CMS-10036 IRF-PAI Instrument

Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities

508c IRF-PAI 2014

Inpatient Rehabilitation Facility-Patient Assessment Instrument

OMB: 0938-0842

Document [pdf]
Download: pdf | pdf
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0842. The time required to complete this
information collection is estimated to average 50.5 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0842

Identification Information*
1.

Payer Information*

Facility Information

20. Payment Source

A. Facility Name
______________________________________________________________
______________________________________________________________

A. Primary Source

_________

B. Secondary Source
(02 Medicare -Fee For Service;
51 Medicare- Medicare Advantage; 99 Not Listed)

_________

______________________________________________________________
______________________________________________________________
______________________________________________________________

Medical Information*
21. Impairment Group

________
Admission

B. Facility Medicare Provider Number _________________________
2.

Patient Medicare Number ____________________________________

3.

Patient Medicaid Number ____________________________________

4.

Patient First Name __________________________________________

________
Discharge

Condition requiring admission to rehabilitation; code according to Appendix
A, attached.

5B. Patient Identification Number _________________________________

22. Etiologic Diagnosis
_________
(Use an ICD code to indicate the etiologic problem
that led to the condition for which the patient is receiving
rehabilitation)

6.

Birth Date

23. Date of Onset of Impairment

7.

Social Security Number _____________________________________

8.

Gender (1 - Male; 2 - Female) ________________________________

9.

Race/Ethnicity (Check all that apply)

5A. Patient Last Name __________________________________________
____/____/_______
MM / DD / YYYY

____/____/________
MM / DD / YYYY

24. Comorbid Conditions
Use ICD codes to enter comorbid medical conditions
A.

J.

S.

B.

K.

T.

C.

L.

U.

D.

M.

V.

American Indian or Alaska Native

A. ________

Asian

B. ________

Black or African American

C. ________

E.

N.

W.

Hispanic or Latino

D. ________

F.

O.

X.

Native Hawaiian or Other Pacific Islander

E. ________

G.

P.

Y.

White

F. ________

H.

Q.

I.

R.

10. Marital Status
(1 - Never Married; 2 - Married; 3 - Widowed;
4 - Separated; 5 - Divorced)

_______________
25. DELETED

11. Zip Code of Patient's Pre-Hospital Residence

________________

12. Admission Date

____/____/_______
MM / DD / YYYY

13. Assessment Reference Date

____/____/_____
MM / DD / YYYY

14. Admission Class
(1 - Initial Rehab; 2 - Evaluation; 3 - Readmission;
4 - Unplanned Discharge; 5 - Continuing Rehabilitation)
15A. Admit From
(01 – Home (private home/apt., board/care, assisted living, group home;
02 Short-term General Hospital; 03 Skilled Nursing Facility (SNF);
50 Hospice; 62 Another Inpatient Rehabilitation Facility; 63 Long-Term
Care Hospital (LTCH); 64 Medicaid Nursing Facility; 65 Inpatient
Psychiatric Facility; 66 Critical Access Hospital; 99 Not Listed)
16A. Pre-hospital Living Setting
________________
01 – Home (private home/apt., board/care, assisted living, group home;
02 Short-term General Hospital; 03 Skilled Nursing Facility (SNF);
50 Hospice; 62 Another Inpatient Rehabilitation Facility; 63 Long-Term
Care Hospital (LTCH); 64 Medicaid Nursing Facility; 65 Inpatient
Psychiatric Facility; 66 Critical Access Hospital; 99 Not Listed)

26. DELETED
Height and Weight
(While measuring if the number is X.1-X.4 round down, X.5 or greater round
up)
25A. Height on admission (in inches) _____________________________
(Record the most recent height measurement)
26A. Weight on admission (in pounds) ____________________________
(Record the most recent weight measure during the 3 day assessment period.
Measure weight consistently, according to standard facility practice (e.g., in
a.m. after voiding, with shoes off, etc.))
27.

