1999-2000 Comprehensive Accreditation Manual for Behavioral Health Care
(CAMBHC)
Care chapter--Physical Therapy Care and Services
Note: New language is underlined.
Standard TX.5
Functional physical rehabilitation status is assessed to determine the
current level of functioning, self-care, self-responsibility, independence,
and quality of life.
Intent of TX.5
The individual's physical status and functional abilities are evaluated
before instruction and treatments are initiated.
Example of Implementation for TX.5
The physical therapist and other qualified professionals develop criteria
that will trigger the need for a comprehensive functional assessment. When
the criteria are met, the physical therapist documents an initial assessment
and therapy evaluation in the progress notes.
Examples of Evidence of Performance for TX.5
Clinical records
Organization policies and procedures
Scoring for TX.5
Are physical therapy evaluations and assessments performed before physical
therapy services are initiated?
Score 1 Yes
Score 2 With a few, minor exceptions
Score 3 Not consistently
Score 4 Rarely
Score 5 No
Standard TX.5.1
Qualified rehabilitation professionals determine the scope of the functional
rehabilitation assessment; provide rehabilitation services consistent with
professional licensure laws, regulations, registration, and certification;
and implement the physical rehabilitation plan with the individual and his
or her family, social network, or support system.
Intent of TX.5.1
Rehabilitation services are provided by competent professionals who are
qualified by education, professional licensure, regulation, registration,
certification, training, and experience.
Qualified professionals develop and implement the rehabilitation plan and
involve the individuals served, families, and their support systems.
Individuals served are encouraged to make choices about their participation
in physical rehabilitation and develop a sense of achievement in progress.
Individuals served and members of their support systems participate in
implementing the physical rehabilitation plan, including
identifying interventions to reach reasonable goals;
coordinating and collaborating on rehabilitation interventions; and
documenting the individual's treatment choices, response to interventions,
progress toward goals and objectives, and changes in condition.
Patients and family receive information about potential benefits and risks
of rehabilitation services in order to make informed decisions. Their
expectations are considered and documented in the rehabilitation plan.
Examples of Evidence of Performance for TX.5.1
Interviews with physical rehabilitation services staff
Policies and procedures addressing rehabilitation care planning
Clinical records
Scoring for TX.5.1
a. Do qualified physical rehabilitation professionals provide rehabilitation
services?
b. Does the rehabilitation plan include the elements as described in the
intent?
Score 1 a. Yes
b. Yes
Score 2 a. With a few, minor exceptions
b. With a few, minor exceptions
Score 3 a. Not consistently
b. Not consistently
Score 4 a. Rarely
b. Rarely
Score 5 a. No
b. No
Standard TX.5.1.1
Discharge planning from rehabilitation services is integrated into the
functional rehabilitation assessment.
Intent of TX.5.1.1
Discharge planning is initiated early in treatment based on continuing
assessments and stated expectations for achieving treatment goals and
objectives. Criteria for discharge or termination of services may vary based
on age, disability, treatment setting, and the organization's bylaws, rules
and regulations, and written plan for professional services.
Examples of Evidence of Performance for TX.5.1.1
Interviews with physical rehabilitation services staff
Policies and procedures addressing rehabilitation care planning
Clinical records
Scoring for TX.5.1.1
Is the individual's discharge from physical rehabilitation services based on
reassessment and written discharge criteria?
Score 1 Yes
Score 2 With a few, minor exceptions
Score 3 Not consistently
Score 4 Rarely
Score 5 No
Standard TX.5.2
Reassessment of the individual receiving physical rehabilitation services is
an ongoing process.
Intent of TX.5.2
Staff periodically assess physical rehabilitation achievement and potential
for each individual.
Physical therapy staff monitor the extent to which services have met the
therapeutic goals established through assessments, caused improvement of the
identified physical dysfunction, or reduced pain associated with movement.
Periodic reassessments are performed, as needed, to review treatment goals.
(See also PE.3PE.3.3.)
