Section 1250.2160  Quality

 

a)         Criteria #1:  Are there established mechanisms for preadmission review/evaluation, utilization review and patient care review?

 

b)         Standard #1:  CPRF's should have a system for preadmission review which includes referrals for those declared ineligible for the program.

 

c)         Data Factors:

 

1)         Review policies and procedures.

 

2)         Eligibility criteria.

 

3)         Intake and referral policies.

 

4)         Casefinding procedures for rehabilitation units in acute care hospitals.

 

5)         Procedures for referral for those not eligible for the program.

 

d)         Standard #2:  Peer review programs and quality assurance programs should exist in all rehabilitation facilities.

 

f)          Data Factors:

 

1)         Peer review programs.

 

2)         Retrospective audit programs.

 

f)          Standard #3:  Utilization review programs should exist in all rehabilitation facilities.

 

g)         Data Factors:  Utilization review system.

 

h)         Criteria #2:  Are patient records available and accessible to the patient and authorized reviewing bodies?

 

i)          Standard #1:  Policies should be in place assuring the legitimate use and release of medical records.

 

j)          Data Factors:  Medical records policies.

 

k)         Criteria #3:  Is the required staff available in the area?

 

l)          Standard #1:  Each rehabilitation facility should have available the necessary staff in sufficient numbers to accommodate the volume and case mix of its patients.  These staffing standards will be utilized unless licensure standards are adopted and promulgated by Illinois Department of Public Health in accordance with the Illinois Administrative Procedure Act.  In that case, those standards will be utilized.

 

1)         Physicians

 

A)        Medical direction of the facility shall be vested in a member of the active medical staff with a specialty in Rehabilitation or a specialty related to rehabilitation.

 

B)        The following types of physicians should be available on staff or through affiliation agreements:

 

i)          Physiatrist and/or Orthopedist.

 

ii)         Internist.

 

C)        The facility should also have available the following physician specialists on at least a consulting basis:

 

i)          Cardiologist;

 

ii)         General Surgeon;

 

iii)         Neurologist;

 

iv)        Ophthalmologist;

 

v)         Orthopedic Surgeon;

 

vi)        Pediatrician (if the facility treats children or adolescents);

 

vii)        Plastic Surgeon;

 

viii)       Psychiatrist;

 

ix)        Radiologist;

 

x)         Urologist;

 

xi)        Neurosurgeon;

 

xii)        Otolaryngologist;

 

xiii)       Obstetrician/Gynecologist.

 

2)         The following personnel shall be available on the facility staff or through affiliation agreements:

 

A)        Rehabilitation Nurses – Supervisors of all nurses participating as part of the rehabilitation team shall have documented education in rehabilitation nursing and at least one year of rehabilitation nursing experience.  These persons must be on the staff of a CPRF.

 

B)        Physical Therapists – Graduates of a program in physical therapy approved by the U.S. Office of Education or the Council on Postsecondary Accreditation.  Also, the physical therapist should be licensed or registered by the state.  These persons must be on the staff of a CPRF.

 

C)        Occupational Therapist – Registered by the American Occupational Therapy Association or should be graduates of an approved educational program, with the experience needed for registration.  Educational program, with the experience needed for registration.  Educational programs are approved by the American Medical Association's council on Medical Education in collaboration with the American Occupational Therapy Association.  The individual should also meet any legal requirements of the State.

 

D)        Speech Pathologist – Should meet the academic and experience standards of the American Speech and Hearing Association for the Certification of Clinical Competence in Speech Pathology and fulfill any applicable legal requirements set by the state.

 

E)         Social Worker – Should have a Master's Degree from a school of social work approved by the Council of Social Work Education and meet applicable legal requirements.

 

F)         Psychologist – Should meet any applicable legal requirements, have a Master's Degree in psychology, and be eligible for membership in, or be a member of, the American Psychological Association.

 

G)        Vocational Counselors or Specialist – Should have a Master's Degree in vocational rehabilitation counseling, vocational guidance, or a related field, or should be members of, of the following organizations:

 

i)          National Rehabilitation Counseling Association;

 

ii)         National Vocational Guidance Association;

 

iii)         American Psychological Association.

 

H)        Dietician – Should be registered by the American Dietetic Association or has met the association's standards for qualifications.

 

F)         Pharmacist – Should be a graduate of a college of pharmacy accredited by the American Council on Pharmaceutical Education or have completed a hospital pharmacy residency program accredited by the American Society of Hospital Pharmacists and meet appropriate licensure or registration requirements.  Dependent on caseload composition, facilities offering Comprehensive Physical Rehabilitation Services should have available the following personnel on at least a consulting basis:

 

J)         Audiologist – Should meet the academic and experience standards of the American Speech and Hearing Association for the Certification of Clinical Competence in Audiology and fulfill any applicable legal requirements set by the state.

 

k)         Educational Specialist - Should be certified by the state department of education.  Teaching specialists include individuals with degrees in primary school education, or industrial education.

 

L)         Prosthetists and Orthotist - Should meet the academic and experience standards of the American Orthotic and Prosthetic Association and must fulfill any applicable legal requirements set by the state; and

 

M)       Dentists.

 

m)        Data Factors:

 

1)         Numbers and type of staff.

 

2)         Staff qualifications.

 

3)         Staff's relationship with facility (i.e., staff, through affiliation agreements or as consultants).

 

4)         Physician coverage plans.

 

n)         Criteria #4:  Are mechanisms for continuing education programs available to staff?

 

o)         Standard #1:  Rehabilitation facilities should provide in-service training programs at regular intervals.

 

p)         Data Factors:

 

1)         Statement that in-service training is provided.