Swallowing Status

________
Admission

________
Discharge

3- Regular Food: solids and liquids swallowed safely without supervision or
modified food consistency
2- Modified Food Consistency/Supervision: subject requires modified food
consistency and/or needs supervision for safety
1- Tube/Parenteral Feeding: tube/parenteral feeding used wholly or partially
as a means of sustenance
28. DELETED

17. Pre-hospital Living With
_______________
(Code only if item 16A is 01-Home: Code using 01- Alone;
02- Family/Relatives; 03- Friends; 04- Attendant; 05- Other)
18. DELETED
19. DELETED
* The FIM data set, measurement scale and impairment codes incorporated or
referenced herein are the property of U B Foundation Activities, Inc. © 1993,
2001 U B Foundation Activities, Inc. The FIM mark is owned by UBFA, Inc.

Version 1.2
Proposed DRAFT Effective October 1, 2014

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0842
39. FIMTM Instrument*

Function Modifiers*
Complete the following specific functional items prior to scoring the
FIM

TM

Instrument:

29. Bladder Level of Assistance
(Score using FIM Levels 1 - 7)
30. Bladder Frequency of Accidents
(Score as below)

31.

32.

Discharge

A.

Eating





B.

Grooming





C.

Bathing

D.

Dressing - Upper

E.

Dressing - Lower

F.

Toileting

SPHINCTER CONTROL

Enter in Item 39G (Bladder) the lower (more dependent) score from Items 29
and 30 above

TRANSFERS

Bowel Frequency of Accidents
(Score as below)

34.

Shower Transfer

Distance Walked

36. Distance Traveled in Wheelchair

38.

Wheelchair

Bowel

Bed, Chair, Wheelchair





J.

Toilet

K.

Tub, Shower



Goal













































W - Walk
C - Wheelchair
B - Both

LOCOMOTION
L.

Walk/Wheelchair

M.

Stairs




Admission

Discharge







N.

Comprehension

O.

Expression

SOCIAL COGNITION
P.

Social Interaction

Discharge

Q.

Problem Solving







R.

Memory

Discharge







(Score Items 37 and 38 using FIM Levels 1 - 7; 0 if activity does not occur)
See training manual for scoring of Item 39L (Walk/Wheelchair)
* The FIM data set, measurement scale and impairment codes incorporated or
referenced herein are the property of U B Foundation Activities, Inc. ©1993,
2001 U B Foundation Activities, Inc. The FIM mark is owned by UBFA, Inc.












V - Vocal
N - Nonvocal
B - Both

Admission

Admission




A - Auditory
V - Visual
B - Both

COMMUNICATION

(Code items 35 and 36 using: 3 - 150 feet; 2 - 50 to 149 feet;
1 - Less than 50 feet; 0 – activity does not occur)

37. Walk

H.

I.

(Score Items 33 and 34 using FIM Levels 1 - 7; use 0 if activity does not
occur) See training manual for scoring of Item 39K (Tub/Shower Transfer)

35.

Bladder

Discharge

Enter in Item 39H (Bowel) the lower (more dependent) score of Items 31and 32
above.

Tub Transfer

G.

Admission

7 - No accidents
6 - No accidents; uses device such as a ostomy
5 - One accident in the past 7 days
4 - Two accidents in the past 7 days
3 - Three accidents in the past 7 days
2 - Four accidents in the past 7 days
1 - Five or more accidents in the past 7 days

33.

Discharge

SELF-CARE
Admission

7 - No accidents
6 - No accidents; uses device such as a catheter
5 - One accident in the past 7 days
4 - Two accidents in the past 7 days
3 - Three accidents in the past 7 days
2 - Four accidents in the past 7 days
1 - Five or more accidents in the past 7 days

Bowel Level of Assistance
(Score using FIM Levels 1 - 7)

Admission













FIM LEVELS
No Helper
7

Complete Independence (Timely, Safely)

6

Modified Independence (Device)

Helper - Modified Dependence
5

Supervision (Subject = 100%)

4

Minimal Assistance (Subject = 75% or more)

3

Moderate Assistance (Subject = 50% or more)

Helper - Complete Dependence
2

Maximal Assistance (Subject = 25% or more)

1

Total Assistance (Subject less than 25%)

