902 KAR 20:240. Comprehensive physical
rehabilitation hospital services.
RELATES TO: KRS 194A.030(1), 216B.010,
216B.015, 216B.040, 216B.045-216B.055, 216B.075, 216B.105-216B.131, 216B.990
STATUTORY AUTHORITY: KRS 216B.042(1)
NECESSITY, FUNCTION, AND CONFORMITY: KRS
216B.042(1) requires the Cabinet for Health and Family Services to establish administrative
regulations for proper administration of the health care facility licensure
function. This administrative regulation establishes minimum licensure requirements
for inpatient comprehensive physical rehabilitation services, including
rehabilitation services in hospital-based rehabilitation units.
Section 1. Definitions. (1) "Dietician"
is defined at KRS 310.005(3).
(2) "Full-time equivalent"
(a) One (1) employee working thirty-seven
and five-tenths (37.5) hours per week; or
(b) More than one (1) part-time employee
whose combined working hours total thirty-seven and five-tenths (37.5) hours
(3) "Governing authority" means
the individual, agency, partnership, or corporation that directs and
establishes policy concerning the management and operation of a comprehensive
physical rehabilitation program.
(4) "Institution" means a
freestanding specialty hospital or a general hospital based unit providing
inpatient comprehensive physical rehabilitation services.
(5) "Medical staff" means an
organized body of physicians, and dentists if applicable, appointed by the governing
authority. Members of the medical staff shall be licensed to practice medicine
or dentistry in Kentucky, except for graduate physicians in the first year of
(6) "Nutritionist" is defined
at KRS 310.005(4).
(7) "Protective device" means a
device designed to protect a person from falling, including a side rail, safety
vest, or safety belt.
(8) "Registered Health Information Administrator"
means a person certified as a registered records administrator by the American Health
Information Management Association.
(9) "Registered Health Information
Technician" means a person certified as an Accredited Record Technician by
the American Health Information Management Association.
(10) "Restraint" means any pharmaceutical
agent or physical or mechanical device used to restrict the movement of a
patient or the movement of a portion of a patient’s body.
Section 2. Administration and Operation.
(1) Governing authority.
(a) The licensee shall be responsible for
compliance with federal, state, and local law pertaining to comprehensive
physical rehabilitation programs.
(b) The governing authority shall appoint
an administrator whose qualifications, responsibilities, authority and
accountability are defined in writing and approved by the governing authority,
and shall designate a mechanism for the periodic performance review of the
(2) Administrator. The administrator
(a) Be responsible for daily management
of the institution;
(b) Provide a liaison between the
governing authority and the medical staff;
(c) Attend meetings of the governing
(d) Report to the governing authority
concerning the conduct of the institution;
(e) Hold departmental and
interdepartmental meetings on a regular basis;
(f) Attend or be represented at
departmental and interdepartmental meetings; and
(g) Present to the departments a report
of pertinent activities of the institution.
(3) Administrative records and reports.
(a) Administrative reports shall be
established, maintained and utilized as necessary to guide the operation,
measure productivity and reflect the programs of the institution. An
administrative report shall include:
1. Minutes of the governing authority and
2. Financial records and reports;
3. Incident investigation reports; and
4. Other pertinent reports prepared in
the regular course of business.
(b) The institution shall maintain a
patient admission and discharge register.
(c) Licensure inspection reports and
plans of correction shall be made available to the general public upon request.
(4) Policies. The institution shall have
written documents on file governing the operation of the institution and the
services provided, including:
(a) A mission statement of the
comprehensive physical rehabilitation service;
(b) A program narrative which describes
in detail the rehabilitation conditions for which the institution provides
services, the delivery of these services, and the goals and treatment;
(c) A description of the organizational
structure of the facility, including lines of authority, responsibility, and
(d) An admission policy to assure patient
admission is in accordance with medical staff protocol;
(e) A list of constraints imposed on
admissions by limitation of service, physical facilities, staff coverage, or
other relevant factors;
(f) The financial requirements for a
patient to be admitted;
(g) The requirement for an informed
consent by patient, parent, guardian or legal representative for diagnostic or
(h) A procedure for:
1. Recording an accident involving a patient,
visitor, or staff member;
2. Recording an incident of drug reaction
or medication error; and
3. Reporting in writing through the
(i) A policy for the use of restraints
and a mechanism for monitoring and controlling their use;
(j) A policy for patient discharge and
termination of services; and
(k) A policy describing the use of
volunteers in program activities.
(5) Patient identification. The
institution shall identify each patient from time of admission to time of discharge
with an identification bracelet imprinted with the name of the patient, and the
date of admission.
(6) Discharge planning.
(a) The discharge decision and plan shall
be established with the participation of the patient, if possible, or a
significant other person. Discharge planning shall begin early in the treatment
phase. Each professional practitioner involved with the patient shall
participate in formulating the discharge plan, including professionals from
agencies outside the institution who have been or will be involved in the
patient's care, if possible.
(b) A discharge authorization and summary
shall be prepared for each patient who has been discharged or transferred from
the institution to a supportive service. The summary shall contain:
1. The reason for referral;
2. The diagnosis;
3. The rehabilitation problem;
4. The services provided;
5. The results of services provided;
6. Any referral action recommended; and
7. Procedures and activities for patient
and family to assist the patient to maintain or improve postdischarge
functioning and to increase independence.
(c) The family, appropriate staff
members, the referring source, and community agencies proposed to work with the
patient, shall receive advance notice of the discharge decision and plan.
(7) Patient follow-up.
(a) The institution shall establish a
procedure for patient follow-up. (b) Follow-up shall be conducted after the
1. Discharged from the institution;
2. Transferred to a supportive service;
3. Placed in an inactive status.
(8) Transfer procedures and agreements.
