216-40-10 R.I. Code R. § 16.10

Current through June 12, 2024

Section 216-RICR-40-10-16.10 - Organization and Management

16.10.1Governing 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.

16.10.2Administrator

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.

16.10.3Medical 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.

16.10.4Medical 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.

16.10.5Organization

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.

16.10.6Personnel 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.

16.10.7Interdisciplinary 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.

16.10.8Contracts 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.

16.10.9Clinical 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.

16.10.10Rights 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.

16.10.11Financial 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

16.10.12Abuse, 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.

16.10.13Uniform 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.

216 R.I. Code R. § 216-RICR-40-10-16.10