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SUPPLEMENT 1979
STANDARDS MANUAL
for Rehabilitation Facilities
Amending the 1978 Edition
COMMISSION ON ACCREDITATION
carf
OF REHABILITATION FACILITIES
SUPPLEMENT 1979
Amending the
STANDARDS MANUAL
FOR
REHABILITATION FACILITIES
1978 Edition
©Copyright 1979 by the
Commission on Accreditation
of Rehabilitation Facilities
2500 North Pantano Road
Tucson, Arizona 85715
(602) 886-8575
IMPORTANT — PLEASE READ
The Commission is pleased to provide this free Supplement to holders of the 1978 Edition
of the Standards Manual for Rehabilitation Facilities. This is the only Supplement which
will be issued to the 1978 Edition. The Commission plans to issue for sale in early 1980
a whole new Edition which will integrate these Supplement modifications as well as provide
for a number of significant new features.
The Supplement incorporates all modifications to the 1978 Edition which were adopted by
the Commission during the period from January, 1978 through December, 1978.
In this Supplement, all modifications reference the page number in the 1978 Edition; and
utilize the following key:
New -- A totally new standard has been added;
Delete -- All or part of an existing standard is being removed;
Revise -- There is a change in the wording of an existing standard.
INTRODUCTION
P. 4 (Revise)
Seven program categories have been identified, based on the emphasis of
Second paragraph from
their services physical restoration, personal and social development, vocational
bottom of page, fourth
development.
sentence
P. 4 (Revise)
and enable the individual to achieve
Last paragraph on the
page, under the example
of number one
P. 4 (Revise)
Primary emphasis of the program is PERSONAL AND SOCIAL DEVELOPMENT.
Last paragraph on the
A program designed to provide advocacy, personal, and/or social development
page, number two
services to maximize the ability of people to live independently in their community.
Types of programs include but are not limited to independent living programs,
residential and group home programs, halfway houses, habilitation programs, and
psychosocial centers.
P. 4 (Revise)
.VOCATIONAL DEVELOPMENT, supported by appropriate medical, social, and
Last paragraph, number
personal development services
three
P. 5 (Revise)
WORK ACTIVITY, supported by appropriate vocational, social, and personal
Number seven
development services.
GLOSSARY OF TERMS
P. 10 (Revise)
The primary objective
upgrade physical function and enable the individual to
"Program Emphasis"
achieve
example for Physical
Restoration
P. 10 (Revise)
Primary emphasis of the program is PERSONAL AND SOCIAL DEVELOPMENT.
"Program Emphasis"
A program designed to provide advocacy, personal, and/or social development
entire Social Adjustment
services to maximize the ability of people to live independently in their community.
section
Types of programs include but are not limited to independent living programs,
residential and group home programs, halfway houses, habilitation programs, and
psychosocial centers.
P. 10 (Revise)
VOCATIONAL DEVELOPMENT, supported by appropriate medical, social,
"Program Emphasis"
and personal development services.
under VOCATIONAL
DEVELOPMENT
P. 11 (Revise)
WORK ACTIVITY, supported by appropriate vocational, social, and personal
'Program Emphasis"
development services.
under WORK ACTIVITY
P. 12 (Revise)
"
appropriate point during the individual's course of treatment?"
First sentence and
"
stated goals of the program and needs of the individual?"
fourth sentence
CRITERIA OF ELIGIBILITY FOR ACCREDITATION
SURVEY AS A REHABILITATION FACILITY
P. 15(Revise)
0.1
of the following: physical restoration, personal and social development,
Second sentence
vocational development,
P. 15 (Revise)
0.2
operates (a) without discrimination on the basis of race, creed, color,
sex, religion, age, or handicap, (b) under a.
1
P. 15 (Delete)
0.5 through 0.5.7.1
P. 15 (Revise)
0.6 through 0.11 subtract .1 from each to read 0.5, 0.6, 0.7, 0.8, 0.9, and 0.10
Numbering
P. 15 (Revise)
New 0.9
is sought for a program emphasis in either speech pathology or
audiology
STANDARDS FOR REHABILITATION FACILITIES
PURPOSES
P. 19 (Revise)
1.5 The facility should identify and remove barriers to the independence of handi-
capped individuals which may be created
ORGANIZATION AND ADMINISTRATION
P. 21 (Revise)
2.1.1.2
of a not-for-profit organization should contain provision
P. 23 (Revise)
2.7.3 Delete the reference to standard 2.1.1
P. 23 (Revise)
2.8.2 Change title to Personal and Social Development Emphasis and delete "None
required".
P. 23 (New)
2.8.2.1 If paid staff members are allowed to serve as guardian, conservator,
and/or representative payee for individuals served, a system of account-
ability for expenditure of the person's funds shall be maintained.
P. 24 (Revise)
2.8.7.2 If paid staff members are allowed to serve as guardian, conservator,
New wording
and/or representative payee for individuals served, a system of account-
ability for expenditure of the person's funds shall be maintained.
SERVICES
P. 25 (Revise)
3.2.1.3 The establishment of at least a preliminary diagnosis, evaluation,
P. 26 (Delete)
3.2.4.7 through 3.2.4.7.3 (The standards are being repositioned)
P. 27 (Revise)
3.4.2 Change title of program emphasis to Personal and Social Development
Emphasis.
P. 27 (New)
3.4.2.3 Facilities which operate or provide for residential services should
meet the following conditions:
3.4.2.3.1 The services in the residential setting should be closely coordinated
and integrated with the community and with all other services
available through the facility.
3.4.2.3.2 There should be provisions to maximize independent living skills,
use of leisure time, and community involvement.
3.4.2.3.3 There should be provisions for emergency medical services.
3.4.2.3.4 A daily activity schedule, reflecting the individual's service needs,
should be established and followed.
3.4.2.3.4.1 The activity schedule should provide for reasonable amounts
of personal free time.
3.4.2.3.4.2 At least 30 hours per week of scheduled, meaningful activity
must be provided outside the living quarters.
3.4.2.3.5 A written description of resident rights and responsibilities should
be provided to each person or his parent or guardian.
2
3.4.2.3.6 Individuals served should be treated with respect and dignity.
3.4.2.3.6.1 The facility should, by written policy communicated to staff,
prohibit corporal punishment including seclusion and physical
restraint.
3.4.2.3.6.2
The facility should, by written policy communicated to staff,
not subject individuals to psychological abuse, i.e., humilia-
ting, frightening, or exploiting forms of punishment.
3.4.2.3.7
Individuals who take exception to the decision or behavior of a
staff person shall have the right and be given the opportunity to
appeal such decision or behavior.
3.4.2.3.7.1 The program should establish an effective mechanism for
dealing with such appeals.
3.4.2.3.8 Written policies and procedures should be developed to govern the
safe administration, handling, storage, and disposal of medica-
tions.
3.4.2.3.9
Where food service is provided, the facility should accomodate
special dietary needs of those served and should comply with
applicable governmental regulations.
3.4.2.3.10 Meetings between staff and residents should be held regularly to
discuss matters of mutual interest and concern.
3.4.2.3.11 The facility shall provide or coordinate available transportation
to day programs and other program activities and/or provide
instruction in the use of available transportation.
3.4.2.3.12 The individual should be placed in the least restrictive residential
environment.
P. 27 (New)
3.4.2.4 All facilities with a Personal and Social Development emphasis should
provide or arrange for a systematic, goal directed array of services
designed to maximize the capacity of individuals to live independently in
their community. These services should include but are not limited to
improving:
3.4.2.4.1 Housekeeping and home/apartment maintenance skills
3.4.2.4.2
Use of community transportation
3.4.2.4.3 Communication skills (oral, written, nonverbal)
3.4.2.4.4 Interpersonal relationships (including sexual, marital, and parental)
3.4.2.4.5 Health maintenance (i.e., personal hygiene, nutrition and diet man-
agement, use of medical services, and medicine)
3.4.2.4.6 Safety practices and dealing with life or injury threatening emergen-
cies
3.4.2.4.7 Financial management, including techniques of consumer purchasing,
loans, taxes, budgeting, and debt repayment
3.4.2.4.8
Academic skills
3.4.2.4.9 Management of personal, legal affairs
3.4.2.4.10 Recreational activities
3.4.2.4.11 Use of other community services and resources (i.e., laundromats,
library, post office, consumer affairs office, etc.)
3
3.4.2.4.12 Basic self care activities (i.e., eating, bathing, toileting, dressing,
grooming, etc.)
3.4.2.4.13 Work attitude and skills exploration.
P. 27 (New)
3.4.2.5
The following independent living services MAY also be provided or
arranged for:
3.4.2.5.1
Maintenance of a listing, referral, certification, and/or provision
of housing
3.4.2.5.2
Maintenance of a listing, referral, and/or training of personal care
attendants
3.4.2.5.3
Involvement in efforts to make local transportation accessible to the
handicapped
3.4.2.5.4
Equipment loan, repair and/or delivery, and provision of information
regarding equipment
3.4.2.5.5
Information and referral regarding vehicle modification services
3.4.2.5.6
Outreach and intake services
3.4.2.5.7
Individual advocacy
3.4.2.5.8
Information and referral for community resources
3.4.2.5.9 Referral for or provision of interpretive services for the deaf
3.4.2.5.10 Teletypewriter services for the deaf
3.4.2.5.11 Maintenance of a listing and/or referral of readers for the blind
3.4.2.5.12 Crisis intervention services.
3.4.2.6
Where vocational evaluation services are provided as part of the
facility's program, the standards under 3.4.3.1.1 shall apply.
3.4.2.7
Where work adjustment services are provided as part of the facility's
program, the standards under 3.4.3.1.2 shall apply.
3.4.2.8
Where job placement services are provided as part of the facility's
program, the standards under 3.4.3.1.6 shall apply.
3.4.2.9
Where remunerative work is offered as part of the facility's program,
the standards under 3.4.4 shall apply.
3.4.2.10
Where work activity is provided as part of the facility's program, the
standards under 3.4.7 shall apply.
P. 31 (New)
3.4.3.4
Where residential services are provided as part of the facility's program,
the standards under 3.4.2.3 shall apply.
P. 32 (New)
3.4.4.6
Where residential services are provided as part of the facility's pro-
gram, the standards under 3.4.2.3 shall apply.
P. 35 (New)
3.4.7.11
Where residential services are provided as part of the facility's pro-
gram, the standards under 3.4.2.3 shall apply.
PERSONNEL
P. 38 (Revise)
4.5.2
Change title of program emphasis to Personal and Social Development
Emphasis.
P. 38 (Delete)
4.5.2.1 through 4.5.2.2.4 (Renumbered and replaced by following content)
4
P. 38 (New)
4.5.2.1
Where residential services are provided or obtained, the facility shall
meet the following:
4.5.2.1.1 An individual shall be designated to provide for the administration
and management of the residential component. This individual should:
4.5.2.1.1.1
Possess at least a high school diploma or its equivalent in ed-
ucation and/or training, have had previous supervision exper-
ience, and have had at least two years experience in a human
service program.
4.5.2.1.1.2
If employed by the facility, the position shall be established at
a peer level with other heads of program service elements.
4.5.2.1.2 An individual(s) should be designated to provide for supervision of
the residential setting(s). This individual(s) should:
4.5.2.1.2.1
Possess at least a high school diploma or its equivalent in
education and/or training.
4.5.2.1.2.2
Have completed an appropriate orientation and training program
prior to beginning regular duties, and be provided with in-ser-
vice training thereafter.
4.5.2.1.3 The facility should employ additional personnel in such number and
of such type as to meet the needs of individuals served consistent
with the purposes and objectives of the facility.
P. 38 (Revise)
4.5.2.2
Dependent on services provided and caseload composition.
P. 38 (New)
4.5.2.2.1 An individual or individuals who assist those served to acquire or
maximize the independent living skills listed under 3.4.2.4.
4.5.2.2.2
Psychologist
4.5.2.2.3
Social worker
4.5.2.2.4
Professional vocational specialist
4.5.2.2.5
Job placement specialist
4.5.2.2.6
Recreation specialist
4.5.2.2.7
Occupational therapist
4.5.2.2.8
Physical therapist
4.5.2.2.9
Physician
4.5.2.2.10 Dentist
4.5.2.2.11 Educational specialist
4.5.2.2.12
Speech pathologist
4.5.2.2.13 Audiologist
4.5.2.2.14 Mobility instructor for the blind
4.5.2.2.15 Interpretor for the deaf
P. 40 (Revise)
4.5.4.4.2 The qualifications of the plant manager should be consistent with the
following requirements:
Education: High school education plus two years of college or its
equivalent in adequate training and/or experience.
5
Delete the next sentence headed, "Substitution for Education" and
the sentence headed "Substitution for Experience".
P. 40 (Revise)
4.5.4.4.3 Substitute the following wording for the existing wording.
The qualifications of the foreman shall be consistent with the following
requirements.
Education/Experience: High school diploma or its equivalent, or a
minimum of four years of full time paid employment in regular in-
dustry or sheltered workshops, including at least one year of work
experience in the type of operations to be supervised in the sheltered
workshop. Up to three years of any combination of military service,
education, or business experience beyond the minimum requirement
may be substituted.
P. 40 (Revise)
4.5.4.5.4 The program shall not discriminate .national origin, sex, disabil-
ity, or age
P. 42 (Revise)
4.5.7.4.1
The qualifications of the director of the program shall be consistent
with the following requirements:
Education/Experience: Bachelor's degree from an accredited college
or university. Two years of supervisory experience in a sheltered
workshop or work activity program may be substituted for each year
of post-secondary education, provided that there has also been three
years of full time paid employment with at least one year of experience
in administrative work directing professional, technical, or super-
visory personnel.
P. 42 (Revise)
4.5.7.4.3
The activities of daily living specialist shall have a bachelor's degree
in home economics, education, family and child development, or
other human service areas or two years of full time paid experience
in working directly in a service relationship with the handicapped.
P. 42 (Revise)
4.5.7.5.4
The program shall not discriminate
national origin, sex, dis-
ability, or age
RECORDS AND REPORTS
P. 43 (Revise)
5.1.2.6
Evaluation reports from each service, reports of staff conferences,
and a total treatment plan shall be available.
P. 43 (Revise)
5.1.2.6.1
The treatment plan should contain
P. 45 (Revise)
5.4.2
Change title of program emphasis to Personal and Social Development
Emphasis and delete "None required".
P. 45 (New)
5.4.2.1
Where residential services are provided, the following information
regarding each person served should be accessible at all times to,
or retained in, the residence.
5.4.2.1.1
Permanent address
5.4.2.1.2
Name, address, and telephone number of next of kin
5.4.2.1.3
Physician preferred
5.4.2.1.4
Hospital preferred
5.4.2.1.5
Allergies
5.4.2.1.6
Current medications
5.4.2.1.7
Essential medical information including diagnosis(es)
6
5.4.2.1.8
Name, address, and telephone number of conservator and/or
guardian if one has been appointed
5.4.2.1.9
Authorization for emergency treatment
5.4.2.1.10 Medical card or insurance information regarding reimbursement
for emergency services
5.4.2.1.11 Identification of the individual's rehabilitation plan
5.4.2.1.12 Statements regarding the progress of the individual toward
achieving program objectives
5.4.2.1.13 Where individuals have been placed in outside employment, the
information set forth in the standards under 5.4.3.9 should also
be retained
5.4.2.1.14 Any limitations on the individual's mobility in the community.
P. 45 (New)
5.4.2.2
Where vocational development services are provided as part of a
Personal and Social Development emphasis, the standards under
5.4.3 shall apply.
P. 45 (New)
5.4.2.3
Where remunerative work is provided as part of a Personal and
Social Development emphasis, the standards under 5.4.4 shall apply.
P. 45 (New)
5.4.2.4
Where work activity is provided as part of a Personal and Social
Development emphasis, the standards under 5.4.7 shall apply.
FISCAL MANAGEMENT
P. 49 (Revise)
6.5.2
Change title of program emphasis to Personal and Social Development
Emphasis and delete "None required".
P. 49 (New)
6.5.2.1
The facility should provide for identification and accountability of any
facility expenditure of funds belonging to those served.
P. 49 (New)
6.5.2.2
Residents engaged in covered work assignments in the residential
setting should be paid in conformance with the Fair Labor Standards
Act, as amended.
PHYSICAL FACILITIES
P. 55 (Revise)
7.9.2
Change title of program emphasis to Personal and Social Development
and delete "None required".
P. 55 (New)
7.9.2.1
Each resident should be provided with adequate personal space in
order to assure privacy of person and property.
P. 55 (New)
7.9.2.2
A suitable location should be provided in the residence to assure
confidentiality of records.
P. 55 (New)
7.9.2.3
Medications should be stored in a locked location.
COMMUNITY INVOLVEMENT AND RELATIONS
P. 57 (Revise)
8.6.2
Change title of program emphasis to Personal and Social Development
and delete "None required".
P. 57 (New)
8.6.2.1
The facility should function in the community as part of an advocacy
effort for the needs of the population served.
8.6.2.1.1
The facility should provide a program to help remove and reduce
attitudinal and physical barriers to the integration of the disabled
in community activities.
7
8.6.2.1.2 The facility should collaborate with other interested community
groups in making information and consultation available to the
community regarding the requirements of existing legislation and
regulations dealing with the rights of the disabled.
INTERPRETATION OF STANDARDS
P. 76 (Revise)
3.2.1.3
supplement this information as needed for initiation or continuation
of treatment or training. The facility
P. 78 (New)
3.4.2.3.1 It is essential that a single program manager be designated for the
individual when residential services are offered by or obtained by a
facility in concert with an array of other services.
P. 78 (New)
3.4.2.3.6.1 Seclusion, as used in this standard, refers to a form of punish-
ment and would not include "time-out", a brief period of isolation
used as a behavior modification technique. Similarly, physical
restraint, as used in this standard, refers to a form of punish-
ment, and would not include restraint necessary to preclude harm
to the individual or others.
P. 81 (New)
4.5.2.1.2 The same individual, depending on the size and scope of the residen-
tial component, may be responsible for the administration and manag-
ement functions referred to in standard 4.5.2.1.1 and for the resi-
dence supervision functions in this standard.
ACCREDITATION POLICIES AND PROCEDURES
P. 102 (New Section)
The Commission on Accreditation of Rehabilitation Facilities has established a
Review of One-year
mechanism to identify whether errors in fact or interpretation have been made in
Accreditation Decisions
a facility's site survey, and to determine if the magnitude of any errors in fact or
interpretation is such as to warrant a change in the accreditation decision. A
rehabilitation facility which receives a one-year accreditation decision, as a result
of any on-site survey, shall, on written request, be entitled to a staff interview to
review its accreditation decision.
To facilitate this review, the following steps and procedures shall be followed:
1. A written request for a review of the facility's accreditation decision
must be received by the Commission within thirty days of the date of the
accreditation decision.
2. Upon receipt of the formal request for a review of the accreditation deci-
sion, the staff will promptly contact the facility to establish the time, date,
and location of a staff interview, and to discuss with the facility the types
of supporting documentation which will be needed. In the interest of time-
liness, every effort shall be made to conduct the interview within sixty
days of the accreditation decision.
3. The facility is required to submit, within forty-five days of the date of
the Commission's mailing of the notification of the accreditation decision,
specific documentation supporting its contention that specific recommenda-
tions contained in the survey report are not appropriate.
4. Normally the staff interview will be held in the Commission's offices.
The cost of the interview shall be the responsibility of the facility.
5. The facility's chief executive officer and any other facility representatives
may attend and participate in the staff interview.
6. After the interview, the facility shall be informed whether sufficient evi-
dence of compliance with the standards cited in the survey report has been
presented to warrant a change in the accreditation decision.
8
7. If the facility does not submit its request and the specific documentation
within the required time lines, the facility will waive its right to a review
of its accreditation decision.
Regardless of the outcome, the date of the original notification shall remain as the
basis for the tenure of the accreditation.
P. 102 (Revise)
upon the failure of the facility to provide such records and reports as are
Conditional Nature
requested by the Commission, including submission within ninety days of a report
of Accreditation
of corrective actions, may review
9
cart
-
STANDARDS MANUAL
for Rehabilitation Facilities
1978
COMMISSION ON ACCREDITATION
carf
OF REHABILITATION FACILITIES
COMMISSION ON ACCREDITATION
OF
REHABILITATION FACILITIES
STANDARDS MANUAL
FOR
REHABILITATION FACILITIES
©Copyright 1978 by the
Commission on Accreditation
of Rehabilitation Facilities
4001 West Devon Avenue
Chicago, Illinois 60646
(312) 282-8787
TABLE OF CONTENTS
Page
Subject
IDENTIFYING NEW OR REVISED CONTENT
1
3
INTRODUCTION
9
GLOSSARY OF TERMS
CRITERIA OF ELIGIBILITY FOR SURVEY
15
STANDARDS FOR REHABILITATION FACILITIES
1. PURPOSES
19
2. ORGANIZATION AND ADMINISTRATION
21
3. SERVICES
25
4. PERSONNEL
37
5. RECORDS AND REPORTS
43
6. FISCAL MANAGEMENT
49
7. PHYSICAL FACILITIES
53
8. COMMUNITY INVOLVEMENT AND RELATIONS
57
9. PROGRAM EVALUATION
59
INTERPRETATIONS OF STANDARDS
1. PURPOSES
65
2. ORGANIZATION AND ADMINISTRATION
69
3. SERVICES
75
4. PERSONNEL
79
5. RECORDS AND REPORTS
83
6. FISCAL MANAGEMENT
85
7. PHYSICAL FACILITIES
87
8. COMMUNITY INVOLVEMENT AND RELATIONS
89
9. PROGRAM EVALUATION
91
TABLE OF CONTENTS (CONT'D)
Subject
Page
SURVEY MATERIAL
94
ACCREDITATION POLICIES AND PROCEDURES
THE SIX STEPS TO ACCREDITATION
99
PRE-SURVEY CONSIDERATIONS
99
ACCREDITATION DECISION-MAKING
101
PUBLIC IDENTIFICATION
103
CONFIDENTIALITY
103
PUBLICATION INFORMATION
The cost of the 1978 Edition of the Standards Manual for Rehabilitation Facilities is $20 (U.S. currency). Price in-
cludes automatic receipt, at no charge, of a Supplement to the 1978 Edition early in 1979. The Supplement includes
revisions of standards, survey policies, etc. adopted by the Commission's Board of Trustees during 1978.
The Commission has formulated a Self-Study Questionnaire for use with the 1978 Edition of the Standards Manual.
This document was developed after considerable field testing in rehabilitation facilities. The Self-Study Questionnaire
is available at cost of $10. However, facilities which submit a completed Application for Accreditation Survey form
automatically receive the document at no cost. Because the Questionnaire is based on the 1978 Edition of the Stan-
dards Manual, it can only be provided to holders of the 1978 Edition.
Filling orders requires that payment or purchase order be received with the publication order. Allow four to six weeks
for delivery. If special service is desired, add $2.50 for special handling and postage.
IDENTIFYING NEW OR REVISED CONTENT
The following listing is presented to facilitate the use of this new Edition of the Standards Manual for Rehabilitation
Facilities as an ongoing resource in facility operation. Listed below are all new or revised items which will be found
in the Glossary of Terms, Criteria of Eligibility, Standards, Interpretations, or Accreditation Policy and Procedures
sections of this Manual. All substantive changes or additions since publication of the 1976 Edition are noted, how-
ever, 1976 Edition content which has been deleted is not referenced.
Glossary of Terms
Criteria of Eligibility
Chief Executive Officer
Program Emphasis-Vocational
0.4
Governing Body
Development, Work Activity
0.5.7.1
Job Placement Services
Program Manager
0.11
Job Placement Specialist
Rehabilitation/Habilitation
Medical Staff
Rehabilitation Facility
Medical Supervision/Direction
Staff Member
Occupational Therapist
Utilization
Physical Therapist
"Note"
THE STANDARDS
Purposes
Fiscal Management
1.1
3.4.7.6.2
6.1.1.2
1.5
3.4.7.6.3
6.1.2
3.4.7.7.2
6.1.3
Organization and Administration
6.1.4
First sentence explaining
Personnel
asterisks and the asterisks
"Note"
6.2
4.2
6.2.2
themselves.
2.1.3.6
4.2.5.1
6.4
2.1.4
4.4.1
6.5.4.1.5.1
2.3.3
4.4.3
6.5.4.1.7
4.5.3.1.10
6.5.4.1.8
2.5.3
4.5.4.3.6
6.5.4.1.9
2.5.3.3
2.8.7.2
4.5.7.1
6.5.7.1.5.1
4.5.7.1.1
6.5.7.1.7
Services
4.5.7.1.2
6.5.7.1.8
3.2.1.2
4.5.7.1.3
6.5.7.1.9
3.2.1.3
3.2.2.2
4.5.7.3.8 through 4.5.7.3.13
Physical Facilities
3.2.4
4.5.7.4.1 Experience
7.2.5.1
4.5.7.4.2
7.2.7
3.2.5.2
4.5.7.4.3
7.3.1.7
3.3.5
4.5.7.5
7.6.1
3.4.1.1.1
4.5.7.5.1 C.
7.6.2
3.4.1.3
4.5.7.5.7 a.
7.9.7.4
3.4.3.1.1.2
8.2
3.4.3.1.1.3 b.
Records and Reports
8.2.1
3.4.3.1.6 through 3.4.3.1.6.3
5.1.1
8.2.1.2
(new job placement standards)
5.1.2.4
8.6.7.1
3.4.4.1.1.9
5.1.2.5
8.6.7.2
3.4.4.2.4.2
5.1.2.7
3.4.4.2.4.3
5.1.2.14
Program Evaluation
3.4.7.1.1.3
5.1.5
"Special Note"
3.4.7.1.1.4
5.1.7.1
Interpretation of Standards
3.4.7.1.1.7
5.3.1.1
3.2.4.4
3.4.7.2.1
5.3.1.3
3.3.5
3.4.7.5 through 3.4.7.5.2
5.3.1.4
3.4.1.3
(new work activity standards)
5.4.3.8
3.4.7.2.4
Accreditation Policies and Procedures
Fees and Survey Team Composition-new charge per surveyor day of $345 and new level of non-refundable deposit of
$300.
Guidelines for Accreditation Decision-Making-new wording of Three-Year Accreditation guideline.
Special Policy on Program Evaluation-new policy.
1
INTRODUCTION
Preface
The Commission on Accreditation of Rehabilitation Facilities (CARF) is the organizational product of ten years of effort,
study, and planning on the part of the primary forces giving shape and direction to the rehabilitation movement.
Central to its establishment were the two national organizations representing rehabilitation facilities, the Association of
Rehabilitation Centers (ARC) and the National Association of Sheltered Workshops and Homebound Programs
(NASWHP).
Formal planning for the Commission was initiated under the able leadership of the National Rehabilitation Association,
which originally sponsored a "Planning Committee for Accreditation of Rehabilitation Centers and Workshops." This
committee, under the chairmanship of Mr. E. B. Whitten, was composed of leaders from public, voluntary, and professional
groups, as well as the two facility associations. After more than two years of study and planning by this committee, the final
planning and detailed organizational steps for establishment of the Commission were completed by a Joint Committee on
Accreditation of ARC and NASWHP, cochaired by Dr. William A. Spencer and Mr. Charles Higgins.
Support and encouragement for all of these efforts for development of standards, planning and establish-
ing the accreditation organization, was provided by the Vocational Rehabilitation Administration (now Rehabilitation
Services Administration). This agency provided basic financial assistance through research, demonstration, and plan-
ning grants. Most important, however, were the encouragement, guidance, and firm support of then Commissioner
Mary E. Switzer and her staff, which made possible the successful culmination of the work of many people and groups.
The purposes of the Commission as summarized from its bylaws are:
1. To upgrade the rehabilitation facility movement and improve the quality of services provided to the disabled and
disadvantaged.
2. Through accreditation, to offer to the general public and providers, purchasers, and recipients of rehabilitation
facility services a single means of identifying throughout the Nation those facilities in terms of concepts and serv-
ices which are rehabilitative in nature and competent in performance.
3. To develop and maintain relevant standards which can be used by rehabilitation facilities in order to measure
their level of performance and strengthen their program.
4. To provide through the accreditation process an independent, impartial, and objective system by which rehabili-
tation facilities can have the benefit of a total organizational review.
5. To offer to the facility, the community, and the consumers a mechanism of program accountability, and assur-
ance of a continuing high level of performance.
6. To feed back to the facility movement information based upon aggregate findings obtained in site surveys in
order to share basic data on common strengths and weaknesses of facility operations.
7. To provide within the voluntary sector an organized forum through which all involved in rehabilitation can parti-
cipate in standard-setting and program improvement.
The Corporate Members of CARF are the American Hospital Association; Association of Rehabilitation Facilities; Good-
will Industries of America; the National Association of Hearing and Speech Action; the National Easter Seal Society for
Crippled Children and Adults; and the National Rehabilitation Association. The CARF Board of Trustees is composed of
two persons appointed by each of the Corporate Members plus At-Large Trustees appointed by the Board of Trustees for
their expertise in specific areas.
The CARF Board of Trustees has full authority and responsibility for governing the Commission, including adoption or
modification of standards, awarding or withholding accreditation, and approval of basic policies and budgets for opera-
tion of the Commission.
CARF is financed by contributions from its Corporate Members, fees for accreditation survey from applying rehabilitation
facilities, sale of publications, and grants from public and private agencies for support of its educational, demonstration,
and research activities.
Acknowledgment is given to the National Accreditation Council for permission to utilize certain of its standards.
This investigation was supported, in part, by a demonstration grant from the Rehabilitation Services Administration,
Department of Health, Education and Welfare, Washington, D.C.; and by a grant from the Easter Seal Research
Foundation of the National Easter Seal Society for Crippled Children and Adults.
Purpose
This STANDARDS MANUAL was planned and organized to fulfill a variety of needs and to accomplish several purposes:
1. To provide an authoritative source of materials for use in a voluntary program of survey and accreditation for
rehabilitation facilities.
2. To establish and give organization to definitions, standards, and evaluative techniques on a level consistent with
current knowledge and experience.
3. To provide a source of guidelines and interpretations for the planning of new facilities and the organization of
new programs.
3
4. To provide a means for self-evaluation and improvement of ongoing programs by facilities.
5. To provide an educational resource for in-service training of executive and program administration personnel as
well as students in formal educational programs for rehabilitation facility administration.
Background
The standards and supporting materials contained in this manual are derived from and based on standards and publica-
tions developed by the two original member organizations of CARF - the Association of Rehabilitation Centers and the
National Association of Sheltered Workshops and Homebound Programs.
Standards for Sheltered Workshops were published by the National Institute on Workshop Standards in 1965. That same
year the Association of Rehabilitation Centers published a three-volume set of standards materials - Standards for
Rehabilitation Centers and Facilities; Manual of Standards for Rehabilitation Centers and Facilities; and Standards
Survey Form for Rehabilitation Centers and Facilities. These documents were adopted by the membership of each
association respectively, and subsequently by the Board of Trustees of the Commission on Accreditation of Rehabilita-
tion Facilities. They represent the consensus of philosophy, knowledge, and experience of the recognized leaders in the
rehabilitation field, including both facility executives and the major professions represented in rehabilitation facility
programs.
One of the original tasks of the Commission was to bring unity to these two sets of standards, all the while providing for
the diversity of organizational settings, program emphases, and service techniques in rehabilitation facility programs.
As a first step forward to this goal, a valid definition of a rehabilitation facility is required.
The definition must be general enough to be inclusive of all rehabilitation facilities and specific enough to be exclusive of
facilities which are not rehabilitative in nature. Many definitions of a rehabilitation facility are currently in use and these
have equal validity in focusing on one or another of the essential characteristics of the rehabilitation facility. These
definitions have in common the following assumptions:
1. Rehabilitation facilities serve *disabled individuals whose handicaps are usually of a permanent residual type.
2. The resulting rehabilitation problems relate to disabilities which are more chronic than acute; inherent in them
are a variety of complicating factors which may involve the physical, emotional, mental, social, and vocational
well-being of the individual.
3. Rehabilitation minimizes the disadvantages of disability; it involves restoration and adjustment services which
are both curative and educative.
4. These services are multiprofessional, interdependent, coordinated, and integrated into an effective functioning
program.
From these assumptions, a conceptual definition of a rehabilitation facility is developed:
A rehabilitation facility is an organizational and physical entity in which a soundly based program of integrated and
coordinated services is provided. The services are directed toward the physical, emotional, mental, social, and voca-
tional restoration and adjustment of handicapped, disabled children and adults. The services consist of evaluation,
treatment, education, training, and placement and are provided by competent personnel especially qualified in the
various phases of the rehabilitation process.
This conceptual definition represents an ideal for a facility that is rehabilitative in its efforts; however, rehabilitation
represents a continuum of services and programs. There is probably no single facility - and certainly no single program
that can serve all types of rehabilitation problems, at every stage in this continuum. For practical application of this
conceptual definition to the realities of facility operation, it is necessary to identify programs by categories that relate to
stages of progression in this continuum. Seven program categories have been identified, based on their services empha-
sis - physical restoration, social adjustment, vocational development, sheltered employment, speech pathology, audi-
ology, and work activity.
While the primary purpose of the facility is to assist its clientele to achieve the optimum level of functioning for which
they are capable, to accomplish this purpose, the facility may operate one or more programs as follows:
1. Primary emphasis of the program is PHYSICAL RESTORATION, supported by social and/or vocational develop-
ment services.
For example:
The primary objective of the program is to apply physical restoration services to upgrade physical function
and enable the patient to achieve a better social adjustment, or to obtain employment.
2. Primary emphasis of the program is SOCIAL ADJUSTMENT, supported by appropriate medical and vocational
development services.
