All Network member practices must have an up-to-date operational Policy and Procedure (P&P) manual specific to each facility. Although it may contain some of the same documentation, an employee handbook or manual will NOT be accepted as a facility’s P&P manual. Items in each section that are marked with an asterisk (*) must be included in the P&P manual.
- Practices may not have any physician ownership (including Chiropractors) or lease any part of their treatment space directly to or from another non-PT/OT practitioner of musculoskeletal medicine.
- At least one owner of the practice must be involved on a full-time basis in the operation of all practice locations applying for membership and must be on-site on a regularly scheduled basis, preferably in at least a part-time clinical role. In situations where an owner does not have a full-time presence in the facility, a senior clinician on-site full-time must be designated as clinic director.
- At least one owner must also be licensed in the state where the practice is located, have a minimum of three years clinical experience in their therapy field and be a member of his/her respective professional organization.
- Each practice must have a mission statement.*
- There must be a description of services provided.*
- Administrative direction of each rehabilitation service offered at the applying facility must be provided by a qualified individual, fully licensed in their state(s) of practice, with a minimum of three years clinical experience in their field of practice.
- Hours of operation for each site within the practice must be clearly stated.*
- All practices must be wheelchair accessible and open full time (minimum of three hours/day, at least five days/week, for a minimum of 40 total hours).
- All care must be rendered free of discrimination as to race, religion, ethnicity, gender and as otherwise guaranteed by law.
- Patient volume may not exceed three patients per hour per therapist or therapy assistant.
- All staff members must be hired and employed in compliance with all applicable laws within the state/local area in which the practice does business.
- All individuals who provide rehabilitation services must have been deemed competent to provide such services as determined by education, training, experience and demonstrated adherence to current standards of care.
- There must be evidence that each individual providing rehabilitation services meets all applicable licensure, certification, or registration requirements.
- Each rehabilitation facility must have a qualified clinical director on-site full-time, who has administrative responsibility for the delivery of patient care and for the supervision of the service(s); who is fully licensed in their state(s) of practice and has a minimum of three years clinical experience in their field of practice.
- There must be a job description on record for all employees of the practice, including non-clinical support staff that clearly delineates the responsibilities and duties of that individual.*
- There must be evidence of performance appraisals for all employees. These appraisals are to be performed no less than once a calendar year. There should be a formal mechanism for these appraisals and a copy of the form used for doing so should be kept on file.*
- Staff education, in-service training, and appropriate continuing education must be provided to all employees, with the procedure for doing so described in the facility’s policies & procedures.* A minimum of two in-services must be presented annually. All professional staff must attend at least six hours of continuing education each year, to include at least six hours of clinically based coursework every 24 months. This continuing education requirement is waived for therapists actively enrolled in a clinically relevant area of study in an accredited graduate program, as well as for newly graduated therapists, for the 12 months following their graduation.
- There must be appropriate reception/clerical coverage available on site a minimum of 50% of the total hours of operation for the practice.
- Provision must be made to allow the practice to be contacted during times when clerical/reception staff is unavailable, i.e. during lunch, after hours.
- Each practice must have a written policy in place to assure appropriate vacation/sick coverage for all staff members* (both clinical and support staff), for expected and unanticipated absence and be able to demonstrate evidence of that coverage. Individuals providing treatment to patients as covering personnel must be a therapist or therapist assistant, licensed &/or registered [as required by state law] to practice in the state in which the coverage takes place.
- Safety issues, including performance requirements and quality controls for all equipment used in the provision of patient care services, must be addressed.
- Sufficient space, equipment and facilities must be available to support the clinical, educational and administrative functions of the rehabilitation services provided.
- Exits must be marked and each facility must have an appropriate number and type of fire extinguishers accessible on the premises, even if a sprinkler system is in place. Extinguishers must be maintained/inspected & tagged annually by a certified vendor (or replaced each year). Emergency phone numbers must be prominently posted by each outgoing telephone, even if only “911”. A map of the facility, picturing all exits and exit paths, must be posted in easy view of patients and staff.
- Basic emergency supplies must be readily accessible on the premises, to include at a minimum a blood pressure cuff, stethoscope and self-contained basic first aid kit.
Each facility must have an emergency plan.* This plan must include, in writing:
- The phone numbers of the ambulance service(s), police department/precinct and local fire station providing coverage in their area.
- The phone number of the local hospital or doctor available to provide emergency care.
- A map of the practice, with fire exits and routes to them clearly marked.* The map & phone numbers must also be posted prominently within the facility.
- Appropriate & specific actions to be taken by staff in the event of medical emergency, fire or other disaster, loss of electricity to the practice, or any other event where patient safety is an issue &/or evacuation of the premises is required.*
- If the facility has an isolated treatment area [i.e. therapeutic pool], there must be a method by which staff can signal for assistance in an emergency. In the case of therapeutic pools, there must be a specific procedure for pool emergencies.*
- General infection control guidelines must be developed and enforced for the protection of patients, staff and equipment.*
- There must be a policy for the cleaning &/or disinfecting of all equipment, which must list the person(s) responsible for the task, the method(s) [including products used] for doing so, and the frequency at which it is done.*
- Where applicable, there must be a policy on use of whirlpools in the facility for wound care/ debridement purposes, or for patients with open wounds or unhealed surgical incisions. The policy must be in addition to, or contained within, the basic whirlpool cleaning policy.*
- For facilities with therapeutic pools, temperature and chemical levels must be regulated as per local governing board standards. These levels must be checked and recorded, with results kept on file on the premises and available for inspection. Cleaning procedures should be described as part of the cleaning policy described above.
- A patient may only be treated upon referral from a physician or their legal agent (i.e. PA), or in accordance with direct access law of the state in which the practice is located.