(a) The institution shall have written
patient transfer procedures and agreements with other health care facilities
which provide a level of inpatient care not provided by the institution. Transfer
procedures and agreements shall include:
1. Written procedures insuring prompt
notification to the receiving facility;
2. Accommodation for safe and appropriate
3. Specification of staff
responsibilities during transfer.
(b) If a patient is transferred to
another health care facility, a transfer form shall accompany the patient. The
transfer form shall include:
1. The attending physician's instructions
for continuing care;
2. A current summary of the patient's
3. Information concerning special
supplies or equipment needed for the patient's care; and
4. Pertinent social information concerning
the patient the patient's and family.
(c) A copy of the patient's signed
discharge summary shall be forwarded to the receiving health care facility
within thirty (30) days following the patient's discharge.
(9) Medical staff.
(a) The facility shall have a medical
staff organized under bylaws approved by the governing authority. The medical
staff shall be responsible to the governing authority for the quality of
medical care provided and for the ethical and professional practice of its
(b) The medical staff shall develop and
adopt policies or bylaws which shall be approved by the governing authority.
The policies or bylaws shall:
1. Establish the qualifications for
medical staff membership, including professional licensure, except for graduate
physicians in their first year of hospital training;
2. Define and describe the
responsibilities and duties of each category of medical staff, including each
person who is designated active, associate, or courtesy;
3. Delineate the clinical privileges of
staff members and allied health professionals;
4. Establish a procedure for granting and
withdrawing staff privileges and credentials;
5. Provide a mechanism for appeal of
decisions regarding staff membership and privileges;
6. Provide a method for the selection of
officers of the medical staff;
7. Establish requirements regarding the
frequency of, and attendance at, general staff and department or service
meetings of the medical staff;
8. Provide for the appointment of
standing and special committees and establish requirements for:
a. Composition and organization;
b. Frequency of and attendance at
c. Maintenance of minutes and reports in
the permanent hospital records:
9. Standing and special committees may
a. An executive committee;
b. A credentials committee;
c. A medical audit committee;
d. A medical records committee:
e. An infection control committee:
f. A tissue committee;
g. A pharmacy and therapeutics committee;
h. A utilization review committee; and
i. A quality assurance committee; and
10. Establish a policy requiring a member
of the medical staff to sign the written documentation of a verbal order for
diagnostic testing or treatment:
a. As soon as possible after the order is
b. Within thirty (30) days of the
patient's discharge if the patient is discharged prior to the order being
(10) Director of rehabilitation. The
director of rehabilitation shall:
(a) Be a licensed physician who has completed
a one (1) year facility internship and has two (2) years of training or
experience in medical management of inpatients requiring rehabilitation services;
(b) Provide services:
1. On a full-time basis for a
freestanding specialty hospital;
2. At least twenty (20) hours per week
for a general hospital based unit with twenty (20) or more beds; or
3. At least ten (10) hours per week for a
general hospital-based unit with less than twenty (20) beds.
(11) Quality assurance and review.
(a) The quality and appropriateness of
major clinical functions shall be monitored and evaluated utilizing:
1. Objective criteria that reflects current
knowledge and clinical experience; and
2. Information about identified aspects
of rehabilitation care that is collected on a routine basis;
(b) Information from the quality
assurance and review shall be:
1. Reviewed and assessed on a periodic basis;
2. Utilized to improve clinical
operations and patient care.
(c) The effectiveness of action taken to
improve patient care shall be evaluated.
(d) Findings and conclusions regarding
the following shall be documented and reported to the administrator and
1. Monitoring and evaluation;
2. Problem-solving activity;
3. Activity for the improvement of
patient care; and
4. The impact of actions taken.
(e) The quality and appropriateness of
patient rehabilitation services provided by an outside source shall be
monitored and evaluated, and identified problems resolved.
(a) The institution shall employ
qualified personnel sufficient to provide effective patient care and related
services and shall make available to all employees written personnel policies
(b) There shall be a written job
description for each position which shall assure that an employee is
appropriately classified and licensed for the position in which he is employed.
(c) There shall be an employee health
program that includes preemployment and periodic health examinations.
(d) Each staff member shall be tested for
tuberculosis, as follows:
1. The skin test status of each staff
member shall be documented in the employee's personnel record.
a. A new staff member shall undergo a
skin test before or during the first week of employment.
b. The results shall be documented in the
employee's personnel record within the first month of employment.
c. A skin test shall not be required at
the time of initial employment if the employee:
(i) Documents a prior skin test of ten
(10) or more millimeters of induration; or
(ii) If the employee is currently
receiving or has completed six (6) months of prophylactic therapy or a course
of multiple-drug chemotherapy for tuberculosis.
d. A two (2) step skin test is required
for a new employee over age forty-five (45) whose initial test shows less than
ten (10) millimeters of induration, unless he can document that he has had a
tuberculosis skin test within one (1) year prior to his current employment. An
employee who has never had a skin test of ten (10) or more millimeters
induration shall be skin tested annually, on or before the anniversary of his last
2. An employee whose initial or annual
skin test results in ten (10) or more millimeters induration shall receive a
chest x-ray, unless:
a. A chest x-ray within the previous two
(2) months showed no evidence of tuberculosis; or
b. The employee can document the previous
completion of a course of prophylactic treatment with isoniazid. An employee
whose initial skin test shows ten (10) or more millimeters of induration shall
be advised of the symptoms of the disease and instructed to report to his
employer and seek medical attention promptly.