For example:
The primary objective of the program is to apply psychological and social services to resolve the individual's
problems in social living and enable him to improve his social adjustment, or to obtain employment.
3. Primary emphasis of the program is VOCATIONAL DEVELOPMENT, supported by appropriate medical and
social adjustment services.
* "disabled individuals" is used here to include persons who may present physical, mental, emotional, social, or vocational problems.
4
For example:
The primary objective of the program is to apply vocational services, which may include evaluation, job ad-
justment, training, job placement, transitional or interim employment, to resolve the problem of unemploy-
ment and to enable the person served to obtain competitive employment or further education/training leading
to employment.
4. Primary emphasis of the program is the provision of SHELTERED EMPLOYMENT within the facility.
For example:
The primary objective of the program is to provide remunerative employment for an indefinite period of time to
individuals who cannot meet the standards of the competitive labor market. Some individuals may, however,
develop sufficient productive skill and adjustment which would enable them to move out of the facility into
the competitive labor market. Rehabilitation services play a supportive role to successful employment in the
facility.
5. Primary emphasis of the facility is SPEECH PATHOLOGY, supported by appropriate audiological, medical, social
and/or vocational development services.
6. Primary emphasis of the facility is AUDIOLOGY, supported by appropriate speech pathology, medical, social and/
or vocational development services.
7. Primary emphasis of the facility is WORK ACTIVITY, supported by appropriate vocational, social, and personal
adjustment services.
For example:
The primary objective is the provision of a goal-oriented program of therapeutic activities designed to enable
individuals served to either move into competitive employment or other rehabilitation programs such as
sheltered employment or vocational development, etc., or to maintain and/or maximize the individual's
independent functioning. Work must be provided, but it is only one of several therapeutic elements which are
utilized to accomplish the program's objective.
Each program includes the following broad service components:
a. Evaluation or assessment
b. Treatment or training
C. Placement or referral
d. Followup for continuation of services as required
e. Followup to assess efficacy of program based on results or outcome obtained.
To bring the conceptual definition and program categories to functional application, it is necessary to specify the basic
requirements and conditions, on a quantitative basis, that a facility must fulfill. These functional definitions are stated as
CRITERIA OF ELIGIBILITY FOR ACCREDITATION SURVEY, contained in the third section of this manual.
The functional definitions relate to the purpose of a facility and its programs as represented by professional staff, rather
than the milieu within which it operates. Thus, a facility that popularly identifies as "work adjustment center," "sheltered
workshop," "halfway house," "mental health center," "rehabilitation department," is more specifically defined in terms
emphasizing program purpose and staff.
The standards are organized and stated under nine basic "Principles." In addition to those standards that are fundamental
to all facilities, Additional Standards applicable to each of the individual program categories are outlined.
The resulting definitions, criteria, standards, interpretative and evaluative materials are based on a unitary philosophy of
rehabilitation. They cover all the elements contained in the documents from which they were drawn and provide for the
diversity present in the rehabilitation field:
Use of the Manual
As stated earlier, this STANDARDS MANUAL is designed to serve a variety of needs and purposes.
Foremost, however, are its functions as a resource for facility self-evaluation and the survey-consultation program for
accreditation. In each case, its use will be similar, although for different purposes.
Central to the evaluative process are the clear delineation and understanding of the purpose or objectives of the facility.
The preceding section of this introduction identifies, defines, and gives examples of the seven primary emphases of pro-
grams to which the standards are designed to apply. Before conducting a self-evaluation or making application for accred-
itation survey, the facility should study carefully these prográm categories and determine which most appropriately
characterize its functions and objectives.
The CRITERIA OF ELIGIBLITY FOR ACCREDITATION SURVEY presents the requirements which must be met in order
to be eligible for accreditation survey under each of the program categories. While this MANUAL and its contents can
provide valuable information and guidelines for facilities that are working to fulfill the criteria for one or more of the
program categories, formal application for accreditation survey should not be submitted until the facility has identified its
programs and confirmed its fulfillment of the criteria of eligibility.
5
The STANDARDS FOR REHABILITATION FACILITIES are organized under nine basic areas. A fundamental principle is
stated for each area. Under each principle is a series of basic standards identified by two digit numbers. Following the basic
standard are specific requirements represented by three or more digit numbers, which identify specific conditions, func-
tions, or activities which are required to fulfill the basic standard. These basic standards and the requirements detailed
under them are universally applicable in any rehabilitation facility and in all the programs in those facilities.
Additional Standards that are uniquely applicable to a specific program category are detailed at the end of each standards
area. In studying the standards, the facility should pay particular attention to those Additional Standards that apply to the
program or programs it provides.
The INTERPRETATION OF STANDARDS FOR REHABILITATION FACILITIES gives the rationale for standards in each
area, helps the facility relate standards to operations, and provides examples of methods for fulfilling a standard. It is in this
section that the principle and basic standards are discussed in terms of rehabilitation philosophy and their practical
application to conditions as they should exist.
In the section on SURVEY MATERIAL, the CHECKLIST OF RESOURCE MATERIALS can act as a guide to identify the
areas within the standards that require documentation. This listing of written material has been cross-referenced to the
specific standards to which they apply and represents not only information reviewed by the CARF surveyors during the site
survey, but the overall documents necessary for a facility to maintain and support an effective and organized program.
The ACCREDITATION POLICIES AND PROCEDURES section sets forth pertinent Commission policies and procedures
relative to the site survey and accreditation process.
The STANDARDS MANUAL is designed to provide a systematized collection of fundamental information which will serve
the rehabilitation community as an authoritative source of definitions, criteria, standards, interpretations, reference and
resource materials on the various elements of rehabilitation facility operation. For the STANDARDS MANUAL to maintain
its utility and applicability, its contents will be continuously reviewed, evaluated, updated, and expanded, based on new
knowledge and experience gained in the CARF program.
6
GLOSSARY OF TERMS
GLOSSARY OF TERMS
CARF's Glossary of Terms has been prepared for the use of individuals who use the CARF Standards Manual and Self-
Study Questionnaire. This present list is not intended to represent the entire list of terms which may eventually be included
in the Glossary. We anticipate that additions will be made from time to time. Items in the present list have been selected for
definition because, on the basis of our information from the rehabilitation field, it appears that they fall into one or both of
two classes. They include terms which are subject to a wide range of interpretations and terms which require clarification
concerning their usage in the CARF Standards materials.
CARF has not attempted to provide definitions which will be universally applicable. Rather, our intention is to provide in
this Glossary definitions which will serve to reflect the meaning of the terms as they have been used in the CARF Standards
Manual and in the Self-Study Questionnaire.
We hope that those who use the CARF Standards Manual will find the Glossary of Terms helpful. As is true of all of CARF's
interpretative materials, the Glossary will be subjected to continuing review in the interest of improvement.
Affiliation
A relationship, usually signified by a written agreement, between two organizations, under the terms of which one
organization agrees to provide specified services and personnel to meet the needs of the other party to the agreement,
usually on a scheduled basis.
Audiologist
An audiologist is a person who meets applicable legal requirements for the provision of audiology services and who
meets the academic and work experience standards established by the American Speech and Hearing Association for
the Certificate of Clinical Competence in Audiology.
Chief Executive Officer
The individual, within the rehabilitation facility, who is in charge of and responsible for the day-to-day operation of the
program(s). As a point of reference, example titles would include, depending upon the setting, executive director,
president, facility manager, rehabilitation coordinator, administrator, etc.
Consultant
An individual who is not a member of the employed staff of the rehabilitation facility, and whose services are not
provided in compliance with the terms of an affiliation agreement, who provides professional services to the facility's
clients or staff, either upon request or on the basis of a prearranged schedule.
Consultation
A procedure whereby an individual who is not a member of the employed staff of the rehabilitation facility, and whose
services are not provided in compliance with the terms of an affiliation agreement, provides services to the facility's
clients or staff, upon request or on the basis of a prearranged schedule.
Governing Body
The individual(s) or group to whom the chief executive officer is responsible. It is understood that ultimate authority,
depending upon the nature of organization of the facility, may rest with a board of directors, members, a state
legislature, state director, owners, etc. In the case of a publicly operated rehabilitation facility or a rehabilitation unit of
a larger entity, the person in charge of the rehabilitation program reports to the governing body through the adopted
organizational structure.
Job Placement Services
The services provided to assist individuals to identify, obtain, and/or maintain employment commensurate with their
vócational, social, psychological, and medical needs and their abilities. In addition, services are made available to
employers to facilitate the successful employment of handicapped individuals.
Job Placement Specialist
The individual(s) with placement skills, and/or training having primary responsibility for planning and/or providing job
placement services to clients.
Medical Staff (Organized Medical Staff)
A formal organization of physicians and dentists, including those who carry on their professional activities entirely or
primarily within the rehabilitation facility, and may include those who refer patients to the facility for treatment. An
organized medical staff meets at stated regular intervals. Complete records are kept of staff meetings. It is the respon-
sibility of the medical staff to develop and utilize appropriate procedures for continuing review and evaluation of the
practice of medicine in the facility, including the prescription and supervision of associated therapies by the members
of the medical staff.
Medical Supervision (Direction)
The functions which shall be provided include:
1. To maintain a liaison role with the medical community;
2. To participate in quality of care review functions, such as utilization review, peer review, program evaluation, etc.;
9
3. To establish, with the participation of professional staff, criteria for the adequacy of individual patient treatment
prescriptions;
4. To advise facility staff on problems in patient care management and to participate in in-service training;
5. To participate in staff evaluation of service concepts and techniques;
6. To advise on the development of new programs and modification of existing programs;
7. To advise on matters on a medical nature;
8. To assure that services required by law to be prescribed by a physician, when available, are provided in such a way
as to assure acceptable levels of quality.
Items 3. and 8. describe essential elements of medical supervision. The remaining items describe required areas of
physician participation in a physical restoration program.
Occupational Therapist
An individual who is currently certified by the American Occupational Therapy Association, or who is a graduate of a
program in occupational therapy accredited by the American Medical Association in collaboration with the American
Occupational Therapy Association, and who meets the legal requirements of the state.
On-The-Job Evaluation
A work setting located outside the facility in which an individual is given the opportunity to experience the specific
requirements necessary to do a specific job. Real work pressures are exerted by the employer, and the individual's
performance is evaluated by the employer and the evaluator.
Physical Therapist (Licensed Physical Therapist, Registered Physical Therapist)
A graduate of a program in physical therapy as approved by the American Physical Therapy Association or the Council
on Medical Education of the American Medical Association and who is licensed or registered by the state.
Physician
An individual who holds a doctor of medicine or doctor of osteopathy degree and who meets applicable legal
requirements for practice.
Professional Vocational Specialist
An individual with a master's degree in vocational rehabilitation (counseling, evaluation, adjustment, etc.) or a
vocationally related field; or eligible for, or a member of, the National Rehabilitation Counseling Association (profes-
sional), American Rehabilitation Counseling Association, National Vocational Guidance Association, or American
Psychological Association; or certified by the Commission on Rehabilitation Counselor Certification (CRC). The
professional vocational specialist may be the rehabilitation counselor, the vocational evaluator, and/or the work
adjustment specialist.
Program Emphasis
Primary emphasis of the program is PHYSICAL RESTORATION, supported by social and/or vocational development
services.
For example: The primary objective of the program is to apply physical restoration services to upgrade physical
function and enable the patient to achieve a better social adjustment, or to obtain employment.
Primary emphasis of the program is SOCIAL ADJUSTMENT, supported by appropriate medical and vocational
development services.
For example: The primary objective of the program is to apply psychological and social services to resolve the client's
problems in social living and enable him to improve his social adjustment, or to obtain employment.
Primary emphasis of the program is VOCATIONAL DEVELOPMENT, supported by appropriate medical and social
adjustment services.
For example: The primary objective of the program is to apply vocational services, which may include evaluation,
work adjustment, job placement, training, transitional or interim employment, to resolve the problem of unem-
ployment, and to enable the client to obtain competitive employment or further education/training leading to
employment.
Primary emphasis of the program is the provision of SHELTERED EMPLOYMENT within the facility.
For example: The primary objective of the program is to provide remunerative employment for an indefinite period of
time to individuals who cannot meet the standards of the competitive labor market. Some individuals, however,
may develop sufficient productive skill and adjustment which would enable them to move out of the facility into the
competitive labor market. Rehabilitation services play a supportive role to successful employment in the facility.
Primary emphasis of the facility is SPEECH PATHOLOGY, supported by appropriate audiological, medical, social,
and/or vocational development services.
10
Primary emphasis of the facility is AUDIOLOGY, supported by appropriate speech pathology, medical, social, and/or
vocational development services.
Primary emphasis of the facility is WORK ACTIVITY, supported by appropriate vocational, social, and personal ad-
justment services.
For example: The primary objective is the provision of a goal-oriented program of therapeutic activities designed to
enable individuals served to either move into competitive employment or other rehabilitation programs such as
sheltered employment or vocational development, etc., or to maintain and/or maximize the individual's inde-
pendent functioning. Work must be provided, but it is only one of several therapeutic elements which are utilized
to accomplish the program's objective.
Program Manager
The individual within the facility who, with the involvement of other staff, bears primary responsibility for the total
program of the persons served, its coordination, conduct, and followup activities. These functions are best accom-
plished when the program manager remains the same throughout.an individual's program, even when it encompasses
multiple services within a given program emphasis. When more than one major program, e.g., physical restoration and
vocational development, is being simultaneously provided, there should be only one program manager. When the
person's program changes sequentially from one major program emphasis area to another, this may require the
assignment of a new program manager.
Psychologist
An individual with a master's degree in psychology who meets applicable legal requirements, and who is eligible for, or
a member of, the appropriate division of the American Psychological Association.
Rehabilitation/Habilitation
The process of providing in a coordinated manner those comprehensive services deemed appropriate to the needs of a
disabled or handicapped individual, in a program designed to achieve objectives of improved health and welfare with
the realization of his maximum physical, social, psychological, and vocational potential for useful and productive
activity. The components of rehabilitation services are melded into the rehabilitation process when the disabled
individual must have assistance and it is, (1) beyond his personal capacities and resources to meet and solve the
problems of maximum potential of personal, social, and economic adjustment, and (2) beyond the services available in
his usual daily experiences. Such assistance continues through a period during which significant and observable
improvement takes place. Habilitation is closely related to and is a part, both conceptually and programmatically, of
rehabilitation. The range of functional goals are the same, as is the range of services which must be provided to attain
the goals. The chief difference is in the condition or nature of who is served. Habilitation refers to the process when it
involves individuals who need to acquire particular skills and/or functional abilities not previously possessed, such as
independent-living skills or vocational skills, while rehabilitation refers to the process when it involves individuals who
need to reacquire or maximize lost skills and/or functional abilities.
Rehabilitation Facility
A distinct organizational entity, either separate or within a larger institution or agency, which provides goal-oriented,
comprehensive and coordinated services to individuals designed to minimize the handicapping effects of physical,
mental, social, and vocational disadvantages; and to effect a realization of the individual's potential.
Service Referrals
The practice of arranging that an individual receives the services provided by a given professional service unit either
within the facility or through some other appropriate agent. This arrangement, or referral, which usually is made by the
individual within the facility who bears primary responsibility for the program of the person being served, should be
documented by a notation in the person's permanent record.
Simulated Job Station
A work setting located within a facility which is typically represented by subcontract work, and work settings such as
janitorial, cafeteria, clerical work, etc. This was formerly known by the term, "situational assessment."
Social Worker, MSW (Qualified Social Worker)
An individual with a master's degree from a school of social work approved by the Council on Social Work Education.
Speech Pathologist
A speech pathologist is a person who meets applicable legal requirements for the provision of speech pathology
services and who meets the academic and work experience standards established by the American Speech and
Hearing Association for the Certificate of Clinical Competence in Speech Pathology.
Staff Member
A person who is directly employed by or assigned to the rehabilitation facility on either a fulltime or parttime basis.
Utilization Review
A process by which a committee meeting at least once per month and composed of at least two physicians, and other
professional staff as desired by the facility, reviews individual in-and out-patient cases. This does not necessarily need
to include all patients. The review should be conducted on cases irrespective of their source of funding. Results of the
reviews should be documented. Occurring during the course of treatment between admission and discharge, the
review should, on an individual case basis, provide answers to at least the following questions:
11
"Did application of the individual services begin at the appropriate point during the patient's course of treatment?"
"Were the appropriate services provided and for the appropriate length of time?"
"Were the appropriate goals stated for each service?"
"Did the services produce the desired results in terms of the stated goals of the program and the needs of the patient?"
Vocational Evaluator
The individual responsible for the provision of vocational evaluation services who meets the requirements of profes-
sional vocational specialist or who has one year's experience and is under the supervision of a professional vocational
specialist.
Work Adjustment Specialist
The individual responsible for the provision of work adjustment services who meets the requirements of professional
vocational specialist or who has one year's experience and is under the supervision of a professional vocational
specialist.
NOTE: The use of the pronoun "he" throughout this STANDARDS MANUAL is for the purpose of simplification of writing
and refers to "he" or "she" as may be applicable. Additionally, inasmuch as the Commission is a standard-setting and
consultative resource, rather than a regulatory or enforcement agency, the term "should" is used with the same meaning as
the word "shall" throughout this document.
12
CRITERIA OF ELIGIBILITY FOR ACCREDITATION
SURVEY AS A REHABILITATION FACILITY
CRITERIA OF ELIGIBILITY FOR ACCREDITATION
SURVEY AS A REHABILITATION FACILITY
0.1 The facility's major purpose is the rehabilitation of individuals requiring restorative and adjustive, or employment,
services in an integrated and coordinated individualized program. In carrying out its program the facility may place
primary emphasis or emphases on one or more of the following: physical restoration, social adjustment, vocational
development, sheltered employment, speech pathology, audiology, or work activity.
0.2 The facility operates (a) without limitation by reason of race, color, or national origin, (b) under a legally constituted
governing body, and (c) with administration vested in a chief executive.
0.3 The physical plant and equipment are designated for use of the rehabilitation facility and the agents having direct
control of the facility are identified.
0.4 Each program submitted for accreditation must have been in operation for at least one year.
0.5 To be considered as a rehabilitation facility, services in each of the following areas are to be available, when
appropriate, through facility staff, affiliation, or consultation.
0.5.1 Medical
0.5.2 Psychological and/or social
0.5.3 Vocational and/or educational
0.5.4 Sheltered employment
0.5.4.1 The facility's major purpose is remunerative employment for an indefinite period of time of individ-
uals who appear to be unemployable in the competitive labor market.
0.5.4.2 Professional services are supportive to the primary objective of achieving successful employment
within the facility.
0.5.4.3 Professional review and reevaluation of the rehabilitation potential of each individual are made at
least semiannually to identify those individuals who have developed sufficient skills to move into
transitional training or into the competitive labor market.
0.5.5 Speech pathology
0.5.6 Audiology
0.5.7 Work activity
0.5.7.1 The appropriateness of the individual's placement in the work activity program shall be periodically
reviewed.
0.6 The facility has in effect a formal mechanism designed to ensure two things: (1) that the various programs and
services will systematically coordinate their efforts and will effectively relate to one another; (2) that the individ-
ual's program will be individually tailored, integrated, and coordinated.
0.7 The rehabilitation process is conducted in a safe work environment in substantial compliance with federal, state,
and local safety laws and regulations.
0.8 A fulltime (at least 30 hours per week) speech pathologist must be employed by the facility if accreditation survey
is requested for a speech pathology program emphasis.
0.9 A fulltime (at least 30 hours per week) audiologist must be employed by the facility if accreditation survey is
requested for an audiology program emphasis.
0.10 If accreditation survey is sought for a program emphasis in either social adjustment, speech pathology, or
audiology, the facility must regularly accept direct referrals for each such program.
0.11 An outpatient physical restoration program must employ one fulltime (minimum of 30 hours per week), qualified
person in at least two primary service areas (a total of two fulltime persons). These areas are physical therapy,
occupational therapy, and physician services. If speech pathology is not a major program emphasis, then this
service can be one of the two areas employing a fulltime, qualified person.
15
STANDARDS FOR REHABILITATION FACILITIES
STANDARDS FOR REHABILITATION FACILITIES
1. PURPOSES
Principle
The purposes of a rehabilitation facility shall be established and stated so as to govern the direction and character of its
programs. Its operations shall be directed to the primary objective of fulfillment of these purposes.
Standards
1.1 The purposes of the facility, as stated in its legal charter, constitution, bylaws, enabling legislation or regulations,
shall be consistent with all legal requirements, if any, for classification as a rehabilitation facility.
1.2 The facility shall state its purposes as a matter of official record, and describe these purposes in form suitable for
distribution.
1.2.1 The purposes of the facility shall be clearly stated in appropriate publications for distribution to staff,
clientele, referral and payment sources, and interested public.
1.3 The stated purposes of the facility shall be related to the human needs it serves. The facility shall declare how its
programs contribute to these purposes, and shall describe any conditions or restrictions on admission or provision
of services.
1.3.1 The facility shall describe the rehabilitation problems or conditions for which it provides services.
1.3.2 The facility shall describe the services. it provides.
1.3.3 The facility shall state special requirements for admission or provision of services.
1.4 The purposes of the facility, their relation to the needs of the facility's clientele, and their degree of fulfillment shall
be reviewed and evaluated at least annually by its staff and governing body.
1.4.1 There shall be a systematic procedure for professional and administrative staff review of the character of
the caseload.
1.4.2 There shall be a systematic procedure for professional and administrative staff review of program effective-
ness in relation to the stated purposes of the facility.
1.4.3 Recommendations of the professional and administrative staff in relation to the character of the caseload
and. program effectiveness shall be regularly transmitted to and considered by the chief executive officer.
1.4.4 The chief executive officer in turn shall regularly submit appropriate reports and recommendations relative
to the character of the caseload and program effectiveness to the governing body or to his immediate
superior as its representative.
1.5 In seeking to accomplish its purposes, the facility should assess and ameliorate any barriers to the independence
of the handicapped which may be created through its own admission policies, program accessibility, recruit-
ment, employment, and promotion practices, and architectural accessibility.
19
STANDARDS FOR REHABILITATION FACILITIES
2. ORGANIZATION AND ADMINISTRATION
Principle
The rehabilitation facility shall be organized and administered so as to achieve its stated goals.
Standards
Rehabilitation facilities. operated by a public agency, such as a county, state, etc., and rehabilitation units of
larger entities such as hospitals, are exempt from the standards in this section which are preceded by an *
*2.1 The facility shall be, or be part of, a legal entity with a charter or constitution, and bylaws, which are in accordance
with those legal requirements which affect its organization.
Exceptions to the standards on Organization and Administration which are applicable to proprietary facilities are
covered in standard 2.7.
*2.1.1 The facility must be one which is incorporated or is established by a public body with authority to establish and
operate such a facility.
*2.1.1.1 The not-for-profit organization shall hold a letter of exemption under the Internal Revenue Service
Code.
*2.1.1.2 Unless provided for by state law, the constitution, bylaws, or articles of incorporation of a not-for
organization shall contain provision for the dissolution of the organization, in such a manner as to
assure that no residual assets can accrue to the benefit of any individual or group of individuals.
*2.1.2 The charter or constitution shall:
*2.1.2.1 Identify the corporate entity
*2.1.2.2 State the objective of the corporate entity
*2.1.2.3 Describe categories of, and qualifications for, membership if applicable.
*2.1.3 Bylaws, which may contain the articles listed under the charter or constitution, shall, in addition:
*2.1.3.1 Provide for a governing body
*2.1.3.2 Describe qualifications for membership in the governing body, election, and tenure of office
*2.1.3.3 Provide for the election and specification of duties of officers
*2.1.3.4 Establish regular and special meetings of the governing body, in no event fewer than three meetings
each year
*2.1.3.5 Provide for committees of the governing body
*2.1.3.6 Describe the body of parliamentary procedure which shall be followed in the conduct of business
meetings
*2.1.3.7 Describe methods of amending the bylaws
*2.1.3.8 Establish quorum requirements of at least one-third of the governing body
*2.1.3.9 Require recording of minutes.
*2.1.4 The facility's continuing adherence to the specifications of its bylaws should be reviewed annually by the
governing body.
2.2 The facility shall comply with laws and regulations of all governmental and legally authorized agencies under whose
authorities it falls.
*2.3 The governing body has a legal and moral responsibility for the formulation of basic policies concerned with the
establishment of its purposes and conduct of its programs.
*2.3.1 The governing body shall be constituted so as to provide effective, ethical leadership, resourcefulness, and
stability for the facility.
*2.3.1.1 To the extent practicable members of the governing body, on a rotating basis, shall reflect a wide
range of community interests.
*2.3.1.2 The conditions under which a relationship may exist between individual members of the governing
body and the facility are specified, and shall not create a conflict of interest.
*2.3.1.3 The governing body and its committees shall meet with a frequency sufficient to effectively discharge
its responsibilities, but in no event shall the full governing body meet less than three times per year.
2.3.2 The governing body shall have the responsibility for the establishment and maintenance of high standards of
operation for the facility, and for its continuing development.
21
2.3.2.1 It shall approve the initiation, expansion, or modification of the facility's program based upon the
rehabilitation needs of the community and the capability of the facility to have an affect upon those
needs within its established goals and objectives.
2.3.2.2 It shall adopt an annual budget, establish policies for administration of funds, and it shall regularly
review the financial status of the facility.
*2.3.2.3 It shall approve general personnel policies.
*2.3.2.4 It shall hold annual and other meetings as may be required to report to the membership.
2.3.3 When an advisory committee or board, etc. is created or is functioning, the facility should document its pur-
pose, structure, responsibilities, authority, if any, and the relationship of the advisory committee or board to
other entities involved with the facility.
2.4 The governing body or, in the case of a proprietary facility, its designated authority, shall appoint a chief
executive. It shall formally state his relationship to the governing body or its designated authority, and his
duties, and delegate to him such authority and responsibility as is necessary to direct the facility in accord-
ance with its policies.
2.4.1 He shall establish and maintain effective liaison with the governing body.
*2.4.1.1 He shall be present at all meetings of the governing body and standing committees, except when his
personal status is under consideration.
*2.4.1.2 Staff members other than the chief executive officer shall not serve as members of the governing body.
*2.4.1.3 facility. The chief executive officer shall orient new members of the governing body to the operations of the
2.4.1.4 He shall assist the governing body in the formulation of policy by presenting and interpreting operat-
ing reports including reports reflecting the efficiency and effectiveness of the facility, and by present-
ing and interpreting financial statements, short-term and long-term plans, changing concepts, needs,
and related information.
*2.4.1.5 He shall assist the governing body as required in such functions as fundraising, community relations,
and related duties.
2.4.2 He shall coordinate and direct activities of the facility in accordance with the policies of the governing body.
*2.4.2.1 He shall develop the organizational structure for the facility's staff.
*2.4.2.2 He shall maintain personnel policies.
2.4.2.3 He shall control the operation of the facility through day-to-day decisions and authorization of ex-
penditures and other procedures in accordance with the policies established by the governing body.
2.4.2.4 He shall upgrade the operation of the facility by analyzing reports of the various services, comparing
the performances against budgetary, administrative, and professional standards and the extent to
which facility goals and objectives are being attained, and by taking appropriate corrective measures.
2.4.2.5 He shall keep abreast of rehabilitation developments locally and nationally.
2.4.2.6 He shall be currently informed on applicable safety laws and regulations affecting the work
environment.
2.5 There shall be a staff organization under the chief executive which sets forth lines of authority, responsibility, and
communication in accordance with policies established by the governing body. This organizational structure shall be
designed to promote efficient and effective operation of the facility's programs.
2.5.1 The delegation of authority and responsibility within the staff organization shall be established and specified in
job descriptions of administrative and professional personnel.
2.5.2 Coordination of activities and policies of administrative and professional departments shall be achieved
through regularly scheduled meetings of appropriate department heads.
2.5.3 Each department head shall be responsible to the chief executive, or his designate, for fulfillment of his
assigned duties. Each department head shall: (NOTE: a publicly operated facility or a rehabilitation unit of a
larger entity should substitute the term "unit" for "department", and "supervisor" for "department head" in
standards 2.5.3 through 2.5.3.6)
2.5.3.1 Carry out the administration of his department in keeping with policies established by the governing
body and by the chief executive
2.5.3.2 Have direct access to the chief executive or his designate
2.5.3.3 Have input into the process leading to decisions affecting his department, such as the establishment
of department goals and objectives, budgeting, employee selection, staff utilization, space allocation,
travel, client selection, in-service training, consultants, public relations, and program development
2.5.3.4 Be responsible for employee scheduling, job performance, and periodic rating of the employee's
effectiveness
2.5.3.5 Be responsible for interns, trainees, aides, and volunteers assigned to his department
22
2.5.3.6 Be responsible for the safety of the staff and persons served under his supervision.
2.6 The facility, its chief executive or other senior staff members, as may be appropriate, shall show evidence of both
significant involvement in local, state, and national rehabilitation-related programs and dissemination of information
obtained through such involvement to other staff members.
2.7 Standards and definitions applicable to proprietary facilities
2.7.1 The governing board of a proprietary facility shall be defined as the individual, group, or corporation in which
the ultimate responsibility and authority for the operation of the facility are vested. (See also the Glossary of
Terms.) The phrases "or its designated authority" or "responsible authority" would apply to most standards
references to the governing body in Organization and Administration.
In certain instances, the governing body and the administrator may be the same individual, as in the case of a
single administrator-owner.
2.7.2 The names and addresses of all owners, general or limited partners, shall be disclosed. In the case of corpor-
ations, the names and addresses of officers and directors shall be made known.
2.7.3 The following standards shall not apply to proprietary facilities:
2.1.1
2.1.2
2.3.1.2
2.4.1.1
2.4.1.2
2.4.1.3
2.8 Additional standards of Organization and Administration required by individual program emphases
2.8.1 Physical Restoration Emphasis
2.8.1.1 There shall be a formal medical staff organization or other system such as peer review to assure proper
quality control of medical services in an inpatient facility. In an outpatient facility, there shall be an
established mechanism for peer review of medical activities and evidence of medical supervision of
physician-prescribed services.
2.8.1.2 The facility shall be licensed, where applicable.
2.8.1.3 Facilities shall be accredited by the Joint Commission on Accreditation of Hospitals, if eligible.
2.8.1.4 The facility shall have an established mechanism for utilization review (see Glossary of Terms).
2.8.1.4.1 There shall be a written utilization review plan.
2.8.1.4.2 There shall be a designated utilization review committee which meets at least once per
month.
2.8.2 Social Adjustment Emphasis
None required
2.8.3 Vocational Development Emphasis
2.8.3.1 Facilities shall be certificated, where applicable, by Wage and Hour Division of the U.S. Department of
Labor.
2.8.3.2 Where any vocational development services includes the use of subcontract or production work, all
applicable regulations established by the Wage and Hour Division of the U.S. Department of Labor as
well as established state and local regulations shall be followed.
2.8.4 Sheltered Employment Emphasis
2.8.4.1 Facilities shall comply, where applicable, with all requirements relating to wages, hours, and condi-
tions of employment, as established by the Wage and Hour Division of the U.S. Department of Labor,
as well as state and local regulations.
2.8.4.1.1 Facilities shall be certificated, where applicable, by the Wage and Hour Division of the U.S.
Department of Labor and by the appropriate state and local agencies.
2.8.5 Speech Pathology Emphasis
2.8.5.1 Speech pathology services shall be under the direct supervision of a speech pathologist.
2.8.6 Audiology Emphasis
2.8.6.1 Audiology services shall be under the direct supervision of an audiologist.
2.8.7 Work Activity Emphasis
2.8.7.1 Facilities shall, where applicable, comply with all requirements relating to wages, hours, and condi-
tions of employment, as established by the Wage and Hour Division of the U.S. Department of Labor
as well as state and local regulations.
23
2.8.7.1.1 Where required by law, facilities shall be certificated by the Wage and Hour Division of the
U.S. Department of Labor and by the appropriate state and local agencies.
2.8.7.2 The facility shall consider whether a conflict of interest shall exist if paid staff members are allowed to
serve as guardian, conservator, and/or representative payee for individuals served in the facility.
24
STANDARDS FOR REHABILITATION FACILITIES
3. SERVICES
Principle
The rehabilitation facility shall provide services essential to implement its programs. These services must be of high quality
and effectively applied through its programs.
Standards
3.1 The facility shall provide clearly identified services that are essential to the effective conduct of its programs. It shall:
3.1.1 Describe to its staff, persons served, other agencies, and its public the services which it provides.
3.1.2 Maintain, or have available, a current descriptive directory of other resources in the community.
3.1.3 Utilize other agencies, whenever possible, to provide services needed by its clientele which are not available in
the facility.
3.2 The facility shall be responsible for services as required for diagnosis and evaluation, treatment or training appropriate
to the needs of its clientele and the purposes of the facility, and for referral or placement and followup. It shall:
3.2.1 Establish and follow policies and procedures for intake.
3.2.1.1 The facility shall have clearly written criteria for admission.
3.2.1.2 All referrals shall be screened by review of application forms, review of referral information, and,
whenever feasible, by personal interview.
3.2.1.3 The establishment of a diagnosis, evaluation, and determination of the problem for which the individ-
ual was referred shall precede initiation of any treatment or training service. This process should
include consideration of the individual's physical, psychological, social, vocational, and educational
status.
3.2.1.4 Individuals ineligible for service, and the referral source, shall be informed as to the reasons and, if
possible, appropriate referrals shall be made.
3.2.2 Establish and follow procedures for evaluation of its clientele to determine the individual's program at the
facility.
3.2.2.1 The current diagnosis and report of findings for each person served shall be available to the profes-
sional staff.