Example of Implementation for TX.5.2
As appropriate, the clinical record includes documentation of discussions
with the individual and family regarding the physical therapy services that
have met the therapeutic goals.
Examples of Evidence of Performance for TX.5.2
Clinical records
Documented performance-improvement activities
Scoring for TX.5.2
Are the outcomes of physical therapy services monitored and assessed for
each individual, as described in the standard and intent?
Score 1 Yes
Score 2 With a few, minor exceptions
Score 3 Not consistently
Score 4 Rarely
Score 5 No
Standard TX.5.3
An interdisciplinary physical rehabilitation plan and goals, developed by
qualified professionals, in conjunction with the individual and /or his or
her family, social network, or support system, and based on a functional
assessment of the individual's needs, guide the provision of physical
rehabilitation services, appropriate to the individual's environment.
Intent of TX.5.3
Whenever physical therapy is provided, treatment goals and plans are
developed that are consistent with the diagnosis, the prognosis, and the aim
of preventing or reducing disability or pain and restoring lost function. A
collaborative, interdisciplinary approach helps coordinate care and planning
to meet individual care goals and achieve optimal outcomes.
Physical therapy goals and plans are designed to help individuals achieve
and maintain their optimal level of functioning, self-care, and independence
by managing the individual's specific health problems; and maximizing the
individual's emotional well-being in accordance with the diagnosis,
prognosis, and treatment program.
Examples of Evidence of Performance for TX.5.3
Clinical records
Organization policies and procedures
Scoring for TX.5.3
Are the physical rehabilitation services for each individual served guided
by a plan that addresses the individual's personal goals and needs for
rehabilitation?
Score 1 Yes
Score 2 With a few, minor exceptions
Score 3 Not consistently
Score 4 Rarely
Score 5 No
Standard TX.5.4
Physical rehabilitation services are appropriate to the individual's needs
and severity of disease, condition, impairment, or disability.
Intent of TX.5.4
Physical rehabilitation services are planned to respond to each individual's
unique needs (including age-specific needs) and expectations. An essential
element in the planning process is assessment of the severity of the
individual's disease, condition, impairment, or disability.
Examples of Evidence of Performance for TX.5.4
Policies and procedures defining assessment and care planning requirements
Protocols
Clinical records
Scoring for TX.5.4
Are the physical rehabilitation services appropriate to individualized
needs?
Score 1 Yes
Score 2 With a few minor exceptions
Score 3 Not consistently
Score 4 Rarely
Score 5 No
Standard TX.5.5
Physical rehabilitation outcomes are restoration, improvement, or
maintenance of the individual's optimal level of functioning, self-care,
self-responsibility, independence, and quality of life.
Intent of TX.5.5
Physical limitations discovered during the rehabilitation assessment are
addressed with therapeutic interventions that enhance functional daily
living skills and abilities. The plan reflects the clinical conditions
requiring the use, application, and intended results of modalities,
therapeutic exercises, and orthotic, prosthetic, and assistive devices.
These interventions address posture, locomotion, strength, endurance,
cardiopulmonary function, balance, coordination, joint mobility,
flexibility, and pain. Applied modalities include, but are not limited to,
heat, cold, light, air, water, sound, electricity, massage, mobilization,
and bronchopulmonary hygiene. These interventions are provided either
directly or through referrals, outside sources, or other arrangements.
Example of Implementation for TX.5.5
The physical therapist documents the chosen therapeutic interventions in the
progress notes and incorporates these interventions into the individual
treatment plan.
Examples of Evidence of Performance for TX.5.5
Clinical records
Interviews with and observations of individuals served
Staff interviews
Scoring for TX.5.5
a. Are physical therapy interventions provided and documented as described
in the intent?
b. Does the organization's performance indicate that rehabilitation
restores, maintains, or improves the individual's level of functioning?
Score 1 a. Yes
b. Yes
Score 2 a. With a few, minor exceptions
b. With a few, minor exceptions
Score 3 a. Not consistently
b. Not consistently
Score 4 a. Rarely
b. Rarely
Score 5 a. No
b. No
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