THERAPY SERVICES

POLICY:

Physical Therapy, Occupational Therapy and Speech Therapy services through the agency will be guided by accepted standards of practice.

PURPOSE:

To assure that therapy services are delivered and supervised by qualified therapists following accepted standards of care and to provide safe and effective therapy services to our patients. 

PROCEDURE: 

Requirements: The qualified therapist for home care will meet the following standards:

The qualified therapists & assistants must be a graduate from an accredited program and have a current Florida license/certification. Speech therapy visits may be provided by Speech Therapy Assistants under the supervision of a Master’s Degree level SLP. 

All patients are admitted to service, supervised and case managed by a Registered Nurse. The qualified, supervising therapist may Case Manage patients receiving therapy services, coordinating care with the RN/DON. 

Care-Related tasks

1. Discuss all referrals with the RN to ascertain the physician’s orders for evaluation and the date for the evaluation visit.

1. Pertinent Medical History
2. Assess physical strengths and deficits to include ADL’s and range of motion,       muscle strength, gait pattern, sensation, balance, coordination, perception skin integrity and respiratory status, functional level or motor developmental level, cognitive and speech deficits.
3. Assess home environment for architectural barriers.

C. Treatment goals will be established and treatment plans will be formulated on the 

basis of the evaluation.

1. Analyze and interpret patient’s needs on the basis of medical history, pertinent precautions, limitations and evaluative findings.

2. Identify short and long-term goals that are measurable, objective and related to functional mobility as determined by medical history and evaluative findings.

3. Formulate a treatment plan to achieve the goals identified. Plan should include frequency and estimated duration of therapy, as well as procedure to be rendered.

1. Review physician’s request for treatment, and if appropriate recommend revisions       on the basis of evaluative findings.
2. Report findings from evaluation and care plan to physician and to RN within 48       hours of visit.

D. Implement and administer appropriate treatment.

1. Use skilled techniques as necessary.

2. Administer a technically complete and correct program that provides flexibility to patient responses.

3. Review and revise care plans as treatment progresses on the basis of ongoing re-evaluation.

4. Re-evaluate, review and revise care plan at the following minimum intervals:-Re-evaluate patients being treated by a PTA/COTA/STA on an ongoing basis with formal re-evaluation, appropriate treatment modifications every 60 days, and monthly supervisory note completed at least every 30 days assessing patient goals.

E. .Delegate portions of patient care to & provide supervision of PTA/COTA/STA

1 Designate appropriate patients for the therapy assistant

2 Supervise therapy at least monthly to determine patient’s progression.

3. Supervising LPT name will be documented on all PTA notes. 

4.  OTR will co-sign all COTA documentation.

5. SLP will co-sign all SLP Assistant documentation. 

1. PTA’s, COTA’s and SLPA’s will practice under supervision of the licensed therapist.
2. Ensure the PTA/COTA/STA have access to the supervising therapist by telephone or through pre-arranged meetings.

F. Document pertinent information in the patient’s record. The content of 

documentation is primarily designed to reflect the patient’s condition and the care 

provided to effect change in that condition. It should include the following:

1. Evaluation—Includes patient information, such as diagnosis, date of onset,

pertinent medical history and objective physical examination findings.

2. Assessment—Includes interpretation and summary of objective evaluation 

findings, prognosis, determination of treatment goals that are objective and measurable with a statement on potential to achieve goals.

3. Treatment plan—Includes interventions, as well as frequency and duration

of care. Will consider Medicare and Medicaid SOC dates to be compliant with physician’s orders. Pt./Cg participate in treatment planning and is in agreement with therapy goals.

4. Treatment note—Includes dates and types of treatments performed, patient 

response to treatment and progress towards goals.

5. Progress note—Summary note should be written as appropriate, every 30 days to include the number and types of treatment provided, objective progress toward goals with use of same parameters as identified in the initial evaluation, modification of treatments, goals and plan and discharge planning activities as appropriate. 

6. Discharge summary—Includes the same information as the progress note 

(summary), as well as the patient’s disposition at the time of discharge, 

reason for discharge, whether goals are met or not met and also to include 

both functional level and follow-up recommendations as indicated. The therapist’s discharge summary and the order for discharge will be sent to referring physician for signature indicating the effective date of the discharge.

7. Missed Visit Report – A Missed Visit Report should be written if a visit is 

missed and the therapist is unable to make up the visit within the patient’s 

Medicaid or Medicare week. Therapist will include the date the visit was 

missed and the reason, the name of the physician, the name of the RN case manager or supervisor who was notified, and the rescheduled visit date. If unable to reschedule the visit, the reason must be indicated.

G. Therapists will follow all agency policies and procedures, including providing

required personnel documents. 

H. Therapists will participate in all case conferences called by the RN to assess and 

evaluate on-going patient conditions and needs and this may be done in person, in writing or by telephone. Participation in in-services and the QI program is also required.

I. Therapists will report all changes in patient’s condition, care plan, frequency 

or dates of visits, and missed visits to the RN Case Manager and the physician at 

the time of occurrence as appropriate. 

K. All initial evaluations, re-evaluations, and discharge documents will be signed 

by the referring physician to indicate physician is in agreement with therapy POC.

L. Communication notes – Should include any unusual occurrences, visits missed with plans to be made up, and change in patient’s POC or status. Include name, MR# and date of birth.