3.2.2.2 The individual's rehabilitation program shall be established, with his involvement, by professional
personnel who participated in the evaluation. The facility should elicit the goals of the person being
served and consider them in the treatment program.
3.2.3 Establish and follow policies and procedures for orientation of the individual and/or his family.
3.2.3.1 The mechanism by which the individual's program will be managed shall be explained to him at, or
shortly after, admission.
3.2.3.2 Program goals shall be discussed with the individual and/or his family.
3.2.3.3 The services to be provided shall be explained to and discussed with the individual and/or his family.
3.2.3.4 Financial arrangements shall be fully explained to and discussed with the individual and/or his family.
3.2.3.5 Once accepted for services, persons without fee sponsorship shall have access to the same range of
services under the control of the facility as are available to persons with fee sponsorship. An exception
to this standard is when certain services are available only through a special project or study.
3.2.4 Establish and follow policies and procedures to ensure that services provided each person, whether by staff, by
affiliation, or by consultation, are coordinated so as to constitute an integrated program geared toward the
accomplishment of specified goals for the person.
3.2.4.1 Scheduling of prescribed services shall be reviewed on an administrative level so as to promote
efficient utilization of the time of both the person being served and the facility's staff.
3.2.4.2 Appropriate, signed notations in the case record shall verify that the person being served
has received all services to which he has been referred.
3.2.4.3 Service heads shall be responsible for ensuring that the person being served receives the services
required from their units.
25
3.2.4.4 The individual's program manager shall regularly evaluate his program and the continuing appro-
priateness of the program in relation to the progress of the person toward the attainment of stated
goals.
3.2.4.5 Conferences, either formal or informal, the results of which are documented, are held regularly to
review the progress of the person being served, to develop further plans, and to maintain an integrated
and coordinated program.
3.2.4.6 There shall be a time frame(s) established for the accomplishment of the specified goals with progress
reviewed and the results communicated to service staff, individuals served, and the purchaser of
services.
3.2.4.7 Facilities which operate or provide for residential services shall meet the following conditions:
3.2.4.7.1 The services in the residential setting shall be closely coordinated and integrated with the
community and with all other services available through the facility.
3.2.4.7.2 There shall be provisions to maximize independent living skills, use of leisure time, and
community involvement.
3.2.4.7.3 There shall be provisions for emergency medical services.
3.2.5 Establish and follow procedures for discharge of the individual.
3.2.5.1 The discharge decision and plan shall be established through the participation of professional
personnel from services contributing to the program of the individual, and other resource personnel as
appropriate to the welfare of the individual.
3.2.5.2 A discharge authorization and summary shall be prepared and appropriately disseminated for each
person who has been served. The summary shall contain the reason for referral, the diagnosis,
rehabilitation problem, services provided, results of services, referral action recommended, and shall
note procedures and activities to be utilized by the person served and his family to assist the individual
to maintain and/or improve postdischarge functioning and increase independence.
3.2.5.3 The individual, family, administration of the facility and referring source, as appropriate, shall receive
ample notice concerning the discharge decision.
3.2.6 Establish and follow procedures for followup of persons served.
3.2.6.1 In those cases in which followup is to be conducted to support the rehabilitation of the person served,
arrangements for followup contacts shall be made with the person and appropriate agencies or
individuals.
3.2.6.2 Data resulting from followup contact shall be reviewed, at least annually, with documentation of that
review in evaluating the facility's total program.
3.3 Each professional service unit shall provide for the following:
3.3.1 Active participation in conferences concerning persons receiving services
3.3.2 The opportunity to recommend the individual being served for any service through the individual's program
manager
3.3.3 Fulfillment of professional supervision by designated staff members qualified by training and by experience
3.3.4 An ongoing evaluation of concepts and techniques utilized by the services in relation to progress of the
persons served toward attainment of established goals and objectives
3.3.5 An emphasis on maximizing the independent functioning of persons served in the environment outside of the
facility.
3.4 Additional standards of Services required by individual program emphases
3.4.1 Physical Restoration Emphasis
3.4.1.1 The following services shall either be provided by the facility's own staff members, or the facility shall
demonstrate that the services are made available and utilized, when appropriate, through the mech-
anism of formal affiliation and/or consultation (see Glossary of Terms: Staff Member, Affiliation,
Consultation).
3.4.1.1.1 Physician services and medical supervision of physician-prescribed services. A physician
shall attend conferences concerning persons served on the request of the program manager
or the prescribing or referring physician, and a physician shall periodically attend other
conferences of patients receiving multiple services.
3.4.1.1.2 Twenty-four-hour nursing services by legally qualified nurses, under the supervision of a
registered nurse, shall be provided if there are inpatient rehabilitation nursing beds
3.4.1.1.3 Physical therapy services
3.4.1.1.4 Occupational therapy services
3.4.1.1.5 Social work services
26
3.4.1.1.6 Psychological services
3.4.1.1.7 Vocational services. These services may not be required for all age levels, such as young
children or geriatric patients. However, the facility is encouraged to provide vocational
consultation for review of vocational potential and development for such groups.
3.4.1.1.8 Diagnostic laboratory services
3.4.1.1.9 X-ray services
3.4.1.1.10 Dietary services, if an inpatient facility
3.4.1.1.11 Pharmacy services, if an inpatient facility.
3.4.1.2 Dependent on caseload composition, the following services shall either be provided by the facility's
own staff members, or the facility shall demonstrate that the services are made available and utilized,
when appropriate, through the mechanism of formal affiliation and/or consultation.
3.4.1.2.1 Speech pathology services
3.4.1.2.2 Audiology services
3.4.1.2.3 Prosthetics and/or orthotics fitting
3.4.1.2.4 Educational services
3.4.1.2.5 Recreational services
3.4.1.2.6 Dentistry services.
3.4.1.3 The facility shall have a program for the prevention and control of infection.
3.4.2 Social Adjustment Emphasis
3.4.2.1 The following services shall either be provided by the facility's own staff members, or the facility shall
demonstrate that the services are made available and utilized, when appropriate, through the
mechanism of formal affiliation and/or consultation (see Glossary of Terms: Staff Member, Affiliation,
Consultation).
3.4.2.1.1 Psychological evaluation services
3.4.2.1.2 Psychological counseling or therapy services
3.4.2.1.3 Social evaluation services
3.4.2.1.4 Social casework or group work services
3.4.2.1.5 Medical services (psychiatric and/or medical services, dependent on caseload composition)
3.4.2.1.6 Vocational services. These services may not be required for all age levels, such as young
children or geriatric patients. However, the facility is encouraged to provide vocational
consultation for review of vocational potential and development for such groups.
3.4.2.2 Dependent on caseload composition, the following services shall either be provided by the facility's
own staff members, or the facility shall demonstrate that the services are made available and utilized,
when appropriate, through the mechanism of formal affiliation and/or consultation.
3.4.2.2.1 Speech pathology services
3.4.2.2.2 Audiology services
3.4.2.2.3 Occupational therapy services
3.4.2.2.4 Educational services
3.4.2.2.5 Recreational services.
3.4.3 Vocational Development Emphasis
3.4.3.1 The following services shall either be provided by the facility's own staff members, or the facility shall
demonstrate that the services are made available and utilized, when appropriate, through the mech-
anism of formal affiliation and/or consultation (see Glossary of Terms).
3.4.3.1.1 Vocational evaluation
3.4.3.1.1.1 Vocational evaluation services shall be provided on a systematic, organized
basis for the purpose of determining individual vocational objective(s); assets,
limitations, and behaviors in the context of work environments in which he
might function; and specific recommendations which may be used in the
development of the individual's rehabilitation plan. The range and scope of the
evaluation services shall be sufficiently comprehensive to assess or obtain
information concerning at least the following:
a. physical and psychomotor capacities
b. intellectual capacities
C. emotional stability
27
d. interests, attitudes, knowledge of occupational information
e. personal, social, and work history
f. aptitudes
g. achievements (e.g., educational, vocational)
h. work skills and work tolerance
i. work habits (e.g., punctuality, attendance, concentration, organization,
interpersonal skills)
j. work-related capabilities (e.g., mobility, communication, hygiene, money
management, homemaking)
k. job seeking skills
I. potential to benefit from further services, which are specifically identified
m. possible job objectives
n. the individual's ability to learn about himself as a result of the information
obtained and furnished through the evaluation experience.
3.4.3.1.1.2
Appropriate adaptive assessment tools and methods shall be used wherever
possible with individuals having sensory, communication, or other functional
impediments (e.g., visual, hearing, speech, language, cultural, or learning
disabilities) which might invalidate otherwise standardized procedures.
3.4.3.1.1.3 Based on referral information, the initial interview, and the stated purpose of
the evaluation, a specific written evaluation plan for each individual shall be
developed. This plan shall:
a. identify the questions to be answered through the evaluation
b. indicate how these questions will be answered
C. where appropriate, specify persons (staff, family, etc.) who will be involved
in carrying out the plan. There should be evidence that these individuals are
aware of their role in carrying out this plan.
d. be periodically reviewed and modified as necessary.
3.4.3.1.1.4 The length of time an individual remains in vocational evaluation shall be
primarily based upon the time necessary to accomplish the individual's
evaluation goals.
3.4.3.1.1.5 Evaluation data shall be supplemented by evaluation interviews and behavior
observations.
3.4.3.1.1.6
Job areas assessed in vocational evaluation shall be based on client capability
and opportunities in the labor market.
3.4.3.1.1.7
The vocational evaluation service shall assure that a variety of work settings
and tasks are available sufficient to meet the evaluation needs of individuals
being served. A vocational evaluation service shall use two or more of the
following techniques.
3.4.3.1.1.7.1 If psychometrics are used: the selection, administration, scoring,
interpretation, and reporting of all psychological and psycho-
metric tests shall be under the supervision of a person who meets
the qualifications as defined by state law and/or the American
Psychological Association standards.
3.4.3.1.1.7.2 If work samples are used:
a. the vocational evaluation service work samples resources
shall be representative of realistic competitive worker skills.
b. work samples shall be established by an analysis of job
tasks or traits related to a specific area of work, and be stan-
dardized as to materials, layout, instructions, and scoring.
C. competitive norms or industrial standards shall be established
and used.
3.4.3.1.1.7.3 If simulated job stations are used, the individual's job per-
formance shall be evaluated against competitive industrial
standards (e.g., quality, quantity, physical demands).
28
3.4.3.1.1.7.4 If on-the-job evaluation is used, each job site shall be evaluated
as to its appropriateness with regard to:
a. adequate supervision
b. appropriate safety
C. physical accessibility
d. transportation accessibility
e. competitiveness of work tasks and demands.
3.4.3.1.2 Work adjustment
3.4.3.1.2.1 Work adjustment services, when offered, shall be provided on a systematic,
organized basis for the purpose of developing and maintaining those indi-
vidual capacities necessary for the pursuit of an optimal level of vocational
development. The facility's work adjustment services shall make provision for,
but not be limited to, the development of:
a. physical capacities (e.g., sitting, standing, and general work stamina)
b. psychomotor skills (e.g., eye-hand coordination, finger dexterity, and tool
usage)
C. interpersonal and communicative skills (e.g., supervisor, co-worker)
d. work habits (e.g., attendance, punctuality)
e. appropriate dress and grooming
f. job seeking skills
g. productive skills (e.g., quality and quantity of work, work pacing)
h. an orientation to work practices (e.g., payroll deductions, insurance,
unions, retirement benefits, an awareness of safety practices)
i. work-related skills (e.g., counting, measuring, telling time, travel, use of
spare time, money management).
3.4.3.1.2.2 Based on previous diagnostic findings, a specific written work adjustment plan
shall be developed for each individual. This plan shall:
a. specify behaviors to be dealt with
b. specify work assignment and/or environment
C. specify treatment techniques and methods
d. specify persons (staff, family, etc.) who will be involved in carrying out the
plan. There should be evidence that these individuals are aware of their role
in carrying out this plan.
e. be periodically reviewed and modified as necessary.
3.4.3.1.2.3
The work adjustment methods shall be oriented to meet individual needs, as
stated in the work adjustment plan, and shall include techniques related to this
plan and appropriate to the individual and the program goals of the facility.
3.4.3.1.2.4 The length of time that an individual remains in work adjustment shall be
primarily based upon the time necessary to accomplish the individual's
adjustment goals.
3.4.3.1.2.5 The work assignment and/or environment shall be selected. to meet the
individual's work adjustment needs.
3.4.3.1.3 Medical services
3.4.3.1.4 Psychological services
3.4.3.1.5 Social work services.
3.4.3.1.6 Where job placement services are provided, the facility should adhere to the following
standards
3.4.3.1.6.1 Job placement services should be provided or made available to individuals to
identify, obtain, maintain, and/or advance in employment. Provided on an
organized, planned basis, these services should include, but not be limited to,
preparation of the client for employment, job development and placement,
followup, and postemployment services.
3.4.3.1.6.1.1 Services to prepare clients for employment should include:
3.4.3.1.6.1.1.1 Assessment of the appropriateness of the referral
for job placement services.
29
3.4.3.1.6.1.1.2 Analysis of pertinent findings from medical,
psychological, vocational evaluation, and/or
work adjustment services in order to maximize
the individual's job performance, satisfaction,
and job retention.
3.4.3.1.6.1.1.3 Individual and/or group counseling and/or train-
ing regarding the techniques for obtaining and
maintaining employment.
3.4.3.1.6.1.1.4 Assisting clients to become knowledgeable
about: job duties and personnel benefits, rates
of pay, employment policies and practices, and
the job location prior to job acceptance.
3.4.3.1.6.1.2 Job development and placement services should include:
3.4.3.1.6.1.2.1
Contact with employers to actively develop and/
or identify job opportunities for handicapped
individuals.
3.4.3.1.6.1.2.2
On-site job analysis, consultation, and recom-
mendations for job modification, when appro-
priate.
3.4.3.1.6.1.2.3 Assisting employers to identify, modify, and/or
eliminate architectural, procedural, and/or atti-
tudinal barriers to the employment and advance-
ment of handicapped persons.
3.4.3.1.6.1.2.4
Education and/or training of prospective em-
ployers about various disabilities and any voca-
tional implications, the use of assistive devices,
job accommodations, and facility services.
3.4.3.1.6.1.2.5
Maintenance of communication and coordina-
tion with other community agencies and re-
sources.
3.4.3.1.6.1.2.6 Maintenance of an organized system of record-
ing job openings including the names of em-
ployers, persons referred, action taken, etc.
3.4.3.1.6.1.2.7
Feedback of information to other facility staff
members regarding community employment op-
portunities and labor market trends.
3.4.3.1.6.1.3 Followup and postemployment services should include:
3.4.3.1.6.1.3.1
Initial contact within two weeks with the client,
and the employer where this is appropriate in
consideration of the prior relationship.
3.4.3.1.6.1.3.2
The length of time in which followup contact will
be maintained should be specified and primarily
based on the client's needs.
3.4.3.1.6.1.3.3
Appropriate personnel being made available to
the employer and client during and, if feasible,
after regular working hours to provide counsel
to either or both.
3.4.3.1.6.1.3.4 The maintenance of contact for a reasonable
period of time to ensure adequate job adjustment
and retention.
3.4.3.1.6.1.3.5 The availability of rehabilitation services, includ-
ing placement, for clients who are unsuccessful
in maintaining employment.
3.4.3.1.6.2 A written placement plan should be developed for each individual served in job
placement. This plan should:
3.4.3.1.6.2.1 Consider the integration of the results and/or recommendations
from other rehabilitation services, and
3.4.3.1.6.2.2 Contain the job objective(s) and the roles and responsibilities of
the individual providing placement and the individual served.
3.4.3.1.6.3
Individuals referred for job placement services who have not been placed should
have their plan reviewed at least by the end of 30 days. Consultation should
30
occur with other appropriate professional staff and/or the referral source to
determine if the placement plan should be amended.
3.4.3.2 Dependent on caseload composition, additional services that shall be provided by the facility staff, or
be available through formal affiliation, or by consultation:
3.4.3.2.1 Job skill training
3.4.3.2.2 Educational services
3.4.3.2.3 Speech pathology
3.4.3.2.4 Audiology.
3.4.3.3 Where remunerative work is used as part of the facility's program, the standards under 3.4.4 shall
apply.
3.4.4 Sheltered Employment Emphasis
3.4.4.1 The following shall be provided by facility staff.
3.4.4.1.1 Remunerative work including supervision and instruction in work activities and observance
of safety principles in a realistic work atmosphere.
3.4.4.1.1.1 Work orientation shall be provided to encourage good work habits, including
proper care of equipment and materials, correct handling of tools and ma-
chines, good attendance, punctuality, and safe work practices; to afford
disciplined interpersonal relations with supervisory personnel and co-
workers; and to promote work tolerance and work pace consistent with the
client's potential.
3.4.4.1.1.2 The layout of work positions and the assignment of operations shall be so
planned as to allow for efficient flow of work and appropriate relationship of
each operation to all other operations in its sequence with respect to the time
required for its completion. The organization of work shall embody an aware-
ness of safe practices and the importance of time and motion economy in
relation to the needs of individuals being served.
3.4.4.1.1.3
Files on work methods, quality control, and production scheduling shall be
maintained and actively used by supervisory personnel.
3.4.4.1.1.4 Written specifications shall be prepared and available for each article pro-
duced. Products shall be made in conformance with relevant specifications
and meet the standards of competitive products in the open market.
3.4.4.1.1.5
The program shall maintain an organized system of inspection, responsibility
for which is vested in specified members of the staff. The quality of products
and services shall meet competitive industrial standards.
3.4.4.1.1.6
Information concerning health and special work considerations which should
be taken into account in the assignment of clients shall be clearly commu-
nicated in writing to supervisory personnel.
3.4.4.1.1.7
Each department engaged in production shall have established production
goals and shall periodically review and disseminate to appropriate personnel
relevant reports on progress toward attaining those goals.
3.4.4.1.1.8
Facilities engaged in retail sales shall meet the following standards:
3.4.4.1.1.8.1 The sales area shall be functional and attractive in layout
and appearance.
3.4.4.1.1.8.2 The merchandising system shall provide for adequate
levels of stock, stock controls, and stock rotation.
3.4.4.1.1.8.3 There shall be an established system of cash control.
3.4.4.1.1.8.4 Where required by law, a retail sales permit or license shall
be obtained.
3.4.4.1.1.9 The facility shall utilize modified equipment, jigs, fixtures, and other tech-
niques to increase the individual's productivity rate in order to maximize the
person's earnings.
3.4.4.2 The following services shall be provided either by facility staff, or through formal affiliation, or by
consultation.
3.4.4.2.1 The program shall obtain and utilize rehabilitation diagnostic and training data from
cooperative programs, whether within its parent organization or other community sources.
3.4.4.2.1.1 A general medical examination shall be obtained prior to planning any work-
shop services for a client. The report on the examination shall include a state-
ment of the client's physical and other limitations, need for treatment, and
31
conditions under which the client may work. Following employment in the
workshop, the staff shall remain cognizant of ongoing medically-related
problems and shall assist the client in finding solutions to those problems.
3.4.4.2.1.2 When indicated, examinations by appropriate medical specialists shall be
arranged. Reports shall be obtained, clearly reflecting the findings and
recommendations.
3.4.4.2.1.3 When indicated, psychological evaluation shall be made, and a report
obtained, clearly reflecting the findings and recommendations.
3.4.4.2.1.4 At least semiannually, the person's plan for services, goals, and progress
toward goals shall be reviewed by staff members appropriate to that plan with
evidence of subsequent implementation where change in plans, goals, etc. is
being made.
3.4.4.2.2 As indicated, social casework services shall be available.
3.4.4.2.3 As indicated, vocational counseling shall be available.
3.4.4.2.4 The program shall maintain provisions, either within its parent organization or through
cooperative agreements with appropriate community services, for the placement in regular
industry of any of its clients who may qualify for such placement.
3.4.4.2.4.1
Clients shall be informed, through the personnel manual of the program and by
other means, of the availability of such services for placement in competitive
industry.
3.4.4.2.4.2
If the client is placed in regular industry from a sheltered employment program,
and if circumstances beyond his control result in the loss of his job within 30
days after the first day on the job, the client's return to a position in the program
shall be guaranteed.
3.4.4.2.4.3 Where job placement services are provided by the facility as part of a sheltered
employment program emphasis, the facility should adhere to the standards
under 3.4.3.1.6.
3.4.4.2.5 The program shall make referrals of clients to programs for supportive services outside the
workshop function, when indicated.
3.4.4.2.5.1
There shall be adequate provision for handling referrals to and from the
agency. All possible pertinent data shall be obtained at the time of referral and
intake. Information shall be secured from sufficient and appropriate sources,
and shall be current, reliable, and complete. All referral data shall be kept in the
client's case record.
3.4.4.3 The facility shall make no charge to the client for the privilege of employment per se. The facility,
however, may make appropriate charges for optional and rehabilitation services and shall invoice the
person served or his legal guardian.
3.4.4.4 Where vocational evaluation services are provided within the sheltered employment program empha-
sis, standards 3.4.3.1.1.1 through 3.4.3.1.1.7.4 shall apply.
3.4.4.5 Where work adjustment services are provided within the sheltered employment program emphasis,
standards 3.4.3.1.2.1 through 3.4.3.1.2.5 shall apply.
3.4.5 Speech Pathology Emphasis
3.4.5.1 The following services shall be provided by facility staff.
3.4.5.1.1 Prevention and conservation through programs designed to inform the public; for example,
dissemination of diagnostic cues, parent/child counseling, language stimulation proce-
dures, etc.
3.4.5.1.2 Case finding, screening, or verification programs in the community for early identification
of disorders of speech and language with subsequent recommendations for evaluation
3.4.5.1.3 Evaluation programs evidencing the capacity to assess the scope, frequency, and severity
of the problem(s) and the dimensions within which they operate
3.4.5.1.4 Counseling and referral services
3.4.5.1.4.1 Of direct concern to the speech and language problems
3.4.5.1.4.2 Relative to needs of the individual, such as referral to physicians, psycholog-
ists, audiologists
3.4.5.1.5 Treatment of speech and language disorders based on the stated goals of the facility and the
results of the person's evaluation.
3.4.5.2 The following required services shall be provided by facility staff, by formal affiliation or by consul-
tation.
32
3.4.5.2.1 Audiological services
3.4.5.2.2 Psychological evaluation and treatment services
3.4.5.2.3 Medical services
3.4.5.2.4 Dental services
3.4.5.2.5 Education (speech and language training in relation to education programs).
3.4.5.3 Dependent on caseload composition, additional services that shall be provided by facility staff, by
affiliation or by consultation are:
3.4.5.3.1 Social work services
3.4.5.3.2 Vocational services. These services may not be required for all age levels. However, the
facility is encouraged to provide vocational consultation for review of vocational potential
and development for such groups.
3.4.5.3.3 Recreational services
3.4.5.3.4 Residential intensive programs
3.4.5.3.5 Physical restorative services such as physical therapy and occupational therapy.
3.4.5.4 Evaluation, treatment plan, recommendations, and supervision of the person's treatment program
shall be provided only by a speech pathologist formally appointed to the facility's staff.
3.4.6 Audiology Emphasis
3.4.6.1 The following services shall be provided by facility staff.
3.4.6.1.1 Prevention and conservation through programs designed to inform the public; for example,
dissemination of diagnostic cues, individual counseling, dissemination of information
related to problems of noise exposure
3.4.6.1.2 Case finding, screening, or verification programs in the community for early identification
of disorders of hearing with subsequent recommendations for evaluation
3.4.6.1.3 Evaluation programs evidencing the capacity to assess the degree and type of hearing loss
and its immediate and long-range implications for treatment
3.4.6.1.4 Counseling and referral services
3.4.6.1.4.1 Of direct concern to the hearing problem
3.4.6.1.4.2 Related to needs of the individual, such as referral to physicians, psychol-
ogists, speech pathologists, educational institutions, and other specialists
related to language development and education
3.4.6.1.5 Treatment of hearing disorders based on the stated goals of the facility and the results of the
individual's evaluation.
3.4.6.2 The following required services shall be provided by facility staff, by formal affiliation, or by
consultation.
3.4.6.2.1 Speech pathology services
3.4.6.2.2 Psychological evaluation and treatment services
3.4.6.2.3 Medical (always including otolaryngological) services
3.4.6.2.4 Dental services
3.4.6.2.5 Education (speech and language training in relation to education programs)
3.4.6.2.6 Resources for hearing aids or other electronic amplification devices.
3.4.6.3 Dependent on caseload composition, additional services that shall be provided by facility staff, by
affiliation, or by consultation are:
3.4.6.3.1 Social work services
3.4.6.3.2 Vocational services
3.4.6.3.3 Recreational services
3.4.6.3.4 Residential and day school services
3.4.6.3.5 Physical restorative services, such as physical therapy and occupational therapy
3.4.6.3.6 Special services for the deaf/blind
3.4.6.3.7 Manual communication instruction.
3.4.6.4 Evaluation, treatment plan, recommendations, and supervision of the person's treatment program
shall be provided only by an audiologist formally appointed to the facility's staff.
33
3.4.7 Work Activity Emphasis
3.4.7.1 The following shall be provided by facility staff:
3.4.7.1.1 Remunerative work, including supervision and instruction in work activities and observance
of safety principles in a realistic work atmosphere.
3.4.7.1.1.1 Work orientation shall be provided to encourage good work habits, including
proper care of equipment and materials, correct handling of tools and ma-
chines, good attendance, punctuality, and safe work practices; to afford
disciplined interpersonal relations with supervisory personnel and co-
workers; and to promote work tolerance and work pace consistent with the
person's potential.
3.4.7.1.1.2
The layout of work positions and the assignment of operations shall be so
planned as to allow for efficient flow of work and appropriate relationship of
each operation to all other operations in its sequence with respect to the time
required for its completion. The organization of work shall embody an aware-
ness of safe practices and of the importance of time and motion economy in
relation to the needs of individuals being served.
3.4.7.1.1.3 When the facility is involved in prime manufacturing and/or subcontract
operations, files on work methods, quality control, and production scheduling
shall be maintained and actively used by supervisory personnel.
3.4.7.1.1.4 When the facility is involved in prime manufacturing and/or subcontract
operations, written specifications shall be prepared and available for each
article produced. Products shall be made in conformance with relevant
specifications and meet the standards of competitive products in the open
market.
3.4.7.1.1.5
The program shall maintain an organized system of inspection, responsibility
for which is vested in specified members of the staff. The quality of products
and services shall meet competitive industrial standards.
3.4.7.1.1.6
Information concerning health and special work considerations which should
be taken into account in the assignment of clients shall be clearly communi-
cated to supervisory personnel.
3.4.7.1.1.7
The facility shall utilize modified equipment, jigs, fixtures, and other tech-
niques to increase the individual's productivity rate in order to maximize the
person's earnings.
3.4.7.2 The program shall obtain and utilize rehabilitation diagnostic, evaluation, and training data from
cooperative programs, whether within its parent organization or other community sources.
The following services shall be provided either by facility staff, or through formal affiliation, or by
consultation.
3.4.7.2.1 A general medical examination shall be obtained prior to planning any services for a client.
The report on the examination shall include a statement of the client's physical and other
limitations, need for treatment, and any conditions under which the client may participate in
various aspects of the program. Following acceptance in the program, the staff shall remain
cognizant of ongoing medically-related problems and shall assist the client in finding
solutions to those problems.
3.4.7.2.2 When indicated, examinations by appropriate medical specialists shall be arranged.
Reports shall be obtained, clearly reflecting the findings and recommendations.
3.4.7.2.3 When indicated, psychological evaluation shall be made, and a report obtained, clearly
reflecting the findings and recommendations.
3.4.7.2.4 At least semiannually, the person's plan for services, goals, and progress toward goals shall
be reviewed by staff members appropriate to that plan with evidence of subsequent imple-
mentation where change in plans, goals, etc. is made.
3.4.7.3 As indicated, social casework services shall be available.
3.4.7.4 As indicated, vocational counseling shall be available.
3.4.7.5 Client evaluation and goal setting shall be done in the context of the client's functioning within his
community. Services shall be provided or obtained which are designed to maximize social, vocational,
emotional, and/or educational functioning.
3.4.7.5.1 On a systematic, orgainzed basis, the facility's services shall make provision for, but not be
limited to, dealing with the following:
3.4.7.5.1.1 Developing socialization and interpersonal skills.
34
3.4.7.5.1.2. Developing cognitive skills including, but not limited to, the handling of emer-
gencies, telling time, money management, making change, recognizing street
and other signs, etc.
3.4.7.5.1.3
Use of recreation and leisure time.
3.4.7.5.1.4 Community orientation and travel training.
3.4.7.5.1.5
Developing or remediating communication skills.
3.4.7.5.1.6
Developing appropriate grooming, sex, dress, and self-care habits.
3.4.7.5.1.7
Enhancing the physical, mental, and dental health of persons served. The
services should deal with prevention and maintenance needs.
3.4.7.5.1.8 Advocacy training or direct advocacy services in dealing with citizenship,
legal, family, and/or social needs.
3.4.7.5.1.9
Developing work skills and behaviors.
3.4.7.5.2 As a direct result of the facility's most recent evaluation of the preceding areas, a specific,
written plan shall be developed for each individual. The plan shall:
a. specify behaviors to be dealt with
b. specify the assignment and/or environment
C. specify treatment techniques and methods
d. specify persons (staff, family, etc.) who will be involved in carrying out the plan. There
should be evidence that these individuals are aware of their role in carrying out this plan
e. be periodically reviewed and modified as necessary.
3.4.7.6 The program shall maintain provisions, either within its parent organization or through cooperative
agreements with appropriate community services, for the placement in industry, regular sheltered
employment, or other programs of any of its clients who may qualify.
3.4.7.6.1 Clients shall be informed through the personnel manual of the facility, or by other suitable
means, of the availability of such services.
3.4.7.6.2 If the client is placed from the program into a job in competitive industry, into a regular
sheltered employment position, or into another program, and if circumstances beyond his
control result in the loss, within 30 days, of his job or program assignment, the client's return
to a position in the program shall be guaranteed.
3.4.7.6.3 Where job placement services are provided by the facility as part of a work activity program
emphasis, the facility should adhere to the standards under 3.4.3.19
3.4.7.7 The program shall make referrals of clients to other agencies for supportive services when indicated.
3.4.7.7.1 There shall be adequate provision for handling referrals to and from the agency. All possible
pertinent data shall be obtained at the time of referral and intake. Information shall be
secured from sufficient and appropriate sources, and shall be current, reliable, and com-
plete. All referral data shall be kept in the client's case record.
3.4.7.7.2 The facility shall refer for guardian, conservator, or advocacy services those individuals who
may benefit from such services.
3.4.7.8 The program shall make no charge to the client for the privilege of employment per se. The facility,
however, may make appropriate charges for optional and other rehabilitation services, and shall
invoice the person served or his legal guardian.
3.4.7.9 Where vocational evaluation services are provided within the work activity program emphasis,
standards 3.4.3.1.1.1 through 3.4.3.1.1.7.4 shall apply.
3.4.7.10 Where work adjustment services are provided within the work activity program emphasis, standards
3.4.3.1.2.1 through 3.4.3.1.2.5 shall apply.
35
STANDARDS FOR REHABILITATION FACILITIES
4. PERSONNEL
Principle
The rehabilitation facility staff shall be competent, ethical and qualified to provide the services essential to the achievement
of the facility's stated goals. It shall establish and maintain personnel policies which contribute to the effective functioning
of its staff.
Standards
Note: In publicly operated facilities, the relationship between the individuals or their elected representatives and the public
agency as their employer is governed by personnel policies, regulations, and procedures established either by the same
public agency or another public agency and not by the facility. Thus, in the instance of a publicly operated facility, in this
section the reference to "facility" means the entire public agency. However, standards of qualification of personnel,
consultants, etc. should not be less than those established by recognized professional groups.
4.1 Personnel shall be employed as are required to provide the services essential to fully implement the facility's program.
4.2 Standards of qualifications for all staff shall be established and maintained. Job descriptions shall be established for
all personnel, including volunteers, and be relevant to the facility. Each job description shall set forth the qualifica-
tions, reporting supervisor, position(s) supervised, and duties and shall be dated and periodically reviewed for con-
tinuing appropriateness and provided to the individual(s) involved.
4.2.1 The governing body has final responsibility for standards of qualification for facility personnel. It shall delegate
authority and responsibility for implementing standards to the chief executive.
4.2.2 All facility personnel shall meet the legal requirements of their positions.
4.2.3 When standards of qualification have been established by recognized professional groups, the facility shall
adopt not less than these as minimum requirements for its respective professional staff.
4.2.4 When standards of qualification have not been established by an organization or group, the facility shall
establish reasonable qualifications and a job description and provide for ongoing assessment of competency
in job performance.
4.2.5 The facility's contractual or consultant services shall meet the standards of qualification established by their
respective professional group or organization, by applicable legal requirements, and by such additional
evidence of competence as the facility may require.
4.2.5.1 The facility shall document the nature and extent of actual involvement by individuals utilized through
consultation or affiliation arrangements.
4.2.6 Volunteers shall be supervised and have the qualifications required for their assignments. If volunteers provide
professional service, they shall meet the standards applied to paid staff.
4.2.7 Supportive personnel or technical assistants shall be supervised and shall function within the goals of the
facility and with specified job duties. As training and proficiency standards develop nationally for supportive
personnel, the facility will conform to these standards, when adopted by the CARF Board of Trustees.
4.3 Current personnel policies and practices shall be established, maintained and readily available in written form.
4.3.1 Personnel policies shall be a matter of official record, and be made available to all staff in employee handbook
or by other suitable means.
4.3.2 Personnel policies shall cover the basic relationships between the employer and employee, the responsibilities
and obligations of each, and the general working arrangements.
