Title: Section 405.18 - Rehabilitation services
405.18 Rehabilitation services. The hospital shall make available rehabilitation services consistent with the needs of the patients, which shall be designed to provide individualized, goal-oriented, comprehensive and coordinated services to minimize the effects of physical, mental, social and vocational disadvantages and to effect a realization of the patient's potential for useful and productive activity while ensuring the health and safety of the patient. Such services shall include but are not limited to audiology, occupational therapy, physical therapy and speech language pathology and shall be delivered in accordance with a written plan for treatment. Hospitals providing general rehabilitation services but not providing comprehensive inpatient physical medicine and rehabilitation programs shall meet the provisions of subdivisions (a) and (b) of this section. Hospitals which do provide comprehensive inpatient physical medicine and rehabilitation programs shall meet the provisions of subdivisions (a) and (c) of this section. Hospitals which provide a spinal cord injury program shall meet the provisions of subdivisions (a), (c) and (d) of this section. Hospitals which provide a tramatic head injury program shall meet the provisions of subdivisions (a), (c) and (e) of this section.
(a) Organization and staffing. (1) There shall be a director of the service who shall have administrative responsibility for the delivery of patient care and for the supervision of the service. The director shall have the necessary knowledge, experience and capabilities to properly supervise and administer the service.
(2) Physical therapy, occupational therapy, speech-language pathology, or audiology services, if provided, shall be provided by staff who meet the qualifications specified by the governing body, and who are licensed and currently registered by the New York State Education Department.
(i) Each individual who provides rehabilitation services shall be competent to provide such services by reason of education, training, experience and demonstrated performance.
(ii) A sufficient number of qualified competent professional and support personnel shall be available to meet the needs of the patient population and the objectives of the service.
(iii) Sufficient space, equipment and facilities shall be available to support the clinical and administrative functions of the service.
(3) Written policies and procedures which describe the mechanism for the management of the rehabilitation service as well as interdepartmental relationships and communications shall be implemented.
(4) Staff orientation and inservice training shall be required, provided and documented in accordance with hospital policies and procedures.
(b) Delivery of services. (1) The hospital shall assure that patients who require rehabilitation services are identified and that appropriate services are provided in accordance with the orders of attending physicians or other practitioners as authorized by the governing body, consistent with the New York State Education Law, to order such services. Working relationships among medical staff, nursing staff and rehabilitation service staff shall be established to ensure the identification of patients and delivery of appropriate services.
(2) Rehabilitation services shall be ordered by the attending physician or authorized practitioners and provided in accordance with a written multidisciplinary treatment plan which is based upon a functional assessment and evaluation performed and documented by a professional who is qualified under the provisions of the New York State Education Law, and shall include the diagnosis or diagnoses, precautions and contraindications, and goals of the prescribed therapy.
(i) The multidisciplinary treatment plan shall identify patient needs, establish realistic and measureable goals and identify specific therapeutic interventions by type, amount and frequency needed to maintain, restore and/or promote the patient's functioning and health, within stated time frames for achievement.
(ii) The multidisciplinary treatment plan shall be prepared by rehabilitation service staff with the involvement of the practitioner who ordered the services, the nursing staff, as well as the patient and the family to the extent possible.
(iii) The patient's progress and response to treatment shall be assessed on a timely and regular basis, in accordance with hospital policies and procedures, and documented in the patient's medical record.
(iv) Multidisciplinary treatment plans and goals shall be revised as appropriate in accordance with the assessment of the patient's progress and the results of treatment.
(v) The rehabilitation service shall monitor and evaluate the quality and appropriateness of patient care and resolve identified problems through implementation of a planned and systematic process. The process shall involve reporting to the quality assurance committee in accordance with hospital policies and procedures.
(vi) In accordance with the provisions of section 405.9(h) of this Part, rehabilitation therapy staff shall work with the attending practitioner, the nursing staff, other health care providers and agencies as well as the patient and the family, to the extent possible, to assure that all appropriate discharge planning arrangements have been made prior to discharge to meet the patient's identified needs.
