Take the "IF" out of IRF. Complete the questionnaire below, and we can determine if your IRF is in compliance and as profitable as it could be.

Take the IF out of IRF Questionnaire

A. GENERAL INFORMATION

Hospital Name:

Address:

City:

State:

Zip:

Telephone:

Email:

Website:

Contact Name:

Contact Title:

IRF Reports to:

# Hospital Licensed Beds:

Average Daily Census:

Average Length of Stay:

B. FINANCIAL & STAFFING DATA
(please fill in appropriate data in each box for Inpatient Rehab Facility only):

Months of Data:
(Annual, Quarter, Etc.)

Gross Revenue:

Contractual Adjustments:

Net Revenue:

Labor or Current Contract Expense
(including all benefits, taxes, etc.)

Is the IRF Rehab Director a
PT, OT or SLP?

Is the Medical Director a
hospital employee?

C. OPERATIONAL DATA
(please provide data for same time period as financial data for applicable service sites):

	Inpatient		Inpatient Rehab Facility
	# visits	#modalities	# rehab pt. days	# total pt. days	# rehab visits
PT
OT
SLP
Total

Definition of terms:
visit - a single patient encounter or appointment
modality - a procedure or unit performed during a visit; typically a 0 - 15 minute block of time
FTE - full time equivalent; 40 hours worked equals 1 FTE, 20 hours worked equals .5 FTE, etc.

D: COMPLETE FOR EXISTING INPATIENT REHAB FACILITIES ONLY

How many licensed IRF beds
do you have now?

Number of discharges per month?

What percentage of admissions
fit CMS 13 diagnoses list?

What improvement(s) would you like
to see in the operations/management
of your IRF?

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