Policy & Procedure Manual Requirements

It is a requirement for Network Membership that all practices have an up-to-date Policy and Procedure (P&P) manual specific to each facility.  At a minimum, there must be a written statement, policy, and/or procedure (as appropriate) for each subject listed below.  The list is not intended to exclude policies or procedures not specifically addressed.  Blank copies of supporting documents should also be included whenever possible (i.e., incident report form).  While the items listed below will be reviewed before the actual site visit inspection, the existence of the complete P&P will be verified at the time of the visit.  Although it may contain some of the same documentation - An Employee Handbook/Manual will not be accepted as a facility's P&P manual.                                                                                       

General:

• Mission Statement
• Description of Services
• Hours of Operation                                                                            

Safety:

• Safety issues must be addressed, including performance requirements and quality control for all equipment that provides patient care services.

• 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 and tagged annually by a certified vendor (or replaced annually).   Emergency phone numbers must be prominently posted by each outgoing telephone, even if only "911".
• Basic emergency supplies must be readily accessible on the premises, including, at minimum, a blood pressure cuff, stethoscope, and self-contained basic first aid kit.
• Each facility must be prepared for emergencies.  In addition to being in the manual, they must post the following conspicuously within the facility:
  • Phone numbers for emergency first responders, the local police department/precinct and fire station providing coverage in their area, and the nearest hospital or doctor available to provide emergency care.    
  • A map of the facility, picturing all exits and exit paths, must be posted for easy viewing by patients and staff.
  • Emergency Plans must be established and documented for:
    • Fire
    • Medical
    • Disaster
    • Utility Failure (including elevator alternatives for facilities not on the ground floor)
    • The above plans and the procedure to be followed for any other event where patient safety is an issue or evacuation of the premises is required must include appropriate specific actions to be taken by staff.
• 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.
• Emergency Closing
  • Plan/procedure followed if the facility closes due to emergency (i.e., inclement weather, fire)
  • Must include a description of the procedure for contacting patients to cancel and/or reschedule.
  • Plan/procedure for referring patients to other providers if the office must be closed for an extended period.          

Infection Control and Cleaning Procedures:

• General infection control guidelines must be developed and enforced to protect patients, staff, and equipment.
  • Regarding illness and/or skin disorders in patients and staff
  • Basic office cleaning procedures
• Specific cleaning policies and procedures must be developed and implemented for each type of equipment, including laundry, treatment tables, exercise equipment, and modality devices.
  • Frequency of cleaning
  • Person(s) responsible for the task
  • Method/products used.
  • Temperature and chemical levels must be regulated per local governing board standards for facilities with therapeutic pools.  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. 

Incident Reporting

• There must be a procedure for reporting incidents that might occur during standard treatment.
  • Outline of steps to be taken by staff in the event of an incident
  • Standard form for reporting the incident.
• 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.

Payment Policy:

• There must be a written policy delineating the billing process used by the practice, including a written explanation of fees and billing given to patients.
• Include a copy of patient information and an authorization form.
• Should note specifics for co-payments and limitations on coverage for patients insured by Medicare.      

Equipment:

• List of all therapy 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.

Personnel:

• Job descriptions and performance requirements for ALL employee types (clinical and non-clinical)                                   
• Staff initial training procedures                                                                                             
• Continuing education policy                                                                          
• Performance appraisals:  These appraisals should be performed at least once a 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.
• Clinical and support staff coverage                                                                           
  • The procedure that is used to maintain coverage levels during planned and unexpected absences.                                           
  • Mechanism for communicating important information to covering staff.                           

Scheduling Procedure

• Standard procedure for scheduling, re: volume, patient contact, insurance verification, etc.
• A policy must be 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 when a facility is temporarily unavailable, regardless of the closure length. * It is preferred that patients of Network members be recommended to other practices within the Network.
• Provision must be made to allow the practice to be contacted when clerical/reception staff are unavailable, i.e., during lunch after hours.

HIPAA/Privacy

• HIPAA form for privacy notification

Coverage Plan                                                

• Each practice must have a written policy in place to ensure appropriate coverage for all staff members * (both clinical and support staff) for expected and unanticipated absences and be able to demonstrate evidence of that coverage.

Closing the Office

• It is preferred that member practices of the Hospital for Special Surgery Rehabilitation Network do not close at any time other than recognized holidays.  However, if an office temporarily closes, it may only do so for up to one week at a time or more than two weeks a year unless the facility is deemed unsafe or otherwise unusable due to physical/structural damage or another emergency.
• If a Network member facility does close, whether temporarily or permanently, the practice must inform the Network Coordinator immediately to update alternate referrals and Network listings.