4.3.3 Personnel policies shall be reviewed no less than annually.
4.3.4 Wage and salary practices shall be consistent with the provisions of the Fair Labor Standards Act as amended.
4.3.5 A job performance evaluation shall be conducted for each staff member on a regular basis by the immediate
supervisor, and the results shall be documented, reviewed with the staff person, and then included in the
personnel file.
4.4 The facility shall encourage and support staff growth and development related to the attainment of facility goals and
objectives through:
4.4.1 The planned conduct of multidiscplinary and departmental in-service training programs for which agendas are
prepared
4.4.2 Ready access to professional reference material relevant to the service and to rehabilitation in general
4.4.3 The establishment, to the extent possible, of affiliations with universities and colleges to provide internship
programs for the various disciplines represented in the facility.
4.4.4 Provision of opportunities for professional education
4.4.5 Provision of opportunities for research
37
4.4.6 Budget provisions to support these staff growth and development activities.
4.5 Additional standards of Personnel required by individual program emphases
4.5.1 Physical Restoration Emphasis
4.5.1.1 The following personnel shall be required either as facility staff members, or the facility shall demon-
strate that the personnel are available and utilized, when appropriate, through the mechanism of
formal affiliation and/or consultation (see Glossary of Terms).
4.5.1.1.1
Physician
4.5.1.1.2
Twenty-four-hour nursing services by legally qualified nurses, under the supervision of a
registered nurse, shall be provided if inpatient beds are maintained.
4.5.1.1.3
Physical therapist
4.5.1.1.4
Occupational therapist
4.5.1.1.5
Social worker
4.5.1.1.6
Psychologist
4.5.1.1.7
Professional vocational specialist
4.5.1.1.8
Clinical pathologist
4.5.1.1.9
Radiologist
4.5.1.1.10 Dietitian, if an inpatient facility
4.5.1.1.11 Pharmacist, if an inpatient facility.
4.5.1.2 Dependent on caseload composition, the following personnel shall be required either as facility staff
members, or the facility shall demonstrate that the personnel are available and utilized, when appro-
priate, through the mechanism of formal affiliation and/or consultation.
4.5.1.2.1 Speech pathologist
4.5.1.2.2 Audiologist
4.5.1.2.3 Prosthetist and/or orthotist
4.5.1.2.4 Educational specialist
4.5.1.2.5 Dentist and, where appropriate, dental hygienist.
4.5.2 Social Adjustment Emphasis
4.5.2.1 The following personnel shall be required either as facility staff members, or the facility shall demon-
strate that the personnel are available and utilized, when appropriate, through the mechanism of
formal affiliation and/or consultation (see Glossary of Terms).
4.5.2.1.1 Psychologist
4.5.2.1.2 Social worker
4.5.2.1.3 Physician
4.5.2.1.4 Professional vocational specialist.
4.5.2.2 Dependent on caseload composition, the following personnel shall be required either as facility staff
members, or the facility shall demonstrate that the personnel are available and utilized, when appro-
priate, through the mechanism of formal affiliation and/or consultation.
4.5.2.2.1 Speech pathologist
4.5.2.2.2 Audiologist
4.5.2.2.3 Occupational therapist
4.5.2.2.4 Educational specialist.
4.5.3 Vocational Development Emphasis
4.5.3.1 The following personnel shall be required either as facility staff members, or the facility shall demon-
strate that the personnel are available and utilized, when appropriate, through the mechanism of
formal affiliation and/or consultation (see Glossary of Terms.)
4.5.3.1.1
Professional vocational specialist
4.5.3.1.2
A plant manager, if work production is part of the program
4.5.3.1.3
A work foreman or supervisor, if work production is part of the program
4.5.3.1.4
Psychologist
4.5.3.1.5
Social worker
4.5.3.1.6
Physician
38
4.5.3.1.7 Vocational evaluator, if vocational evaluation is part of the program
4.5.3.1.8 Work adjustment specialist, if work adjustment services are part of the program
4.5.3.1.9 Rehabilitation counselor, if rehabilitation counseling is part of the program.
4.5.3.1.10 Job Placement Specialist. Where job placement services are provided, the facility should
identify the knowledge, skills, and abilities which must be possessed by the job placement
specialist(s) and should ensure that the job placement specialist(s) has such. Examples of
these include, but are not limited to: awareness of the legal issues in placement, such as
minimum working age requirements; awareness of local labor market trends and employ-
ment practices; knowledge of job analysis; knowledge of the vocational implications of
various handicapping conditions, etc.
4.5.3.2 Dependent on caseload composition, the following personnel shall be required either as facility staff
members, or the facility shall demonstrate that the personnel are available and utilized, when appro-
priate, through the mechanism of formal affiliation and/or consultation.
4.5.3.2.1 Occupational skill instructor
4.5.3.2.2 Educational specialist
4.5.3.2.3 Speech pathologist
4.5.3.2.4 Audiologist.
4.5.3.3 The normal size caseload of a vocational evaluator shall assure adequate time for personal involve-
ment, observation, and individual planning for each person served.
4.5.4 Sheltered Employment Emphasis
4.5.4.1 The following positions shall be provided for in the facility's organization structure. The duties
connected with these positions shall be performed by staff members employed by the facility on a
fulltime basis.
No staff member shall be responsible for the functions involved in more than two of the following
positions:
4.5.4.1.1 Director of the facility (alternate titles may be: general manager, workshop manager)
4.5.4.1.2 Plant manager (alternate titles may be: production superintendent, operations director)
4.5.4.1.3 Plant foreman or supervisor (alternate titles may be: production department supervisor,
group leader).
4.5.4.2 The following personnel-to-client ratios shall be maintained.
4.5.4.2.1 In extended employment programs, the workshop shall employ a minimum of three super-
visory and administrative staff for the first 15 clients or fewer, plus an additional employee in
direct client service for each additional 15 clients.
4.5.4.2.2 Where vocational evaluation and/or work adjustment services are provided, the facility shall
employ aminimum of two supervisory and administrative staff and a professional vocational
specialist for the first 10 clients, plus an additional employee in direct client service for each
additional 10 clients.
4.5.4.3 The following personnel shall be made available and utilized, either through formal affiliation with
another agency, or by consultation.
4.5.4.3.1 Physician
4.5.4.3.2 Psychologist
4.5.4.3.3 Professional vocational specialist
4.5.4.3.4 Systems and production specialist
4.5.4.3.5 Social worker.
4.5.4.3.6 Job placement specialist. Where job placement services are provided by the facility as part
of a sheltered employment program emphasis, the facility should adhere to standard
4.5.3.1.10
4.5.4.4 The qualifications of all members of the staff and of all consultants whose services are utilized shall be
appropriate to their respective positions.
4.5.4.4.1 The qualifications of the director of the workshop shall be consistent with the following
requirements.
Education: Bachelor's degree from an accredited college
Substitution for Education: Two years of supervisory experience may be substituted for
each year of required education beyond the high school level, provided that at least half of
this experience is in a supervisory position in a sheltered workshop.
39
Experience: A minimum of eight years of fulltime paid employment with at least four years
of experience in administrative work directing professional, technical, or supervisory
personnel.
Substitution for Experience: Graduate training may be substituted for up to three years of
experience exclusive of the administrative experience. A master's degree in business ad-
ministration, industrial administration, or one of the helping professions may be accepted
as equivalent to one year of administrative experience.
4.5.4.4.2 The qualifications of the plant manager shall be consistent with the following requirements.
Education: High school education plus two years of college or equivalent education in a
recognized program of technical training.
Substitution for Education: Two years of supervisory experience may be substituted for
each year of required education beyond the tenth grade level.
Experience: A minimum of five years of fulltime paid employment in regular industry or
sheltered workshops, including at least two years of supervisory experience.
Substitution for Experience: College education above the minimum requirement may be
substituted on a year-for-year basis for up to two years of experience, excluding the
supervisory experience.
4.5.4.4.3 The qualifications of the foreman shall be consistent with the following requirements.
Education: High school graduate.
Experience: A minimum of four years of fulltime paid employment in regular industry or in
sheltered workshops, including at least one year of work experience in the type of opera-
tions he is to supervise in the sheltered workshop.
Substitution for Education and Experience: Up to three years of any combination of military
service, education, or business experience beyond the minimum requirements may be
substituted for either the education or experience requirements.
4.5.4.5 The personnel policies shall be consistent with good policy and practice in regular industry.
4.5.4.5.1 Clients in extended employment shall be provided with the following benefits:
a. Old age survivors' and disability insurance or its equivalent in a public program except
where client earnings do not exceed $50 in a quarter
b. Workmen's compensation insurance or its equivalent
C. Minimum of five days' full pay for vacation, a minimum of five days' full pay for sick leave,
and a minimum of five holidays with full pay, annually.
4.5.4.5.2 A personnel manual shall be prepared and distributed to all clients, outlining the conditions,
benefits, and responsibilities of employment.
4.5.4.5.3 The program shall comply with federal laws and regulations concerning rights and equal
pay.
4.5.4.5.4 The program shall not discriminate with regard to employment, promotion, pay, or place of
work because of race, creed, national origin, sex, nonjob-related disability, or age if be-
tween ages 40-65.
4.5.4.5.5 All personnel in extended employment shall have equal opportunity to use the same
equipment, where such use is appropriate to the individual client's capabilities and to his
job, in the opinion of his supervisor.
4.5.4.5.6 Provisions for meeting safety and health standards shall apply uniformly to all personnel.
4.5.4.5.7 Meetings of clients and management shall be held regularly during the year for the purpose
of discussing matters of mutual concern. Among the purposes of these meetings should be
the following:
a. To inform clients concerning those aspects of workshop operations and plans which
bear upon their welfare
b. To enlist clients' informed cooperation toward achieving efficient use of resources of the
workshop in their best interests
C. To receive clients' suggestions and to answer their questions
4.5.4.5.8 Clients who take exception to the decision of a staff member shall have the right and be
given the opportunity to appeal such decision.
4.5.4.5.9 The program shall establish an effective mechanism for dealing with such appeals.
4.5.5 Speech Pathology Emphasis
4.5.5.1 The following personnel shall be required on the facility staff:
40
4.5.5.1.1 Speech pathologist.
4.5.5.2 The following personnel shall be required either on the facility staff, or be available through formal
affiliation or by consultation:
4.5.5.2.1 Audiologist
4.5.5.2.2 Psychologist
4.5.5.2.3 Physician
4.5.5.2.4 Dentist
4.5.5.2.5 Educational specialist
4.5.5.3 Dependent on caseload composition, the following personnel shall be required either on facility staff,
or be available through formal affiliation or by consultation:
4.5.5.3.1 Social worker
4.5.5.3.2 Vocational specialist
4.5.5.3.3 Physical therapist and occupational therapist.
4.5.6 Audiology Emphasis
4.5.6.1 The following personnel shall be required on the facility staff:
4.5.6.1.1 Audiologist.
4.5.6.2 The following personnel shall be required either on the facility staff, or be available through formal
affiliation or by consultation:
4.5.6.2.1 Speech pathologist
4.5.6.2.2 Psychologist
4.5.6.2.3 Physician
4.5.6.2.4 Dentist
4.5.6.2.5 Educational specialist
4.5.6.2.6 Hearing aid dealers.
4.5.6.3 Dependent on caseload composition, the following personnel shall be required either on facility staff,
or be available through formal affiliation or by consultation:
4.5.6.3.1 Social worker
4.5.6.3.2 Vocational specialist
4.5.6.3.3 Physical therapist and occupational therapist.
4.5.7 Work Activity Emphasis
4.5.7.1 The following positions shall be provided for in the facility's organizational structure. The duties
connected with these positions shall be performed by staff members employed by the facility.
No staff member shall be responsible for the functions involved in more than two of the following
positions:
4.5.7.1.1 Director of the program.
4.5.7.1.2 Work supervisor
4.5.7.1.3 Activities of daily living specialist
4.5.7.2 In a work activity program, the facility shall employ a minimum of three supervisory and administrative
staff for the first 15 clients or fewer, plus an additional employee in direct client service for each addi-
tional 10 clients.
4.5.7.3 The following personnel shall be made available, either through formal affiliation with another agency,
or by consultation:
4.5.7.3.1
Physician
4.5.7.3.2
Psychologist
4.5.7.3.3
Professional vocational specialist
4.5.7.3.4
Systems and production specialist
4.5.7.3.5
Social worker
4.5.7.3.6
Educational specialist
4.5.7.3.7
Recreational specialist
4.5.7.3.8
Dentist
41
4.5.7.3.9
Speech pathologist
4.5.7.3.10 Audiologist
4.5.7.3.11 Occupational therapist
4.5.7.3.12 Physical therapist
4.5.7.3.13 Where job placement services are provided by the facility as part of a work activity program
emphasis, the facility should adhere to standard 4.5.3.1.10.
4.5.7.4 The qualifications of all members of the staff and of all consultants whose services are utilized shall be
appropriate to their respective positions.
4.5.7.4.1 The qualifications of the director of the program shall be consistent with the following
requirements:
Education: Bachelor's degree from an accredited college.
Substitution for Education: Two years of supervisory experience may be substituted for
each year of required education beyond the high school level, provided that at least half
of this experience is in a supervisory position in a sheltered workshop or work activity
program.
Experience: A minimum of three years of fulltime paid employment with at least one year
of experience in administrative work directing professional, technical, or supervisory
personnel.
4.5.7.4.2 The work supervisor shall have a high school diploma or its equivalent and at least two years
of fulltime paid employment in regular industry. The individual shall have at least one year
of supervisory experience.
4.5.7.4.3 The activities of daily living specialist shall have a bachelor's degree in home economics,
education, family and child development, or other human service areas or two years of full-
time paid experience working with the handicapped.
4.5.7.5
The personnel policies of the work activity program shall be consistent with principles of fairness and
equitability.
4.5.7.5.1 The program shall provide clients with the following benefits:
a. Old age survivors' and disability insurance or its equivalent in a public program except
where client earnings do not exceed $50 a quarter.
b. Workmen's compensation insurance or its equivalent.
C. Individuals in the work activity program beyond two years shall be provided a minimum
of five days' full pay for vacation, a minimum of five days' full pay for sick leave, and a
minimum of five holidays with full pay, annually.
4.5.7.5.2
A client handbook shall be prepared by the program and distributed to all of its clients,
outlining the conditions, benefits, and responsibilities of the facility and the client.
4.5.7.5.3
The program shall comply with federal laws and regulations concerning rights and equal
pay.
4.5.7.5.4 The program shall not discriminate with regard to employment, promotion, pay, or place of
work because of race, creed, national origin, sex, nonjob-related disability, or age, if be-
tween ages 40-65.
4.5.7.5.5
All personnel in the work activity program shall have equal opportunity to use the same
equipment, where such use is appropriate to the individual client's capabilities and to his
job, in the opinion of his supervisor.
4.5.7.5.6
Provisions for meeting safety and health standards shall apply uniformly to all personnel.
4.5.7.5.7
Meetings of clients and management shall be held regularly during the year for the purpose
of discussing matters of mutual concern. Among the purposes of these meetings should
be the following:
a. To inform clients concerning those aspects of program operations and plans which bear
upon their wages or welfare.
b. To enlist clients' informed cooperation toward achieving efficient use of resources of
the program in their best interests.
C. To receive clients' suggestions and to answer their questions.
4.5.7.5.8
Clients who take exception to the decision of a staff member shall have the right and be
given the opportunity to appeal such decision.
4.5.7.5.9 The program shall establish an effective mechanism for dealing with such appeals.
4.5.7.5.10 In a dual program (where a work activity and another type of work program are operated by
the same facility), separate direct supervision shall be maintained for the work activity
program.
42
STANDARDS FOR REHABILITATION FACILITIES
5. RECORDS AND REPORTS
Principle
The rehabilitation facility shall maintain accurate and complete records necessary to the conduct of its programs. It shall
prepare and distribute reports that demonstrate and interpret the level of fulfillment of its purposes.
Standards
5.1 Individual case records and reporting systems necessary to meet all applicable professional, administrative, and legal
requirements shall be established and maintained.
5.1.1 A single case record for each person admitted to the facility shall be prepared. The location of the case record,
and the information contained therein, shall be controlled from a central location by a designated staff mem-
ber. Information in the case record shall communicate clearly, concisely, completely, and promptly the appro-
priate case information. The information and documents in individual case records shall be organized in a
systematic fashion and affixed to the record jacket.
5.1.2 Completed case records shall include:
5.1.2.1 Case identification data
5.1.2.2 Reports from referring sources
5.1.2.3 Pertinent history, diagnosis, rehabilitation problem, goals, and prognosis
5.1.2.4 Designation of program manager for the individual or a written policy identifying who carries the pro-
gram management responsibility for facility cases.
5.1.2.5 Service referrals inside and outside of the facility. Records of persons who have been referred to other
agencies for services should contain, as a minimum, the following information:
1. Place, date, and reason for referral
2. Contact person
3. Report of outcome
5.1.2.6 Evaluation reports and treatment plan from each service and from staff conferences of each service
involved shall be available.
5.1.2.6.1 Each treatment plan shall contain statements of:
a. the individual's goals
b. the treatment to be applied
C. the specific goals of treatment
d. time interval at which treatment effects shall be reviewed
e. the measures to be used to assess the effects of treatment.
5.1.2.7 Signed clinical and progress reports from each service which relate the status of the person served to
program goals and objectives.
5.1.2.8 Reports from outside consultation, and from laboratory, radiology, orthotic and prosthetic services,
etc.
5.1.2.9 Correspondence pertinent to the person being served
5.1.2.10 A signed authorization from the person served or his parent or guardian, as appropriate, to release
the information on any case in which information has been released
5.1.2.11 Discharge report
5.1.2.12 Followup reports which specifically relate status to program goals and objectives
5.1.2.13 Evidence of the individual's participation in the decision-making process of his own rehabilitation
program
5.1.2.14 The name and address of the conservator, guardian, and/or representative payee if one has been
appointed for the person served.
5.1.3 Each professional service unit shall maintain a work sheet for each person receiving services within a unit.
5.1.4 Statements of professional judgment and reports of services to an individual shall be signed by-the person
qualified by professional competency and official position.
43
5.1.5 Individual case records shall be maintained on a current basis, with clinical information recorded within 48
hours of the event to be reported, and discharge summaries recorded within two weeks following discharge.
5.1.6 Reports based upon individual case records shall be authorized by the person served or his legal representative
for transmission to individuals and agencies. Any information released should be limited to the need to know
on the part of the individual or agency requesting the information and a proper release should be obtained from
the person served or his guardian.
5.1.7 Appropriate safeguards shall be applied to protect confidential records and to minimize the possibility of loss
or destruction of records.
5.1.7.1 A designated staff member shall be responsible for the control of case records and for assuring the
implementation of the facility's policies and procedures pertaining to case records.
5.1.7.2 Access to case records shall be limited to the professional staff providing direct service to the person
served, plus such other individuals as may be administratively authorized.
5.1.7.3 An indexing and filing system shall be maintained for all records.
5.1.7.4 Records shall be stored under lock, with protection against fire, water, and other hazards.
5.1.8 Case records shall be retained for a period of time consistent with professional, administrative, and legal
requirements.
5.2 The facility shall regularly review and evaluate its case records, and policies and procedures relative to them, with
participation of representatives of its service units, for purposes of evaluating their adequacy, and to propose
improvements in the recordkeeping system.
5.2.1 A case record committee, representative of the major professional services and responsible to the chief execu-
tive, shall be established. The committee shall:
5.2.1.1 Regularly review, at least once every four months, an appropriate sample of the case records to
measure their adequacy and fulfillment of recordkeeping requirements
5.2.1.2 Regularly review, in no event less than annually, the policies and procedures concerning case records
and reports, and make recommendations which shall be considered by the chief executive.
5.3 Administrative records and reports shall be established, maintained, and used as necessary to guide the operations,
measure productivity, and reflect the programs of the facility.
5.3.1 Administrative records and reports shall be developed to guide the operations of the facility, measure and
communicate productivity, and reflect the facility's status. They shall include:
5.3.1.1 Minutes of meetings of the full governing body and of its committees which accurately document all
actions taken at the meetings; e.g., approval of the annual budget, adoption of personnel policies, etc.
Publicly operated facilities and rehabilitation units of larger entities are exempt from this standard.
5.3.1.2 Minutes of administrative and professional staff meetings
5.3.1.3 Personnel records which contain the information necessary to carry out the personnel management
function including, but not limited to, application, credentials verification, evidence of current
licensure where applicable, and reports of performance evaluation. In a publicly operated facility or a
rehabilitation unit of a larger entity, such information must be obtained but may be maintained
elsewhere. A copy of performance evaluation reports must be accessible to the manager of the
rehabilitation facility program.
5.3.1.4 Fiscal records and reports, including payroll, purchasing, and financial statements of the facility.
Publicly operated facilities and rehabilitation units of larger entities are exempt from this standard.
5.3.1.5 Statistical records describing the operations of the facility
5.3.1.6 Correspondence file
5.3.1.7 Safety, fire inspection, public health inspection, and related reports.
5.3.1.8 A written plan shall be established for the reporting of all accidents and serious illnesses occurring in
the facility or on its premises, whether or not they give rise to injuries requiring medical treatment.
5.3.1.8.1 The plan shall provide for the following:
5.3.1.8.1.1 Prompt reporting of the accident to appropriate persons within the facility and
to obtain emergency care
5.3.1.8.1.2 Recording of the essential facts surrounding the accident
5.3.1.8.1.3
A log shall be maintained of injuries and serious illnesses involving persons
served and staff
5.3.1.8.1.4
A periodic summary of injuries and serious illnesses, such as by type of injury
or illness, location of accidents, etc.
5.3.1.8.1.5
Review of accident reports by facility staff members, with resulting
recommendations for improving the facility's safety program and its handling
of accidents and injuries.
44
5.3.2 Appropriate safeguards shall be applied to protect confidential administrative records.
5.3.2.1 Access to administrative records shall be limited to individuals authorized by the chief executive.
5.3.2.2 A suitable filing system shall be maintained.
5.3.2.3 Controls shall exist so that the location of all essential records will be known at any time.
5.3.2.4 Records shall be stored under lock, and where there is maximum protection against fire and water
damage and other hazards.
5.3.3 Records shall be retained for a period of time consistent with professional, administrative, and legal require-
ments.
5.4 Additional standards of Records and Reports required by individual program emphases
5.4.1 Physical Restoration Emphasis
5.4.1.1 Minutes of meetings of the utilization review committee shall be taken and retained by the facility.
5.4.1.2 The facility shall obtain and retain a signed informed consent form where applicable.
5.4.2 Social Adjustment Emphasis
None required
5.4.3 Vocational Development Emphasis
5.4.3.1 Records and reports shall include the earnings of the person served.
5.4.3.21 Records and reports shall include the wage supplements paid to the person served.
5.4.3.3 Records and reports shall include work tolerance reports concerning the person served.
5.4.3.4 Records and reports shall include statements on work progress and production records of the person
served.
5.4.3.5 Client goals shall be expressed in job possibilities for the client in terminology such as job titles or job
families related to existing occupations in the community.
5.4.3.6 For each individual served in vocational evaluation, a written, functional evaluation report shall be
prepared and properly interpreted to the individual and disseminated to the program manager, referral
source, and other appropriate agencies or individuals.
5.4.3.7 In work adjustment services, the procedures used in administering work adjustment techniques shall
be in written form and contain all pertinent information necessary to ensure an appropriate and uni-
form application of the techniques.
5.4.3.8 Where job placement services are provided, records should indicate the date of referral for placement
services.
5.4.3.9 Records of clients who have been placed in outside employment should contain, as a minimum, the
following information:
5.4.3.9.1 Place of employment
5.4.3.9.2. Job title
5.4.3.9.3 Rate of pay and fringe benefits
5.4.3.9.4 Date on which employment commenced
5.4.3.9.5 Employment status 60 days after employment commences
5.4.3.9.6 Name of the immediate supervisor, if available, at the work site.
Where remunerative work is used as a part of Vocational Development services, the standards under 5.4.4
shall apply.
5.4.4 Sheltered Employment Emphasis
5.4.4.1 The program shall maintain the following payroll and other records:
5.4.4.1.1 For each staff member and client employed
a. Full name
b. Home address
C. Date of birth
d. Social security number
e. Occupation
f. Time of day and day of week on which workweek begins. A single notation may be made
for any group of employees where the workweek begins and ends the same time for all.
45
5.4.4.1.2 For each staff member and client employed, except those employed in a bona fide execu-
tive, administrative, or professional capacity, or in the capacity of outside salesmen, the
following additional information shall be recorded:
a. Regular hourly rate of pay
b. Hours worked each workday and workweek
C. Total daily or weekly straight-time earnings
d. Total overtime pay for the week
e. Total additions to or deductions from wages paid each pay period
f. Total wages paid each pay period
g. Total amount of bonuses paid, if any
h. Date of payment and pay period covered by the payment.
5.4.4.1.3 For each client employed
a. Special work considerations to be taken into account in the assignments of clients
b. Statement on work progress
C. Production record of client
d. Identification of client on payroll.
5.4.4.2 Records of clients who have been placed in outside employment should contain, as a minimum, the
information noted in standard 5.4.3.9.
5.4.5 Speech Pathology Emphasis
None required
5.4.6 Audiology Emphasis
None required
5.4.7 Work Activity Emphasis
5.4.7.1 The program shall maintain the following payroll and other records:
5.4.7.1.1 For each staff member and client
a. Full name
b. Home address
C. Date of birth
d. Social security number
e. Occupation
f. Time of day and day of week on which workweek begins. A single notation may be made
for any group of employees where the workweek begins and ends the same time for all.
5.4.7.1.2 For each staff member and client, except those employed in a bona fide executive, admini-
strative, or professional capacity, or in the capacity of outside salesmen, the following
additional information shall be recorded:
a. Regular hourly rate of pay
b. Hours worked each workday and workweek
C. Total daily or weekly straight-time earnings
d. Total overtime pay for the week
e. Total additions to or deductions from wages paid each pay period
f. Total wages paid each pay period
g. Total amount of bonuses paid, if any
h. Date of payment and pay period covered by the payment.
5.4.7.1.3 For each client
a. Special work considerations to be taken into account in the assignments of clients
b. Statement on work progress
C. Production record of client
d. Identification of client on payroll. In a dual program, identification of client by type of
program on payroll.
46
5.4.7.2 Records of clients who have been placed in outside employment should contain, as a minimum, the
information noted in standard 5.4.3.9.
5.4.7.3 In a dual program, separate records (income, expenditures, and client payroll) shall be maintained for
the work activity program.
47
STANDARDS FOR REHABILITATION FACILITIES
6. FISCAL MANAGEMENT
Principle
The rehabilitation facility shall manage its fiscal affairs consistent with the purposes of the organization in accordance with
sound practices and legal requirements.
Standards
6.1 Financial operations shall conform to legal requirements, and shall be based upon sound financial planning and
prudent management of capital, operating income, and expenditures.
6.1.1 The facility shall operate on an annual budget. The budget shall:
6.1.1.1 Reflect and anticipate the facility's needs and resources for realizing its goals
6.1.1.2 Be approved by the governing body or its designated authority prior to the initiation of the new fiscal
year
6.1.1.3 Be used, during the year covered, as a yardstick to assess accomplishment of budgetary goals.
6.1.2 An examination of the facility's financial statements must be conducted annually by an accountant, licensed
and qualified to express an opinion on the fairness of presentation of the facility's financial statements. The
result of the examination and any accompanying recommendations shall be reviewed and acted upon by the
governing body or its designated authority. This standard shall not be applicable in the instance of a publicly
operated facility or a rehabilitation unit of a larger entity. In these instances, the facility should adhere to
requirements of the public agency or larger entity.
6.1.3 Fiscal data or reports shall be prepared and communicated to the governing body or its designated authority at
no less than quarterly intervals, or more frequently if needed.
6.1.4 A fiscal description of program activities shall be prepared and communicated to the facility's public at least
annually. This standard shall not apply to a proprietary facility. A publicly operated facility or a rehabilitation
unit of a larger entity should adhere to the policies and practices of the larger agency or entity.
6.2 The facility shall maintain its financial solvency through such means as establishing and collecting fees, and obtaining
grants, donations and endowments. A publicly operated facility shall be exempt from this standard.
6.2.1 Generally accepted accounting principles appropriate to the facility shall be employed.
6.2.2 Charges for services or products shall be based on a knowledge of their costs (both direct and indirect). The
facility shall identify its cost per service unit.
6.2.2.1 All long-term contracts shall be reviewed at least annually to ensure an adequate pricing structure.
6.2.2.2 Where residential services are provided, fiscal records shall separate maintenance costs from service
costs.
6.2.3 Where fees for services are charged, the facility shall have an established schedule of fees for services.
6.2.3.1 The schedule of fees shall be available in printed form.
6.2.3.2 The schedule of fees shall be applied fairly and equitably to each person served.
6.2.3.3 Fees shall not be split with other agencies or individuals as consideration for referral of persons to be
served.
6.3 Fundraising programs shall conform to legal requirements and established ethical standards for fundraising activities.
6.4 The facility shall have a risk protection program adequate to preserve its assets and to compensate its staff, volunteers,
board members if applicable, clientele, and the public for reasonable claims due to untoward events for which the
facility is liable. Evaluation of the needs for insurance and the types of protection offered shall be reviewed annually, or
more frequently if necessary. Insurance or risk coverage shall include building(s), equipment and inventory, work-
men's compensation, social security, and bonding of appropriate personnel. A publicly operated facility or a rehabil-
itation unit of a larger entity should follow the policies and practices of the larger agency or entity.
6.4.1 The facility shall consider its needs and responsibilities in relation to malpractice liability insurance, product
and service liability insurance, directors' and officers' errors and omissions insurance, etc.
6.5 Additional standards of Fiscal Management required by individual program emphases
6.5.1 Physical Restoration Emphasis
None required
6.5.2 Social Adjustment Emphasis
None required
49
6.5.3 Vocational Development Emphasis
6.5.3.1 Sound and accepted practices shall be observed in all business and industrial activities, including
purchase of materials, expansion of capital resources, sale of products, and subcontracting.
6.5.3.1.1 The facility shall avoid unfair competition with other facilities and/or commercial organiza-
tions in selling its services and products.
6.5.3.1.2 The wage rates paid to clients shall correspond with those which are paid for comparable
levels of productivity in private industry.
Where remunerative work is used as a part of Vocational Development services, the standards under 6.5.4 shall
apply.
6.5.4 Sheltered Employment Emphasis
6.5.4.1 Sound and accepted practices shall be observed in all business and industrial activities, including
purchase of materials, sale of products, and subcontracting.
6.5.4.1.1 The workshop shall seek business only on a fair and competitive basis.
6.5.4.1.1.1 An overhead markup supported by precise analysis of production costs,
including direct labor, shall be charged for contract work. The value of any
services, equipment, or space provided by the contractor for the contract
operation shall be included in the determination of this markup.
6.5.4.1.1.2
Selling prices of the workshop's manufactured products shall be based upon
full cost reimbursements and in line with the prevailing price range for such
products in the areas in which its products are marketed.
6.5.4.1.1.3
Contract prices and selling prices of manufactured items shall be reviewed at
least annually to assure that they remain fair and competitive.
6.5.4.1.1.4 The workshop shall not knowingly accept struck work.
6.5.4.1.2 Bidding for work shall be based on the costs involved, including:
6.5.4.1.2.1
Local industry prevailing piece or time rates for comparable work
6.5.4.1.2.2
Production rate norms established based upon nonhandicapped people when
verifiable industry rates are not available
6.5.4.1.2.3
Costs of supplies, of equipment peculiar to the work, and of administrative
overhead.
6.5.4.1.3 The workshop shall seek to achieve optimum efficiency consistent with the rehabilitation
needs of its clients.
6.5.4.1.4 The workshop shall pay wage rates commensurate with those paid for similar types and
amounts of work by local commercial and industrial establishments maintaining approved
labor standards.
6.5.4.1.4.1
Facility wage scales shall be reviewed at least semiannually for this purpose.
6.5.4.1.4.2
For each client paid at piece rates, or whose productivity can be measured, a
continuing production record shall be maintained.
6.5.4.1.4.3
For other clients, the records shall contain at least a semiannual report on the
client's work performance in relation to his earnings.
If there has been no increase in his hourly rate within the past one year, the
record shall contain an explanation.
6.5.4.1.4.4
For each type of work performed, the workshop shall maintain records
reflecting the best information available as to normal productivity of average
nonhandicapped workers. These records shall show the sources of informa-
tion, whether from commercial or industrial establishments, time studies, or
other sources.
6.5.4.1.4.5
The workshop shall maintain records, reviewed at least semiannually, of local
prevailing wage rates in industry for the same or similar types of work as done
in the workshop; or, if these are not readily available, for work requiring a
similar level of skill. The records shall show dates and sources of information.
6.5.4.1.5 The workshop shall comply with governmental wage and hour regulations.
6.5.4.1.5.1
All clients shall be paid at least the applicable certificate minimums and over-
time pay required by law. Publicly operated facilities shall be exempt from the
requirement of obtaining a certificate but should show evidence of paying
commensurate wages.
6.5.4.1.5.2
The workshop shall comply with legal minimum age requirements.
6.5.4.1.5.3
Wage payments made to clients shall be of a monetary nature, and not
payments in kind.
50
6.5.4.1.5.4 Each client shall receive a written statement for each pay period indicating his
gross pay, hours worked, and deductions.
6.5.4.1.6 Financial records shall make it possible to identify separately at least the following operat-
ing costs:
Client earnings
Insurance
Wage supplements
Maintenance
Direct labor
Occupancy
Indirect labor
Receiving and shipping
Payroll taxes
Administration
Raw materials
Production development
Marketing and selling
Transportation
Warehousing
Materials handling
6.5.4.1.7 When nonfee-for-service funds, such as maintenance or personal allowance monies, are
received in behalf of the person served, or when the facility serves as representative payee,
such funds shall not be commingled with other funds but shall be segregated and used only
for the purpose for which the funds were received.
