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STANDARD 20: Rehabilitation Services

20.1 General

1. If the healthcare organization provides rehabilitation, physical therapy, occupational therapy, audiology or speech pathology services, the service(s) shall be provided in a manner that ensures the patient’s health and safety. The service shall be integrated with the other processes of the healthcare organization and operate within a defined scope of service and available resources.

2. The healthcare organization shall define and document the necessary processes for all rehabilitation services in order to achieve the intended patient care results.

3. These processes shall adhere to acceptable standards of practice and recommendations promoted by nationally recognized professional organizations.

20.2 Organization and Control

1. The healthcare organization shall ensure that there is the appropriate management and support all rehabilitation services. At a minimum these requirements shall include:

a) a Director who has the responsibility for the management, direction and accountability for ensuring services are carried throughout the organization;

b) the director shall have the qualifications, experience and/or training defined by the healthcare organization and appropriate for this position;

c) staff who meet the qualifications as defined by the medical staff and healthcare organization;

d) patient care shall be provided by qualified physical therapists, physical therapists assistants, occupational therapists, occupational therapist assistants, speech-language pathologists, or audiologists defined by regulatory and other licensing requirements consistent with healthcare organization policy.

20.3 Rehabilitation Treatment Plan

1. Rehabilitation services shall be provided on the written order of an authorized medical staff physician or other LIP.

2. Based on the above requirement a rehabilitation treatment plan in accordance with the practitioner’s orders shall be developed and approved by the ordering physician.

3. The orders, rehabilitation treatment plan, results, notes, and other related documents shall be maintained and retained in the patient’s medical record.

20.4 Rehabilitation Facilities

1. Physical and work environment, equipment, and supplies shall be appropriate for the types of rehabilitation services offered. They shall be maintained for safe and efficient performance in accordance with STANDARD 28.1. (to be included in all standards under facilities).