- Patient evaluations may only be performed by a licensed Physical or Occupational therapist.
- Measurable goals, which must be described in functional or behavioral terms, must be established for the patient and be stated in writing, including time frames for achievement.
- Physical Therapy Assistances (PTAs) and Certified Occupational Therapy Assistants (COTAs) may not evaluate, re-evaluate or independently progress a patient’s program. They may however, collaborate with the therapist on the patient’s treatment and progression, within the boundaries set by the laws of the state in which the facility is located and as per APTA/AOTA guidelines/standards. Certified Athletic Trainers (ATCs), or other unlicensed staff may not provide any part of actual therapy treatment unless and specifically permitted by law in the state of practice.
- A treatment plan must be developed based on an evaluation that includes an assessment of functional ability appropriate to the patient.
- The patient (& family if/where appropriate) must participate in the development and implementation of the treatment plan, which must be designed to achieve stated patient and therapy goals.
- Treatment goals must be revised as appropriate.
- There must be a note in the medical record, documenting the treatment given, as well as the patient’s progress and response to treatment, for each visit.
- There must be evidence that Medicare referrals and plans of care are updated &/or certified in accordance with current CMS rules.
- There must be written evidence of written &/or verbal communication with the referring physician &/or other appropriate personnel during the course of therapy.
The medical record of the patient receiving rehabilitation services must include, at minimum, the following information:
- A valid written prescription (unless exempt due to valid Direct Access). Verbal orders must be documented & followed up by a written order from the physician
- The reason for referral to rehabilitation services
- A summary of the patient’s clinical condition
- An initial evaluation, including objective/subjective findings, therapy goals with achievement time frames and a treatment plan, including frequency and duration
- Treatment and progress records, including daily treatment session documentation and appropriate re-assessments and updating of patient/therapy goals and treatment plan
- Any incidents involving patients recommended by the Hospital for Special Surgery &/or the Rehabilitation Network must be reported to the Network office within 24 hours of occurrence.
- There must be a procedure for reporting any incidents that might occur during the course of normal treatment.*
- This procedure must include an outline of the steps to be taken by staff &/or administrative staff in the event of an incident, as well as a standard form to be used for reporting the incident.
- There must be a written policy, delineating the billing process used by the practice.*
- There must be a written explanation of fees and billing given to patients, including specific information on co-payments and limitations on coverage for patients insured by Medicare.
- There must a listing of all equipment used by the practice.*
- References re: indications and contraindications of all modalities and categories of exercise equipment (i.e. cardiovascular, PRE, etc.) used in the facility must be available on-site.*
- There must be a process for and evidence of, staff education and competency on all equipment.*
- All electro modality devices used in the treatment of patients [except those in use less than 12 months] must be appropriately calibrated &/or professionally inspected on any annual basis by a vendor qualified to do so. Proof of inspection must be kept on-site.
- It is preferred that member practices of the Hospital for Special Surgery Rehabilitation Network not close at any time other than recognized holidays. However, if an office does temporarily close, it may not do so for more than one week at a time or for more than two weeks a year; unless the facility is deemed unsafe or otherwise unusable due to physical/structural damage or other emergency situation.
- There must be a policy & mechanism in place for the treatment and/or referral of patients for use in the event a member facility must close.* Within this mechanism must be a provision for emergency treatment of patients during the period of time that a facility is temporarily unavailable, regardless of length of closure.* It is preferred that patients of Network members be recommended to other practices within the network.
- If a Network member facility does close, whether on a temporary or permanent basis, the practice must inform the Network Coordinator immediately so alternate referrals can be made and Network listings updated.
- There must be evidence of malpractice insurance for the practice as a whole, which covers each clinician who treats within the practice, with a minimum coverage of $1,000,000\ $3,000,000 aggregate in all cases.
- There must be evidence of general liability coverage for the practice, with a minimum coverage amount of $1,000,000\ $2,000,000 aggregate.
- Practices must maintain workman’s compensation insurance coverage in accordance with the law for the state(s) in which they operate and Employer’s Liability insurance with limits not less than $1, 000,000) per incident.
- Hospital for Special Surgery must be listed as an additional insured on both the malpractice and general liability policies held by the practice.
- It is preferred that all Network member practices are certified Medicare providers.
- All Medicare participants must submit their provider number for all facilities applying for Network membership and demonstrate an appropriate mechanism for updating Medicare plans of care.
- Each practice must provide evidence of a Quality Assurance plan with demonstrable outcomes.*
- This may include but is not limited to: patient satisfaction surveys, functional outcomes measurements/assessments &/or documentation/chart review to check for the completeness and appropriateness of clinical documentation.
Network membership does not automatically transfer in the event of an ownership or address change & may also be affected by significant structural changes to an existing facility.
- The Network must be notified immediately in the event a member site is planning to move, undergoes change or addition to ownership &/or changes the practice name.
- In the event there is any significant change in the ownership or management of a Network member Facility, membership may be suspended while the new ownership structure is reviewed. If more than 50% of the facility’s ownership/management changes, the new ownership entity will be required to re-apply for membership, subject to all required application fees, if it wishes to continue as a Network member. A new membership agreement must also be executed.
- A new application is not required if a member facility changes location however, Network policy on geography will apply and as a result, ongoing membership in the new location is not guaranteed. A new location of an existing member must be inspected within three months of opening, to verify compliance with Network standards.
- If a member facility undergoes significant structural renovation &/or expansion, the Network must be notified upon completion of the work and site inspection conducted within three months, to verify continued compliance with Network standards.
- Application fees cover administrative costs involved with processing and reviewing the submission, verification of information provided and completing the site inspection where required. Once an application is received by the Network, processing fees are not refundable.