216 R.I. Code R. § 216-RICR-40-10-16.10 - Organization and Management
16.10.1
Governing Body
A. There shall be
an organized governing body or equivalent legal authority ultimately
responsible for:
1. The management, fiscal
affairs, and operation of the rehabilitation hospital center;
2. The assurance of quality care and
services; and
3. Compliance with
all federal, state and local laws and regulations pertaining to rehabilitation,
fire, safety, sanitation, communicable and reportable diseases, and other
relevant health and safety requirements and with all rules and regulations of
this Part.
B. The
governing body or other legal authority shall furthermore be responsible to
define the population and communities to be served and the scope of services to
be provided.
C. The governing body
or other legal authority shall also be responsible to:
1. Provide physical resources and equipment
to facilitate the delivery of prescribed services and to ensure that the entire
center is accessible to the disabled;
2. Provide a sufficient number of trained,
experienced and competent personnel to provide appropriate care and supervision
for all patients and to ensure that patients' needs are met; and
3. Determine that qualifications of
personnel, including consultants, as may be required in this Part, and to
consider such qualifications as education, training, experience, board
certification, and evidence of current professional practice and licensure as
may be required by law or regulation, and such other relevant
factors.
D. The governing
body or other legal authority shall designate:
1. an administrator who shall be responsible
for the management and operation of the center; and
2. a medical director who assumes overall
responsibility for the health and rehabilitation care and to ensure achievement
and maintenance of quality standards of professional practice.
E. The governing body shall adopt
and maintain written by-laws and rules and regulations or acceptable equivalent
which defines responsibilities for the operation and performance of the
organization, identified purposes, and means of fulfilling such. Such by-laws,
rules and regulations shall include:
1. A
statement of purpose;
2. A
statement of qualifications for membership and method of selecting members of
the governing body;
3. A statement
of the authority and responsibility delegated to the administrator, the medical
director and to the medical staff;
4. Provision for the selection and
appointment of medical director and medical staff;
5. Provision for the approval of the medical
staff by-laws and/or rules and regulations;
6. Provision of guidelines for the
relationships among the governing body, the administrator, the medical director
and medical staff;
7. A policy
statement concerning the development and implementation of short and long range
plans in accordance with R.I. Gen. Laws Chapter 23-17;
8. A policy statement concerning the
publication of an annual report, including a certified financial statement;
and
9. Provision that contracts
with outside providers of services be restricted to those which comply with
federal, state and local laws and regulations and in accordance with
§16.10.8 of this Part.
F. In addition, the governing body or other
legal authority shall establish administrative policies pertaining to no less
than the following:
1. Responsibilities of
the administrator and the medical director;
2. Conflict of interest on the part of the
governing body, professional staff and employees;
3. The services to be provided;
4. Criteria for the selection, admission,
discharge and transfer of patients from one level of care to another (inpatient
- day patient - outpatient) or transfer to another facility; (see
§16.11.1(B) of this Part)
5.
Patient/family consent and involvement in the development of patient care
plan;
6. Developing support network
as may be deemed appropriate;
7.
Linkages and referrals with community and other health care facilities or
agencies to assure continuity of patient care and to support services of the
center; and
8. Such other matters
as may be relevant.
16.10.2
Administrator
The administrator shall be directly responsible to the governing body for the management and operation of the center and shall provide liaison between the governing body and the medical staff.
16.10.3
Medical Director
A. The overall responsibility for the
rehabilitation and health care needs and services of patients shall be under
the direction of a physician who is licensed in the State of RI and certified
by the American Board of Physical Medicine and Rehabilitation, or who has
specific education and experience in rehabilitation and who shall be
responsible for:
1. The coordination and
supervision of holistic health care and rehabilitation programs and
services:
2. The achievement and
maintenance of quality assurance of professional practices through a mechanism
for the assessment of patient care outcomes;
3. Participation in the interdisciplinary
team and in the development, implementation and assessment of patient of
care;
4. Establishment and
maintenance of a quality assurance program in accordance with the provisions of
§16.11.9 of this Part; and such other responsibilities as may be deemed
appropriate.