6.5.4.1.8 In calculating the standard rate for a given operation, the facility shall use an appropriate
allowance for personal, fatigue, and delay factors.
6.5.4.1.9 The facility shall have a written plan identifying activity options to be used in the event of a
reduction in work available or when production delays are expected to be in excess of one
day.
6.5.5 Speech Pathology Emphasis
None required
6.5.6 Audiology Emphasis
None required
6.5.7 Work Activity Emphasis
6.5.7.1 Sound and accepted practices shall be observed in all business and industrial activities, including
purchase of materials, sale of products, and subcontracting.
6.5.7.1.1 The program shall seek business only on a fair and competitive basis.
6.5.7.1.1.1 An overhead markup supported by precise analysis of production costs,
including direct labor, shall be charged for contract work. The value of any
services, equipment, or space provided by the contractor for the contract
operation shall be included in the determination of this markup.
6.5.7.1.1.2
Selling prices of the program's manufactured products shall be based upon
full cost reimbursement and in line with the prevailing price range for such
products in the areas in which its products are marketed.
6.5.7.1.1.3
Contract prices and selling prices of manufactured items shall be reviewed at
least annually to assure that they remain fair and competitive.
6.5.7.1.1.4 The program shall not knowingly accept struck work.
6.5.7.1.2 Bidding for work shall be based on the costs involved, including:
6.5.7.1.2.1
Local industry prevailing piece or time rates for comparable work
6.5.7.1.2.2
Production rate norms established based upon nonhandicapped people when
verifiable industry rates are not available
6.5.7.1.2.3
Costs of supplies, of equipment peculiar to the work, and of administrative
overhead.
6.5.7.1.3 The program shall seek to achieve optimum efficiency consistent with the rehabilitation
needs of its clients.
6.5.7.1.4 The program shall pay wage rates commensurate with those paid for similar types and
amounts of work by local commercial and industrial establishments maintaining approved
labor standards.
6.5.7.1.4.1
Facility wage scales shall be reviewed at least semiannually for this purpose.
6.5.7.1.4.2
For each client paid at piece rates, or whose productivity can be measured, a
continuing production record shall be maintained.
6.5.7.1.4.3
For other clients, the records shall contain at least a semiannual report on the
client's work performance in relation to his earnings.
If there has been no increase in his hourly rate within the past one year, the
record shall contain an explanation.
51
6.5.7.1.4.4 For each type of work performed, the program shall maintain records reflecting
the best information available as to normal productivity of average nonhandi-
capped workers. These records shall show the sources of information, whether
from commercial or industrial establishments, time studies, or other sources.
6.5.7.1.4.5
The program shall maintain records, reviewed at least semiannually, of local
prevailing wage rates in industry for the same or similar types of work as done
in the program; or if these are not readily available, for work requiring a similar
level of skill. The records shall show dates and sources of information.
6.5.7.1.5 The program shall comply with governmental wage and hour regulations.
6.5.7.1.5.1
All clients shall be paid at least the applicable certificate minimums and
overtime pay required by law. Publicly operated facilities shall be exempt from
the requirement of obtaining a certificate but should show evidence of paying
commensurate wages.
6.5.7.1.5.2 The program shall comply with legal minimum age requirements.
6.5.7.1.5.3
Wage payments made to clients shall be of a monetary nature, and not pay-
ments in kind.
6.5.7.1.5.4 Each client shall receive a written statement for each pay period indicating his
gross pay, hours worked, and deductions.
6.5.7.1.6 Financial records shall make it possible to identify separately at least the following oper-
ating costs:
Client earnings
Insurance
Wage supplements
Maintenance
Direct labor
Occupancy
Indirect labor
Receiving and shipping
Payroll taxes
Administration
Raw materials
Production development
Marketing and selling
Warehousing
Transportation
Materials handling
6.5.7.1.7 When nonfee-for-service funds, such as maintenance or personal allowance
monies, are received in behalf of the person served, or when the facility serves
as representative payee, such funds shall not be commingled with other funds
but shall be segregated and used only for the purpose for which the funds were
received.
6.5.7.1.8 In calculating the standard rate for a given operation, the facility shall use an
appropriate allowance for personal, fatigue, and delay factors.
6.5.7.1.9 The facility shall have a written plan identifying activity options to be used in
the event of a reduction in work available or when production delays are ex-
pected to be in excess of one day.
52
.920q1uq bns STANDARDS FOR REHABILITATION FACILITIES le HA 18"ST
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The rehabilitation facility shall be designed, located, constructed, equipped, and operated so as to promote the efficient,
effective conduct of its programs and to protect the health and safety of persons served and staff.
Burdey
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Standards
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7. The facility shall be so located in the community that is readily accessible to its clientele, staff, and visitors, and shall
make available adequate parking, dining areas, and other common services.
7.2 The physical plant, equipment, and operation of the facility shall meet all applicable legal requirements for design,
construction, health, and safety.
Y-7.201 In the conduct of its programs, the facility shall show an awareness of its responsibility to not contribute to the
pollution of the environment.
7.2.2 Where residential services are provided, applicable legal requirements shall be met for design, construction,
health, safety, and personnel.
7.2.3 The facility shall equip and maintain all powered equipment, machinery, and powered hand tools with the
safety guards, shields, and other devices necessary to protect the health and safety of the operators and others
in the work area.
7.2.3.1 All exposed rotating parts, motor shafts, drive belts, chains, cables, gears, cutting blades, wheels, and
other moving parts of machinery must be adequately guarded.
7.2.3.2 Personal protective equipment and clothing must be provided to employees, and clients when appro-
priate, when handling dangerous materials or working at hazardous operations.
7.2.4 Adequate fire protection equipment in the form of automatic sprinkler systems, fire hoses, and portable fire
extinguishers, or combinations thereof, shall be provided in each occupied building. This equipment shall not
be obstructed or obscured from view. Clearance shall be maintained between the top level of the stored ma-
terial and the sprinkler heads which meets national, state, and local fire safety requirements.
7.2.4.1 An internal alarm system, (bell, horn, siren, flashing lights, etc.) appropriate to the population, must be
provided so that building occupants can be alerted to an emergency.
7.2.5 A sufficient number of exits shall be provided in each usable area of every building. The number of exits shall be
based on the type of occupancy and the occupancy load of the area, excluding elevators and overhead doors.
Sliding doors, unless meeting all applicable legal requirements, may not be considered as a part of the required
number of exits.
7.2.5.1 Panic hardware shall be required on all exit doors which would be used by more than 50 persons in an
emergency.
7.2.6 All aisles, hallways, stairways, and main routes of egress shall be maintained free of obstacles and stored
materials.
7.2.6.1 Permanent aisles, and passageways shall be clearly defined by painted lines, curbings,
or other methods of marking and shall be kept clear and in good repair.
7.2.6.2 All floor surfaces, platforms, and walking surfaces shall be kept clean and dry and free of holes or
projections which constitute hazards.
7.2.6.3 All materials stored in tiers shall be stacked, racked, blocked, interlocked, or otherwise secured to
prevent sliding, collapsing, or falling.
7.2.7 All floor and wall openings, open-sided mezzanine areas or platforms, 30 inches or more above the adjacent
ground level, shall be guarded by a standard railing.
7.2.8 Adequate rest room facilities must be provided in each occupied building of the facility.
7.2.9 Where persons served or employees are permitted to lunch or to prepare food on the premises, adequate space
and facilities should be provided. All food preparation equipment and installations shall be maintained in a
sanitary manner. Covered receptacles for waste food disposal shall be provided:
7.2.10 Adequate natural or mechanical powered ventilation of all working areas should be provided.
7.2.10.1 Where dust, fume, or vapor producing operations are conducted, suitable exhaust systems shall be
installed to control these air contaminating sources.
7.2.11 Adequate general illumination must be provided in all buildings of the facility based upon the nature of
utilization.
7.2.12 Electrical panels, disconnect switches, and other distribution service areas must have adequate clearance in
front of them.
53
7.2.12.1 All electrical panels, switches, and controls must be identified as to voltage and purpose.
7.2.12.2 All electrically powered hand tools or equipment shall be properly grounded.
7.3 The physical plant shall be adequate in size and design so as to promote efficiency and flexibility in operations, and
equipped to meet established standards for each professional or industrial service it provides as well as general
services such as housekeeping.
7.3.1 Facilities involved in the transportation of people and/or materials shall meet the following standards:
7.3.1.1 To assure life-safety, regular inspection and maintenance of vehicles is provided based upon appli-
cable legal requirements and the needs for safe operation of the vehicles.
7.3.1.2 Vehicles and related auxiliary equipment such as ramps, restraining straps, forklift equipment, etc.,
shall meet applicable legal requirements and be maintained in safe and efficient operating condition.
7.3.1.3 Facilities involved in materials collection shall maintain collection centers including collection boxes,
stationary trailers, and buildings in attractive condition and shall provide for regularly scheduled
pickup of material.
7.3.1.4 A system shall be established and utilized to assure that only properly licensed drivers operate agency
vehicles.
7.3.1.5 Provision is made for initial and ongoing training of vehicle operators which is appropriate to the
purpose for which the vehicle will be used. The training shall include proper techniques for movement
of people and/or materials.
7.3.1.6 A means shall be provided by which the vehicle operator can be identified as an authorized representa-
tive of the facility.
7.3.1.7 Provision is made for insurance coverage at a level appropriate to the purpose for
which the vehicles are used. A publicly operated facility shall be exempt from this standard.
7.4 The staff shall be consulted concerning need and selection of equipment, or modification of facilities used in the
conduct of the program.
7.5 The convenience of persons served and accessibility to services should be met insofar as possible in the design and
maintenance of the physical plant and equipment. Where architectural barriers are present, the governing body has
approved a plan for the remediation of these barriers.
7.6 The facility shall have an established, written plan for dealing with fire and other emergencies which is in keeping with
the facility's caseload composition. The plan and other aspects of the facility's total safety program shall be reviewed
by a designated safety committee which meets at least three times per year. Recommendations resulting from this
review shall be submitted in writing to the chief executive.
7.6.1 Tests of emergency provisions shall be conducted no less than once per month and at varied times for each
tour of duty. The involvement of individuals being served is optional, but the kinds of difficulties presented in
the evacuation of persons with various disabilities should be simulated in the drills to provide the staff with the
preparation necessary for actual emergencies.
7.6.2 Details of the fire and emergency plan shall be in written form, and shall be available to, and communicated to,
all members of the staff and other supervisory personnel. The plan shall include provisions for temporary
shelter and other handling of evacuees. Evacuation routing charts shall be displayed throughout the facility at
principal points of passage.
7.6.3 The facility's emergency plans shall include provisions for dealing with bomb threats, medical emergencies,
power failures, and natural disasters.
7.6.4 A written analysis of the conduct and effectiveness of each test of emergency provisions shall be prepared by
specified staff members and submitted to the chief executive officer and to those staff members who are
responsible for the plant safety program.
7.6.5 Fire extinguishers of the appropriate type shall be suitably located and visually identified as to type of use.
Evidence of adequate maintenance of extinguishers shall be provided.
7.6.6 The facility's emergency plans shall provide for the training of designated staff members in techniques of fire
suppression.
7.6.7 The facility's emergency plans shall provide for suitable first aid facilities, equipment, and supplies.
7.6.7.1 A sufficient number of appropriate persons shall be trained in administering first aid services to ensure
the presence of at least one such individual in the facility during all working hours.
7.6.7.2 A formal plan shall be established for the referral of persons who have required and received first aid to
a local hospital or physician's office for further care. An outline of such a plan shall be posted at the
first aid station and at other appropriate places in the facility.
7.7 The facility which participates in a community disaster plan shall establish and test plans for the purpose of meeting its
responsibilities for providing emergency casualty care at the time of external disaster, based upon its capabilities.
Such plans shall be in written form, and shall be communicated to the staff.
7.8 There shall be written evidence of annual inspection by local fire control agencies and by a safety consultant repre-
54
senting the fire insurance companies holding the facility's coverage, or by other competent authority. There shall be
evidence of review and action taken with respect to reports and recommendations received from such inspections.
7.9 Additional standards of Physical Facilities required by individual program emphases
7.9.1 Physical Restoration Emphasis
7.9.1.1 For inpatient nursing bed facilities, rehabilitation beds shall be in a designated area specifically
assigned to the rehabilitation facility.
7.9.1.2 For inpatient nursing bed facilities, there shall be an automatic fire control system, such as sprinklers,
smoke detection devices, automatic visible and audible alarms, smokeproof stairway enclosures, etc.
in all areas.
7.9.2 Social Adjustment Emphasis
None Required
7.9.3 Vocational Development Emphasis
7.9.3.1 The facility shall use laborsaving tools, equipment, and machinery comparable to that used in in-
dustry, unless there are clearly defined reasons for exceptions in dealing with specific groups of
persons.
7.9.3.2 A suitable location shall be provided to ensure confidentiality of information about the individual
served for such activities as interviews, case dictation, staff conferences, psychometric testing, etc.
7.9.3.3 Equipment used in vocational evaluation shall represent the type currently used in competitive
industry.
7.9.3.4 Equipment in vocational evaluation shall be based on client capabilities and opportunities in the labor
market.
7.9.3.5 The vocational evaluation area shall be suitably designed for the activities carried out and have
sufficient space for current operations.
7.9.3.6 When work adjustment services are provided, the organization of the work settings shall be designed
to meet individual work adjustment needs.
When remunerative work is performed in vocational evaluation or work adjustment, the standards
under 7.9.4 shall apply except where otherwise indicated in a standard.
7.9.4 Sheltered Employment Emphasis
7.9.4.1 The work production area shall be designed to ensure the most efficient flow and control of materials
in and out of the facility.
7.9.4.1.1 Provision shall be made for storage and control of raw materials.
7.9.4.1.2 Provision shall be made for storage and control of finished products.
7.9.4.2 The facility shall use laborsaving tools, equipment, and machinery comparable to those used in indus-
try, unless there are clearly defined reasons for exceptions in dealing with specific groups of clients.
7.9.5 Speech Pathology Emphasis
7.9.5.1 The facility shall provide equipment in the speech pathology area which is appropriate to the needs of
the persons being served and the facility's stated goals.
7.9.5.2 The insulation. location and construction of therapy rooms shall provide reasonable privacy and sound
7.9.5.3 Direct or indirect observation facilities shall be provided.
7.9.5.4 Where audiological testing facilities are provided, the auditory testing rooms shall meet the standards
for acceptable sound rooms established by the American National Standards Institute.
7.9.5.5 The audiometers used shall be on the approved list established by the American Academy of
Ophthalmology and Otolaryngology for acceptable instruments and shall be calibrated and main-
tained in accordance with standards established by the American National Standards Institute.
7.9.5.6 Electroacoustic equipment shall be checked periodically to ascertain adequacy of functioning, and
evidence of a program of repair and maintenance shall be provided.
7.9.6 Audiology Emphasis
7.9.6.1 The facility shall provide equipment in the audiology area which is appropriate to the needs of the
persons being served and the facility's stated goals.
7.9.6.2 Thelocation insulation. and construction of therapy rooms shall provide reasonable privacy and sound
7.9.6.3 Direct or indirect observation facilities shall be provided.
7.9.6.4 The auditory testing rooms shall meet the standards for acceptable sound rooms established by the
American National Standards Institute.
55
7.9.6.5 The audiometers used shall be on the approved list established by the American Academy of
Ophthalmology and Otolaryngology for acceptable instruments and shall be calibrated and main-
tained in accordance with standards established by the American National Standards Institute.
7.9.6.6 Electroacoustic equipment shall be checked periodically to ascertain adequacy of functioning, and
evidence of a program of repair and maintenance shall be provided.
7.9.6.7 Where guidance in selection of hearing aids is offered, minimum requirements recommended by the
American Speech and Hearing Association shall be observed.
7.9.7 Work Activity Emphasis
7.9.7.1 The work production area shall be designed to ensure the most efficient flow and control of materials
in and out of the facility.
7.9.7.1.1 Provision shall be made for storage and control of raw materials.
7.9.7.1.2 Provision shall be made for storage and control of finished products.
7.9.7.2 The facility shall use laborsaving tools, equipment, and machinery comparable to those used in
industry, unless there are clearly defined reasons for exceptions in dealing with specific groups of
clients.
7.9.7.3 In a dual program, as required by the Wage and Hour Division of the U.S. Department of Labor, the
work activity program shall be physically separated from the other work program; e.g., aisles, parti-
tions, separate floors or buildings, etc.
7.9.7.4 The program shall provide needed structure for those served by clear physical and/or programmatic
definition of the work area from other areas of the activity program.
56
STANDARDS FOR REHABILITATION FACILITIES
8. COMMUNITY INVOLVEMENT AND RELATIONS
Principle
The rehabilitation facility shall actively participate in community planning organizations and programs as they relate to
rehabilitation, and shall conduct a public information program.
Standards
8.1 The facility shall develop its program and add new services based upon identified rehabilitation needs and resources
in the community which it serves.
8.1.1 The facility shall identify the geographic and other characteristics of its service community.
8.1.2 Identification of rehabilitation needs and resources in the facility's service community shall be carried out in
cooperation with community groups concerned with health and welfare.
8.1.3 Contents of such studies shall be reported and interpreted periodically to the governing board.
8.1.4 Personnel of the facility shall actively participate in interagency and community planning activities.
8.1.5 The rationale and direction of such planning activities, as well as the facility's part in them, shall be reported to
the governing board periodically.
8.2 The facility or parent entity shall conduct a public information program using appropriate forms of communication to
encourage understanding, cooperation, and assistance from other agencies, as well as from civic, religious, fraternal,
business, and industrial groups in the community.
8.2.1 Responsibility for maintaining an appropriate program in the area of public relations shall be vested in a
designated individual. This responsibility may be carried by the chief executive, or by someone else whom he
may appoint.
8.2.1.1 A productive relationship shall be maintained with the press, radio, and television facilities. Activity in
these areas should be documented by suitable records.
8.2.1.2 The facility or parent entity shall prepare and distribute to appropriate recipients such materials as
leaflets and other mail enclosures in which the services offered by the facility are described.
8.2.1.3 The facility shall maintain a program for contacts with appropriate community groups.
8.3 The facility shall maintain, where applicable, a program designed to provide opportunities for participation by mem-
bers of the community, whether in groups or as individuals, in its work.
8.4 There shall be an established procedure for providing acknowledgment and donation receipts for income tax pur-
poses upon the receipt of any gift, donation, contribution, or bequest. A system shall be in effect to assure the trust of
the public by protecting against the misappropriation of contributed materials.
8.5 The need for the protection of the confidential relationship of all persons served shall be fully observed in connection
with all public relations, fundraising, and community programs.
8.5.1 The facility and its representatives shall employ only ethical methods of publicity, promotion, and solicitation
of funds.
8.5.1.1 Public information materials shall enhance the dignity, respect, self-worth, and the striving for
independence of the disabled.
8.5.1.2 No use shall be made of any living disabled person's name or picture without prior permission of the
individual concerned.
8.5.1.3 No rights shall be granted to profitmaking or nonprofit groups to couple their support of programs for
the disabled with their sales promotions in such a manner as to exploit the disabled.
8.6 Additional standards of Community Involvement and Relations required by individual program emphases
8.6.1 Physical Restoration Emphasis
None required
8.6.2 Social Adjustment Emphasis
None required
8.6.3 Vocational Development Emphasis
8.6.3.1 Client evaluation and goal-setting shall be done in the context of the client's functioning within his
community.
8.6.4 Sheltered Employment Emphasis
57
8.6.4.1 Facilities which are involved with used or recycled materials shall establish and maintain a systematic
procedure for the collection of a sufficient quantity of such materials from community sources to
maintain the facility's program.
8.6.4.2 There shall be no representation of products as made by the disabled unless the facility employs the
labor of disabled persons to an extent constituting not less than 75 percent of the total man hours
worked in the direct labor of production of manufactured products.
Temporary exceptions may be recognized in the case of experimentation with new products or
processes.
8.6.5 Speech Pathology Emphasis
8.6.5.1 Prevention and conservation through programs designed to inform the public; for example, dissemi-
nation of diagnostic cues, counseling, language stimulation procedures, etc. should be provided.
8.6.5.2 Case finding, screening, or verification programs in the community for early identification of disorders
of speech and language should be provided.
8.6.6 Audiology Emphasis
8.6.6.1 Prevention and conservation through programs designed to inform the public; for example, dissemi-
nation of diagnostic cues, counseling, dissemination of information related to problems of noise
exposure should be provided.
8.6.6.2 Case finding, screening, or verification programs in the community for early identification of disorders
of hearing should be provided.
8.6.7 Work Activity Emphasis
8.6.7.1 Facilities which are involved with used or recycled materials shall establish and maintain a systematic
procedure for the collection of a sufficient quantity of such materials from community sources to
maintain the facility's program.
8.6.7.2 There shall be no representation of products as made by the disabled unless the facility employs the
labor of disabled persons to an extent constituting not less than 75 percent of the total man hours
worked in the direct labor of production of manufactured products.
Temporary exceptions may be recognized in the case of experimentation with new products or
processes.
58
STANDARDS FOR REHABILITATION FACILITIES
9. PROGRAM EVALUATION
Special Note: Please refer to the Interpretation of Standards, page 91 and to the Special Policy on Program Evaluation
on page 102.
Principle
The facility shall have an evaluation system to identify the results of facility services and the effect of the program on indi-
viduals served in such a way that program performance can be improved and community support can be enhanced.
Standards
9.1 The evaluation system shall provide for a statement of purposes, program goals, and objectives.
9.1.1 The statements of purposes, program goals, and objectives shall be written and available for review.
9.1.2 The purpose statement should describe in general terms who is served, services provided, and goals of the
facility.
9.1.3 A purpose statement should enable the facility to be distinguishable from other community agencies.
9.1.4 The purpose statement must enable more specific goals and objectives to be set.
9.2 There shall be a relationship between the statement of purposes, program goals, objectives, who is served, and serv-
ices provided.
9.2.1 The attainment of all program goals should enable the purposes to be achieved.
9.2.2 The services provided should lead to the accomplishment of the program goals.
9.2.3 The characteristics of the persons served should be logically related to the goals to be achieved and the
services to be provided.
9.3 Statements of program goals and objectives shall meet the following conditions:
9.3.1 The goals and objectives must be achievable.
9.3.2 The objectives must be capable of measurement.
9.3.3 The attainment of all objectives should enable the program goals to be achieved.
9.4 The facility's evaluation system shall provide for measures of effectiveness.
9.4.1 The effectiveness measures shall be related to the needs of consumers, governing body and staff of the facility,
purchasers, and the public.
9.4.2 The effectiveness measures must determine the extent to which benefits are achieved by persons following
cessation of treatment services.
9.4.3 Some of the effectiveness measures should determine the benefits achieved by all persons accepted for serv-
ices by the facility.
9.4.4 The effectiveness measures must be able to determine if the objective was achieved.
9.4.5 The effectiveness measures should be reliable.
9.4.6 The method of collecting results data should be such that biases in reporting are eliminated.
9.4.7 The measures must be able to detect changes in benefits if they occur.
9.4.8 Measures need to be applied to a benefit at a point in time when the results are considered to be stable.
9.4.9 Measures need to be applied within a period of time following cessation of services when the results obtained
can be attributed to the services provided.
9.5 The facility's evaluation system shall provide for measures of the efficiency of the facility.
9.5.1 The efficiency measures should enable the facility to minimize costs.
9.5.2 The cost formula should reflect all costs which can be attributed to a program.
9.6 There shall be a system to describe and monitor who is being served by the facility.
9.6.1 The facility shall state any criteria established for admission or provision of services which would affect who
will be served.
9.6.2 The facility shall state and describe the rehabilitation problems or conditions for which it provides services.
9.6.3 Admission criteria need to be defined in such a way that the facility can determine if it is serving those persons
for whom the services were intended.
9.6.4 There shall be a systematic mechanism for ongoing review of the characteristics of persons served.
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9.6.5 The facility should generate periodic information to determine if it is serving the target population.
9.6.6 Descriptions of persons served should identify difficulty level so that expectancies can be realis-
tically established.
9.7 The evaluation system results shall be communicated to appropriate parties and be utilized in facility decision-
making.
9.7.1 Results information shall reflect the degree to which goals and objectives were achieved.
9.7.2 Explicit criteria or expectancies must be applied to each result measured so that program performance can be
properly judged.
9.7.3 Reports identifying benefits achieved must also provide descriptions of persons served to facilitate making
appropriate judgments as to the adequacy of results obtained.
9.7.4 If a program within the facility has more than one measurable objective, the relative importance of each
objective should be made known.
9.7.5 Performance reports in part should describe what results were achieved by all persons who where served.
9.7.6 The performance reports should facilitate an appraisal of results obtained in relationship to the conditions of
persons served and the cost of obtaining results.
9.7.7 Results data should reflect the impact of services that were recently provided.
9.7.8 The number of persons or events measured in performance reports should be of sufficient volume to validly
assess program performance.
9.8 Appropriate information on results shall be made available in an understandable fashion to the governing body and
staff of the facility and to the public, including purchasers, contributors, and consumers.
9.8.1 Performance data needs to be communicated to those persons or organizations who can improve program
performance.
9.8.2 Results data need to be communicated to and understood by those persons or organizations who can enhance
the support of the facility.
9.8.3 Results data need to be communicated to and understood by those persons who may wish to obtain services
from the facility.
9.9 The facility shall have a mechanism to provide for a continuous review of the adequacy of its evaluation system.
9.9.1 A formal review of the evaluation system should take place on a regular basis.
9.9.2 Those affected by the evaluation system should have an opportunity to recommend or make modifications in
the system.
9.9.3 The review mechanism should involve assessing the evaluation system's success in increasing benefits,
reducing costs, and maintaining or improving community support.
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INTERPRETATION OF STANDARDS
INTERPRETATION OF STANDARDS
Introduction
This Interpretation of Standards section represents a definition, elaboration, and illustration of the principles and stan-
dards outlined in the preceding section of this Manual.
Virtually all statements of standards are subject to varied interpretation and influenced by the diverse background of
training and experience of individuals and groups conducting self-evaluation or survey-consultation activities. This makes
it essential to provide a common frame of reference designed to increase the potential for consistent interpretation in
applying the standards, both by the facility and the survey-consultation team.
The necessary formality of style and content of standards documents tends to constrict the delineation and description of
elements such as justification, significance, procedures for application, and the more subtle nuances which give consis-
tency, continuity, and depth to a process or program.
In order to provide for consistency and uniformity in application of standards, these interpretations are designed as an
integral part of the Manual.
An example of the diversity in rehabilitation is the variation in terminology used to identify the persons served. Some of the
more common terms are: patient, client, trainee, member, etc. For the sake of consistency and clarity, the word client is
used in this section to include and be synonymous with all such terms in use.
Not every standard is specifically discussed in the interpretations. It is only when there appears to be a possibility for
misunderstanding or necessity for providing the rationale for a specific standard that it is discussed. The reader will note a
difference in presentation of interpretative materials between Sections 1-2 and Sections 3-9 in the following pages. The
Interpretation of Standards for Sections 1-2 does not provide specific Standard Reference Numbers as will be found in
Sections 3-9. Necessarily, Sections 1-2 are keyed to the interpretation and discussion of the standards in functional
groupings by subject matter.
Modifications of these interpretations will be an ongoing process. CARF has established a continuing dialogue with users
of the Manual, designed to stimulate continuing review and critical comment as a means of expanding and improving the
present materials.
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INTERPRETATION OF STANDARDS
1. PURPOSES
Principle
The purposes of a rehabilitation facility shall be established and stated so as to govern the direction and character of its
programs. Its operations shall be directed to the primary objective of fulfillment of these purposes.
Structure and Function of Objectives
A clear and appropriate definition of a facility's objectives is fundamental to any self-evaluation or survey effort. Without
such a frame of reference it is not possible to assess the need, extent, and appropriateness of such facility components as
personnel, program, physical plant, administration, and organizational structure. The performance characteristics of such
components are directly related to the specific objectives set forth for accomplishment.
In any consideration of the goals of an organization such as a rehabilitation facility, it is important to distinguish between
institutional objectives and those of the individual client. Rehabilitation facilities are organized to provide a service delivery
system which is designed to reflect the collective expectations of society with respect to the quality, cost, timeliness, and
accessibility of services.
There is no single standardized organization design which will satisfy the needs of all rehabilitation programs. Rehabili-
tation facilities are in fact very diverse, representing a wide array of implied or stated objectives, functioning within a range
of settings, and providing a wide spectrum of services within a diversified organizational, administrative, and clinical
structure. Facilities pursuing different objectives may provide the same services and, despite their differences in objec-
tives, they should meet the same high standards of performance.
The very existence of a rehabilitation facility implies the existence of some need for which it was established. The nature of
this need as defined in operational terms represents the essence of the statement of objectives. The dynamic nature of
objectives is inherent in an ongoing process in which modifications in community needs, patterns of community services,
and available resources are periodically assessed as a means for updating the facility's objectives.
Clear goals, consistent with one another, provide the common purpose which is essential for coordination of effort. Many
rehabilitation facilities are parts of larger institutions. Examples include the department of physical medicine and reha-
bilitation within a hospital, or a rehabilitation unit as part of a medical center. Even though the larger institution has stated
overall goals, it still is desirable for the facility to present its own individual statement of purpose. This serves to identify
the facility and to make its special function clear. It helps to project the facility's image. It serves to give the staff members
a strong sense of unity of purpose, and it helps them to create a therapeutic environment which may spell the difference
between successful and unsuccessful rehabilitation efforts.
The ways in which an agency fits into the broad pattern of social and health services is considered especially significant for
rehabilitation facilities, since they are relatively recent developments in the delivery of health services. The specification of
objectives will provide the rehabilitation facility with a vehicle for projecting its program effectively into the community
focus and will help to assure its integration and coordination with other related structures.
The facility's stated objectives, therefore, serve to provide the necessary point of reference for the application of standards
in self-assessment and accreditation survey programs.
Establishment of Objectives
In order to establish appropriate objectives, the facility should have available information and data in each
of the following areas.
The facility's place in the community
Each community has an existing web of vocational, social, welfare, and health organizations and programs. The relative
success or failure of a facility program will largely be determined by the extent to which communication, liaison, and
mutual effort are pursued and implemented by means of the facility's coordination of its efforts with these other
programs.
Knowledge of existing programs will allow the facility to define its objectives through a broader perspective than that
of a specific physical plant location. This wide perspective permits an accurate perception of community needs as
these relate to the competency of the rehabilitation facility in coping with a particular aspect of the system for delivery
of services.
A statement of objectives should, therefore, also relate to those elements of community coordination which serve to
define the specific role of the facility in relation to a holistic view of the social health needs of the community and of
the various programs established to cope with social and health problems.
While certain types of information can be gathered through published reports and directories, emphasis should be placed
on face-to-face communication. It is imperative that the facility's representatives be familiar with discrepancies between
formal statements of program and actual operating procedures, since these may differ in significant respects. It also is
important for the facility's representatives to be aware of planned modifications in existing programs, as these may have a
bearing upon the evolvement of new patterns and roles affecting current relationships and the facility's planning.
65
Rehabilitation facilities have frequently been described as being in the forefront of evolving new and better concepts
and techniques for meeting the needs of individuals with vocational, social, psychological, or physical problems. The
significance of these developments can in large part be assessed on the basis of their impact upon other related organ-
izations and programs.
Knowledge of and involvement with other programs is basic to the facility's self-determination of objectives. However,
the facility should not limit its information and impact to an acceptance of the status quo as the most desirable model.
Emphasis should be placed upon a critical evaluation of existing services and the identification of gaps and inadequacies,
should these exist. The process of such a critical evaluation procedure will allow the facility more readily to define its
objectives with respect to the introduction of innovative procedures which will modify the nature and extent of services
provided within a community. Such a role, however, places additional responsibility upon the facility for making a valid
and reliable assessment of current efforts as a basis upon which it can undertake to assume a role of leadership in
innovation.
The objectives of a facility do not need to be in harmony with existing programs. However, where they differ substan-
tially, ample justification derived from thorough study should be available to support the facility's choice of focus and
direction.
Resource potential of a facility
The objectives established for a facility should be realistically based upon its resource capabilities. The concept of
resources refers to such factors as money, personnel, physical plant, and the organizational framework and leadership
which serve to relate these elements to one another and to the facility's objectives.
An objective is only as significant as the facility's capability for implementation. In some instances, for example, the
financial basis may be adequate, with the major barrier to implementation being staff shortage. This staff resource
barrier is becoming increasingly significant as new programs are developing in the presence of a failure of professional
training programs to expand to a concomitant degree.
While it is not necessary to specify the implementation resources for each stated objective, it is recommended that the
time lapse between the statement and implementation of an objective be relatively short.
It also is necessary for a facility to maintain a resonable balance between available resources and those the acquisition
of which is planned for the future.
Many facilities define objectives in clusters on a time lapse basis. A facility may classify its objectives on the basis of
the short term, the intermediate term, or the long term. In such a system it is imperative that the facility clearly desig-
nate the time lapse factor so that long-term goals are not confused with immediate potential, and so that the commu-
nity's expectations are not set at a level which is beyond the actual capacity of the facility. In such a system, some
degree of realistic planning should serve to indicate the way in which specified procedures are related to the accom-
plishment of long-term objectives.
It should be recognized that any projection for the future has its associated probability of error. Since prediction tech-
niques are far from perfect, statements of future objectives should not be fixed as absolutes. They can provide useful
guidelines for planning which will be modified as necessary, on the basis of future developments.