3.a. The director of rehabilitation shall
be responsible for ensuring that skin tests and chest x-rays are done in
accordance with subparagraphs 1 and 2 of this paragraph.
b. Skin testing dates and results and
chest x-ray reports shall be recorded as a permanent part of the employee's personnel
4. The administrator shall report to the
local health department, immediately upon discovery, the name of an employee
a. Skin test results are ten (10)
millimeters or more induration at the time of employment;
b. Skin test results change from less
than ten (10) millimeters induration to more than ten (10) millimeters; or
c. Chest x-rays are suspicious for
5. Prophylaxis of a person with recent
infection but no disease.
a. A resident or staff member whose skin test
status changes upon annual testing from less than ten (10) to ten (10) or more
millimeters of induration shall be considered to be recently infected with Mycobacterium
b. A recently infected person who has no
sign or symptom of tuberculosis disease upon chest x-ray or medical history shall
be given preventive therapy with isoniazid for six (6) months unless medically
contraindicated by a licensed physician.
c. Medications shall be administered to
patients only upon the written order of a physician or other practitioner acting
within his statutory scope of practice.
d. If an infected person is unable to
take isoniazid therapy, the person shall be advised of the clinical symptoms of
the disease, and shall have an interval medical history and a chest x-ray taken
and evaluated for tuberculosis disease every six (6) months during the two (2)
years following conversion, for a total of five (5) chest x-rays.
6. A staff member who documents
completion of preventive treatment with isoniazid shall be exempt from further
(e) A current personnel record shall be
maintained for each employee which shall include the following:
1. Name, address, and Social Security
2. Health records;
3. Evidence of current registration,
certification or licensure;
4. Records of training and experience;
5. Records of performance evaluation;
6. Evidence of completion of an
orientation to the facility's written policies initiated within the first month
of employment; and
7. Evidence of regular in-service
training which corresponds with job duties and includes a list of training and
(13) Physical and sanitary environment.
(a) The physical plant and premises shall
be maintained to promote the safety and well-being of patients, personnel and
(b) A person shall be designated to be in
charge of services and shall be responsible for the establishment of policies
and procedures for plant maintenance, laundry, and housekeeping.
(c) The institution's buildings, equipment
and surroundings shall be in good repair and shall be neat, clean, free from
accumulations of dirt and rubbish, and free from foul, stale, or musty odors.
(d) The institution shall be free of insects
(e) Garbage receptacles and trash cans shall
be kept clean and shall be stored away from areas used for preparation and
storage of food and the contents shall be regularly removed from the premises.
(f) Hazardous cleaning solutions,
compounds, and substances shall be labeled, stored in closed containers and shall
not be stored with nonhazardous items.
(g) The institution shall have a supply
of clean linen available at all times for the proper care and comfort of
1. Linens shall be handled, stored and
processed to prevent the spread of infection.
2. Clean linen and clothing shall be
stored in clean, dry, dust-free areas.
3. Soiled linen and clothing shall be
placed in suitable bags or closed containers and stored in separate areas.
(h) Sharp wastes, including needles,
scalpels, razors, or other sharp instruments used for patient care procedures
shall be segregated from other wastes and placed in puncture resistant
containers immediately after use.
2. A needle or other contaminated sharp
shall not be purposely bent, broken, or otherwise manipulated by hand as a
means of disposal, except as permitted by Occupational Safety and Health Administration
guidelines at 29 C.F.R. 1910.1030(d)(2)(vii).
3. A sharp waste container shall be
incinerated on or off site, or shall be rendered nonhazardous.
4. Nondisposable sharps, such as large-bore
needles or scissors, shall be placed in a puncture resistant container for
transport to the Central Medical and Surgical Supply Department, in accordance
with 902 KAR 20:009, Section 22.
(14) Patient medical records.
(a) The institution shall have a health
information management service that is responsible for the integrity and
confidentiality of a patient's medical records. A medical record shall be
maintained, in accordance with accepted professional principles, for each
patient admitted to the facility or receiving outpatient services.
(b) The health information management
service shall be under the direction of a Registered Health Information Administrator,
either on a full-time, part-time, or consultative basis, or by a Registered
Health Information Technician on a full-time basis and shall have available a
sufficient number of regularly-assigned employees to insure that records are
stored and retrieved efficiently.
(c) Medical records shall be retained for
a minimum of five (5) years from date of discharge or, in the case of a minor,
three (3) years after the patient reaches age eighteen (18).
(d) The facility shall designate a
location and maintain medical records there in the event the facility ceases to
operate for any reason.
(e) Medical record contents shall be
pertinent and current and shall include the following:
1. Identification data and signed consent
forms, including name and address of next of kin and of person or agency
responsible for patient;
2. Date of admission, name of attending
medical staff member, and allied health professional responsible for the
provision of therapy services;
3. Chief complaint;
4. Medical history including present
illness, past history, family history, and physical examination results;
5. Report of special examinations or
procedures performed and results;
6. Provisional diagnosis or reason for
7. Orders for diet, diagnostic tests,
therapeutic procedures, and medications, including patient limitations, signed
and dated by the medical staff member or other ordering personnel acting within
the limits of his statutory scope of practice if applicable, including records
of all medication administered to the patient;
9. Complete surgical record signed by
attending surgeon or oral surgeon, to include anesthesia record signed by anesthesiologist
or anesthetist, preoperative physical examination and diagnosis, description of
operative procedures and findings, postoperative diagnosis, and tissue diagnosis
by qualified pathologist on tissue surgically removed;
10. Patient care plan which addresses the
comprehensive care needs of the patient, to include the coordination of the
facility's service departments that impact patient care;
11. Nurses' observations and progress
notes of a physician, dentist, or other ordering personnel acting within his
statutory scope of practice;
12. Record of temperature, blood
pressure, pulse, and respiration;
13. Final diagnosis using terminology in
the current version of the International Classification of Diseases or the
American Psychiatric Association's Diagnostic and Statistical Manual, as
14. Discharge summary, including
condition of patient on discharge and date of discharge.
