Rehabilitation Services

Initiation of Care Orders: The rehab agency must receive written orders from the clients’ primary HIV medical provider before initiation of care by the agency. The provider must be a licensed practitioner to include the following:

• Dentists
• Doctor of Medicine (MD)
• Doctor of Osteopathy (OD)
• Nurse Practitioner (NP)
• Clinical Nurse Specialist (CNS)
• Physician Assistant (PA)

1. Percentage of clients with documentation of signed orders for rehab services by a qualified licensed practitioner before initiation of care by the rehab agency.

Comprehensive Assessment: The rehab agency staff will complete a comprehensive assessment within 5 business days of the referral to include:

• Presenting issue
• Physical examination and evaluation performed by the therapist relevant to the type of therapy prescribed
• Diagnosis
• Prognosis

2. Percentage of clients with documentation of comprehensive assessment within 5 business days of referral that includes the following:
    
   1. Presenting issue
   2. Physical examination as applicable
   3. Diagnosis
   4. Prognosis

Plan of Care: In collaboration with the client a plan of care will be developed within 10 business days of the completed comprehensive assessment.

The plan of care should be signed and dated by the client and located in the client’s primary record. A copy of the plan will be offered to the client and documented in the client’s record.

The plan of care should include:

• Objective for rehab services
• Client-centered goals
• Estimated number of sessions
• Type of therapy
• Estimated duration

Documentation that the plan of care is being followed will include the date therapy was received, therapy performed, and progress toward meeting objectives in the client’s primary record.

The plan of care must be reviewed every 6 months at minimum with updates as needed.

3. Percentage of clients with documentation of a plan of care developed within 10 business days of the completed comprehensive assessment and includes the following components:
    
   1. Objective for rehab services
   2. Goals of services for client
   3. Type of therapy or therapies
   4. Estimated number of sessions
   5. Estimated duration of client’s need for rehab services to meet goals.
       
4. Percentage of clients with documentation that the plan of care was reviewed every 6 months at a minimum.

Referrals: If the needs of the client are beyond the scope of the services provided by the agency/provider, an appropriate referral to another level of care is made.

Documentation of referral and outcome of the referral is present in the client’s primary record as applicable.

5. Percentage of clients with documentation of referrals as applicable for ancillary services necessary to meet goals.
    
6. Percentage of clients with documentation of the outcome of the referral.

Transfer/Discharge: Transfer and discharge of clients from rehab services should result from a planned and progressive process that considers the needs and desires of the client and the caregiver(s), family, and support network.

A transfer plan must be developed when one or more of the following criteria are met:

• Agency no longer meets the level of care required by the client.
• Client transfers services to another service program.
• The client is not stable enough to be cared for outside of the acute care setting as determined by the agency and the client's primary medical care provider.
• The client no longer has a stable home environment appropriate for the provision of rehab services as determined by the agency.
• Client is unable or unwilling to adhere to agency policies.
• An employee of the agency has experienced a real or perceived threat to his/her safety during a visit to a client's home, in the company of an escort or not. The agency may discontinue services or refuse the client for as long as the threat is ongoing. 

Notification of Transfer/Discharge: The following criteria must be followed when a client is transferred or discharged from services:

• Provide written notification to the client or the client’s parent, family, spouse, significant other, or legal representative.
• Notify the client’s attending physician or practitioner.
• Written notification must be delivered no later than 5 days before the date on which the client will be transferred or discharged.

Note: Staff should not inactivate clients in Take Charge Texas (TCT) at the time of discharge, unless the case is being closed due to a deceased client.

7. Percentage of clients with documentation of a discharge plan developed with client/caregiver(s), and multidisciplinary team as applicable.
    
8. Percentage of clients with documentation of notification of transfer/discharge within 5 days before the date of transfer or discharge as applicable to the following parties:
    
   1. The client or legal representative as applicable.
   2. The client’s referring and attending practitioner as applicable.