16.10.4
Medical Staff
A. Each center shall have an organized
medical staff responsible to the governing body who shall be responsible to
maintain standards of professional performance through staff appointment
criteria, continuing peer review and other appropriate evaluation
mechanisms.
B. The medical staff,
subject to the approval of the governing body, shall adopt by-laws and/or rules
and regulations incorporating details of its general powers, duties and
responsibilities including the types of committees, delineation and clinical
privileges of non-physician practitioners and designation of personnel
qualified to prescribe or administer drugs.
C. A copy of approved medical staff by-laws
and/or rules and regulations and revisions thereto, shall be submitted to the
state agency.
16.10.5
Organization
A. The internal
organization of the center shall be structured to include appropriate clinical
programs and services consonant with the health and rehabilitative needs of its
defined population.
B. Each center
shall maintain clearly written definitions of its organization authority,
responsibilities and relationships.
C. Each clinical program and service shall
maintain:
1. Clearly written definitions of
its organization, authority, responsibilities and relationships;
2. Written patient care policies and
procedures; and
3. Written
provision for systematic evaluation of programs and services.
D. Every licensed center and its
insurance carrier shall cooperatively, as a part of their administrative
function, establish an internal risk management program in accordance with the
requirements of R.I. Gen. Laws §
23-17-24.
16.10.6
Personnel and Safe Patient
Handling
A. The center shall maintain a
sufficient number of qualified personnel to provide effective patient care and
all other related services.
1. Various
categories of personnel working in patient care areas shall be clearly
identifiable to patients and the public.
B. There shall be written personnel policies
and procedures which shall be made available to personnel.
C. There shall be a job description for each
position which delineates the qualifications, duties, authority and
responsibilities inherent in each position.
1.
For those selected non-licensed personnel authorized to administer drugs in
accordance with §16.11.4(B)(3) of this Part, a job description delineating
qualifications, duties and responsibilities shall be
provided.
D. Provisions
shall be made for orientation and continuing in-service education for
personnel.
E. There shall be
written evidence that staff demonstrate competencies necessary to work in
specific areas and/ or with specific patient populations.
F. Upon hire and prior to delivering
services, a pre-employment health screening shall be required for each
individual who has or may have direct contact with a patient in the
rehabilitation hospital. Such health screening shall be conducted in accordance
with the rules and regulations pertaining to Immunization, Testing, and Health
Screening for Health Care Workers (Part
20-15-7
of this Title).
G. National
criminal background checks shall be conducted in accordance with R.I. Gen. Laws
§§23-17.7.1 -17,
23-17-62
and 23-17.7.1 -20 for Center personnel whose employment involves routine
contact with a patient.
H.
Personnel records shall be maintained for each employee, shall be available at
all times for inspection and shall include:
1.
Current and background information covering qualifications for
employment;
2. Records of
completion of required training and educational programs;
3. Records of all required health
examinations which shall be kept confidential; and
4. Evidence of current registration,
certification or licensure for all personnel subject to statutory
requirements.
I. An
in-service educational program shall be conducted on an ongoing basis, which
shall include an orientation program for new personnel and a program for the
development and improvement of skills of all personnel. The in-service program
shall be geared to the rehabilitation needs of patients, food service
sanitation, fire prevention and safety, confidentiality of patient information,
rights of patients and any other area related to rehabilitation.
1. Provision shall be made for written
documentation of programs, including attendance. Flexible program schedules
shall be formulated at least two months in advance.
J. A health care facility shall require all
persons, including students, who examine, observe, or treat a patient or
resident of such facility to wear a photo identification badge which states, in
a reasonably legible manner, the first name, licensure/registration status, if
any, and staff position of such person.
K. Safe Patient Handling. Each licensed
center hospital shall establish a safe patient handling committee, which shall
be chaired by a professional nurse or other appropriate licensed health care
professional. A center may utilize any appropriately configured committee to
perform the responsibilities of this section. At least half of the members of
the committee shall be hourly, non-managerial employees who provide direct
patient care.