(f) Records shall be indexed according to
disease, operation, and attending medical staff member. Any recognized indexing
system may be used.
1. The disease and operative indices
a. Use recognized nomenclature;
b. Include each specific disease
diagnosed and each operative procedure performed; and
c. Include essential data on each patient
having that particular condition.
2. The attending medical staff index
shall include all patients attended or seen for consultation by each medical
3. Indexing shall be current, within six
(6) months following discharge of the patient.
(g) Medical record review.
1. The institution shall regularly review
and evaluate records maintenance and retention policies and shall propose
improvements if necessary and appropriate.
2. The institution shall establish and
maintain a medical records committee, which shall include a representative from
each service department and which shall report to the administrator. The
a. Review at least quarterly a sampling of
records to measure their adequacy and compliance with established record
maintenance policies and procedures; and
b. Review at least annually the medical
records policies and procedures and make recommendations for consideration by
(h) A statement of professional judgment
and a report of services to an individual shall be signed by the person
qualified by professional competency and official position. The medical record
shall record that services recommended and planned were received by the patient
at the time stated.
(i) Clinical information shall be
recorded as soon as practicable, but no later than forty-eight (48) hours after
(j) Discharge summaries shall be recorded
within thirty (30) days of discharge.
(k) A completed medical record shall
1. Name, address and next of kin;
2. The name and address of the personal
representative, conservator, guardian, or representative payee, if one has been
appointed for the person served;
3. Pertinent history, diagnosis of
disability, rehabilitation problem, goals, and prognosis;
4. Reports from referring sources;
5. Reports of service referrals;
6. Reports from outside consultation, and
from laboratory, radiology, orthotic and prosthetic services;
7. Designation of the case manager for
the patient, unless there is a written policy identifying who is responsible
for the plan management of specified groups;
8. Evidence of the patient's
participation in devising his own plan;
9. Evaluation reports from each service;
10. Reports of staff conferences;
11. The patient's total treatment plan;
12. Treatment plans from each service;
13. Signed and dated service and progress
reports from each service;
14. Correspondence pertinent to the
person being served;
15. A signed and dated authorization from
the patient, his parent or guardian, if information or photographs have been released
16. Discharge report; and
17. Follow-up reports.
Section 3. Provision of Services. (1)
(a) A medication or treatment shall not
be given without a written or verbal order signed by a physician, dentist, or
other ordering practitioner acting within his statutory scope of practice.
(b) A verbal order for a medication shall
be given only to a licensed practical or registered nurse, paramedic, or
pharmacist and shall be signed by a member of the medical staff or other ordering
1. As soon as possible after the order is
2. Within thirty (30) days of the
patient's discharge if the patient is discharged prior to the order being
(c) A verbal order for a diagnostic test
or treatment order may be given to a licensed practitioner acting within his
statutory scope of practice and the institutions' protocols.
(d) At the time received, verbal orders
from medications, diagnostic tests, and treatments shall be:
1. Immediately transcribed by the person
receiving the order;
2. Repeated back to the person requesting
the order to ensure accuracy; and
3. Annotated on the patient's medical
record by the person receiving the order as repeated and verified.
(e) Medications shall be administered by
a physician, registered nurse, dentist, or a licensed practical nurse under the
supervision of a registered nurse, advanced practice registered nurse,
physician's assistant, or a paramedic acting within his scope of practice.
(f) A restraint or protective device,
other than bed rails and wheelchair safety belts shall not be used, except in
an emergency until the attending medical staff member can be contacted, or upon
written or telephone orders of the attending medical staff member. If restraint
is necessary, it shall be the least restrictive protective device which affords
the patient the greatest possible degree of mobility and protection. A locking
restraint shall not be used under any circumstances.
(g) Patient physical. A physician
shall conduct a physical examination and determine whether the patient can
benefit from a rehabilitation program through the use of therapies provided by
the institution within twenty-four (24) hours after admission.
(h) Psychosocial history. Each patient
shall have a history and assessment interview within seventy-two (72) hours
after admission. The following resultant data shall be entered on the patient
1. A determination of current emotional
2. Vocational history;
3. Familial relationships;
4. Educational background;
5. Social support system; and
6. A determination of whether the patient
can benefit from a rehabilitation program through the use of therapies provided
by the institution.
(i) Basic cardiopulmonary resuscitation
shall be available within the institution twenty-four (24) hours a day, seven
(7) days a week.
(2) Staffing requirements.
(a) The program shall have personnel
adequate to meet the needs of patients on a twenty-four (24) hour basis. The
number and classification of personnel required shall be based on the number of
patients and the individual treatment plans. If the staff to patient ratio does
not meet the needs of the patients, the Office of Inspector General shall
determine and inform the program administrator in writing how many additional
personnel are to be added and of what job classification, and shall give the
basis for this determination.
(b) The staffing ratio of therapists and
pathologists to patients shall be equal to or greater than one (1) full-time
equivalent for every three (3) patients. Only licensed or certified therapists
or speech and language pathologists in the areas of physical therapy,
occupational therapy, speech and language pathology, or psychology shall be
utilized in the computation of this ratio. Certified or licensed assistants
shall not be utilized in the computation of this ratio. The staffing for the facility
shall be utilized in the computation of the ratio.
(c) There shall be no more than one (1)
aide or assistant for each licensed or certified therapist or speech and
language pathologist on staff.
(3) Medical staff services.