Emphasis should be placed upon the evaluation of the availability of all resource components prior to the formal
establishment of objectives to be fulfilled. The facility will do well to establish objectives which can be implemented in
the foreseeable future.
Availability of the client population
The major objective of any facility will be the provision of rehabilitation services in one form or another to individuals
who have social, psychological, vocational, educational, or physical problems. Since the population of handicapped
individuals covers a wide array of conditions and degrees of severity, a facility's objectives will serve further to define
that portion of the total handicapped population toward which it will direct its resources and efforts. It is, therefore,
imperative that the facility's representatives have a clear understanding of the characteristics, dimensions, and loca-
tions of the population selected for their service focus.
An objective which cannot be implemented because of system deficiencies may be more disruptive in the long run
than even the absence of precisely stated objectives. For example, there are situations in which proof of the existence
of the need for rehabilitation services on the part of potential clients has not led to the involvement of such clients in
rehabilitation programs.
In essence, the concern expressed here is with the discrepancy which often exists between actual need and effective
demand. The absence of an effective demand for a facility's services may be due to such factors as its isolation from
community contacts and referral sources; inappropriate intake policy, practices or criteria; unrealistic program orienta-
tion or structure; or to fiscal or geographic factors. While these elements will be discussed in connection with other
sections of this Manual, they are relevant here to the establishment of objectives which are realistically based upon
experience with the population to be served, and which can serve to motivate the development of a system for achiev-
ing a harmonious relationship between facility programs and client needs.
Implementation of Objectives
The nature of an organization's goals cannot be analyzed realistically without giving some consideration to the plan-
ning and program development which facilitate the implementation of goals. Definition of the rehabilitation facility's
goals is logically followed by the development of a long-range plan or grand strategy for goal achievement. While each
66
section of this Manual deals with some aspect of the facility's planning for achievement of its institutional goals, it
would be appropriate here to call attention to the hierarchical characteristics of an organization's goal structure.
Attainment of the ultimate goals of an organization, such as a rehabilitation facility, requires the achievement of many
intermediate objectives. Long-range planning includes the task of identifying intermediate objectives which can serve
as stepping stones toward the attainment of the long-range goals. The series of steps to be taken in the long-range
plans formulated for the purpose of achieving the facility's institutional goals are translated into program objectives at
the departmental level. By means of this process, overall goals which are so broad and all-encompassing as to be non-
operational are subdivided, as it were, and thereby rendered individually attainable.
An effective long-range plan will set forth the facility's goals and objectives with respect to all of the significant aspects
of its operation. The goals should be set forth on a yearly basis for no less than some five years into the future. The
plan should include identification of the specific steps which each department will take in achieving the stated objec-
tives. The steps should be integrated into an overall action plan with specific timetables.
Over a period of time, broad technological and demographic changes, in addition to changes in the composition of the
patient population, have significant effects upon the operation of the rehabilitation facility. Such developments are
reflected in further changes in the facility's personnel and organization structure. The facility's leadership may change.
The overall plan should provide for periodic review, with provision for modification to meet changing conditions.
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INTERPRETATION OF STANDARDS
2. ORGANIZATION AND ADMINISTRATION
Principle
The rehabilitation facility shall be organized and administered so as to achieve its stated goals.
Incorporation
Incorporation is emphasized in connection with the fundamental legal structure of a rehabilitation facility. This require-
ment applies to the facility which is not part of a governmental agency. The authority and jurisdiction of a facility which is
operated by a unit of government should rest upon a clear statutory basis. It is important for the rehabilitation unit of a
larger institution to set forth in clear fashion its organizational structure in such a way as to delineate those powers and
responsibilities which have been granted to it by the parent institution.
Incorporation gives the institution a life of its own, distinct from that of governing board or staff. Thus, the ability of an
incorporated facility to continue serving the needs of its clients does not legally depend upon the continuing presence
and efforts of any particular individual or group. Incorporation tends to provide institutional continuity and stability, in
that the institution itself transcends the individuals who are part of it. The interests of client service clearly are served by
such continuity and stability.
Incorporation imposes upon the organization a necessary fiscal discipline. Compliance with state regulations governing
corporations entails the use of generally accepted accounting practices, with periodic disclosure of financial status. This
factor tends to motivate the responsible officers of the organization in the use of sound financial and management
practices.
The standards for accreditation make proprietary facilities eligible for survey. Since their organizational types may vary,
not all of them being incorporated, the general principles in connection with incorporation, as stated above, may not
apply to all of them.
The Corporate Entity: The Charter or Constitution
Depending upon local statutes, the rehabilitation facility may have a charter, granted by the state. If the facility has been
established by statute, it will operate without a charter, but its existence must rest upon a clear statutory provision.
Legal requirements as to form and content of corporate charters may vary. In states where little detail regarding the
organization is called for in the charter, a more inclusive statement concerning the details of purpose and structure
should be adopted.
The charter or constitution, or both documents, should clearly identify the corporate entity as well as its relationship to
any parent organization, in order to establish the source of authority and the jurisdictional framework within which the
facility operates. Such documents also should specify that the facility's organizational structure and purpose satisfy the
state's requirements for incorporation.
Object of the Corporate Entity
The flexibility which is needed in order to respond effectively to environmental changes should be built into a charter or
constitution. One method is the use of language which is sufficiently broad to cover the foreseeable options and which
lends itself to interpretation in the light of changing conditions. Another method is the inclusion in the document of
provision for amendment of the instrument and of its various sections. Both techniques are useful in framing a viable
instrument of government.
The document should contain a general description of the facility's major purpose. This statement should be couched in
language broad enough to encompass relevant aspects of the general goals, yet sufficiently concrete to give direction to
the organization in its operations.
Framing the statement of purpose in fairly broad terms reduces the necessity for frequent revision of the constitution to
reflect changing conditions, with its attendant inconvenience and expense. The aim is to achieve some optimal combina-
tion of organizational stability with the flexibility which is necessary in order to adapt to changing conditions.
Categories of, and Qualifications for, Membership
Where different categories of membership are to be established, and where certain qualifications for membership, either
in the corporation or in each membership category, are imposed, these should be set forth in the constitution or bylaws.
Inclusion of provision for such classifications and restrictions in an official document may serve to prevent the bringing
of charges of personal discrimination at a later date. More important, a clear explanation of the rationale for the stratifica-
tion system helps the corporation's members to interpret differences in voting rights and the right to hold office in terms
of their personal contribution to the organization.
Community Orientation
The state is empowered by society to delegate to a particular organization the authority to provide rehabilitation services.
The state formally grants this authority by means of a statutory provision creating an agency or corporation, or by granting
a charter creating a corporation with certain stated purposes, responsibilities, and structural properties.
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Under the terms of an official document such as a constitution or a set of bylaws, the members of the organization which
are responsible for the operation of the rehabilitation facility establish the governmental structure by means of which they
propose to attain their collective goals. The organization vests legal responsibility for its actions in a governing board,
which serves as its agent, and which is responsible to the organization and to the community.
The Facility's Community
It is important for the rehabilitation facility in the interest of providing guidelines for its own effective operation to define its
community in terms of clients served and of geographical areas covered. The facility may relate to two different commu-
nities-its service community and its geographical community.
Thus, its community is composed of the types of clients being served and of clients in a given geographical area. For
example, the client population may be composed of patients all of whom suffer from a particular type of disability and who
are drawn from several geographical areas, remote as well as neighboring. The geographical community, on the other
hand, might be defined in terms of relative ease of access to the facility by automobile. It could be defined as some area
around the facility delineated by a combination of natural boundaries and arterial highways.
Over the long term the facility's relevant community may change. This process may be the result of changes in the inci-
dence of diseases and disabling conditions, of changes in technology, of changes in transportation and communication, or
of changes in the demographic composition of the area in which the facility is located.
In view of these processes of change which are characteristic of American communities, the governing board should
reexamine and redefine from time to time the community which the facility actually serves. One reason for this is to ensure
that the orientation of the facility has not turned away from its geographical area. For example, it is possible that in its
interest in its total potential client population the facility may neglect disabled persons close to home. Another reason for
periodic reexamination is to ensure appropriate community representation on the governing board of the facility.
Composition and Size of the Governing Body
of a Not-for-Profit Corporation
The community's interest in the rehabilitation facility is represented by the governing body. It is important that the organ-
ization and its governing body recognize this, and that they therefore make every effort to provide for genuine community
representation on the board.
Accomplishing this objective means that the board will include members who represent a cross section of diverse elements
in the community. To a limited extent, this is possible even for a facility whose governing body, under the terms of its char-
ter or constitution, is required to represent a particular religious or ethnic group. For the facility which is operated by a
religious order, a board composed at least in part of laymen who represent various segments of the community provides an
avenue of communication with local agencies and individuals which might otherwise be lost to it.
To the extent practicable, the composition of the governing body should reflect a wide range of community interest
groups, directly related to its sponsoring groups and to the population it serves. This factor is important in gaining the
broad support which is necessary for the success of the facility's developmental programs. Furthermore, a pluralistic
board composition, by preventing the facility from becoming identified exclusively with any one element in the commu-
nity's power structure, lends the facility and its governing body a measure of stability and continuity.
One method of sustaining interest in the facility's development is through the injection of new spirit into the governing
board by selection of new members to replace those whose terms have expired. The objective here is the combination of
stability with a spirit of ongoing community involvement.
The board's composition will be determined in part by qualifications for membership, either in the corporation or on the
board. Where such qualifications are required, they should be specified in the bylaws to obviate uncertainty as to eligibility
for membership on the board.
In size, the governing board should be large enough to provide representation to the membership, and to give the facility an
adequately broad base for its fundraising and other developmental activities within the community. It should not be so
large as to impede timely response to needs and opportunities. There is no fixed number which represents optimum size.
Much depends upon the size of the community. In any event, the size of the board should e stipulated in the bylaws.
If the board does have a sizable number of members, such as twenty or more, it is increasingly important that a relatively
small executive committee, numbering perhaps from six to nine persons, be established and that this committee be
empowered to undertake such responsibilities as the board deems advisable.
The governing board is the liaison body between community and facility. In this role, the board can promote the facility's
objectives by educating and encouraging the community in the most effective ways of assisting in the community adjust-
ment of the disabled. From its position of leadership, the board should acquaint the community with its collective respon-
sibility for the care of the facility's clients. Appropriate public relations programs should be directed toward the objective of
ensuring the willingness of community leaders and representatives to serve on the facility's governing board.
Conflict of Interest
The governing board should adopt a policy stipulating the conditions under which a business or other relationship may
exist between an individual trustee and the facility.
The question of a board member's conflict of interest could be evident in small communities. Thus, in such settings, the
community's interests may be limited in number, so that it may be difficult to find a member of the governing body who
does not face a possible conflict of interest. The leading citizens in small towns may be the sole sources of goods and
services which the facility requires.
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If the members of the governing body adhere to high ethical standards, then actual or potential conflicts of interest will be
minimized. No board member should be penalized by virtue of his having a business relationship with the facility if such a
relationship can be defended upon a clear showing that it serves the best interests of the facility.
Duties and Responsibilities of Officers
The duties of each officer of the organization should be listed in the bylaws. This facilitates the smooth functioning of the
corporation, by clearly allocating responsibility and helping to eliminate jurisdictional conflicts and uncertainties.
Annual Meeting
At least annually, the corporation should hold a formal meeting, for the purpose of reporting to its constituency on the
current status of its affairs and on the activities and programs of the facility, as well as to carry out such other business as
may be required by the bylaws.
Functions of the Governing Body
of a Not-for-Profit Corporation
Functions of the governing board should be stated in broad, general terms in the bylaws. It should be noted that the board
has and exercises very broad powers. Any actions which the board may not take without securing prior approval from the
corporate membership should be specified. The procedures to be followed in securing such membership approval should
be clearly outlined. It is not advisable to state the board's responsibilities in restrictive terms here, because to do so would
lead to the need for frequent revision of the statements as conditions changed. Rather, the appropriate conceptual orienta-
tion to be used here is that of residual authority.
Fundamental administrative functions for which the board is responsible include planning, formulation, and modification
of staff structure, budgetary and fiscal review, the formulation and review of personnel policies, and the establishment and
review of effective systems for self-monitoring at the institutional, departmental, and individual levels.
Theform and complexity of the organization of the board needed to discharge these responsibilities effectively is a deter-
mination which must be made by the board of each individual facility. They will vary substantially depending upon the size
and composition of each governing board. While committee establishment is the most common device, other methods are
acceptable provided their effectiveness can be demonstrated by the documentation of effort.
Organization of the board into standing committees is extremely helpful in terms of expediting the board's handling of its
administrative functions. Such a form of organization facilitates careful study of problems which may come before the
board, and permits the informed evaluation of the possible alternative actions.
In particular, it is advisable that an executive committee be formed for the purpose of interim decision-making for the
governing board between board meetings, under such limitations as may be set by the board.
The longer the intervals between regular meetings of the governing body, the more important is it that an executive
committee be formed and given authority to act, subject to review by the governing body. Such authority granted to the
executive committee should be set forth in the bylaws.
The following list includes examples of suitable standing committees:
Finance Committee
Buildings and Grounds Committee
Nominating Committee
Program Committee
Executive Committee
These are offered as examples only; it is recognized that the most effective type of committee structure will depend upon
the complexity and scope of the facility, the size of the community, and the size of the governing body. In any event, these
basic functions should be fulfilled within the framework of the board's committee structure.
In view of the functions performed by the nominating committee, it is important that systematic provision be established for
changing the composition of this committee at specific regular intervals. In addition, ideally, the nominating committee
should include some members who are not members of the governing body.
In addition to the standing committees, it may be necessary to appoint ad hoc committees to undertake specific time-
limited projects.
Responsibilities of the Governing Body
The governing body of a rehabilitation facility has ultimate authority and responsibility for all aspects of its functions. In
exercising this authority and responsibility, the governing body must, in turn, delegate authority to staff of the facility for
documents. the implementation of programs, the maintenance of the budget, and safety and protection of clients, staff, buildings, and
The governing body is responsible for the form taken by the facility's organizational structure. In reviewing the existing
structure, and in examining proposals for structural change, the board should evaluate alternative combinations of per-
sonnel, skills, and technology in terms of their potential for achievement of the facility's stated objectives.
A budget is essential, as a method of depicting the operating plan of the facility for a specified period of time, and also as an
instrument of control and coordination. There should be written evidence that the governing board has considered and
adopted an annual budget, and has adopted appropriate policies regarding its administration. In addition, policy should
provide for frequent, systematic review of the financial status of the facility.
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In order to provide supporting evidence of the integrity of the facility's fiscal management, which is useful in connection
with fundraising and developmental activities, it is essential to have an outside firm conduct an annual audit of the facility's
financial operations and status. As a minimum, the results of this audit should be reported to the governing board and the
members.
The establishment and maintenance of the general policies governing terms of employment by the facility are a responsi-
bility of the governing body. Especially in view of the board's legal liabilities in this area, the board should assume the
responsibility of periodically reviewing the facility's personnel policies.
The need for evaluating the quality of client services is fundamental to any rehabilitation effort. The governing body is
ultimately responsible for the nature of the outcomes of the facility's programs. Therefore, the governing body is respon-
sible for reviewing and approving the self-monitoring programs oriented to client outcomes as well as to processes which
have been planned and are applied by members of professional and technical staffs.
The establishment of, and modification of, the facility's programs, organizational structure, budget, and personnel policies
should require prior consideration and approval by the governing body. Such consideration and approval should be
documented by the minutes of board meetings.
Bylaws
In addition to designating an agent (the governing body) to carry on its business, the organization adopts a set of rules and
regulations by which it will govern itself. This step is necessary, even in a small organization, for a number of reasons. For
one thing, the mere act of organizing tends to generate a certain amount of power, and the rules, or bylaws, provide a way of
determining the manner in which this power will be used.
In the absence of bylaws which represent the consensus of the membership and which are faithfully observed by the
governing board, control of the enterprise can more easily pass into the hands of one or a small group of individuals. Such
a transition may be detrimental to the best interests of the facility and its clients.
The existence of an internal rule of law, in the form of a set of bylaws, provides a foundation for the orderly conduct of
business by the governing board, and it serves to implement the control of the membership over the board.
Elections
At least two election procedures should be covered by the bylaws. One is the election of members to the governing board,
and the other is the election of officers of the corporation. Establishment of orderly procedures for the nomination and
election of board members and of officers, at stated intervals, provides for the transfer of power and the continuation of
leadership in the organization.
Meetings
There should be established in the bylaws a schedule of the regular meetings of the governing body, along with a pro-
cedure for the calling of special meetings. The standard requires that a minimum of three meetings per year be held.
The call for a meeting, whether regular or special, of the board or of a committee should give members of the group suffi-
cient time to make arrangements to attend. In addition, the call should be accompanied by an agenda. If each participant
has some acquaintance with the questions to be considered and acted upon, the efficiency of the board or committee
should be enhanced. Furthermore, a heightened sense of participation usually tends to increase the board's rapport with
the staff of the facility, and thus to motivate board members in the direction of constructive action.
Minutes
The minutes of every board and committee meeting, whether regular or special, should be recorded and promptly tran-
scribed. Three major functions are served by keeping the minutes of each meeting. These are:
1. The legal function
The minutes serve to record and document consensus, and they serve as the written authority for decisions taken.
2. The historical function
Minutes of meetings provide a continuous record of the board's consideration of, and views on, various questions.
This historical record is a vital aid to the board's operation during the course of turnover of board membership. It
provides for the transfer of knowledge which is necessary in orienting new board members.
3. The assignment of responsibility
Reliance upon the written record concerning the allocation of responsibility for specified tasks serves to prevent
confusion and conflict within the board.
Recording and preservation of minutes is extremely important in preventing misunderstanding as to actions taken,
responsibilities allocated, and commitments made on behalf of the organization. To facilitate future reference, all addenda
to the minutes should be filed with the minutes. Copies of the minutes of each meeting should be disseminated to all
members of the participating groups. Copies of board and committee minutes should be collected and filed by years for
their preservation.
The Quorum
A quorum requirement of at least one-third of the board's membership, for board meetings, should be established in the
bylaws. This would appear to be the minimum quorum requirement consistent with the objectives and procedures of
participatory democracy.
72
Parliamentary Procedure
In the interest of the group's efficiency in conducting its business meetings, there should be general agreement and
understanding concerning the set of procedures to be used in considering and acting upon matters brought before the
meeting. Therefore, the parliamentary procedures which are to be followed should be specified in the bylaws. Usually, a
simple statement to the effect that the conduct of meetings will be guided by some recognized set of standard procedures,
such as those outlined in Robert's Rules of Order, is sufficient.
Amendment of the Bylaws
As the character of its service community and other circumstances change during the life of a facility, it sometimes be-
comes necessary or desirable to revise the bylaws in the interest of organizational adaptation. Necessary change can be
brought about in an orderly and timely manner, if the procedure for making changes has been described in the bylaws.
Responsibility for Compliance with External Regulations
The governing body bears the responsibility for the facility's being in full compliance with all applicable federal, state, and
local laws and regulations, including those relating to licensure, fire inspection, and other safety measures, as well as the
applicable regulations of health and welfare agencies. Under the general supervision of the governing body, the facility's
chief executive officer is responsible for reviewing and acting upon the reports of authorized inspecting agencies.
As a matter of policy, the rehabilitation facility should strive to exceed minimum legal requirements in all matters relating to
the welfare of its clients.
The Chief Executive
The qualifications, authority, and duties of the chief executive officer should be clearly defined in a written statement which
has been adopted by the governing body. The chief executive serves as a link between the governing board and the
operating staff of the facility. In this capacity, he has the responsibility of keeping the board fully informed as to important
developments concerning the facility. Therefore, in order that his personal knowledge of the facility's current operation
may be available to the board, he should, except when his personal status is under consideration, attend all meetings of the
governing board and standing committees.
One of the responsibilities of the chief executive is the orientation of new members of the governing body to the facility's
programs and operations, to its relationship with the other health care agencies of the community, and to its long-range
plans. He should review for them the history of the facility's development, and define for them its current service commu-
nity. His orientation discussion should include a description of current needs and problems. A brief tour of the facility
should be a part of the orientation program.
The chief executive assists the governing board in the performance of its functions by presenting and interpreting operat-
ing reports, financial statements, and related information at the meetings. He should help the members to keep abreast of
developments in the field by discussing with them changing concepts, trends, and standards. By sending the board mem-
bers brief memoranda at fairly frequent intervals on topics of common interest, he can foster in the board a sense of
involvement in the facility's operation and its problems.
Whatever responsibilities the governing board wishes to assign to the chief executive in such areas as fundraising and
community relations should be specified as clearly as possible in the job description for his position. It is a major respon-
sibility of the chief executive to cooperate with the board in all activities designed to further the development of the facility
and its programs.
Relationship of the Chief Executive to the Staff
A major responsibility of the chief executive is the development of an organization capable of achieving the facility's
program objectives. The chief executive should assess the facility's needs for organizational subdivisions, positions, and
personnel, and translate these into a plan which can be presented in written or graphic form. Structural relationships
among and between the subdivisions and positions within this organization should be set forth in the form of a chart or
outline for the ready comprehension of others such as members of the governing board or of the staff itself. The organiza-
tion plan should present with precision and clarity the supervisory relationships and the channels of responsibility.
Strong interdependencies exist typically between and among the various specialized professional and administrative
departments in a rehabilitation facility, creating a need for coordination. While the organization chart may depict the
vertical communication channels, lateral communication among the heads of the subdivisions provides a very effective
means of coordinating the efforts of the various independent departments. Regularly scheduled meetings for the con-
sideration of common problems, supplemented by frequent informal discussions, tend to speed up the process of solving
operating problems.
The ways in which the chief executive delegates responsibility will depend in large part upon the size and complexity of the
facility in general. Even when the chief executive is professionally competent in a clinical field or other service, he should
not attempt to supervise the service unit directly unless the facility is of such size as to require that he fill two roles.
In most cases, the chief executive should appoint department chiefs to assume responsibility for the routine functioning of
the various specialized units. It is important that the chief executive avoid overemphasis upon any one specialized unit or
subdivision to the possible detriment of the facility's progress in all program areas. A job description should be prepared
for each position in the department structure. Such a description should include clear statements of job objectives,
recommended procedures, educational and experience requirements, supervisory relationships, and authority to be
exercised.
73
The chief executive bears the general responsibility for the recruiting, hiring, assignment, and development of staff. He
should be guided by the wishes and recommendations of the relevant department heads and of other professional staff
members in the departments. He should prepare and maintain written statements describing the facility's hiring, promo-
tion, and salary policies. The facility's personnel policies should be consistent with local labor market conditions and
practices, as well as relevant governmental policies and statutory regulations.
The use of systematically formulated policies covering terms of employment is extremely helpful in providing support for
administrative decisions. The fact that an organization is known to rely upon established, written personnel policies often
goes far in minimizing the occasions for charges of discrimination or of inequitable treatment of employees.
A copy of his job description should be made available to each employee. Job descriptions should be reviewed annually in
consultation with the job incumbent and his supervisor, and should be modified if necessary to reflect significant changes
in job content or in supervisory relationships.
In whatever personnel decisions he makes, the chief executive always should give careful consideration to the recom-
mendations of the department heads whose units will be affected.
Rehabilitation programs of whatever kind contain strong elements of interpersonal process. Therefore, in the interest
of good client service, it is uniquely important that the rehabilitation staff be characterized by a high level of group
cohesiveness.
In this setting, it is a special responsibility of the chief executive to take appropriate measures to develop and enhance the
internal cohesiveness of the staff under his leadership. He should be alert at all times to the needs and attitudes of person-
nel, and should try to respond promptly and cogently to their communications. Although the demands upon his time may
make it difficult, the chief executive should take every opportunity to maintain casual personal contact with the members of
the operating staff.
Ongoing evaluation of the organization's performance in relation to its objectives is the major responsibility of the chief
executive. He is expected to provide himself with the necessary criteria in the form of departmental and program standards
for comparison with operating results.
A plan or schedule of periodic departmental performance evaluation should be established. The plan should, ideally,
utilize conferences in which the chief executive and the department head compare departmental objectives with
departmental performance, for a given period. These conferences, with the resultant agreements as to corrective measures
and new objectives, should be documented for future reference.
The chief executive also has general supervisory responsibility for the planning and conduct of the facility's self-monitor-
ing programs in connection with the evaluation of client outcomes.
The chief executive is expected to be conversant with results of recent research, technological developments, and tech-
nical modifications in his field. The adequacy of the time and effort he expends in this direction can be measured not only
by the number of organizations of which he is a member, but by the degree to which the programs of the facility are using
the latest recognized and available techniques and is attacking the appropriate current problems of the community.
It is important from the standpoint of staff and ultimately of client morale that the chief executive possess and exercise
sufficient authority to implement his decisions. While the board exercises general supervisory responsibility, it does this by
means of performance review with respect to the chief executive officer rather than by means of day-to-day direct super-
vision. The chief executive remains accountable to the governing board and he is responsible for making decisions which
are consistent with the policies by which the facility is governed.
The Department Head
In consultation with the chief executive or his designated representative, the department head should set intermediate and
short-term objectives for his department. These departmental objectives should be consistent with the program of the
facility.
The department head is responsible for devising suitable plans directed toward the achievement of departmental objec-
tives. Such plans should specify the appropriate deployment of personnel, and where applicable, should establish utiliza-
tion schedules for equipment and space. Budget preparation and administration for his department are responsibilities of
the department head.
The department head should be delegated the authority he needs for the implementation of his decisions. He should be
consulted, and his recommendations should be given thorough consideration, in the making of all plans and decisions
affecting his department and its operation.
Supervisory authority over the department head is vested solely in the chief executive or his designated line assistant. The
chief executive or his assistant is expected to make himself available to the department head for consultation when this is
indicated.
The department head is responsible for planning and supervising programs of professional training, in-service training,
and volunteer orientation and training in his department. The provision of appropriate supervision and performance evalu-
ation for persons receiving training in his department are his responsibility. In addition, he is responsible for the keeping of
records on all aspects of work scheduling and employee evaluation in his department, with accuracy and timeliness.
74
INTERPRETATION OF STANDARDS
3. SERVICES
Principle
The rehabilitation facility shall provide services essential to implement its programs. These services must be of high quality
and effectively applied through its programs.
The rehabilitation program is more likely to be effective when the facility can offer visible assurance that the relationship
between services and objectives is direct and close. It is helpful to clients, staff, and the community to be able to see this
relationship clearly. While it is necessary for the facility to provide those services required by its purposes, it is also neces-
sary for it to restrict or minimize the progression of services into areas not covered by the purposes. Services develop as
new techniques and concepts evolve. How they can best be utilized will be revealed through reappraisal of the purposes of
the facility.
To clarify the discussion, the term "services" as used in this section refers to the evaluative and treatment components of a
professional discipline, rather than to an organizational element such as a department. If a facility purports to make a given
service available, this generally means that the facility should have at least one fulltime professionally qualified staff
member to provide the service. This allows for a full commitment to the concepts and techniques relevant to rehabilitation
and for the formal and informal communication central to the concept of integration and coordination of services.
Standard
Reference
Number
Interpretation
3.1.1
In general, even though the facility may feel little pressure to produce a statement of services because it
enjoys sufficient income or number of referrals without close community involvement, this does not eliminate
the obligation to keep the staff, clients, and other members of the rehabilitation community informed. The
client's reentry into community life itself requires community liaison activity. The facility's public is broadly
conceived to include anyone having a relationship with the facility. What was said concerning distribution of
information on Purpose (discussed under the principle in the section on "Purpose") is applicable to distribu-
tion of the description of services. It is particularly pertinent that the description of services should be adapted
to the intended audience.
In accurately describing the services which it provides, the facility makes a major contribution to the client's
need for continuity of care.
A dovetailing of services cannot be accomplished effectively unless there is accurate description of services.
Usually it is possible to describe only in broad terms the services required to fulfill a given set of purposes or
goals. However, the more specific a facility is in stating its purposes, the easier it is to determine what services
are necessary. Definitive determination of the type and extent of services essential to a facility's purposes
must rest mainly upon the judgment of professionals in the field and the state of current professional
knowledge.
3.1.2
There should be evidence that the facility is aware of the array of services and resources available to it for
meeting the needs of its client population, or to aid in making appropriate referrals of the individuals not
eligible for its services.
3.1.3
The services provided by the facility may require supplementation when unusual developments or complica-
tions in treatment occur. In anticipation of such occasions, the facility has the obligation of surveying outside
services and selecting those which best meet the needs of the client in the program. The facility must apply
the same yardstick to services which it contracts for or purchases from personnel outside the facility as it
applies to personnel and services within the facility. Beyond establishing the fact that outside services are of
the same standard of excellence as those of the facility, there is the need to make such services an integral
part of the client's program. These outside services must be obtained and scheduled in such a manner as to
coordinate with the program of services provided within the facility. In addition, these outside services must
be integrated into the pattern of services within the facility in such a manner as to contribute to the effective
functioning of the total rehabilitation team as it concentrates on the specific human needs of the client within
the facility. In instances where conflict may arise because of a client's desire to be treated by certain outside
personnel who in the judgment of the facility do not meet the standards of excellence imposed by the facility,
the facility has the duty and the right to refuse to provide such services.
3.2.1
Any facility is limited in the number. of people it can serve. It is incumbent upon the facility to determine which
3.2.1.1
people it can serve most effectively and to formulate this decision in writing so that a minimum of subjectivity
is involved in the process of screening referrals for service. Clearly written admission criteria are not intended
to be a substitute for the exercise of clinical judgment in deciding whether or not the program is applicable to
the client's needs; rather they are intended to conserve the need for such judgments. Written admission
criteria are particularly helpful for preliminary screening when the facility limits its services to specified types
75
Standard
Reference
Number
Interpretation
of disabilities, or has other special requirements concerning age, residential location, or financial condition.
3.2.1.2
In the screening process the referral information is reviewed or the client is interviewed, and the initial deter-
mination is made as to his eligibility for evaluation or treatment service. There must be at least a preliminary
statement of rehabilitation problem. The screening process should reflect the purposes of the facility.
3.2.1.3
After the admission of the client to the program, the facility must review the referral information and through
evaluation tests and procedures, supplement this information as needed for initation of treatment or training.
The facility can be truly responsible for its program and the appropriateness of its services only if every client
has a rehabilitation plan based on competent and comprehensive evaluation. This appraisal should include
evaluation of physical, psychological, social, vocational, and educational status. Areas covered in the evalu-
ation are determined by the needs of the client and goals of the facility.
3.2.1.4
Despite the most careful public communications efforts of the facility, there will be referrals of clients whose
needs are not consistent with the services provided by the facility. When the inconsistency is obvious, a
prompt and appropriate redirection of the referral is required.
3.2.2
Multidisciplinary involvement is just as necessary for postadmission evaluation and the determination of the
3.2.2.1
client's program as it is for the screening process. One person can make only a gross evaluation of the full
range of client needs. Therefore, each needed service should conduct its own evaluation, having available to
it beforehand the current diagnosis and referral information. If evaluation findings of a particular service are
negative, and the service consequently will not be involved with the client, the client's program manager
should be notified to that effect.
3.2.3
In general, clients should be informed of the goals of their program insofar as their condition permits. In some
3.2.3.1
instances, the client's problem will limit his ability to understand; in other instances, unrealistically high
expectations on the part of the client will contraindicate immediate exposition of modest program goals.
Beyond such limiting factors, there should be full discussion with the client concerning his program, his
participation, and the goals.
3.2.3.2
The necessity for including the client as a member of the rehabilitation team is widely accepted. If self-
sufficiency of the disabled person is an earnest goal, surely the client will be encouraged to be independent in
all feasible areas as soon as treatment begins. This dictates a full and early orientation program which in-
cludes an introduction to the staff and the facility; arrangements concerning fees and other financial matters;
and explanation of daily procedures, services available to the client, the goals of his program, and the nature
of his participation. The client's family or other persons significant in his life should be drawn into the orienta-
tion procedure. Treatment in isolation denies reality and closes the door on outside resources which can
enrich the rehabilitation program. Considerable reorientation is required to shift the client's concept of him-
self from that of a helpless, dependent person to one who is active and responsible for much of his program. It
will not be accomplished overnight. The contribution of staff members to the orientation procedure, and the
role of the client's program manager in particular, cannot be overemphasized. Not only in words but in their
behavior they can demonstrate their acceptance of and respect for the client. A client handbook or brochure
incorporating the above considerations is a useful supplement to the orientation program. It should be
thorough, but not unnecessarily technical.
3.2.3.3
The facility is obligated to fully explain the financial arrangements whereby services will be provided to the
client. Such an explanation should include and stipulate the rate for the services to be provided, a reasonable
projection (to the extent possible) of time for which the services will be provided and the conditions of
payment.
3.2.3.5
The standard is intended to assure that all provision of services to nonfee-sponsored persons is made without
regard to the lack of fee sponsorship. The standard does NOT:
1. Require the admission of nonfee-sponsored persons if the facility makes fee sponsorship an explicitly
stated criterion of admission for facility services;
2. Require the provision of unneeded or inappropriate services to nonfee-sponsored persons;
3. Require that services be provided to fee-sponsored persons beyond those requested and/or funded by a
third party; e.g., referring physician, fee sponsoring agency, etc.;
In essence, once a person is accepted by a rehabilitation facility, services should be made available on a basis
other than whether that person is or is not fee-sponsored.
3.2.4
A comprehensive rehabilitation plan involves many variables with a high risk of complications, conflicts,
3.2.4.1
distortion, and abridgment. Therefore, appropriate checkpoints, safeguards, and overall supervision are
necessary. The objective is to have the client proceed through his program with a minimum of inconvenience
and a maximum of efficiency. Very soon after the formulation of the plan, scheduling should be reviewed on
an administration level to assure its appropriateness, compatibility, and feasibility. The client's program
manager should have the responsibility for seeing that coordination does, in fact, take place.