0

Activity does not occur; Use this code only at admission

Version 1.2
Proposed DRAFT Effective October 1, 2014

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0842

Discharge Information*
40. Discharge Date

____/____/________
MM / DD / YYYY

41. Patient discharged against medical advice?

______________
(0 - No; 1 - Yes)

42. Program Interruption(s)

______________
(0 - No; 1 - Yes)

43. Program Interruption Dates
(Code only if item 42 is 1 - Yes)
A. 1st Interruption Date

B. 1st Return Date

MM / DD / YYYY
C. 2nd Interruption Date

MM / DD / YYYY
D. 2nd Return Date

MM / DD / YYYY
E. 3rd Interruption Date

MM / DD / YYYY
F. 3rd Return Date

MM / DD / YYYY

MM / DD / YYYY

44C. Was the patient discharged alive?

_____________
(0 - No; 1 - Yes)

44D. Patient’s discharge destination/living setting, using codes below: (answer
only if 44C = 1; if 44C = 0, skip to item 46)
(01 – Home (private home/apt., board/care, assisted living, group home;
02 Short-term General Hospital; 03 Skilled Nursing Facility (SNF); 50
Hospice; 62 Another Inpatient Rehabilitation Facility; 63 Long-Term
Care Hospital (LTCH); 64 Medicaid Nursing Facility; 65 Inpatient
Psychiatric Facility; 66 Critical Access Hospital; 99 Not Listed)
44E. Was patient discharged with Home Health
Services?

_____________

(Code only if item 44C =1 and 44D is 01 – Home)(0 - No; 1 - Yes)
45. Discharge to Living With

_____________

(Code only if item 44C is 1-Yes and 44D is 01 - Home; Code using 1 Alone; 2 - Family / Relatives; 3 - Friends; 4 - Attendant;
5 - Other)
46. Diagnosis for Interruption or Death

_____________

(Code using ICD code)
47. Complications during rehabilitation stay
(Use ICD codes to specify up to six conditions that
began with this rehabilitation stay)
A. ____________

B. ____________

C. ____________

D. ____________

E. ____________

F. ____________

* The FIM data set, measurement scale and impairment codes incorporated or
referenced herein are the property of U B Foundation Activities, Inc. © 1993,
2001 U B Foundation Activities, Inc. The FIM mark is owned by UBFA, Inc.

Version 1.2
Proposed DRAFT Effective October 1, 2014

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0842

Quality Indicators- Admission Assessment

Quality Indicators- Discharge Assessment

Unhealed Pressure Ulcer(s)- Discharge

Unhealed Pressure Ulcer(s)- Admission
Enter Code

Enter Number

M0210. Does this patient have one or more unhealed pressure
ulcer(s) at Stage 1 or higher at Admission?

Enter Code

0. No  skip to question I0900 on Admission
Assessment
1. Yes  continue to question M0300A on Admission
Assessment

0. No skip to question M0900A on Discharge
Assessment
1. Yes  continue to question M0300A on Discharge
Assessment

M0300. Current Number of Unhealed Pressure Ulcers
at Each Stage- Admission

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage- Discharge

M0300A. Stage 1: Intact skin with non-blanchable redness of

M0300A. Stage 1: Intact skin with non-blanchable redness of a

a localized area usually over a bony prominence. Darkly
pigmented skin may not have a visible blanching; in dark skin
tones it may appear with persistent blue or purple hues.

localized area usually over a bony prominence. Darkly pigmented
skin may not have a visible blanching; in dark skin tones it may
appear with persistent blue or purple hues.

M0300A1. Number of Stage 1 pressure ulcers: enter how
many were noted at the time of admission

Enter Number

M0300A1. Enter total number of pressure ulcers currently at Stage
1. If patient has no Stage 1 pressure ulcers at
discharge, skip to Item M0300B1.

Enter Number

M0300A2. Of these Stage 1 pressure ulcers present at discharge,
enter number that were: (a) present on admission as a
Stage 1 and (b) remained at Stage 1 at discharge.