(a) Medical care provided in the
institution shall be under the direction of the medical director or a medical
staff member in accordance with staff privileges granted by the governing
(b) Physician services shall be available
twenty-four (24) hours a day on at least an on-call basis.
(c) There shall be sufficient medical
staff coverage for services provided in the institution in keeping with the
size of the institution, the scope of services provided and the types of patients
admitted to the facility.
(d) An individual rehabilitation program
plan shall be developed for each patient under the supervision of a physician.
The attending physician shall attend and actively participate in conferences
concerning those served.
(e) The attending physician shall
complete the discharge summary and sign the records within thirty (30) days of
(f) The physician responsible for the
patient's rehabilitation program shall have specialized training or experience
(g) There shall be direct individual
contact by a physician on any day there is an active interdisciplinary
(4) Nursing services.
(a) Nursing services shall be directed
toward prevention of complications of disability, restoration of optimal
functioning, and adaptation to an altered lifestyle.
1. The institution shall have a nursing
department organized to provide basic nursing services and rehabilitation
nursing services. A registered nurse with training and experience in rehabilitative
nursing shall serve as director of the nursing department.
2. A registered nurse shall be on duty at
a. Nursing staff for each nursing unit
shall be supervised by a registered nurse in order to insure immediate
availability of a registered nurse with rehabilitation experience on a
twenty-four (24) hour basis.
b. Other nursing personnel shall be
present in sufficient numbers to provide nursing care not requiring the
services of a registered nurse.
c. Nursing care shall be documented on
each shift by staff members rendering care to patients. This documentation
shall describe the nursing care provided and shall include information and
observations significant to the continuity of patient care.
(b) Rehabilitation nursing services shall
include physical and psychosocial assessment of the following:
1. Body systems related to the patient's
physical rehabilitation nursing needs, with special emphasis on skin integrity,
bowel and bladder function, and respiratory and circulatory systems function;
2. Self-care skills development;
3. Interpersonal relationships;
4. Adaptation mechanisms and patterns
used to manage stress; and
5. Sleep and rest patterns.
(c) Nursing services shall include the
1. Health maintenance and discharge
2. Prevention of the complications of
3. Physical care including hygiene, skin
care, physical transfer from one place to another, positioning, and bowel and
4. Psychosocial care including
socialization, adaptation to an altered lifestyle; and
5. Reinforcement of the multidisciplinary
(d) A nurse shall collaborate with the
patient, family, and other disciplines and agencies in discharge planning and
(e) Rehabilitation shall monitor the
degree of achievement of individualized nursing patient care goals.
(5) Multidisciplinary team. A
multidisciplinary team shall develop individual treatment plans and discharge
plans and shall conduct quality assurance reviews. The multidisciplinary team
shall include a physician, rehabilitation nurse, social worker or psychologist,
and a therapist involved in the patient's care.
(6) Case manager.
(a) A single case manager shall be
designated for each patient served. The provision of services by the
institution to each patient shall be organized through the patient's case manager.
The case manager shall:
1. Assume responsibility for the patient
during the course of treatment;
2. Coordinate the treatment plan; and
3. Cultivate the patient's participation
in the program.
(b) If more than one (1) major program is
being provided simultaneously, there shall be only one (1) case manager. If the
patient's plan changes sequentially from one (1) program area to another, a new
case manager may be assigned.
(c) The patient's case manager shall
evaluate regularly the appropriateness of the treatment plan in relation to the
progress of the patient toward the attainment of stated goals. The case manager
shall assure that:
1. The patient is adequately oriented;
2. The plan proceeds in an orderly,
purposeful, and timely manner; and
3. The discharge decision and
arrangements for follow-up are properly made.
(7) Treatment plan.
(a) The multidisciplinary team, with the
participation of the patient shall, within seven (7) days after admission for
rehabilitation, develop an individual treatment plan based on the patient's
medical evaluation and psychosocial history and assessment, which shall be
reviewed at least biweekly. The treatment plan shall include:
1. An assessment of the biological,
social and psychological needs of the patient, performed by qualified health
2. A description of the patient's
capacities, strengths, disabilities, and weaknesses;
3. Identification of the patient's
rehabilitation goals stated in functional, performance and behavioral
objectives relative to the performance of life tasks and capabilities, with
criteria for termination of treatment or discharge from the program;
4. Participation of the patient and his
family, to the extent possible;
5. Physician input relative to both the
general medical and rehabilitation medical needs of the patient;
6. Discharge planning addressed as part
of goal setting as early as possible in the rehabilitation process;
7. Time intervals at which treatment or
service outcomes will be reviewed;
8. Anticipated time frames for accomplishment
of the individual's specified goals;
9. The measures to be used to assess the
effects of treatment or services; and
10. The person responsible for
implementation of the plan.
(b) The institution shall obtain and
retain a signed consent form if applicable.
(c) The institution shall adopt a
procedure to protect against release of a patient to an unauthorized individual
if a patient is unable to represent his own interests.
(8) Therapeutic services.
(a) The institution shall provide allied
services directly or under contract. Skilled therapy shall be provided to a
patient at an intensity appropriate to the disability and to the patient's
ability to tolerate treatment, at least three (3) hours per person per day, and
at least five (5) times per week, or, if the patient's medical condition limits
participation, an equivalent amount of combined therapy, medical, nursing, and
other professional care that shall be provided.
(b) Occupational therapy services shall
be provided by or under the supervision of an individual certified by the
American Occupational Therapy Association as an occupational therapist.
Services shall include:
1. Assessment and treatment of functional
performance; independent living skills; prevocational or work adjustment
skills; educational, play or leisure and social skills.