1. Each licensed center shall
develop a written safe patient handling program, with input from the safe
patient handling committee, to prevent musculoskeletal disorders among health
care workers and injuries to patients. As part of this program, each licensed
health care facility shall:
a. Implement a
safe patient handling policy for all shifts and units of the facility that will
achieve the maximum reasonable reduction of manual lifting, transferring, and
repositioning of all or most of a patient's weight, except in emergency,
life-threatening, or otherwise exceptional circumstances;
b. Conduct a patient handling hazard
assessment. This assessment should consider such variables as patient-handling
tasks, types of nursing units, patient populations, and the physical
environment of patient care areas;
c. Develop a process to identify the
appropriate use of the safe patient handling policy based on the patient's
physical and mental condition, the patient's choice, and the availability of
lifting equipment or lift teams. The policy shall include a means to address
circumstances under which it would be medically contraindicated to use lifting
or transfer aids or assistive devices for particular patients;
d. Designate and train a registered nurse or
other appropriate licensed health care professional to serve as an expert
resource, and train all clinical staff on safe patient handling policies,
equipment, and devices before implementation, and at least annually or as
changes are made to the safe patient handling policies, equipment and/or
devices being used;
e. Conduct an
annual performance evaluation of the safe patient handling with the results of
the evaluation reported to the safe patient handling committee or other
appropriately designated committee. The evaluation shall determine the extent
to which implementation of the program has resulted in a reduction in
musculoskeletal disorder claims and days of lost work attributable to
musculoskeletal disorder caused by patient handling, and include
recommendations to increase the program's effectiveness; and
f. Submit an annual report to the safe
patient handling committee of the facility, which shall be made available to
the public upon request, on activities related to the identification,
assessment, development, and evaluation of strategies to control risk of injury
to patients, nurses and other health care workers associated with the lifting,
transferring, repositioning, or movement of a patient.
2. Nothing in this section precludes lift
team members from performing other duties as assigned during their
shift.
3. An employee may, in
accordance with established facility protocols, report to the committee, as
soon as possible, after being required to perform a patient handling activity
that he/she believes in good faith exposed the patient and/or employee to an
unacceptable risk of injury. Such employee reporting shall not be cause for
discipline or be subject to other adverse consequences by his/her employer.
These reportable incidents shall be included in the facility's annual
performance evaluation.
16.10.7
Interdisciplinary Team
A. The governing body or other legal
authority shall designate an interdisciplinary team composed of staff personnel
which includes:
1. Patient/family;
2. Physician(s) (to include physician(s) who
are experts in the treatment of specific conditions and also in the
rehabilitation of the patient as a whole);
3. Professional (registered) nurse;
4. Social worker;
5. Physical, occupational, speech and
hearing, psychologists; and
6. Such
other staff and non-staff personnel as may be deemed necessary.
B. The interdisciplinary team
shall be responsible for patient education, the development, implementation and
assessment of patient/family plans of care, and in addition:
1. The supervision of care, clinical health
and rehabilitation services provided;
2. The provision of direct patient care as
may be required and appropriate;
3.
The review on an ongoing regularly scheduled basis of patient/family plans of
care, and the revision of such plans of care, and development of a discharge
plan as may be required;
4. The
development of policies and procedures governing patient/family care and
services; and
5. Such other duties
as may be deemed appropriate.
16.10.8
Contracts or Agreements
A. There shall be written contract(s) or
agreement(s) for the provisions of those services which are not provided
directly by the center. The contract(s) or agreement(s) shall clearly delineate
the responsibilities of the parties involved and shall include no less than the
following provisions:
1. The responsibilities,
functions, objectives, terms of agreement, financial arrangements, charges and
other pertinent requirements shall be clearly delineated in the terms of the
contract or agreement negotiated between the parties involved;
2. Assurance that the services to be provided
are in accordance with the plan of care;
3. The manner in which the contracted
services are coordinated, supervised and evaluated;
4. Establish the frequency of patient care
assessment; and
5. Such other
provision as may be deemed appropriate.
