902 KAR 20:240. Comprehensive physical rehabilitation hospital services

Link to law: http://www.lrc.ky.gov/kar/902/020/240.htm
Published: 2015

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      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



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"

(FTE) means:

      (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

per week.

      (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

facility training.

      (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

staff meetings;

      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

treatment procedure;

      (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

appropriate committees;

      (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

patient is:

      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

transfer; and

      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

medical record;

      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

meetings; and

      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

given; or

      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

appropriate committees:

      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.

      (12) Personnel.

      (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

and procedures.

      (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

skin test.

      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

screening requirements.

      (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

dates completed.

      (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

and rodents.

      (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

applicable; and

      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

staff member.

      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

committee shall:

      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

the administrator.

      (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

the event.

      (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

or used;

      16. Discharge report; and

      17. Follow-up reports.


      Section 3. Provision of Services. (1)

General requirements.

      (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

given; or

      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

in rehabilitation.

      (g) There shall be direct individual

contact by a physician on any day there is an active interdisciplinary

treatment program.

      (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

all times.

      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

following interventions:

      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

bladder care;

      4. Psychosocial care including

socialization, adaptation to an altered lifestyle; and

      5. Reinforcement of the multidisciplinary

treatment plan.

      (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

care professionals;

      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

psychosocial skills.

      3. Therapeutic interventions, adaptations

and prevention.

      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

different arrangements.

      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

orthotic devices;

      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;

      i. Positioning;

      j. Work simplification and energy

conservation; and

      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

with movement.

      (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

patient's disability.

      (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

discharge plans.

      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

training; and

      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

vocational objectives.

      (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

specialized equipment;

      c. Designing and fitting specialized

equipment; and

      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

socialization skills.

      (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

services; and

      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

administrative regulations.

      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

nutritional care.

      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

eating habits.

      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

medical staff.

      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

administrative regulations.

      (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.)