Enter Number

M0300A3. Of these Stage 1 pressure ulcers, enter the number that
were not present on admission. (i.e. – New stage 1
pressure ulcers that have developed during the IRF
stay)

M0300B. Stage 2: Partial thickness loss of dermis presenting
as a shallow open ulcer with a red or pink wound bed, without
slough. May also present as an intact or open/ruptured blister.
Enter Number

M0210. Does this patient have one or more unhealed
pressure ulcer(s) at Stage 1 or higher on Discharge?

M0300B1. Number of Stage 2 pressure ulcers: enter how
many were noted at the time of admission

M0300B. Stage 2: Partial thickness loss of dermis presenting as a
shallow open ulcer with a red or pink wound bed, without slough.
May also present as an intact or open/ruptured blister.
Enter Number

M0300B1. Enter total number of pressure ulcers currently at Stage
2. (If patient has no Stage 2 pressure ulcers at
discharge, skip to Item M0300C1.)

Enter Number

M0300B2. Of these Stage 2 pressure ulcers present at discharge,
enter the number that were: (a) present on admission,
and (b) remained at Stage 2 at discharge.

Enter Number

M0300B3. Of these Stage 2 pressure ulcers present at discharge,
enter the number that were: (a) present on admission as
an unstageable pressure ulcer due to the presence of a
non-removable device and (b) when it became
stageable, the pressure ulcer was staged as a Stage 2,
and (c) it remained at Stage 2 at the time of discharge.

Enter Number

M0300B4. Of these Stage 2 pressure ulcers present at discharge,
enter the number that were: (a) not present on
admission; or (b) were at a lesser stage at admission
and worsened to a Stage 2 during the IRF stay

Version 1.2
Proposed DRAFT Effective October 1, 2014

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES

Enter Number

OMB No. 0938-0842

Quality Indicators- Admission Assessment, Continued

Quality Indicators-Discharge Assessment, Continued

M0300. Current Number of Unhealed Pressure Ulcers
at Each Stage- Admission, Continued

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage-Discharge, Continued

M0300C. Stage 3: Full thickness tissue loss. Subcutaneous fat
may be visible but bone, tendon or muscle is not exposed.
Slough may be present but does not obscure the depth of tissue
loss. May include undermining and tunneling.

M0300C. Stage 3: Full thickness tissue loss. Subcutaneous fat
may be visible but bone, tendon or muscle is not exposed. Slough
may be present but does not obscure the depth of tissue loss. May
include undermining and tunneling.

M0300C1. Number of Stage 3 pressure ulcers: enter how
many were noted at the time of admission

Enter Number

M0300C1. Enter total number of pressure ulcers currently at Stage
3. (If patient has no Stage 3 pressure ulcers at
discharge, skip to Item M0300D1.

Enter Number

M0300C2. Of these Stage 3 pressure ulcers present at discharge,
enter the number that were: (a) present on admission,
and (b) remained at Stage 3 at discharge.

Enter Number

M0300C3. Of these Stage 3 pressure ulcers present at discharge,
enter the number that were: (a) present on admission as
an unstageable pressure ulcer, and (b) when it
became stageable, it was staged as a Stage 3; and (c) it
remained at Stage 3 at the time of discharge.

Enter Number

M0300C4. Of these Stage 3 pressure ulcers present at discharge,
enter the number that were: (a) not present on
admission; or (b) were at a lesser stage at admission
and worsened to a Stage 3 during the IRF stay; or (c)
were unstageable due to a non-removeable device at
admission, initially became stageable at a lesser stage, ,
but then progressed to a Stage 3 by the time of
discharge.

M0300D. Stage 4: Full thickness tissue loss with exposed
bone, tendon or muscle. Slough or eschar may be present on
some parts of the wound bed. Often includes undermining and
tunneling.
Enter Number

M0300D. Stage 4: Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be present on some parts of
the wound bed. Often includes undermining and tunneling.
Enter Number

M0300D1. Enter total number of pressure ulcers currently at Stage
4. (If patient has no Stage 4 pressure ulcers at
discharge, skip to Item M0300E1.)