16.10.9
Clinical Records
A. A clinical record shall be established and
maintained for every person admitted to any level of care (inpatient, day
patient or outpatient). Such record shall follow the patient at each level of
care in order to insure continuity of care.
B. Written policies and procedures shall be
established regarding content and completion of clinical records.
C. Entries in the clinical record shall be
made by the responsible person providing care or services in accordance with
the center's policies and procedures.
D. The clinical record shall contain
sufficient information to identify the patient and the problem and to describe
the rehabilitation treatment modalities of care and the patient's response to
the rehabilitation care and services.
E. The content of the clinical records
(inpatient, day patient, outpatient) shall conform with applicable standards of
§
16.2(A) of
this Part
F. Provisions shall be
made for the safe storage of clinical records of reproduction in accordance
with §
16.2(B) of
this Part.
G. All clinical records
either original or accurate reproductions shall be preserved for a minimum of
five (5) years following discharge of the patient in accordance with R.I. Gen.
Laws §
23-3-26.
1. Records of minors shall be kept for at
least five (5) years after such minor shall have reached the age of 18
years.
16.10.10
Rights of Patients
A. Every
center shall observe the standards as enumerated in R.I. Gen. Laws Chapter
23-17-19.1
with respect to each patient who is admitted to its center.
B. A copy of the Rights of Patients shall be
given to each patient or his/ her representative upon admission and shall be
posted in a conspicuous place on the premises in accordance with R.I. Gen. Laws
§
23-17-19.2.
16.10.11
Financial
Disclosure
A. Any health care facility
licensed pursuant to R.I. Gen. Laws Chapter 23-17, which refers clients to
another such licensed health care facility or to a residential care/assisted
living facility licensed pursuant to R.I. Gen. Laws Chapter 23-17.4, or to a
certified adult day care program in which the referring entity has a financial
interest shall, at the time a referral is made, disclose in writing the
following information to the client:
1. That
the referring entity has a financial interest in the facility or provider to
which the referral is being made; and
2. That the client has the option of seeking
care from a different facility or provider which is also licensed and/or
certified by the state to provide similar services to the client.
3. The referring entity shall also offer the
client a written list prepared by the Department of Health of all such
alternative licensed and/or certified facilities or providers. Said written
list may be obtained by contacting:
Rhode Island Department of Health |
Center for Health Facility Regulations |
3 Capitol Hill, Room 306 Providence, RI 02908 |
401.222.2566 |
16.10.12
Abuse, Neglect, or
Mistreatment
A. The center shall report
within 24 hours, to the state agency, allegations of patient abuse, neglect or
mistreatment as defined in R.I. Gen. Laws Chapter
23-17-8.
1. The center shall maintain evidence that
all allegations of abuse, neglect, and/or mistreatment have been thoroughly
investigated and that further potential abuse has been prevented while the
investigation is in progress. Appropriate corrective action shall be taken, as
necessary. The results of said investigation shall be reported to the state
agency within five (5) business days.
16.10.13
Uniform Reporting
System
A. Each center shall establish
and maintain records and data in such a manner as to make uniform the system of
periodic reporting. The manner in which the requirements of this regulation may
be met shall be prescribed from time to time in directives promulgated by the
Director with the advice of the Health Services Council.
B. Each center shall report to the state
agency detailed financial and statistical data pertaining to its operations,
services, and facilities. Such reports shall be made at such intervals and by
such dates as determined by the Director and shall include but not be limited
to the following:
1. Utilization of the
center and its services;
2. Unit
cost of center services;
3. Charges
for rooms and services;
4.
Financial condition of the center; and
5. Quality of rehabilitative
care.
C. The state agency
is authorized to make the reported data available to any state agency concerned
with or exercising jurisdiction over the reimbursement or utilization of the
center.
D. The directives
promulgated by the Director pursuant to this Part shall be sent to each center
to which they apply. Such directives shall prescribe the form and manner in
which the financial and statistical data required shall be furnished to the
state agency.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.