2. Assessment and treatment of
performance components; neuromuscular, sensori-integrative, cognitive and
3. Therapeutic interventions, adaptations
4. Individualized evaluations of past and
current performance, achieved through observation of individual or group tasks,
standardized tests, record review, interviews, or activity histories.
5. Assessment of architectural barriers
in home and workplace, and recommendation for equipment, adaptations, and
6. Treatment goals, achieved by
modalities and techniques which include:
a. Task oriented activities; simulation
or actual practice of work, self-care, home management, leisure and social
skills and their components, creative media, games, computers and other
b. Prevocational training;
c. Sensorimotor activities;
d. Patient and family education and
e. Design, fabrication and application of
f. Guidance in use of adaptive equipment
and prosthetic devices;
g. Adaptation to physical and social
environment, and use of therapeutic milieu;
h. Joint protection and body mechanics;
j. Work simplification and energy
k. Cognitive remediation.
7. Occupational therapy services that
monitor the extent to which goals are met relative to assessing and increasing the
patient's functional ability in daily living skills.
(c) Physical therapy services shall be
provided by or under the supervision of a licensed physical therapist employed
on a full-time basis by a freestanding specialty hospital, or at least twenty
(20) hours per week for a general hospital based unit.
1. Services shall include the following:
a. An initial physical therapy evaluation
and assessment of the patient prior to the provision of services;
b. Development of treatment goals and
plans in accord with the initial evaluation findings, with treatment aimed at
preventing or reducing disability or pain and restoring lost function; and
c. Therapeutic interventions which focus
on posture, locomotion, strength, endurance, balance, coordination, joint
mobility, flexibility, and restoring loss of function.
2. Physical therapy services shall
monitor the extent to which services have met therapeutic goals relative to the
initial and all subsequent examinations, and the degree to which improvement
occurs relative to the identified movement dysfunction or reduction of pain associated
(d) Psychological services shall be
provided by or under the supervision of a licensed psychologist.
1. Assessment areas shall include
psychological, vocational, and neuropsychological functioning.
2. Interventions include individual and
group psychotherapy; family consultation and therapy; and design of specialized
psychological intervention programs including behavior modification, behavioral
treatment regimens for chronic pain, and biofeedback and relaxation procedures.
3. Psychological services shall monitor
the cognitive and emotional adaptation of the patient and family to the
(e) Speech-language services shall be
provided by or under the supervision of a licensed speech-language pathologist
certified in clinical competency by the American Speech-Language-Hearing Association.
Services shall include the following:
1. Screening to identify individuals who
require further evaluation to determine the presence or absence of a communicative
2. Speech and language competency
evaluation resulting in the pathologist's plan, direction, and conduct of habilitative,
rehabilitative, and counseling programs to improve language, voice, cognitive
linguistic skills, articulation, fluency, and adjustment to hearing loss, and
an assessment and provision of alternative and augmentative communicative
3. A plan for discharge and provision for
the patient's understanding of communication abilities and prognosis; and
4. Monitoring of services for
effectiveness of actions taken to improve communication skills of patients.
(9) The institution shall provide the
following services directly or through a contractual arrangement with other
providers, as needed, in accordance with the institution's program narrative:
(a) Social work services shall be
provided by an individual with a masters degree in social work from a
curriculum accredited by the Council for Social Work Education.
1. The scope of rehabilitation social
services shall include the following areas related to work assessment and
interventions to facilitate rehabilitation:
a. Assessment of the personal coping
history and current psychosocial adaptation to the disability;
b. Assessment of immediate and extended
family and other support persons relative to increasing support networks; and
c. Assessment of housing, living
arrangements, and stability and source of income relative to facilitating
2. Intervention strategies, aimed at
increasing effectiveness of coping, strengthening informal support systems, and
facilitating continuity of care, shall include at least the following:
a. Discharge planning;
b. Casework with individual patients;
c. Family counseling and therapy;
d. Group work focused on both education
and therapy; and
e. Community service linkage referrals.
3. Social work services shall monitor the
achievement of goals relative to discharge planning activities designed to meet
the basic sustenance, shelter, and comfort needs of patients and their
(b) Audiology services shall be provided
by or under the supervision of a licensed audiologist who is certified by the
American Speech-Language-Hearing Association. The audiologist shall direct and
conduct required aural habilitation and rehabilitation programs after determination
of the patient's range, nature, and degree of auditory and vestibular function
using instrumentation such as audiometers, electroacoustic emittance equipment,
brain stem evoked response equipment, and electronystagmographic equipment.
Programs shall include:
1. Hearing aid and assistive listening
device selection and orientation;
2. Counseling, guidance and auditory
3. Speech reading.
(c) Vocational and vocational
rehabilitation services shall provide assessment and evaluation of the
patient's or client's need for services to enable return to productive activity
through the use of testing, counseling, and other service-related activities.
Identified needs are met either directly or through referral. Services shall
1. Evaluation and assessment focusing on
maximizing the independent, productive functioning of the individual;
2. Comprehensive services to include at
least the following areas:
a. Physical and intellectual capacity
b. Interest and attitudes;
c. Emotional and social adjustment;
d. Work skills and capabilities;
e. Vocational potential and objectives;
f. Job analysis;
3. The use of instruments, equipment and
methods, under supervision of a qualified therapist;
4. Preparation of a written report, with
interpretation and recommendations, to be shared with the individual and
referral source; and
5. Monitoring the degree to which
appropriate work skills are achieved; the improvement in independent
functioning relative to work skill capability; and, the achievement of
(d) Prosthetic or orthotic services.
1. Prosthetic and orthotic services shall
be provided by a specialist who is qualified to manage the orthotic or prosthetic
needs of a patient by:
a. Performing an examination;
b. Participating in the prescribing of
c. Designing and fitting specialized
d. Following up to ensure that the
equipment is properly functioning and fitting.