Enter Number

M0300D2. Of these Stage 4 pressure ulcers present at discharge,
enter number that were: (a) present on admission at
Stage 4 , and (b) remained at Stage 4 at discharge.

Enter Number

M0300D3. Of these Stage 4 pressure ulcers present at discharge,
enter the number that were: (a) present on admission as
an unstageable pressure ulcer, and (b) when it
became stageable, it was staged as a Stage 4, and (c) it
remained at Stage 4 at the time of discharge.

Enter Number

M0300D4. Of these Stage 4 pressure ulcers present at discharge,
enter the number that were: (a) not present on
admission); or (b) were at a lesser stage at admission
and worsened to a Stage 4 by discharge; or (c) were
unstageable on admission, initially became stageable at
a lesser stage, and then progressed to a Stage 4 by the
time of discharge.

M0300D1. Number of Stage 4 pressure ulcers: enter how
many were noted at the time of admission

Version 1.2
Proposed DRAFT Effective October 1, 2014

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES

Enter Number

Enter Number

Enter Number

OMB No. 0938-0842

Quality Indicators-Admission Assessment, Continued

Quality Indicators-Discharge Assessment, Continued

M0300E. Unstageable Pressure Ulcers due to nonremovable dressing/device: Known but not stageable due to

M0300E. Unstageable Pressure Ulcers due to a nonremovable dressing or device: pressure ulcers that are known

the presence of a non-removable dressing/device.

but not stageable due to the presence of a non-removable dressing
or device.

M0300E1. Number of unstageable pressure ulcers due to
non-removable dressing/device: enter how many
were noted at the time of admission

Enter Number

M0300E1. Enter total number of pressure ulcers currently
Unstageable due to a Non-removable dressing or
device. (If patient has no pressure ulcers
Unstageable due to Non-Removable Device at
discharge, skip to Item M0300F1.)

Enter Number

M0300E2. Of these Unstageable pressure ulcers due to a nonremovable dressing or device present at discharge,
enter number that were:(a) present on admission as an
unstageable pressure ulcer due to non-removable
dressing or device; and (b) remained unstageable due
to non-removable dressing or device until discharge.

Enter Number

M0300E3. Of these Unstageable pressure ulcers due to nonremovable dressing or device present at discharge,
enter number that were (a) present on admission as a
stageable pressure ulcer and became unstageable due
to non-removable dressing or device during the IRF
stay; and (b) remained unstageable due to a nonremovable dressing or device until discharge.

M0300F. Unstageable Pressure Ulcers due to slough
and/or eschar: pressure ulcers that are known but not

M0300F. Unstageable Pressure Ulcers due to slough or
eschar: pressure ulcers that are known but not stageable due to

stageable due to coverage of wound bed by slough and/or eschar.

coverage of wound bed by slough and/or eschar.

M0300F1. Number of unstageable pressure ulcers due to
slough and/ or eschar: enter how many were noted
at the time of admission

Enter Number

M0300F1. Enter total number of pressure ulcers currently
Unstageable due to a Slough and/or Eschar. ( If
patient has no pressure ulcers Unstageable due to
Slough and/or Eschar at discharge, skip to Item
M0300G1.)

Enter Number

M0300F2. Of these Unstageable pressure ulcers due to slough
and/or eschar present at discharge, enter number that
were: (a) present on admission as an unstageable
pressure ulcer due to slough and/or eschar; and (b)
remained unstageable due to slough and/or eschar
until discharge.

Enter Number

M0300F3. Of these Unstageable pressure ulcers due to slough or
eschar present at discharge, enter number that were: (a)
present on admission as a stageable pressure ulcer and
became unstageable due to slough and/or eschar,
during the IRF stay; and (b) remained unstageable due
to slough and/or eschar until discharge.

M0300G. Unstageable Pressure Ulcers with Suspected
Deep Tissue Injury (DTI) in evolution: suspected deep

M0300G. Unstageable Pressure Ulcers with Suspected
Deep Tissue Injury (DTI) in evolution: suspected deep tissue

tissue injury in evolution.

injury in evolution.