(c) Comprehensive inpatient physical medicine and rehabilitation programs, if provided, shall be approved by the department and shall be organized and operated in accordance with the following:
(1) the beds shall be in a designated area forming a distinct organizational unit, shall be staffed and equipped for the specific purpose of providing a comprehensive physical medicine and rehabilitation program, and shall be used exclusively for such purpose;
(2) patients exhibiting conditions, including but not limited to the following, shall be considered as candidates for admission to a comprehensive inpatient physical medicine and rehabilitation program: severe disabling impairments of recent onset or recent progression, those being readmitted for such conditions, or those with such conditions who previously have not received comprehensive rehabilitation services;
(3) the program shall be directed by a chief of physical medicine and rehabilitation who shall be full-time with the physical medicine and rehabilitation program. The chief of physical medicine and rehabilitation shall be a board certified physiatrist or a physician who by training and experience is knowledgeable in physical and rehabilitative medicine;
(4) the attending physician for a patient admitted to the program shall be a rehabilitation physician, a physician who is board certified in physical medicine and rehabilitation or a physician who by training and experience is knowledgeable in physical medicine and rehabilitation;
(5) nursing care shall be provided under the direction of a registered professional nurse who has appropriate training and experience in rehabilitation nursing as determined by the program and the hospital;
(6) the program shall provide a core of services which includes: rehabilitation nursing, physical therapy, occupational therapy, medical social work, psychology and speech-language pathology;
(7) dependent upon the needs of the patients served, the program shall provide or make formal arrangements for the following services: dental, vocational rehabilitation, education, orthotics, prosthetics, respiratory therapy, rehabilitation engineering, driver education, audiology and therapeutic recreation;
(8) physician consultation shall be available, including but not limited to: general surgery, internal medicine, neurology, neurosurgery, opthalmology, orthopedic surgery, otorhinolaryngology, pediatrics, physicial medicine and rehabilitation, plastic surgery, psychiatry, pulmonary medicine and urology;
(9) patient care services shall be provided through a coordinated interdisciplinary team approach. Participation of members of the core team in the direct care of each patient will vary dependent upon individual patient needs. Patients shall receive a comprehensive evaluation within seven days following admission followed by regular team conferences at intervals appropriate to the treatment goals established for the patient. These conferences shall result in documentation of decisions on rehabilitation goals that meet professional standards of care, identification of services needed for the patients to progress toward those goals, and evaluation of progress toward meeting established goals;
(10) each program shall develop and implement written policies and procedures for the following: patient admission and orientation, assessment and evaluation, program management, discharge planning and follow-up;
(11) the program shall establish formalized relationships with other area hospitals and providers of comprehensive rehabilitation services, regardless of setting, which shall include provisions for consultation, inservice eduation, and the evaluation of common treatment protocols;
(12) programs shall have written agreements in place for the transfer of patients who need medical or specialty care not available at the hospital of admission. Transfer agreements shall be mutually agreed upon by both the transferring and receiving facility and shall be reviewed on at least an annual basis;
(13) there shall be an organized outpatient physical medicine and rehabilitation program at the hospital which shall provide a range of services equal in scope to that of the inpatient program including spinal cord and head injury programs where they are provided; and
(14) there shall be an organized program for follow-up care to maintain or improve patient health status and functioning following discharge. (d) A spinal cord injury program, if provided, shall provide coordinated and integrated services for spinal cord injured persons, whether from trauma or disease, enabling those patients served to achieve optimal functioning;
(1) The spinal cord injury program shall be a designated unit for spinal cord injured people with a designated staff to serve the spinal cord injured patients.
(2) The spinal cord injury program shall be directed by a physician with special interest and competence in the care of those with spinal cord injury.
(3) Nursing services for the spinal cord injury program shall be provided under the direction of a registered professional nurse who has appropriate training and experience in the provision of rehabilitation nursing for spinal cord injured patients as determined by the program and the hospital.
(4) The following shall be available seven days a week, 24 hours per day: registered professional nurses, trained personnel capable of provided intermittent catheterization, as required, and respiratory therapy services.
(5) There shall be a formally organized program for patient and family spinal cord injury education regarding bladder management, bowel management, pulmonary care, skin care, instruction in medications, nutrition, access to follow-up medical care, care of equipment, and sexual counseling.
(e) A traumatic head injury program, if provided, shall be designed specifically to serve medically stable, traumatically brain injured individuals. The program shall provide goal-oriented, comprehensive, interdisciplinary and coordinated services directed at restoring the individual to the optimal level of physical, emotional, cognitive and behavioral functioning.
(1) General requirements. The hospital shall ensure:
(i) the development and consistent application of written admission and continued stay criteria for this service which include but are not limited to the use of a generally recognized classification system for measuring each individual's physical, behavioral and cognitive level of functioning and the family's capabilities and functioning, and are consistent with the following requirements:
(a) a patient admitted for active rehabilitation shall be a person who has suffered a traumatic brain injury with structural nondegenerative brain damage, is medically stable, is not in a persistent vegetative state, demonstrates potential for physical, behavioral and cognitive rehabilitation and may evidence moderate to severe behavior abnormalities. The patient must be capable of exhibiting at least localized responses by reacting specifically but inconsistently to stimuli;
(b) a patient admitted for active coma stimulation shall be a person who has suffered a traumatic brain injury with structural nondegenerative brain damage and is in a coma. The patient may be completely unresponsive to any stimuli or may exhibit a generalized response by reacting inconsistently and nonpurposefully to stimuli in a nonspecific manner; and
(c) a patient who has diffuse brain damage caused by anoxia, toxic poisoning, cerebral vascular accident, or encephalitis may be considered appropriate for admission to this program either for active coma stimulation or active rehabilitation.