3.2.4.2
The client's program manager must have the cooperation of personnel in all service areas to ensure that the
3.2.4.3
designated treatment and training services for each client are effectively carried out. Evidence of fulfillment
should be validated in the case record of the person served through a full signature or a typed name with
verification through initialing.
76
Standard
Reference
Number
Interpretation
3.2.4.4
The provision of services by the facility to each client should be organized through a client program manager.
This refers to the staff member who is designated to (1) assume responsibility for the client during the course
of treatment; (2) coordinate the treatment plan; and (3) cultivate the client's participation in the program.
The program manager, being responsible for the individual, should see to it that: (1) the client is adequately
oriented; (2) the client's program proceeds in an appropriate orderly, purposeful manner; and (3) the dis-
charge decision and arrangements for followup are properly made. The management and coordination of
services prescribed for clients in a rehabilitation facility can be intensively personal and supportive to the
client. It can be a service which is impersonally provided, or it can leave the client with no anchor point for
his feelings about what is being done to him. In assigning staff members to the role of client program
manager, first consideration should be given to those whose performance would fit into the first category.
3.2.4.5
Inasmuch as communication among staff is the primary means of coordinating and integrating the program,
the opportunities provided for such communication are of critical importance. In small facilities, opportu-
nities for staff communication are almost self-presenting, because staff share offices, lunch together, and
have other frequent occasion for contact. In large facilities more formal arrangements are necessary, such
as ward rounds in which all disciplines visit those served in a group or chart rounds and staff conferences
in which staff reviews the person's progress, develops further plans, and continues coordination of efforts.
The frequency of such meetings is determined by the needs of the person and the size and intensity of the
program.
Staff communication is essential to ensure the continuing appropriateness, efficiency, and effectiveness of
the program. The nature and frequency of the communication, be it daily informal telephone conversation or
monthly formal staff conference, must be such that it enables meaningful review of the person's progress and
coordination of an appropriate program. There must be evidence that staff communication which meets the
above criteria takes place.
3.2.5
Discharge planning should begin early in the treatment phase, and all professions involved with the person
3.2.5.1
should participate in formulating the discharge plan. This includes agencies outside the facility, such as a
family service bureau, who can ease the transition from the rehabilitation facility to the community. The
discharge (closure) period is particularly critical in that it tends to focus many pressures upon the person, the
facility, and the community. In large measure, discharge presents a test of: the efficacy of the facility's
program; the ability of the service units to work and plan together; the person's ability to maintain gains that
have been made; and the capacity of his family and society to accept him and facilitate his reentry into the
community. It is obvious that the adequate preparation which is needed for discharge requires more than
routine notice to the person that his program is complete. Early and active involvement of the person, his
family, referring source, and other community agencies that will be working with him is necessary.
The critical nature of discharge has led some rehabilitation facilities to experiment with trial or interim dis-
charges. These are multiple discharges which take place as the person progresses through his program,
particularly appropriate during plateau periods. It is hoped that through a number of such discharges, the
final transition into the community is not as traumatic an experience as the single discharge might be.
3.2.5.2
A discharge (closure) authorization and summary should be prepared. It is the program manager's respon-
sibility to see to it that reports are transmitted to various agencies so that information pertinent to the needs of
the person served is at hand.
3.2.5.3
The requirements for notice of discharge (closure) will vary depending upon the complexity of the indi-
vidual's presenting problems, the discharge plan, and the kinds and extent of resources required to imple-
ment the plan. There should be evidence that the person, his family, the administration and, if indicated, the
referral source, were given reasonable notice of the discharge decision.
3.2.6
Arrangements for followup of those served should be made a part of the discharge procedure. The individual,
3.2.6.1
as well as the appropriate individuals and agencies, should be promptly informed of such arrangements.
3.2.6.2
Followup of persons served should not be limited to such needs as periodic medical surveillance; it should
also determine to what degree his program at the facility has been successful and whether the facility's total
program of services offered is adequate. It is through information gathered during followup contacts that the
facility is able to ascertain if further services are required, and to evaluate the effectiveness of its services and
programs. The need for the facility to be flexible and to modify its program can be met best through awareness
of the degree to which the person achieves the goals which had been decided upon.
3.3.1
All service units have a responsibility for active participation in rehabilitation case conferences concern-
ing the clients who are receiving their services and the families of those clients. Much of the value of a serv-
ice is lost if the outcome of specific treatments are not conveyed to members of the team. While information
is imparted through written reports in the case record, the give-and-take of discussion provides a more
meaningful exchange of information. Not only is more knowledge gained concerning the effects of the
service from different perspectives, but a better understanding of the results of services. Understanding of
the person served is a critical factor when personal communication is involved in the application of clinical
knowledge.
77
Standard
Reference
Number
Interpretation
3.3.2
In keeping with the philosophy of interdependent functioning of professional service units, all staff members
should have equal opportunity to recommend to the case program manager the application of other services
that the person may require.
3.3.3
Each staff member should have the benefit of appropriate supervision of his professional activities. The
supervision should be of a quality which contributes to the staff member's occupational and personal
development. A formal conference between the supervisor and the member should be held at regular intervals
to review job performance. A written summary of the conference or a rating scale should be entered in the
personnel file. The importance of a formal conference should not overshadow the more meaningful and
instructive approach of evaluation and assistance provided through informal discussions on an ongoing
basis. The supervisor also has an obligation to the facility to take corrective action as needed.
3.3.4
Just as the rehabilitation facility engages in self-evaluation through periodic surveys, reviews of goals, and
other procedures, each professional service unit should conduct a conscious, ongoing evaluation of the
concepts and techniques it utilizes in relation to progress of those served. The staff should have sufficient
time to gather and evaluate followup information and research data, and apply criteria for a periodic, thor-
ough self-study. The use of outside consultants to assist in the services' self-evaluation is merited from time to
time.
3.3.5
While rehabilitation facility services are primarily delivered in the facility, patient goals are usually concerned
with function in the world outside the facility. Thus, services should focus on enhancing functioning in that
real world. For example, mobility training should train the patient to function at the highest potential in the
out-of-doors, to transfer safely to autos, to use public transportation, and to move about in the home safely.
Further examples include activities of daily living training to use home equipment that will be actually avail-
able, to function sexually with the abilities present, to utilize social, recreational, and spiritual services of the
community to enrich the individual's life and remain integrated in the community. In a work-oriented pro-
gram, examples of this same point would include training the client in how to use transportation to go to work,
training the family, if applicable, in how to motivate the client to keep his job, establishing procedures to
stimulate the client to take prescribed medications daily after his facility program terminates, and/or training
a group home operater to check daily hygiene of the client.
3.4.1.3
The facility should engage in periodic culturing for bacteria in area involving both those vulnerable to
infection if exposed, and those who could contribute to the spread of infection. Areas which should be
checked are those with hydrotherapy, mats, etc.
3.4.3.1.1.1
Vocational evaluation services are an integral part of the total system of vocational services in rehabilitation.
Provisions for vocational evaluation should exist prior to, during, at the conclusion of, and as a part of follow-
up to other vocational services.
A part of the evaluation process involves the assessment of the person's physical capabilities as they relate to
specific job requirements. This requires personnel in the evaluation area with the capability to interpret
medical information as it relates to work evaluation tasks so that this information can be translated into usable
vocational data.
Vocational evaluation services involve utilization of a variety of different appraisal methods and techniques
appropriate to case problems. The major appraisal alternatives are: analysis of past history, psychometric
testing, and situational assessments, including job tryouts, training tryouts, and/or work samples.
3.4.3.1.1.3.b
The evaluation plan should consider such factors as are relevant for each individual including physicial
demands, environmental factors, academic level required, dexterity, eye-hand coordination, etc.
3.4.3.1.1.7
This standard does not preclude the use of other techniques.
3.4.3.1.1.7.2.b
Each work sample shall have an examiners manual which specifies: (1) its relationship to the Dictionary
of Occupational Titles, Occupational Divisions, Worker Trait Groups, or some appropriate job analysis
system; (2) prerequisites; i.e., any specific work sample task requirements which might make admini-
stration of sample unfeasible for a given individual; (3) the work sample purpose; i.e., specifically what is
the sample attempting to assess; (4) the materials and equipment used; (5) preparations for testing and
the layout of materials; (6) instructions to the individual; (7) instructions for timing, evaluating errors, and
scoring if applicable; (8) instructions for interpreting scores.
3.4.7.2.4
In addition to other facets being considered, the facility staff should try to be aware of changes which may
occur over time in the mental and physical health status of people served because of medications, etc.
78
INTERPRETATION OF STANDARDS
4. PERSONNEL
Principle
The rehabilitation facility staff shall be competent, ethical, and qualified to provide the services essential to the achieve-
ment of the facility's stated goals. It shall establish and maintain personnel policies which contribute to the effective
functioning of its staff.
This principle applies to all paid personnel, consultants, and volunteers of the facility who participate in the rehabilitation
process. Their combined resources of time, understanding, and skill, coupled with the client's own efforts, produce
restoration and adjustment-thus fulfilling the goals of the facility.
Standard
Reference
Number
Interpretation
4.1
The types of rehabilitation problems or conditions presented by persons served, the frequency with which
they are presented, and the goals and objectives which the facility purports to achieve should be the chief
factors in determining whether services should be provided by full-or parttimé employees of the facility, by
affiliation, or by consultation. Services essential to the attainment of the facility's goals and objectives may be
provided by personnel outside of the facility if those services are provided by a qualified person: (1) who is
able to serve the range of the caseload needing such services and (2) who is active in the in-facility program of
persons served; e.g., attends conferences, participates in program planning.
Ideally, all of the relevant physical, mental, emotional, social, educational, and vocational needs of each client
should be considered both separately and in relation to one another. The successful satisfaction of needs
in one area usually hinges upon the satisfaction of needs in other areas. No area is an island; all are inter-
dependent. Only if the special contributions of each staff member are related to the contributions of others
can there be an integrated, coordinated approach to the problems and needs of the handicapped, disabled
individual.
Personnel policies influence the quality of the staff's contribution to the rehabilitation process. Adequate
policies will reflect the basic needs of personnel and foster staff morale. They should result in a smoothly
functioning operation and a therapeutic environment based on mutual respect among team members. The
client benefits from both.
When a shortage of qualified candidates for employment exists, the facility should not employ an individual
who has less than the minimum qualifications unless it is prepared to arrange for the individual to work under
the supervision of a qualified person, and to acquire the qualifications necessary for the position within a
reasonable period of time. The chronic shortage of qualified professional personnel places an obligation
upon all rehabilitation facilities to participate in recruitment activities of a broad nature. In addition to
cooperating with agencies and community groups concerned with health career recruitment, rehabilitation
facilities can develop work experience programs to provide students with a firsthand, thorough compre-
hension of health-related occupations, cooperate with schools in career days, sponsor tours, etc.
4.2.1
Basic qualifications for professional staff shall be considered and approved by the governing board upon
recommendation by the chief executive and/or professional staff committee.
4.2.2
In developing standards of qualification for facility personnel, the chief executive should know and apply the
licensure or certification requirements of the state in which the facility is located. He should also consider
standards in comparable facilities.
4.2.3
When standards of qualifications have been established by recognized professional groups, the facility shall
adopt these as minimum requirements for its respective professional staff. The basic activity of a rehabilita-
tion facility is centered in its professional staff. The qualifications which staff bring to their respective posi-
tions are fundamental in determining the effectiveness and efficiency of the facility's operations. In estab-
lishing standards of qualifications for its staff, the facility is not without legal and professional guidelines.
Generally, one's peers are best qualified to define competence. Therefore, when standards of qualification
have been established by a recognized national professional organization, they should be considered as
minimum requirements. The facility may expand these minimum requirements by adding its own in terms of
length or type of experience. The nature of the-problems encountered in the evaluation, treatment, and train-
ing of the disabled often requires skills supplemental to those ordinarily appropriate for serving acute
problems.
4.2.4
Newly created positions which do not have standards of qualification should be clearly outlined in a job
description so as to provide an objective basis for evaluating applicants for the position. Once the job
description has been tested, amended, and accepted, it provides a basis for comparison with job performance
to evaluate the individual's competence.
4.2.5
Personnel standards established for employees should not be lowered for contractual, consultant, or
volunteer personnel. It is the nature of the task, rather than the class of personnel, which should govern the
standards of qualification. Services which are provided by personnel other than employees should be at a
level of competence compatible with the facility's rehabilitation effort.
-79
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Personnel policies must have an official basis if they are to be effective. They should have general approval of
the governing body, with specific details authorized by the chief executive. If they are extracted from minutes
of meetings, they should be amplified, clearly written, and complete.
Personnel policies should be included in a staff handbook and given to each staff member as part of his
employment orientation program. It cannot be assumed that the personnel within a facility are familiar with
the policies simply because they are a matter of public record. The chief executive should establish pro-
cedures which ensure that staff understand the facility's personnel policies. Employees should always have
the opportunity to ask for and receive clarification of any policy.
4.3.2
In establishing and maintaining personnel policies, the facility should rely on several contributing sources.
The points of general agreement among personnel administration experts provide a foundation on which to
build. Greater specificity and focus can be added by appropriately applying the best practices of comparable
institutions. The past and current experience of facilities which are similar in goals, size, community setting,
and other respects will have demonstrated the merits and faults of various personnel policies.
Personnel policies and procedures should delineate hiring practices, and make clear what the organization
expects of staff as well as what staff may expect of the organization; they should establish a frame of reference
for dealing with all contingencies related to the activities of personnel within the facility; and they should
provide general guidelines for staff conduct. Specific policy requirements will vary considerably among
facilities. The subjects which should generally be covered by personnel policies include:
1. Employment procedures
a. Authority for hiring and firing
b. Administrative requirements
C. Availability of job descriptions for each position
2. Operating policies
a. Any probationary period and provision for periodic evaluation
b. Conduct and general regulations
C. Hours of work, holidays, vacation, leave
d. Laundry and uniforms
e. Promotion policy
f. Grievance procedures
g. Disciplinary action
h. Employee representation
3. Wage and benefits
a. Salary plans
b. Method and period of payment
C. Fringe benefits (insurance, health care, etc.)
d. Meals, housing, transportation, etc.
4.3.3
Because of the close relationship between staff morale and personnel policies, the staff should participate in
the formulation of personnel policies. A committee of representatives of the various departments should meet
at established intervals to review policies and make recommendations to the chief executive. Some profes-
sional organizations, such as the American Occupational Therapy Association and the American Physical
Therapy Association, have made recommendations concerning administrative practices and personnel
policies. These should also be consulted. Each facility's pattern of resources and purposes is unique. For this
reason, the chief executive must consider many factors in formulating the most meaningful and appropriate
personnel policies for review by the governing body.
To the extent to which changes occur in conditions upon which the personnel policies are based, it is neces-
sary to review established policies. The frequency of review, then, is determined by how often policies and job
descriptions need to be changed to keep them appropriate and useful. While the staff committee and other
factors described above will make a substantial contribution to the review, much depends upon the degree to
which the chief executive is sensitive to and aware of the needs and attitudes of the facility staff. Formal
avenues of communication provided by committees will not suffice; they must be supplemented by informal
communication and empathy. The morale of the staff will be an index of how successfully the chief executive
is maintaining realistic, appropriate, and meaningful personnel policies.
4.4.1
In-service training programs are necessary for each service unit in order to maintain staff competency and to
provide for growth and development. A variety of techniques should be utilized, such as staff meetings
focused upon theoretical concepts or analysis of representative client programs for instructional purposes,
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training films, guest speakers, review of literature, etc. In a small unit, an above-average standard would be to
arrange meetings with other agencies that have the same service and set up a combined in-service training
program.
4.4.2
The specification that each service unit should have access to resource material relevant to rehabilitation in
general is based on the assumption that each professional staff member will have a personal collection of
basic books and periodicals which he has acquired in his professional studies and to which he adds during his
professional lifetime. However, beyond this, the facility has a responsibility to provide reference material
which is especially pertinent to the program and purposes for the facility, plus such additional general
reference material as is appropriate but may be too expensive for the individual staff member to purchase.
4.4.3
To the extent possible, the rehabilitation facility should establish affiliations with universities to provide
internship programs for the various disciplines represented in the facility. Internship programs have been
increasingly a part of essential training for all professional disciplines. As such, it provides the student with
guided, progressive contact with those served in an actual work setting. It also provides the facility with
contact with professional training institutions which stimulates and assists the facility staff in keeping abreast
of current professional developments. The planning and curriculum of an internship program is customarily
developed between the facility and the specific training institution which has agreed to enter into such an
arrangement.
4.4.5
The opportunity should be present and pursued by the facility for study and research into service methods,
procedures, and results. This may be accomplished either by facility personnel or through arrangements with
interested individuals or organizations such as nearby college or university programs.
4.5.3.1.7
These standards do not preclude that one person provide all three services. This person or any one of them
4.5.3.1.8
may also be the professional vocational specialist, if qualifications are met as defined in the Glossary of
4.5.3.1.9
Terms.
4.5.5.1.1
Personnel assuming independent responsibility for clinical services in speech pathology meet the training
and experience standards established by the American Speech and Hearing Association for the Certificate of
Clinical Competence in Speech Pathology and applicable legal requirements.
Personnel not fully qualified for independent clinical work shall be under the direct and immediate super-
vision of a speech pathologist who meets the training and experience standards established by the American
Speech and Hearing Association for the Certificate of Clinical Competence in Speech Pathology and
applicable legal requirements.
Speech pathology services obtained on a consultant or contract basis shall be provided by personnel meeting
the same requirements for professional competence as outlined above.
4.5.6.1.1
Personnel assuming independent responsibility for clinical services in audiology meet the training and
experience standards established by the American Speech and Hearing Association for the Certificate of
Clinical Competence in Audiology and applicable legal requirements.
Personnel not fully qualified for independent clinical work shall be under the direct and immediate super-
vision of an audiologist who meets the training and experience standards established by the American
Speech and Hearing Association for the Certificate of Clinical Competence in Audiology and applicable legal
requirements.
Audiology services obtained on a consultant or contract basis shall be provided by personnel meeting the
same requirements for professional competence as outlined above.
4.5.7.5.3
The reference is to a requirement of the Wage and Hour Division of the U.S. Department of Labor for a work
activity center certification and may be satisfied by having the same person providing supervision in the work
activity center and another work program, providing that the supervision is in significant blocks of time and a
specific scheduled is followed.
G
81
INTERPRETATION OF STANDARDS
5. RECORDS AND REPORTS
Principle
The rehabilitation facility shall maintain accurate and complete records necessary to the conduct of its programs. It shall
prepare and distribute reports that demonstrate and interpret the level of fulfillment of its purpose.
Records and reports are an essential element of professional service, administrative control, and legal responsibility. The
extent to which records and reports are developed and maintained is directly related to the quality of services, organiza-
tional effectiveness, and accountability of the rehabilitation facility. Records and reports may be divided into two groups-
case records and administrative records. The former are essential to the program of those served, and, in addition, permit a
review of the quality of services and results. Case records also are indispensable tools for research and education.
Administrative records and reports provide a basis for policymaking, program and production management and control,
public relations, and accounting.
The significance of records and reports has led some recognized national organizations to establish a variety of
recommendations concerning their preparation and maintenance. In addition, various states have legal requirements
relative to medical and other reports. Legal requirements constitute minimum standards for case records and reports.
Standard
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Interpretation
5.1.1
A single case record for each person admitted to the facility should be prepared and maintained so as to
communicate clearly, concisely, completely, and promptly.
The desirable qualities of a case record are largely self-evident in the terms "clear", "concise", "complete",
and "current". Some elaboration of "clear" may be needed because it refers to both technique and substance.
The technique of reporting should be such that sentences make sense. The necessity for the reader to attempt
to guess what the writer is trying to say defeats the purpose of the communication. Lengthy reports require
particular forethought; they should be well organized and convey the message properly. "Clear", when it
refers to the substance of the report, means that there should be clear distinction between fact and opinion.
Reports should be objective. Information which is subjective should be so designated. It is desirable, gener-
ally, to report data by method or source, evaluate the data, and state the conclusions or recommendations
which are drawn.
5.1.2
Rehabilitation case records are very similar to medical records, with the additional requirements which reflect
the interdisciplinary character of rehabilitation: the evaluation report from each service unit evaluating the
person, the treatment and training plan based on a staff conference of the services involved, and periodic
progress reports and reevaluation.
Each record should include at least the items listed in the standard. Qualitatively, the items should substan-
tiate the evaluation and diagnosis, treatment plan, treatment procedures, and discharge (closure) decision
recommendations.
5.1.2.13
This evidence can be found during initial evaluation and planning, in selecting specific rehabilitation
methods, in dealing with feedback during the rehabilitation process, and in decisions regarding treatment
effectiveness, outcomes, and future plans.
5.1.3
While all essential data should be located in the single or master case record, each professional service unit
should maintain worksheets for each person to record information which is of value only to the specific
service such as daily attendance, raw scores of tests, and similar data. The term "worksheet", is used to
emphasize that departmental records should not be a substitute for the main client record. The main record
should receive first priority in the recording of case information.
5.1.4
The case record should include some assurance, in writing, that services recommended and planned have
actually been received by him at the time stated. Such assurances may be in the form of the signature of the
staff person rendering the service. The procedure of having a record countersigned by a qualified individual
who has an official position in the facility is also necessary to protect the facility in instances where profes-
sional judgment expressed in a record may be challenged. Demonstration by the facility that qualified pro-
fessional individuals are responsible for the content of case records will help to establish that the facility is
providing services based upon high levels of competency.
5.1.5
Because of the wide variety of professional skills focused upon the individual in a rehabilitation setting, the
effectiveness of the total effort is closely associated with the ability of the professional staff to communicate
accurately and appropriately with one another in their day-to-day activities. The appropriateness of the
communication has several dimensions, including the method, form, and time. The method of communica-
tion ranges from informal verbal messages to legal documents. The form ranges from colloquialisms to
technical jargon and symbols. The time varies both in immediacy and in frequency. Obviously, it is impossible
to delineate appropriate communication for every activity in the rehabilitation facility. In general, communi-
cation should be both prompt and clear. Information concerning clinical procedures or occurrences should
be entered into the record within 48 hours of the event to be reported. Some procedures, such as comprehen-
sive psychological testing, will be exceptions; however, these should be completed and reported before the
83
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Interpretation
period lapses when they are of greatest value to the program. Discharge summaries should be recorded
within two weeks. Inquiries from other agencies and interested parties should be responded to promptly.
5.1.6
Personal information regarding those served by a facility shall not be provided outside personnel or agencies
unless there is a release signed by the person, or unless the release is legally permissible and the information
provided does not violate the professional standards of confidentiality. Unless otherwise legally required,
such information should be limited to that which is appropriate to the extent and type of responsibility which
outside individuals and other agencies have for the client's welfare. Data to be included in summary reports
and research data which does not identify the individuals may not require a signed client release.
5.1.7.2
Access to case records should be limited to the professional staff providing direct service to the client, plus
such other individuals as may be administratively authorized. Client records are confidential, representing
communications of a privileged nature.
5.1.7.3
Records instituted in the facility for care and treatment of individuals served are the property of the facility.
Provision for their use and protection is required. The usefulness of records should not be negated through
haphazard filing and careless storing. An indexing and filing system which is efficient and appropriate to the
needs of the facility should be maintained. A sign-out system or other means of control should be in effect.
5.1.7.4
Records should be kept in locked metal filing cabinets, or in a room with controlled access and which can be
locked; they should be safe from fire and water damage and other hazards.
5.1.8
The retention of records and reports should be guided by professional, research, administrative, and legal
requirements. An appropriate policy should be maintained so that files are not indiscriminately retained nor
prematurely discarded.
5.2.1
The quality of case records should be judged by the professional services which contribute to and use the
5.2.1.1
records. A records review committee selected from the various professional services should meet regularly, at
least once every four months. In smaller facilities all central case records should be reviewed and measured as
to their adequacy and their fulfillment of recordkeeping requirements.
5.2.1.2
The client records review committee should also review at least annually the policies and procedures con-
cerning records and reports and make recommendations to the chief executive. The chief executive should
review all recommendations and discuss their disposition with the committee.
5.3.1
Administrative records and reports are needed to provide control and give direction to the activities of the
facility as well as to satisfy legal requirements appropriate to its status. Little is unique to the rehabilitation
facility in the development of such reports, other than the description of the facility's operation.
5.3.1.7
While documentation of findings by the agency conducting the inspection for safety, fire, public health or
other purposes is desirable, it is recognized that the facility may not always be able to secure such documen-
tation. If such be the case, the facility should retain a copy of letters to the inspecting agencies which set forth:
a. the date of the inspection
b. the name(s) of the person(s) conducting the inspection
C. the facility's understanding of the results of the inspection.
5.3.3
The Commission on Accreditation of Rehabilitation Facilities has no time standard regarding the retention of
records. The facility must accept the responsibility for determining its own needs and for conforming with any
existing legal requirements.
5.4.3.9.3
The intent of the standard with respect to the collection of information as to the person's fringe benefits is to
assure that the facility is in a position to fulfill its responsibility in advocacy for the rights of the person who
was served.
84
INTERPRETATION OF STANDARDS
6. FISCAL MANAGEMENT
Principle
The rehabilitation facility shall manage its fiscal affairs in accordance with sound practices and legal requirements.
The very existence of the rehabilitation facility depends on its financial viability. Unless its fiscal affairs are soundly
managed the facility will not be able to stay afloat, much less to guarantee services in keeping with its purposes. Funda-
mentally, the fiscal management of the rehabilitation facility does not differ greatly from that of any business organization.
Basic requirements are: (1) efficient and effective recording, reporting and control of earnings, expenses, assets, and lia-
bilities; (2) collection and reporting of statistical data; (3) determination of costs of services and activities, some of which
are unique to rehabilitation; and (4) preparation of budgets. To assure soundness of method, professionally acceptable
accounting practices should be employed. Legal requirements must be met, and should be exceeded to achieve sound
fiscal management.
Regardless of the type of ownership, financial solvency is an obligation which cannot be neglected unless the facility is to
discontinue operation. Facilities must demonstrate financial responsibility or risk a reduction or cessation of public
support. Facilities in straitened financial circumstances are not justified in using this condition as an excuse for applying
shortcuts which result in a below-standard program. It is better to eliminate a service and reduce the goals of the facility
than to stretch resources to the point of inadequate coverage.
Standard
Reference
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Interpretation
6.1.1
The annual budget is an instrument used to analyze past accomplishments, control present operations, and
guide program development and planning. The budget should relate to anticipated needs, resources, and the
overall purposes of the facility.
6.1.1.2
There should be evidence that the governing body has fulfilled an essential responsibility in developing,
reviewing, and approving the annual budget.
6.1.1.3
As a tool, the budget should not be used in a completely rigid, nonadaptive manner. If unantiipated factors
develop, major budgetary modifications should be submitted to the governing body for approval. However,
the greater the departure from the original budget, the less useful the budget is as a controlling device.
Periodic comparison of the budget as formulated with the actual income and expenditures provides a means
of measuring ongoing facility performance.
6.1.2
The financial operations of the facility should be audited annually. To help assure impartiality, the accountant
must not be on the staff or governing board of the facility. In governmental facilities a unit of the government
may conduct the audit, but in such instances the accountant should be administratively independent of the
facility.
6.1.3
Fiscal reports will require transmittal and presentation to various groups, according to the nature and obliga-
6.1.4
tions of the facility. Examples are: the governing body, community fund budget review committees, profes-
sional organizations, and the general public. The frequency of such reports will vary according to the size and
other characteristics of the facility, but should not be less than quarterly for the governing body nor annually
for other groups. Reports should be presented in such a manner that they clearly and accurately reflect the
operations which are being fiscally analyzed and do so in relation to the program's purposes.
6.2.1
The legal requirements concerning the conduct of business vary from state to state; they constitute minimum
levels of operation. The rehabilitation facility should stipulate additional requirements as indicated for
superior fiscal management. The use of professionally acceptable accounting practices is essential. It is
expected that whatever system is adopted will be based on the needs of the facility and that the simplicity or
complexity of the system will be related to the degree of control required.
6.2.2
An essential factor in maintaining financial solvency is the application of good cost accounting principles in
determining charges, fees, or rates for services or products. The application of such principles requires a
knowledge of all component costs of services or products in order to establish meaningful charges for
services.
6.2.3
A schedule of fees must be based upon a knowledge of the actual cost of services rendered. It is unethical for a
6.2.3.3
facility to employ monetary incentives or rebates in consideration for referral of clients. The referral of clients
for services should be guided primarily by their rehabilitation needs rather than the financial reward to the
agencies involved. It is, therefore, improper for the facility to split fees with other agencies or individuals as a
consideration for referral of clients. The decision as to where the client is referred should be directly related to
such criteria as determine which resource best meets the client's rehabilitation needs.
6.3
All fundraising campaigns and activities should truthfully represent the objectives, program, and perform-
ance of the facility and must be ethically conducted.
6.4
The variation of insurance requirements from state to state requires each rehabilitation faciity to be in contact
6.4.1
with the State Insurance Commissioner concerning workmen's compensation, malpractice, and other types
85
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Interpretation
of insurance applicable to the facility. It is the responsibility of the facility to develop a risk protection program
adequate for the preservation of the assets of the facility and for the reasonable compensation of the staff,
volunteers, persons served, board members, and the public who may be casualties in situations for which the
facility is financially liable. The risk protection program of the facility should be reviewed at least annually by
the chief executive and a qualified adviser to make sure that the policies carried provide the amounts and
types of protection needed. The adequacy of the risk protection program is the ultimate responsibility of the
governing body.
6.5.3.1
Where production of goods or materials is carried out in the facility, sound and accepted practices shall be
6.5.4.1
observed in all business and industrial activities, including purchase of materials, sale of products, and
subcontracting. Expansion of capital resources shall be financed from money other than that received as a
direct result of the work of its clientele. The workshop should not engage in unfair competition with other
workshops and/or commercial organizations in selling its services and products. The workshop should build
its program on the basis of its strengths rather than ask for special consideration because of its handicaps.
The practice of undercutting the bids of other organizations at the expense of work that is below specifica-
tions is unethical and self-defeating. In communities where a large proportion of the labor force is unionized,
it would be well for the workshop manager to establish good relationships by providing unions with an under-
standing of the principle and goals of the sheltered workshop.
6.5.4.1.1.1
If an overhead markup averaging less than 80% on direct labor is utilized, a written justification shall be
6.5.7.1.1.1
provided. Overhead includes all those indirect operation expenses attributable to the production effort such
as occupancy costs, procurement costs, etc. Direct labor is defined for the present purpose as all work
required for preparation, processing and packing, but not including supervision, administration, inspection,
and shipping.
6.5.3.1.2
The wage rates paid to persons served shall be commensurate with those which are paid for comparable
6.5.4.1.2
levels of productivity in private industry. In no event may the rates be less than legally permitted. Documen-
tation relating to prevailing local wage rates for each kind of work performed by clients of the facility should
be readily available.
Professional services which are provided by the programs of the facility should be financed by sources other
than the client's production.
86
INTERPRETATION OF STANDARDS
7. PHYSICAL FACILITIES
Principle
The rehabilitation facility shall be designed, located, constructed, equipped, and operated so as to promote the efficient,
effective conduct of its programs and to protect the health and safety of persons served and staff.
Physical facilites refers to the physical structure, its locations, and its equipment. The physical setting of the rehabilitation
facility is determined in relation to all other elements: institutional goals, organizational structure, clientele, personnel,
and services. It is the material property, the identifiable spatial unit in which rehabilitation treatment and training of, the
handicapped, disabled individual takes place. It houses personnel and equipment and is designed to effect optimum
restoration and adjustment of the individual in accordance with his problems and needs.
Standard
Reference
Number
Interpretation
7.1
In order to best serve its public, a facility should be conveniently located to main thoroughfares and to public
transportation.
7.2
It need hardly be emphasized that rehabilitation facilities must conform to all laws-federal, state, and local-
which relate to them directly. With respect to "physical plant and equipment," this means conforming to
health department requirements, safety regulations, building codes, zoning ordinances, and other legal acts
which pertain to construction, safety, and design. In short, if the law is there, the rehabilitation facility must
obey it unless there is sound justification for seeking legal exemption. In addition to the obvious legalistic
conformity required of the rehabilitation facility, there is a moral obligation for it to conform to statutes which
are permissive in nature, but which suggest desirable standards of construction, safety, and design. The
rehabilitation facility should exceed minimum legal sanctions in matters significantly related to the success of
the program and the welfare of the clients.
7.3
Some recognized professional organizations have established standards for physical plant and equipment-
just as they have for personnel qualifications and for records and reports. Where these standards are relevant,
they should be accepted as minimum requirements. Ultimate responsibility for determining standards and
providing proper physical facilities for a professional service rests with the governing body and the chief
executive, but their decisions should be based on the best advice obtainable from qualified representatives of
the respective professions. The practicing expert-better than anyone else-knows what he needs to help
him do a good job. The governing body should recognize that any person involved in the application of a
professional service has an obligation to the client to refuse to apply that service if the application must take
place under conditions which are demonstrably adverse to the health, welfare, and safety of the client. In
addition to meeting legal and professional requirements, the physical plant of a rehabilitation facility should
be designed primarily to meet the unique needs of disabled, handicapped individuals. Barriers to client self-
care should be eliminated insofar as possible. The general atmosphere should engender a feeling of vitality.