M0300G1. Number of unstageable pressure ulcers with
Suspected Deep Tissue Injury in evolution: enter
how many were noted at the time of admission

Enter Number

M0300G1. Enter total number of unstageable pressure ulcers
with Suspected Deep Tissue Injury. (If patient has
no Unstageable pressure ulcers with Suspected Deep
Tissue Injury at discharge, skip to Item M0900A.)

Enter Number

M0300G2. Of these unstageable pressure ulcers with Suspected
DTI present at discharge, enter number that were:(a)
present on admission as an unstageable pressure ulcer
due to a suspected deep tissue injury; and (b)
remained unstageable due to a suspected DTI until
discharge.

Version 1.2
Proposed DRAFT Effective October 1, 2014

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0842

Quality Indicators- Admission Assessment, Continued

Quality Indicators-Discharge Assessment, Continued

I0900. Pressure Ulcer Risk ConditionsAdmission

M0900. Healed Pressure Ulcers- Discharge
Indicate the number of pressure ulcers that were: (a) present on
Admission; and (b) have completely closed (resurfaced with
epithelium) upon Discharge. If there are no healed pressure ulcers
noted at a given stage, enter 0.

Indicate below if the patient has any of the following pressure
ulcer risk conditions:
(NOTE: You must also document the appropriate ICD codes
for any pressure ulcer risk conditions documented below in Item
24 “Comorbid Conditions” above.)
Enter Number

Enter Number

Enter Number

I0900A. Peripheral Vascular Disease (PVD)
0. No 1. Yes
I0900B. Peripheral Arterial Disease(PAD)
0. No 1. Yes
I2900A. Diabetes Mellitus (DM)
If I2900A = 0, skip I2900B-D
0. No 1. Yes

Enter Number

I2900B. Diabetic Retinopathy
0. No 1. Yes

Enter Number

I2900C. Diabetic Nephropathy
0. No 1. Yes

Enter Number

I2900D. Diabetic Neuropathy
0. No 1. Yes

Enter Number

M0900A. Stage 1

Enter Number

M0900B. Stage 2

Enter Number

M0900C. Stage 3

Enter Number

M0900D. Stage 4

O0250. Influenza Vaccine- Discharge- Refer to current version of
IRF-PAI Training Manual for current influenza vaccination
season and reporting period.
Enter Code

O0250A. Did the patient receive the influenza vaccine in this
facility for this year's influenza vaccination season?
0. No  Skip to O0250C, If influenza vaccine not
received, state reason
1. Yes  Continue to O0250B, Date influenza vaccine
received
O0250B. Date influenza vaccine received  Complete
date and skip to Z0400A, Signature of Persons
Completing the Assessment

MM

DD

YYYY

O0250C. If influenza vaccine not received, state reason:
Enter Code

1. Patient not in this facility during this year's influenza
vaccination season
2. Received outside of this facility
3. Not eligible - medical contraindication
4. Offered and declined
5. Not offered
6. Inability to obtain influenza vaccine due to a declared
shortage.
9. None of the above

Version 1.2
Proposed DRAFT Effective October 1, 2014

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0842

Item Z0400A. Signature of Persons Completing the Assessment*

I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected or coordinated collection of this
information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid
requirements. I understand that this information is used as a basis for ensuring that patients receive appropriate and quality care, and as a basis for payment
from federal funds. I further understand that payment of such federal funds and continued participation in the government-funded health care programs is
conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to or may subject my organization to substantial criminal,
civil, and/or administrative penalties for submitting false information. I also certify that I am authorized to submit this information by this facility on its behalf.
Signature

Title

Date Information Is Provided

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.

Version 1.2
Proposed DRAFT Effective October 1, 2014


File Typeapplication/pdf
File TitlePatient Assessment Instrument for Use in an Inpatient Rehabilitation Facility
SubjectIRF-PAI, rehab, assessment, function, quality, pressure ulcer, vaccination, IRF
AuthorCenters for Medicare & Medicaid Services
File Modified2013-04-16
File Created2013-04-11

© 2024 OMB.report | Privacy Policy