(ii) records shall be maintained for at least two years identifying persons who were determined by the facility to be ineligible for admission under the head injury program. The records shall indicate the reason for ineligibility and any referral action taken;
(iii) inservice and continuing education programs which address the medical, physical, cognitive, psychosocial and behavioral needs of head injured patients shall be conducted on a regular basis for all personnel caring for such patients;
(iv) educational programs shall be conducted for personnel not providing direct care but who come in contact on a regular basis with head injured patients. The programs should familiarize personnel with the specific needs of these patients; and
(v) education and counseling services shall be available and offered to the patient and families as needed.
(2) Program management and staffing. There shall be distinct staffing for the direct care services in the head injury program unit.
(i) The program shall be administered by a program director who has at least two years of clinical or administrative experience in head injury rehabilitation programs. The program director shall have specific responsibilities which include, but are not limited to:
(a) administrative direction and oversight of the program;
(b) ongoing review of the program and implementation of program changes as identified; and (c) development and implementation of educational programs on an ongoing basis for staff working with head injured patients.
(ii) A physician who has advanced training and experience in the care of the head injured shall be responsible for the medical direction and medical oversight of the head injury program and may serve as the program director.
(iii) A qualified specialist in physical medicine and rehabilitation or a physician who has training and experience in the care and rehabilitation of head injured patients shall be responsible for the care of each patient.
(iv) A primary interdisciplinary team of health care professionals with special interest, training, experience and expertise in head injury rehabilitation shall be responsible for the assessment, coordinated program and care planning, and direct services for each head injured patient. The interdisciplinary team members shall be specifically assigned to serve head injured patients and the team shall include as a minimum the following types of health care professionals:
(b) registered professional nurse;
(c) physical therapist;
(d) occupational therapist;
(e) speech-language pathologist;
(f) social worker;
(h) therapeutic recreation specialist; and
(i) clinical psychologist with training and experience in neuropsychology.
(v) Nursing services for the head injury unit shall be provided under the direction of a registered professional nurse who is certified or eligible for certification in rehabilitation nursing or who has demonstrated appropriate clinical competency, training and experience in the provision of rehabilitation nursing for head injured patients as determined by the program and the hospital.
(vi) There shall be at least one registered professional nurse with experience in rehabilitation nursing assigned to each shift on the head injury unit.
(vii) Depending upon types of patients being served and individual patient's need, the program shall provide or make formal arrangements for vocational rehabilitation services and special education services.
(3) Interdisciplinary care planning. (i) A member of the interdisciplinary team managing the patient shall be designated to:
(a) coordinate the overall plan of care and services and identify unmet needs for each patient including discharge and follow-up plans;
(b) serve as a liaison among patient, family and staff to ensure that patient and family concerns are addressed; and
(c) serve as a liaison with the educational, social and vocational resources in the community which are serving the patient.
(ii) A written, comprehensive care plan shall be developed and implemented which establishes rehabilitation goals for each patient. The plan shall be developed on admission by the interdisciplinary team and the attending physician in consultation with the patient, the patient's family and outside agencies, as necessary. The care plan shall be reviewed at least every 14 days and modified according to the patient's needs by the interdisciplinary team. The comprehensive care plan is based upon initial and ongoing integrated, interdisciplinary assessments which shall address as a minimum, medical, dental and neurological status, nutritional status, sensorimotor capacity, the developmental needs of children and adolescents, cognitive, perceptual and communicative capacity, affect and mood, activities of daily living skills, educational or vocational capacities, sexuality issues and concerns, family unity counseling and community reintegration needs and recreation and leisure time interests.
(iii) Findings from the comprehensive care plan reviews shall be integrated into the utilization review program of the facility.
(iv) A written discharge plan shall be developed for each patient as part of the overall care plan and shall include input from all professionals caring for the patient, the patient's family, the patient if capable and, as appropriate, any outside agency or resource that will be involved with the patient following discharge.
(v) The family and patient shall receive preparation for discharge through the facility's educational and counseling services.
(vi) There shall be effective provision for follow-up care and post discharge care which shall include as a minimum, formal linkages to other sources of care and services for head-or brain-injured patients including outpatient services, residential health care facility-based services, home care service agency services and vocational education and rehabilitation services.
(4) Utilization review monitoring. The facility shall participate with the commissioner or his designee in a program of patient care and services monitoring which shall include, but not be limited to: review of admissions, care and services provided, continued stays, and discharge planning. The facility shall furnish such records and reports at such frequency as the commissioner or his designee may require and shall make available members of the interdisciplinary patient care team for case conferences as the commissioner or his designee deems necessary.
VOLUME C (Title 10)