2. Monitoring of prosthetic or orthotic
services shall include:
a. Documented evidence of communication
with the prescribing physician; and
b. Patient satisfaction with the function
and fit of the equipment.
(e) Therapeutic recreation services shall
be provided by or under the supervision of a therapeutic recreation specialist
or an occupational therapist. The services may be provided in conjunction with
occupational therapy services. Services shall include the following:
1. Assessment of the patient's leisure or
social or recreational abilities, deficiencies, interests, barriers, life
experiences, needs, and potential;
2. Treatments designed to improve social,
emotional, cognitive and physical functional behaviors as a necessary prerequisite
to future leisure or social involvement;
3. Leisure education designed to help the
patient acquire knowledge, skills and attitudes needed for independent leisure
or social involvement, community adjustment, responsible decision-making, and
use of free time; and
4. Monitoring which measures the extent
to which goals are achieved relative to the use of leisure time and
(f) Pharmaceutical services. The
institution shall provide for handling, storing, recording, and distributing pharmaceuticals
in accordance with state and federal law. A supply of medicinal agents adequate
to meet institutional needs shall be available on site. They shall be stored in
a safe manner and kept properly labeled and accessible. Controlled substances
and other dangerous or poisonous drugs shall be handled in a safe manner to
protect against their unauthorized use. Controlled substances shall be under
double lock. There shall be adequate refrigeration for biologicals and drugs
which require refrigeration.
1. An institution which maintains a
pharmacy for the compounding and dispensing of drugs shall provide
pharmaceutical services under the supervision of a registered pharmacist on a
full-time or part-time basis, according to the size and demands of the program.
a. The pharmacist shall be responsible
for supervising and coordinating the activities of the pharmacy department.
b. Additional personnel competent in
their respective duties shall be provided in keeping with the size and activity
of the department.
2. An institution not maintaining a
pharmacy shall have a drug room utilized only for the storage and distribution
of drugs, drug supplies and equipment. Prescription medications shall not be
dispensed in this area. The drug room shall be operated under the supervision
of a pharmacist employed at least on a consultative basis.
a. The consulting pharmacist shall assist
in establishing procedures for the distribution of drugs, and shall visit the
institution on a regular schedule.
b. The drug room shall be kept locked and
the key shall be in the possession of a responsible person on the premises, as
designated by the administrator.
c. A record shall be kept of each
transaction of the pharmacy or drug room and shall be correlated with other
institution records if indicated.
3. The pharmacist shall establish and
maintain a system of records and bookkeeping, in accordance with policies of
the institution, for maintaining control over requisitioning and dispensing of drugs
and drug supplies, and for charging patients for drugs and pharmaceutical supplies.
4. A record of the stock on hand and of
the dispensing of all controlled substances shall be maintained in such a
manner that the disposition of any particular item may be readily traced.
5. The medical staff in cooperation with
the pharmacist and other disciplines, as necessary, shall develop policies and
procedures that govern the safe administration of drugs, including:
a. The administration of medications only
upon the order of an individual who has been assigned medical clinical
privileges or who is an authorized member of the house medical staff;
b. Review of the ordering practitioner's
original order, or a direct copy, by the pharmacist dispensing the drugs;
c. The establishment and enforcement of
automatic stop orders;
d. Proper accounting for and disposition
of unused medications or special prescriptions returned to the pharmacy as a
result of the patient being discharged, or if such medications or prescriptions
do not meet requirements for sterility or labeling;
e. Provision for emergency pharmaceutical
f. Provision for reporting adverse
medication reactions to the appropriate committee of the medical staff.
6. Therapeutic ingredients of medications
dispensed shall be included in the United States Pharmacopeia- National
Formulary (USP-NF), the United States Pharmacopeia-Drug Information (USP_DI),
or the American Dental Association (ADA) Guide to Dental Therapeutics except
for those drugs and biologicals unfavorably evaluated in the ADA Guide to
Dental Therapeutics, or shall be approved for use by the appropriate committee
of the medical staff.
a. A pharmacist shall be responsible for
determining specifications and choosing acceptable sources for all drugs, with
approval of the appropriate committee of the medical staff.
b. There shall be available a formulary
or list of drugs accepted for use in the institution which shall be developed
and amended at regular intervals by the appropriate committee of the medical
(g) Radiology services.
1. The institution shall provide
diagnostic radiology services directly or through arrangements with a radiology
service that has a current license or registration pursuant to KRS 211.842 to
211.850 and associated administrative regulations. If the institution provides
radiology services directly, the institution shall have:
a. A radiologist, on at least a
consulting basis, to function as medical director of the department and to
interpret films that require specialized knowledge for accurate reading; and
b. Personnel adequate to supervise and
conduct the services.
2. Written policies and procedures
governing radiologic services shall be in accordance with 902 KAR 100:115.
3. The radiology department shall be free
of hazards for patients and personnel. Proper safety precautions shall be maintained
against fire and explosion hazards, electrical hazards and radiation hazards.
(h) Laboratory services. The institution
shall provide laboratory services directly or through arrangements with a
licensed facility which has the appropriate laboratory facilities, or with an
independent laboratory licensed pursuant to KRS 333.030 and associated
1. Laboratory facilities and services
shall be available at all times.
a. Emergency laboratory services shall be
available twenty-four (24) hours a day, seven (7) days a week, including
holidays, either in the institution or through a contractual arrangement as
specified in subsection (10) of this section.
b. The conditions, procedures, and
availability of services provided by an outside laboratory shall be in writing
and available in the institution.