 

2)         Frequency of programs.

 

3)         Description of programs.

 

4)         Title of person responsible for the program.

 

5)         Records of in-service training.

 

q)         Standard #2:  All staff of area rehabilitation facilities should participate in continuing education programs.

 

r)          Data Factors:

 

1)         Number and type of staff participating in continuing education programs in the latest 12 month period.

 

2)         Facility participation in university internship programs for medical and allied health.

 

3)         Formal teaching relationships for allied health students.

 

4)         Annual continuing education budget.

 

s)         Criteria #5:  Do rehabilitation facilities have mechanisms to assure coordinated delivery of rehabilitation services through a multi-disciplinary approach?

 

t)          Standard #1:  Services should be provided utilizing a multi-disciplinary team approach.

 

u)         Data Factors:

 

1)         Description of rehabilitation team system including team composition, leadership and role of patient.

 

2)         Existence and frequency of case conferences.

 

3)         Attendance policy for case conferences.

 

4)         Written staff communication mechanisms.

 

v)         Standard #2:  Each patient should have one member of the rehabilitation team designated as his/her comprehensive case manager.

 

w)        Data Factors:

 

1)         Title of person responsible for designating case manager.

 

2)         Responsibilities of case manager.

 

x)         Standard #3:  Free-standing rehabilitation facilities shall have transfer agreements with acute care facilities for acute and emergency care.

 

y)         Data Factors:

 

1)         Transfer agreements.

 

2)         Location of facilities.

 

3)         Plan for transportation of patients.

 

z)         Criteria #6:  Do all rehabilitation facilities have procedures to promote continuity of care?

 

aa)       Standard #1:  All rehabilitation facilities shall involve the patient's family and/or significant others in the patient's program.

 

bb)       Data Factors:

 

1)         Existence of family orientation and education programs.

 

2)         Policies for family participation in the patients care and program design.

 

3)         Procedures for family assessment in preadmission review.

 

4)         Existence of psychological and other support services for family.

 

5)         Procedures for family preparation for post discharge care.

 

6)         Availability of bilingual staff members, interpreters, or pre-printed materials or visual aids, for patients and families who cannot communicate.

 

cc)       Standard #2:  Discharge planning services should be provided to all patients.  This process should:

 

1)         Begin early in the treatment phase and involve patient and family;

 

2)         Have a designated person responsible for it whenever possible;

 

3)         Allow for a trial discharge whenever appropriate; and

 

4)         assure that all aftercare referral arrangements are completed prior to discharge.

 

dd)       Data Factors:

 

1)         Discharge planning policies and procedures.

 

2)         Title of responsible staff.

 

3)         Existence of referral agreements with home care and social service agencies.

 

4)         Referral procedure to the Illinois Department of Rehabilitation Services.

 

5)         Existence of written mechanisms for communication of aftercare instruction to physicians or other professionals providing follow-up care.

 

6)         Existence of community resource file.

 

ee)       Standard #3:  Rehabilitation facilities should conduct post discharge patient follow-up to monitor compliance with prescribed regimen, to perform patient reassessment and to modify the treatment plan when necessary.

 

ff)         Data Factors:

 

1)         Existence of follow-up procedures.

 

2)         Frequency of follow-up procedures.

 

3)         Percentage of total inpatients in the latest 12 month period for which data is available, who received follow-up.

 

gg)       Criteria #7:  Are rehabilitation services delivered in a way which promotes realization of the patient's potential for independent functioning?

 

hh)       Standard #1:  An individual treatment plan should be developed for each inpatient.  This plan should:

 

1)         Specify goals and measurable objectives;

 

2)         Provide for periodic inpatient and post discharge interdisciplinary assessment to monitor patient progress and identity when a revision of the patient's goals and treatment plan is necessary; and

 

3)         Include input from the patient and his family.

 

ii)         Data Factors:

 

1)         Treatment plan format.

 

2)         Responsible staff.

 

3)         Existence of assessment instruments.

 

4)         Reassessment schedule.

 

5)         Procedures for patient and family participation in plan formulation.

 

jj)         Standard #2:  All facilities should have a statement of patient rights and responsibilities.

 

kk)       Data Factors:  Existence of statement.

 

ll)         Standard #3:  Rehabilitation facilities shall have a mechanism for evaluation of each patient which includes evaluation of change of patients status from initiation of treatment to discharge to a follow-up period after discharge.

 

mm)     Data Factors:

 

1)         Responsible staff.

 

2)         Existence of a management information system for data collection.

 

nn)       Criteria #8:  Do rehabilitation facilities have systems for on-going program evaluation?

 

oo)       Standard #1:

 

1)         All rehabilitation facilities shall conduct program evaluation.  The evaluation scheme shall include measurable goals and objectives and preestablished levels of acceptable and non-acceptable conformance.  The program evaluation should address the following components:

 

A)        Program objectives;

 

B)        Organization;

 

C)        Staff;

 

D)        Communication procedures;

 

E)         Case conference procedures;

 

F)         Administration and utilization of service;

 

G)        Service and treatment criteria; and

 

H)        Discharge and transfer criteria.

 

2)         The evaluation system should be structured so that the following can be determined:

 

A)        The utilization of services by various categories of patients;

 

B)        The degree to which existing services fall short of or surpass demand for service; and

 

C)        The level of unmet need for services which are not presently provided in the facility.

 

pp)       Data Factors:

 

1)         Description of program evaluation system.

 

2)         Responsible staff.

 

3)         Report of facility evaluation for the latest 12 month period for which information is available.

 

(Source:  Added at 5 Ill. Reg. 3214, effective March 18, 1981)