAPs)
-Utilization guideline (specified in State Operations Manual)
SNF monitor some of the following quality indicators:
You are the consultant for the long-term-care facility that has recently undergone a survey in which the facility received several deficiencies for noncompliance with federal requirements. The most significant deficiency involved a noted pattern (7 out o10 examples) in which comprehensive assessments (MDS) were not completed within the required time frame (within 14 days of admission). In addition, suveyors identified that there was no documentation to support that the triggered RAPs were being used in the assessment and care planning process. It was also noted that the nursing staff stated they did not understand what the resident assessment protocols were and they were unaware of the federal criteria for determining when a significant change had occurred. The administrator of this facility has called you to help develop a plan to correct these deficiencies.
Rehabilitation is the development of a person to the fullest physical, psychological, social, vocational, and educational potential consistent with his or her physiological anatomic impairment and environmental limitations.
Acute rehabilitation- rehabiliative care provided for two to ten weeks until the patient is medicallly stable and has reached his or her maximum short-term improvement
Postacute rehab- a setting providing long-term therapy to maximize functional status for patients who have successfully completed acute rehab, or have passed all acute medical problems, or are medically stable and ready for postacute rehab.
Subacute rehab- rehabilitative care of lesser intensity provided to patients who have a discharge goal to return home or to a less restrictive environment, but are unable to participate or benefit from a higher level of rehabilitative care.
2 voluntary accrediting agencies for rehab facilities
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Commission for Accreditation of Rehabilitation Facilities (CARF)
CARF guidelines in patient’s medical records.
FIM scores are an reliable and valid instrument in documenting the severity of disabilities as well as outcomes in rehabilitation. FIM scores are issued in thirteen motor and five cognitive areas. Each area receives a score ranging from one to seven.