2. Dated reports of laboratory services
provided shall be filed with the patient's medical record and duplicate copies
shall be kept in the department.
a. The original report from work
performed by an outside laboratory shall be filed in the patient's medical
b. The laboratory report shall have the
name of the technologist who performed the test.
c. A request for a laboratory test shall
be ordered and signed by an ordering practitioner acting within his statutory
scope of practice.
3. If laboratory services are provided
directly, there shall be a basic clinical laboratory which provides services
necessary for routine examinations.
a. Equipment necessary to perform the
basic tests shall be provided by the facility.
b. Equipment shall be in good working
order, routinely checked, and precisely calibrated.
c. Clinical laboratory examinations shall
include chemistry, microbiology, hematology, serology, and clinical microscopy.
d. There shall be a clinical laboratory
director and a sufficient number of supervisors, technologists and technicians
to perform promptly and proficiently the tests requested of the laboratory.
Laboratory services shall be under the direction of a pathologist on a
full-time, part-time, or a consultative basis. The laboratory shall not perform
procedures and tests which are outside the scope of training of the laboratory
(i) Dietary services.
1. The institution shall provide dietary
services directly or by contract.
2. The dietary service shall be
organized, directed and staffed to provide quality food service and optimal
a. The dietary department shall be
directed on a full-time basis by an individual who by education or specialized
training and experience is knowledgeable in food service management.
b. The dietary service shall have at
least one (1) dietician or nutritionist, either full time, part time, or on a
consultative basis, to supervise the nutritional aspects of patient care.
c. Sufficient additional personnel shall
be employed to perform assigned duties to meet the dietary needs of all
d. The dietary department shall have
available for all dietary personnel current written policies and procedures for
food storage, handling, and preparation.
e. An in-service training program, which
shall include the proper handling of food, safety and personal grooming, shall
be given at least quarterly for new dietary employees.
3. Menus shall be planned, written and
rotated to avoid repetition. Nutritional needs shall be met in accordance with
recommended dietary allowances of the Food and Nutrition Board of the National
Research Council of the National Academy of Sciences and in accordance with the
medical staff member's orders.
4. Meals shall correspond with the posted
menu. If changes in menu are necessary, substitutions shall provide equal nutritive
value and the changes shall be recorded on the menu. Menus shall be kept on
file for thirty (30) days.
5. Each diet, regular or therapeutic,
shall be prescribed in writing, dated, and signed by the attending medical
staff member or other ordering practitioner acting within his statutory scope
of practice. Ordering information shall be specific and complete and shall
include the title of the diet, modifications in specific nutrients stating the
amount to be allowed in the diet, and specific problems that may affect diet or
6. Food shall be:
a. Prepared by methods that conserve
nutritive value, flavor, and appearance;
b. Served at the proper temperature; and
c. Served in a form to meet individual
patient needs, including cut, chopped, or ground.
7. If a patient refuses foods served,
nutritious substitutions shall be offered.
8. At least three (3) meals or their
equivalent shall be served daily with not more than a fifteen (15) hour span
between a substantial evening meal and breakfast, unless otherwise directed by
the attending medical staff member. Meals shall be served at regular times. Between-meal
or bedtime snacks of nourishing quality shall be offered.
9. The dietary service shall comply with
KRS 217.015 to 217.045 and 902 KAR 45:005.
(10) If a service is provided under
contract, the contract shall:
(a) Require that the service is in
accordance with the plan of care approved by the physician responsible for the
patient's care, except in the case of an adverse reaction to a specific
(b) Specify the geographical area in
which the service is to be furnished;
(c) Provide that personnel and services
contracted for meet the same requirements as those which would be applicable if
the personnel and services were furnished directly;
(d) Provide that personnel will
participate in conferences required to coordinate the care of an individual
patient, as needed;
(e) Provide for the preparation of
treatment records, with progress notes and observations, and their prompt
incorporation into the clinical records of the institution; and
(f) Specify the period of time the
contract is to be in effect and the manner of termination or renewal.
(11) Outpatient services.
(a) An institution which has an organized
outpatient department shall have written policies and procedures relating to
the staff, functions of service, and outpatient medical records.
(b) The outpatient department shall be
organized in sections or clinics, the number of which shall depend upon the
size and degree of departmentalization of the medical staff, the available
facilities, patient needs, and the program narrative.
(c) The outpatient department shall have
appropriate cooperative arrangements and communications with community agencies
such as home health agencies, the local health department, social and welfare
agencies, and other outpatient departments.
(d) Services offered by the outpatient
department shall be under the direction of a physician who is a member of the
1. A registered nurse shall be
responsible for the nursing services of the department.
2. The number and type of other personnel
employed shall be determined by the volume and type of services provided and
type of patient served in the outpatient department.
(e) Necessary laboratory and other
diagnostic tests shall be available either through the facility or a laboratory
in a licensed facility or a laboratory licensed pursuant to KRS 333.030 and associated
(f) Medical case records shall be
maintained and, if appropriate, coordinated with other institution case
1. The outpatient medical record shall be
filed in a location which ensures ready accessibility to the medical staff
members, nurses, and other personnel of the outpatient department.
2. Information in the medical record
shall be complete and sufficiently detailed relative to the patient's history,
physical examination, laboratory and other diagnostic tests, diagnosis, and
treatment to facilitate continuity of care. (14 Ky.R. 105; Am. 452;
eff. 9-10-1987; 18 Ky.R. 852; eff. 10-16-1991; 25 Ky.R. 2971; 26 Ky.R. 1161;
eff. 12-15-1999; 33 Ky.R. 1159; 1849; 2306; eff. 3-1-2007; TAm eff. 3-11-2011.)