42 C.F.R. § 456.370

(a) Before admission to an ICF or before authorization for payment, an interdisciplinary team of health professionals must make a comprehensive medical and social evaluation and, where appropriate, a psychological evaluation of each applicant's or beneficiary's need for care in the ICF.

(b) In an institution for Individuals with Intellectual Disabilities or persons with related conditions, the team must also make a psychological evaluation of need for care. The psychological evaluation must be made before admission or authorization of payment, but not more than three months before admission.

(c) Each evaluation must include—

(1) Diagnoses;

(2) Summary of present medical, social, and where appropriate, developmental findings;

(3) Medical and social family history;

(4) Mental and physical functional capacity;

(5) Prognoses;

(6) Kinds of services needed;

(7) Evaluation by an agency worker of the resources available in the home, family and community; and

(8) A recommendation concerning—

(i) Admission to the ICF; or

(ii) Continued care in the ICF for individuals who apply for Medicaid while in the ICF.