In other words, the setting should contribute to a therapeutic environment. Many individuals spend a critically
important period of their lives at the rehabilitation facility. It is essential that their surroundings be not only
physically comfortable, but psychologically and aesthetically appropriate. When plans for a new facility are
being made, it would be well to survey the clients of a similar facility to get their ideas and recommendations.
7.4
The professional staff of the rehabilitation facility should participate in the periodic review of needs asso-
ciated with physical plant and equipment. This review should assess those needs as they relate to the basic
pattern of integration and coordination of services within the facility and not as they relate to isolated service
functions. The physical plant and its equipment should be viewed as a mechanism for bringing together
diverse professional specialties for the application of a program to a person in need of rehabilitation. To the
degree that the physical surroundings reinforce this focusing of services on the individual client, they are
efficiently supporting the rehabilitation concept.
7.5
Architectural barriers shall be defined by American National Standard - Specifications for Making Buildings
and Facilities Accessible and Usable by the Physically Handicapped - A117-1-1961 (reaffirmed 1971),
copies of which may be purchased from the American National Standards Institute, Inc., 1430 Broadway, New
York, N.Y. 10018.
7.6
A critical aspect in the operation of a rehabilitation facility, whether freestanding or a unit within a larger
institution, is the taking of reasonable steps to assure the safety of persons served against fire and other
emergencies such as bomb threats, medical emergencies, power failures, natural disasters, etc. The plan
should be in keeping with the unique needs of persons served in the facility such as the capacity of persons
served to ambulate, to hear the fire alarm, etc.
Note: Refer to the Special Policy on Safety on page 102.
87
INTERPRETATION OF STANDARDS
8. COMMUNITY INVOLVEMENT AND RELATIONS
Principle
The rehabilitation facility shall actively participate in community planning organizations and programs as they relate to
rehabilitation, and shall conduct a public information program.
The development of organizational goals and objectives and the establishment and operation of a rehabilitation facility
must be closely intertwined with the community (in the broadest sense of the word) which is served. If a facility is to
succeed in fulfilling its mission and realize its fullest potentials, it is incumbent upon its representatives to actively
participate with appropriate governmental and voluntary agencies and establish and maintain itself within the mainstream
of community services. It shall, as appropriate, cooperate in studies or planning activities which are designed to identify its
role and function within the total spectrum of resources; and/or independently assume a responsibility to engage in efforts
directed at achieving the same objective.
The result of these efforts should enable the facility to more meaningfully measure its impact on meeting community
needs. In addition, the facility should recognize the value and benefits of communicating, through organized public
relations efforts, its pertinent activities on an ongoing basis to all levels and segments of its total population. An active
public relations program can prove to be invaluable to the facility in terms of community understanding and support,
referrals, financial support from third-party purchasers, fundraising activities, etc.
Standard
Reference
Number
Interpretation
8.1
A decision on the part of the facility to modify or increase its existing program shall be based upon factual
knowledge of unmet needs within the community and an assessment of the organization's capabilities to
provide for these needs. The information may be available or generated through participation in community
planning groups, state plans for vocational rehabilitation agencies, state or local cooperative planning efforts
or data compiled independently by the facility. This information should be assembled and periodically
communicated to the governing body in order to keep the governing body apprised of the facility's position
within the total community and to facilitate program and fiscal policy decisions.
8.2
The facility shall assign the responsibilities for ongoing public relations activities. These actvities should be
designed to increase and improve public knowledge, cooperation, and support of the goals of the facility; the
needs of the population served; and the services the facility provides. The techniques and methods used
should include, but not be limited to, annual reports; newspaper, TV, and radio coverage of special events;
presentations to professional, business, civic, religious, and fraternal organizations; invitations to various
interested groups to tour the facility, etc.
8.3
The facility shall, where applicable, both generate structured programs and avail itself of the opportunity to
include members of the community in appropriate areas of the facility's activities. Examples of these
programs would include volunteer groups; involvement of community service groups; assignment of special
need projects to fraternal, civic or other bodies; cooperative efforts with other social, vocational, recreational,
industrial organizations, etc.
8.4
The facility shall have written procedures which establish the party(ies) in the facility authorized to
acknowledge and the manner in which acknowledgment is made for gifts, donations, contributions, or
bequests. Since these may be in the form of cash, goods, or services and are closely regulated by various
governmental bodies, it would be helpful to the facility to seek the advice of legal counsel in establishing these
procedures so as to protect the propriety of both the donor and the facility.
8.5
The facility is encouraged to take advantage of opportunities to communicate the human interest aspects of
its program and focus on the people-oriented examples which best illustrate and depict its unique accom-
plishments. However, in doing so the facility must adhere to its moral and legal responsibilities to protect the
rights of individuals involved in this effort and to portray them in a manner which brings credit and positive
community response to the handicapped and to the organization. It is suggested that legal advice be sought
in developing and reviewing forms and procedures utilized in obtaining permission from individuals to utilize
their photographs and/or names in any of the facility's publications or public relations efforts.
89
INTERPRETATION OF STANDARDS
9. PROGRAM EVALUATION
Principle
The facility shall have an evaluation system to identify the results of facility services and the effect of the program on
individuals served in such a way that program performance can be improved and community support can be enhanced.
The intent of this section of the standards is to focus those in and involved with the rehabilitation facility on the need to
develop a means to identify the outcome or results of the facility's services to people. Preceding sections of the standards
necessarily have dealt with "input" and "process." What kinds of problems are presented by the people being served by the
facility? What kinds of services are available to deal with those problems? Who provides those services and in what manner
are they provided?
The next question which must be dealt with is, "What are the outcomes or results of the facility's services in reducing the
problems of individuals served and assisting them to attain their goals? The facility's ability to answer this latter question is
important not only to know how well it is doing and where change may be needed but it will also be a significant asset in
obtaining future community support for its work.
In order to answer these questions, the facility needs what is called an "evaluation system." No single evaluation system is
universally applicable in all rehabilitation facilities because the basis of any evaluation system is a facility's established
goals and objectives and these obviously differ from facility to facility.
The standards of the Commission provide guidance in terms of the elements which should be present in the facility's eval-
uation system. They in effect provide a foundation on which those associated with the facility can build.
The Commission recognizes that, while the rehabilitation facility needs to make evaluation an established part of opera-
tions, this will take considerable effort over a period of time. It is for this reason that the Commission is taking an unusual
approach in applying the new standards in site surveys. Commission surveyors will be able to assist the facility in relating
its efforts in program evaluation to the intent of the standards. In order to facilitate this approach by the Commission's
surveyors, their findings in this area will not be considered In arriving at the actual accreditation decision. Written recom-
mendations will, however, be provided in the report of survey findings.
Standard
Reference
Number
Interpretation
9.1
A complete treatment of purposes, goals, and objectives can be found in the INTERPRETATION OF
STANDARDS, Section 1, Purposes of the Standards Manual.
9.2
The facility's system of evaluation must involve assessments made within a context that relates one element
with another. For example, the effectiveness of the program must be evaluated in the context of who is being
served. Further, the extent to which the facility is fulfilling its purposes must be evaluated in the context of
organizational goals and objectives attained. In order to make these assessments in context, it is necessary
that an "interlocking rationality" exist among elements in the way they are described. For example, if goals
relate to employment, and services provided include counseling and skill training, it would not be logical to
cite medical diagnoses to describe who is being served. For purposes of evaluation, this description would
best be stated in terms of employment-related factors (e.g., work skills) expected to be affected by facility
services offered toward attainment of a goal.
Effectiveness, basically, is measured by the degree to which established goals and objectives are achieved.
Measurements should be taken at reasonably regular intervals, on at least a representative sample of persons
served. It is essential that at least this sample be followed up after treatment services have been completed.
The time of measurement is very important in order that results be stable and relatable to services provided.
Reliable measures should be developed for application to all program emphases at the facility. They should
be sensitive and precise enough to identify increases or decreases in effectiveness when they occur.
9.5
The efficiency of a program can be determined by considering total costs involved, time required to achieve
results, etc. Measures of program efficiency must be of sufficient sensitivity and precision to identify in-
creases or decreases in efficiency when they occur.
9.6
The nature of results obtained by the facility will be heavily influenced by the kinds of persons served. It is,
therefore, important that the facility's evaluation system provide a description of relevant characteristics of
these persons. Descriptive characteristics should logically relate to results obtained by the facility. A method
or system to describe barriers to goal attainment by persons served should also be developed. Any major
changes in the kinds of persons served; e.g., an influx of persons displaying increased severity of conditions,
will necessitate review of of the evaluation system to modify expectancies for goal attainment.
9.7
Information related to results should be linked to facility decision-making in altering admission requirements,
9.8
adding new services, modifying or eliminating existing services, or in allocating financial resources. It is
important that the information on results be produced both with reasonable frequency and within a reason-
able time after services have been provided in order to facilitate changes called for in the delivery system.
9.9
As changes occur in the kinds of persons served, in the services provided, and in organizational and program
goals and objectives, the evaluation system itself will need changing. It is, therefore, important that the facility
regularly review the adequacy of the evaluation system.
91
SURVEY MATERIAL
CHECKLIST OF RESOURCE MATERIALS REQUIRED
FOR SURVEY
When organizing the materials listed, the evaluator can check the appropriate column: "Yes" or "No," if the document is
not available; or "N/A," if the document is not applicable. For convenience, each standard requiring the use of the resource
item is listed in the "Standards Reference" column. Assembling these materials is an important part of the self-evaluation
process, since deficiencies are readily seen.
A facility should feel free to include other documents as evidence of fulfillment of standards. Such additional documents
should be listed under "Other," and the number of the basic standard(s) to which they relate should be indicated.
Information from these resource materials will be supplemented by survey team interviews with selected individuals, and
by direct observation.
94
CHECKLIST OF RESOURCE MATERIALS REQUIRED FOR SURVEY
STANDARD
AVAILABLE
REFERENCE
RESOURCE
NUMBER
DOCUMENT
YES
NO
N/A
1.1, 2.1, 2.1.1.2, 2.1.2 Charter
1.1, 2.1, 2.1.1.2, 2.1.2
Constitution
1.2, 2.1, 2.1.1.2, 2.1.3
Bylaws
1.2.1, 1.3, 3.1.1, 8.1, 8.2
Brochures (Pamphlets)
1.2.1, 1.3, 3.1.1, 4.3.1
Staff Handbook
1.2.1, 1.3, 3.1.1, 4.3.1
Client Handbook
1.4, 1.4.4, 2.3, 2.4, 5.3.1.1, 6.1.1.2, 8.1
Minutes of Board Meetings
1.4, 1.4.3, 5.3.1.2, 7.4
Minutes of Administrative Staff Meetings
2.1.1.1
Letter of Exemption from I.R.S
2.1.1, 2.2, 2.8.1.2, 2.8.1.3, 3.4.4.1.1.8.4
Licenses and Permits
2.2, 2.8.1.3, 5.3.1.7, 7.2, 7.8
Inspection Certificate and Reports
2.2, 5.3.1.7, 7.2, 7.8
Fire Inspection Report
2.2, 5.3.1.7, 7.2, 7.8
Insurance Underwriters' Reports
2.2, 2.8.3, 2.8.4, 2.8.7,
4.5.4.5.2.1, 4.5.7.5.2.1
Wage and Hour Certificate
2.3.1.1, 2.7.2
Roster of Governing Board with Affiliations
and Dates Elected
2.3.2.2, 4.4.5, 5.3.1.1, 6.1.1
Annual Budget
2.3.2.3, 2.4.2.2, 4.3, 4.4, 4.5.4, 4.5.7
Personnel Policies
2.3.2.4, 6.1.4
Annual Report
2.4, 2.5.1, 3.2.4.3, 4.2, 4.5.4.4, 4.5.7.4
Job Descriptions
2.4.1.4, 5.3.1.4, 6.1.3
Financial Statements
2.4.2.1, 2.5, 2.5.3.2
Organizational Chart
2.4.2.4, 5.4.3, 5.4.4, 5.4.7, 5.4.7.3, 7.4
Departmental Records and Reports
2.4.2.5, 2.6, 2.8.4.2, 2.8.7.2
Organizational Memberships of Chief
Executive and Senior Staff Members
2.5.2, 5.3.1.2, 7.4
Minutes of Departmental Staff Meetings
2.5.3.4, 4.2.4, 4.2.8, 4.3.5, 5.3.1.3
Personnel Records and Files
2.5.3.5, 4.2.6
Roster of Volunteers
2.8.1.1, 3.4.1.1.1
Medical Staff Organization Bylaws
2.8.1.4.1
Utilization Review Plan
2.8.1.4.2, 5.4.1.1
Minutes of Utilization Review
Committee Meetings
3.1,4.1
Summary of Services
3.1.2 Directory of Community Services
3.1.3, 3.4, 6.2.2.1, 6.5.3.1.1,
6.5.4.1.1, 6.5.7.1.1
Copies of Current Contracts
3.1.3, 3.4, 3.4.4.2.5.1, 3.4.7.6, 4.5
Service Contracts with Affiliates
and Other Facilities
3.2, 5.1, 5.3, 8.4
Administrative Policies, Procedures,
and Reports
3.2.1.1 Written Criteria for Admission
3.2.6.1, 3.2.6.2, 5.3.1.5
Reports and Statistics from Followup Studies
3.4, 4.2.5, 4.5
Roster of Consultants
3.4, 4.5.4, 4.5.7
Roster of Professional Staff
3.2, 3.4.3, 3.4.4, 3.4.7, 5.1, 5.4
Case Records
3.4.4.1.1.3, 3.4.7.1.1.3
Files on Work Methods
3.4.4.1.1.3, 3.4.4.1.1.5, 3.4.7.1.1.3
Files on Quality Control
3.4.4.1.1.3, 3.4.7.1.1.3
Files on Production Scheduling
3.4.4.1.1.4, 3.4.7.1.1.4
Written Work Specifications
3.4.4.2.4.1, 3.4.7.6.2, 4.3.1,
4.5.4.5.2, 4.5.7.4.2
Personnel Manual
4.4.1, 7.6.6, 7.6.7
Records of In-service Training Programs
4.4.4 Reports of Facility Research
4.5.4.5.2.5
Minutes of Client-Management Meetings
5.1.2.10, 5.1.6, 8.5.1.2
Information Releases
5.1.3 Worksheets of Service Units
5.2.1 Minutes of Case Records Review Committee
5.3.1.4, 6.1.3
Fiscal Records and Reports
5.3.1.4, 6.1.2, 6.5.3.1, 6.5.4.1, 6.5.7.1
Annual Audit
5.3.1.4, 5.4.3, 5.4.4, 6.5.3.1,
6.5.4.1, 6.5.7.1
Payroll Records
95
CHECKLIST OF RESOURCE MATERIALS REQUIRED FOR SURVEY
STANDARD
AVAILABLE
REFERENCE
RESOURCE
NUMBER
DOCUMENT
YES
NO
N/A
5.3.1.6 Correspondence File
5.3.1.8
Accident Plan
5.3.1.8
Accident Reports
5.3.1.8
Log of Injuries and Illnesses
5.4.3.4, 5.4.4.1.3, 5.4.7.1.3,
6.5.4.1.4.2, 6.5.7.1.4.2
Production Records
5.4.3.9, 5.4.4.2, 5.4.7.2
Placement Records
6.2.2.1, 6.5.3.1.1, 6.5.4.1, 6.5.7.1
Copies of Bids
6.2.3, 6.5.4.1, 6.5.7.1
Schedule of Fees
6.4, 7.3.1.7
Insurance Portfolio
6.5.4.1.4, 6.5.7.1
Record of Local Wage Rates
7.5
Plan for Remediation of Architectural Barriers
7.6 Fire and Emergency Plans
7.6 Minutes and Reports from Safety
Committee Meetings
7.6.4 Written Analysis of Emergency Drills
7.6.7.2
First Aid Hospital Referral Plan
7.7.6.5, 7.9.5.5 Audiological Equipment Inspection Reports
8.1 Reports of Cooperative Community Studies
8.1 Staff and Board Member Participation
in Community Activities
8.1 Facility Membership in Organizations
8.2 Press Releases
8.2 List of TV, Radio, and Public
Information Activities
9.1 thru 9.9
Written Program Evaluation Plan and System
Special Policy on Program Evaluation
Governing Body Policy
96
ACCREDITATION
POLICIES
AND
PROCEDURES
ACCREDITATION POLICIES AND PROCEDURES
Introduction
The intent of this section of the Standards Manual for Rehabilitation Facilities is to set forth pertinent policies and
procedures of the Commission relative to the survey and accreditation process. Because all aspects of the Commission's
program are constantly being reviewed for continuing appropriateness, these statements of policy and procedure are
subject to change in the interim between Standards Manual publication dates. Notification of changes, additional infor-
mation, and clarification can be obtained by contacting the national office of the Commission. Submission of a signed
application for survey by a facility shall constitute the facility's consent to implement and adhere to the policies and
procedures in effect on the date the application is received by the Commission.
The Six Steps To Accreditation
1. The facility conducts its own self-study and evaluation using the Commission's Standards. It may also utilize the Self-
Study Questionnaire.
2. The facility completes and sends to the Commission an application for site survey for accreditation.
3. The Commission identifies an appropriate survey-consultation team composed of from one to four persons and notifies
the facility of the date of the site survey.
4. The on-site visit, usually lasting one and one-half days, is conducted by the Commission's survey team which then
reports its findings to the Commission.
5. The Commission evaluates the survey findings and makes an accreditation determination.
6. The facility is notified of the Commission's accreditation decision and receives a detailed written report both ac-
knowledging its strengths and presenting specific recommendations for program improvement.
These steps will be expanded upon in the following paragraphs.
Presurvey Considerations
Materials
A facility considering application for accreditation should contact the Commission's national office to obtain neces-
sary materials. These materials include:
a. The Standards Manual for Rehabilitation Facilities, which is available at cost.
b. The Self-Study Questionnaire. This document is provided at cost only to holders of the Standards Manual for
Rehabilitation Facilities. It is designed for utilization in a process of self-study and evaluation of performance. This
can be done independently of any request for formal accreditation, or it can be the first step. A facility which submits
an application for accreditation receives, at no charge, a copy of the Self-Study Questionnaire.
C. The Application for Accreditation Survey form. This form is available at no charge. The form should be completed
by the facility and forwarded to the Commission, along with the supplementary information requested on the
application, when the facility is ready for the Commission to establish survey dates (see Scheduling the Survey
Dates).
The facility, in its application for survey, identifies for the Commission the basic or primary emphasis or emphases of its
operation. The number and type of surveyors is based upon this declaration by the facility. The Commission surveys
program(s) of service rather than discrete individual services. A facility should therefore differentiate, when applying for
site survey, between a constellation of services coordinated into a program thrust (program emphasis) in a given area and a
service which, while important, is nonetheless supportive to a larger area of emphasis.
Scheduling the Survey Dates
Survey dates are established by CARF staff in consultation with surveyors. The survey is scheduled to take place during the
workweek, normally within a period of 30 to 120 days after the Commission receives an application for survey. The dates
established by the Commission are final. The Commission must be advised, in covering correspondence accompanying
the application, if there are days or periods during this scheduling period which will pose an insurmountable problem for
the facility.
At least thirty days are provided between the Commission's receipt of the application and the actual visit unless
this requirement is waived by the facility.
An accredited facility will be notified by the Commission, approximately six to nine months before expiration of accred-
itation, of the need to request a site survey to retain its accreditation. The resurvey should be conducted approximately two
months prior to the month in which accredited status will expire.
The Commission reserves the right to conduct, with or without prior notice and at its sole expense and discretion, an on-
site visit in any accredited facility.
Fees and Survey Team Composition
The charge to a facility is $345 per day per surveyor. The per day charge is subject to change upon public notification by the
Commission. This daily rate is for any type of on-site review conducted by the Commission-initial surveys, resurveys, and
99
return visits. The exact amount of a facility's survey fee is based upon (1) the number of surveyors needed to conduct the
survey, and (2) the number of days needed to conduct the survey, both of which of necessity must be determined by the
Commission. The presence of a surveyor at the facility for any part of a day is treated as a whole day.
The Commission has four basic types of expertise related to the program emphasis which facilities submit for accred-
itation: administrative, physician, vocationally-oriented, and speech/hearing. The number of surveyors who comprise a
given team is determined by CARF in relationship to the program(s) submitted by a facility for accreditation.
Note: For clarity in writing the word "team" will be used to describe the individual or group of individuals who conduct the
on-site visit.
A typical vocationally-oriented facility which applies for CARF accreditation will usually have a two-person team for a two-
day period: an administrative person plus a person to review any or all of the following programs-Social Adjustment,
Vocational Development, Sheltered Employment, and Work Activity. The survey fee would be $1380 ($345 X two days X two
surveyors).
A facility applying for Physical Restoration alone would usually have two surveyors for two days (the administrative person
plus the physician) with a fee of $1380. A medically-oriented facility applying for accreditation in Physical Restoration and
Speech Pathology and/or Audiology would have a team of three surveyors: an administrative expert, a physician, and a
speech/hearing expert. The survey fee would be $2070 ($345 X three surveyors X 2 days).
A survey fee of $2070 would usually be charged a medically-oriented facility applying for Physical Restoration and/or any
one or more of the following-Vocational Development, Sheltered Employment or Work Activity. The team would be
comprised of the administration person, physician, and vocational expert. If a medically-oriented facility also has major
program emphases in Speech Pathology and/or Audiology, in addition to the above programs, the survey fee would be
$2760 because of the addition of the speech and hearing consultant.
In a freestanding speech and hearing facility, the fee would be $1380 for the two-day period. The team will be composed of
the administrative expert along with the speech and hearing consultant.
Specific questions about the calculation of a facility's survey fee should be directed to the CARF office in Chicago.
A $300 deposit must accompany the completed Application for Accreditation Survey and materials listed on the applica-
tion form and is nonrefundable in the event that the facility cancels a site survey or withdraws this application.
Upon review of the materials and determination by the Commission of the number of surveyors needed to conduct the
survey, an invoice will be sent to the facility crediting the $300 nonrefundable deposit and identifying the remaining
balance. The balance of the survey fee must then be paid within 30 days of the facility's receipt of the invoice.
In the case of public agencies where advance payment is not legally permissible, a binding purchase order, signed by an
authorized official in the amount of the full fee for the survey must accompany the application form.
The Survey Process
The following is a time-phased guide to a typical site survey (times shown are approximate):
First Day
The survey team arrives at the facility and conducts an orientation session with representatives of the
9:00 a.m.
governing body, administration, and staff of the facility, and others invited by the facility. The orientation
session provides the team with the opportunity to clarify with persons in the facility why the team is there
and what it will be doing in the survey. The facility should be prepared to provide the team with a brief but
basic verbal overview of the entire facility's operation. This includes the facility's role in the community, the
types of conditions served, the array of services provided, the programmatic objectives of the facility, how
effectiveness is evaluated, etc.
10:30 a.m.
Brief tour of the physical facilities
11:00 a.m.
Team meeting. The purpose of this meeting is to identify those types of personnel whom the team will need
to interview during the course of the site survey. The chief executive in the facility is asked to schedule
these individuals based upon their availability. Every effort is made to minimize disruption to a facility's
ongoing service program.
11:30 a.m.
With a short break for lunch, the remainder of the day is spent by the team in both reviewing documents
to
such as case records, fiscal reports, bylaws, etc., and in individual interviews with various staff members of
5:00 p.m.
the facility. A responsible official of the facility should be in the agency at all times to answer questions of
the team but should not attend individual interviews.
Evening
Following dinner, the team begins the process of going through each standard applicable to the facility's
operation. The intent of the team is to, where sufficient information has been obtained, make a determi-
nation of the facility's level of fulfillment of a standard. During that process, it becomes evident what
additional information will need to be obtained in order to make a determination of compliance with some
of the standards. This evening session is closed.
Second Day The team returns to the facility to obtain the additional information which was found to be necessary
9:00 a.m.
during the previous evening's discussion.
11:30 a.m.
Team meeting. At this time the team holds its final meeting to pull together its findings. Preparations are
also made for the Exit Conference.
12:00
noon The Exit Conference. The Exit Conference lasts approximately one hour and is conducted by the team with
representatives of the governing body, administration, appropriate staff of the facility, and others invited
by the facility. The purpose is to provide feedback to the facility concerning the strengths of the facility's
100
operations in terms of the standards and recommendations for program improvement. The facility may at
this time question any interpretations of the team.
After the site survey has been completed, the team prepares a detailed written report of its findings of facility strengths and
documents specific recommendations for improvement and forwards this report, along with a recommendation for
accreditation action, to the Commission.
Commission surveyors are not permitted to divulge the accreditation recommendation to facility personnel nor to any
person or organization other than the Commission.
The length of time from site survey to notification of the Commission's accreditation action is approximately six to eight
weeks.
Other site survey-related policies and procedures are noted below:
Observation of Site Surveys
Permission to observe the site survey must be obtained in advance from the facility for other than Commission
surveyors.
Resurveys
A facility must, after notification by the Commission, reapply for site survey and be surveyed or be in process of survey
to maintain accredited status beyond the expiration of accredited tenure. The process of resurvey is the same as for the
initial survey in that all appropriate standards are applied; however, special attention is given to actions taken to
implement prior recommendations.
Branch or Satellite Programs
Branch operations must be separately surveyed to be accredited. A branch shall be considered for this purpose to exist
if any one or more of the following are present:
a. If the annual expenses of operation of the unit are in excess of $50,000
b. If the central case record for persons served in the unit is kept in the unit
C. If admission of persons to be served could be made by a referral source directly to the unit without processing
through the base facility
d. If the central character of the service in the unit is different from that in the base facility
e. If personnel policies of the unit are different from those of the base facility operation.
A store which basically constitutes a sales outlet shal! not be considered as a branch for this purpose.
ACCREDITATION DECISION-MAKING
The written report of the findings of the site survey team is reviewed by Commission staff and is forwarded with recom-
mendations to the Accreditation Committee of the Commission's Board of Trustees. This Committee makes the final
accreditation decision when its action is to accredit at any level.
Appeals
The Accreditation Committee's decision is deemed preliminary when the Committee's judgment is not to award
accreditation. An appeals process exists from this latter action of the Accreditation Committee. It provides, in essence,
that the facility is informed of the Committee's action and the reason(s) for it and is granted, within certain time con-
straints, the opportunity for an interview with staff and/or a hearing before a special Appeals Committee of the Board.
Its decision, if other than to accredit, is also subject to appeal. The final appeal is to the Board of Trustees, without
participation of members of either the Accreditation or Appeals Committees. The complete written policies covering
appeals are available upon request.
Guidelines for Accreditation Decisions
A facility is not expected to be in full compliance with every applicable standard. The accreditation decision is
consequently based upon the balancing of a facility's strengths and areas needing improvement as related to the
standards and certain guidelines. The following guidelines are used by surveyors and by Commission staff and
Trustees in making this decision.
Three-Year Accreditation
Although there are deficiencies, the facility shows substantial fulfillment of the standards, and its program, per-
sonnel, and documentation clearly indicate that present conditions represent an established pattern of total
facility operations so as to give confidence that these conditions are likely to be maintained and/or improved over
the foreseeable future.
One-Year Accreditation
The facility has significant deficiencies, but shows evidence of capability, commitment, and progress in their
correction. On balance, the program is benefiting its clientele and there is no serious threat to their health, welfare,
and safety.
101
No Accreditation
The facility has major deficiencies in several areas of standards, to the extent that there is serious question as to
the rehabilitation benefits, health, welfare, or safety of its clientele, or the facility has failed to bring itself over time
into substantial conformance with the standards.
A facility may be considered to be functioning between the three-year and one-year levels previously described
because of the existence of certain problem areas. In this instance, accreditation for one year shall be awarded.
A facility may be found to approximate but fall short of one-year accreditation because of the presence of certain
critical conditions affecting the service benefits, health, welfare, or safety of persons served. If, in the judgment of the
Commission, there is both a willingness and a capability on the part of the facility to correct these conditions, then the
decision of the Commission's Trustees to accredit or not accredit will not be made until the facility is provided up to
twelve months to correct these problems. Verification of corrective action is made via the mail or through a return visit,
as appropriate. The final decision on accreditation is then made on the basis of the basic survey visit and corrective
action findings.
Conditional Nature of Accreditation
It shall be an expressed condition of an accreditation award that the Commission, upon being apprised by any source
of material change in the facility's functioning in terms of the standards, or upon the failure of the facility to provide
such records and reports as requested by the Commission, may review the facility's accreditation and may modify its
accreditation decision. Such review may, at the expense and discretion of the Commission, include an on-site visit.
All or None Principle
If a facility purports to have multiple program emphases and any one program is operating at a lower level of accred-
itation (or nonaccreditation) than the other programs, then the level of accreditation for all program emphases is the
level at which the weakest program is functioning. For example, if the facility has two program emphases with one
functioning at the three-year and one at the one-year level, then the accreditation award for the facility is for one year.
If one program emphasis is not accreditable, then the facility is not accredited. A facility must submit for survey all
program emphasis areas for which the Commission has formulated standards.
Consecutive One-Year Accreditation
A facility must have brought itself to a level of functioning at which three-year accreditation can be awarded or be not
accredited on the survey following two consecutive surveys of the same program or programs in which one-year
accreditation was awarded.
Special Policy on Safety
The Commission on Accreditation of Rehabilitation Facilities affirms the principle that a paramount consideration in
the operation of any accredited rehabilitation facility should be the taking of reasonable steps to help ensure the basic
safety of the persons served by that institution. While the Commission has promulgated a number of standards which
can help a rehabilitation facility to remain sensitive to this responsibility, it is the policy of the Commission on Accred-
itation of Rehabilitation Facilities that no facility shall be recognized with accredited status unless it can demonstrate:
a. That it has developed a written plan to deal with fire and other emergencies, and
b. That it has tested the effectiveness of that plan at least once during the three-month period prior to the site
survey.
It shall further be the policy of the Commission on Accreditation of Rehabilitation Facilities that when, upon site
survey, a facility is found not to meet the above two requirements that no decision will be made to accredit or not
accredit until the facility is provided with up to 60 calendar days to furnish evidence of compliance with the two subject
requirements.
Special Policy on Program Evaluation
The Commission on Accreditation of Rehabilitation Facilities affirms the principle that a continuous program evalu-
ation system is needed within a rehabilitation facility as a means to identify and evaluate, against preestablished goals,
the outcomes or results of the facility's services to people. At the same time, the Commission recognizes that this can
only be accomplished with a substantial and demonstrated commitment on the part of the facility over an extended
period of time. Such a commitment must originate at the highest level of the facility. In recognition of this, the Com-
mission has adopted the following policy:
a. On all surveys conducted after July 1, 1978, facilities must have a written policy approved by their governing body
(as defined in the Glossary of Terms) which specifies a date for the installation of a program evaluation system
which is in compliance with the Commission's standards. The system must be operating within three years from
the date of enactment of the governing body policy.
b. It shall further be the policy of the Commission that when, upon site survey, a facility is found not to meet the above
written policy requirement, that no decision will be made to accredit until the facility is provided with up to 60
calendar days to furnish evidence of compliance with the requirement.
C. On the first site survey after the date specified in the facility's policy, the Commission's program evaluation stan-
dards will be applied, and any recommendations will be considered as part of the accreditation decision-making
process.
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Independence in Decision-Making
To preserve the character of independence in the accreditation process, Commission policies provide that:
a. Corporate sponsoring member organizations shall not be informed of the accreditation recommendation nor
participate in the rendering of an accreditation decision for an individual facility.
b. In instances where a member of the Commission's Board of Trustees represents a corporate sponsoring member
which has affiliate facilities, or where there might be a conflict of interest, that Board member shall disqualify himself
from voting on the accreditation action of that facility.
PUBLIC IDENTIFICATION
A facility awarded accreditation will be provided, at no charge, a Certificate of Accreditation. Additional certificates are
available at cost. This certificate, suitable for framing, identifies the institution (or unit or branch thereof) which was
surveyed, the program(s) accredited and the year in which accreditation tenure expires.
This certificate and all copies and facsimiles shall remain the property of the Commission and must be returned upon the
expiration or loss, for any reason, of accreditation.
A facility which is accredited is permitted, and is in fact encouraged, to publicly identify this achievement through use of
the words "Accredited by the Commission on Accreditation of Rehabilitation Facilities" on its brochures, letterhead,
annual reports, etc.
Within 30 days after notification of the termination or loss of accreditation, the failure of a facility to return the Certificate(s)
of Accreditation and/or to terminate purporting to be accredited by the Commission shall constitute consent for the
Commission to publicly disclaim the accredited status of the facility.
The Commission, several times each year, disseminates to over 6,000 persons an up-to-date listing of accredited facilities
throughout the Nation. In addition, the Commission notifies the Governor and members of the federal congressional
delegation when accreditation is awarded. No public differentiation is made by the Commission between three-year and
one-year accreditation awards.
CONFIDENTIALITY
The policy of the Commission is to consider as strictly confidential, information arising out of the survey and accreditation
process in an individual facility. The Commission will release information obtained through the survey and accreditation
process only with the facility's written permission. Exceptions to this policy are:
1. As provided in the policies and procedures stated in the PUBLIC IDENTIFICATION section
2. The release of information as required by law
3. In the application for survey express authorization is given the Commission to request-and given to public or publicly-
recognized licensing, examining, or reviewing agencies to release-information and official records and reports for the
Commission's analysis in arriving at an accreditation determination. The Procedures Committee of the Commission's
Board of Trustees is authorized to grant an exception where just cause has been provided by a facility.
It is the practice of the Commission to routinely request information from the state rehabilitation agency, the state welfare
department, the state public health agency, etc. The Commission reserves the right to contact other public or publicly-
recognized agencies.
Authorization for release of the survey report shall be solely at the discretion of the surveyed facility.
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CCINT
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