RULES AND REGULATIONS FOR LICENSURE OF REHABILITATION FACILITIES

CHAPTER 16

  Section 1. Authority. These rules are promulgated by the Department of Health pursuant to the Health Facilities Licensure Act at W.S. 35-2-901 et seq. and the Wyoming Administrative Proce- dures Act at W.S. 16-3-101 et seq.

  Section 2. Purpose. These rules have been adopted for the licensure of rehabilitation facili- ties. The purpose of these standards is to provide minimum requirements for services, structure, opera- tion and personnel practices designed to protect the health and safety of patients and employees.

  Section 3. Severability. If any portion of this rule is found invalid or unenforceable, the remainder shall continue in effect.

  Section 4. Definitions. "Acceptable plan of correction" means an Office of Health Quality, Planning and Program Evaluation (Office of Health Quality) approved plan to correct the deficiencies identified through a survey. The plan of correction shall bea written document and shall contain who is responsible for correction, what was done to correct the problem, who will monitor to ensure that the situation does not develop again, and a timely date for completion of the correction.

  "Administrator" is the person in charge of the operation of the facility twenty-four hours per day and is:

  A physician, or

  A Registered Nurse, or

  A rehabilitation counselor, or

  An occupational therapist, or

  A physical therapist, or

  A speech and language pathologist, or

  A respiratory therapist, or

  An individual with a bachelors degree and one years experience in health service administration preferably in a comprehensive outpatient rehabilitation facility; or

  An individual with at least five years of management experience in a comprehensive outpatient rehabilitation facility.

  "Central Registry" means the registry operated by the Wyoming Department of Family Ser- vices pursuant to W.S. §14-3-213, which indexes perpetrators of child abuse or neglect and abuse, neglect, exploitation or abandonment of disabled adults.

  "Certified Occupational Therapy Assistant" is a person who is licensed to practice as a certi- fied occupational therapy assistant by the Wyoming Board of Occupational Therapy.

  "Dietitian" means a person who is registered by the American Dietetic Association and provides nutritional and dietary consultation services.

  "Facility" -- a "comprehensive outpatient rehabilitation facility", CORF, or "facility" means nonresidential facility that: Is established and operated exclusively for the purpose ofproviding diagnostic, thera- peutic, and restorative services to outpatients for the rehabilitation of injured, disabled, or sick persons, at a single fixed location, by or under the supervision of a physician.

  "Fidelity bond" means a contract of fidelity insurance. One agrees to insure another against loss arising from the want of honesty, integrity or fidelity of an employee of the rehabilitation facilities.

  "Licensed Practical Nurse" is a graduate of an approved school of practical or vocational nursing who is currently licensed to practice as a licensed practical nurse by the Wyoming Board of Nursing.

  "Occupational therapist" is a graduate of an approved school of occupational therapy who is currently licensed to practice as a registered occupational therapist by the Wyoming Board of Occupa- tional Therapy.

  "Physician" means a person licensed to practice medicine in Wyoming by the Wyoming Board of Medicine.

  "Registered Nurse" is a graduate of an approved school of professional nursing, who is currently licensed to practice as a registered nurse by the Wyoming Board of Nursing.

  "Rehabilitation Facility" means an outpatient facility which is operated for the primary pur- pose of assisting the rehabilitation of disabled persons by providing comprehensive medical evaluations and services, psychological and social services, or vocation evaluations and training or any combination of these services and in which the major portion of the services is furnished within the facility.

  "Social Worker" is a person who has graduated with a bachelors degree from a school of social work accredited by the Council on Social Work Education.

  Section 5. Licensing.

  Licensing requirements. The Office of Health Quality has been duly authorized to issue licenses to rehabilitation facilities. The Office of Health Quality has established a system of licensure to comply with minimum requirements for protecting the health, welfare and safety of patients receiving this type of service.

  Licensing procedure.

  For an initial license to be issued the facility shall submit:

  A completed application form. (The blank application form shall be supplied by the Office of Health Quality.)

  The required licensure fee outlined in Chapter 1 Rules and Regulations for Health Care Facilities Licensure Fees. The check or money order shall be made payable to the Trea- surer, State of Wyoming.

  Demonstrated compliance with the requirements for licensure as required in paragraph (c) of this section. This documentation shall be available through the Office of Health Quality following the on site survey.

  The effective date of the initial license shall be:

  The date of the survey, if there are no deficiencies, or

  If deficiencies exist, the date an acceptable plan of correction is devel- oped.

  The length of the license shall be from the effective date of the license until the next June 30th.

  For renewal of a full license for one year beginning July 1st, and unless suspended, or revoked, shall expire on June 30th of the following year, the Office of Health Quality shall receive:

  A completed application form returned by the date indicated in the cover letter.

  The application form shall be mailed by the Office of Health Quality to the facility.

  License fee. Each application shall be accompanied by the required licensure fee outlined in Chapter 1, Rules and Regulations for Health Care Facilities Licensure Fees. The check shall be made payable to the Treasurer, State of Wyoming.

  Must demonstrate full compliance with the requirements for licensure as required in paragraph (c) of this section or an acceptable plan of correction for deficiencies from the standards. This documentation is maintained on file at the Office of Health Quality following the on site survey.

  Requirements for licensure. The Office of Health Quality shallconsider: The rehabilitation facility shall be in conformity with all laws and standards relating to communicable and reportable diseases as promulgated by the Department of Health, Public Health Division.

  Existing deficiencies shall not create a hazard to the health, safety or welfare of the patients.

  The rehabilitation facility is making a positive effort to correct all existing deficien- cies.

  Adequate policies and procedures are in place to guide operations.

  There is adequate and appropriately trained staff.

  The rehabilitation facility has an organized and implemented quality improvement plan.

  There is an approved plan of correction for all cited deficiencies.

  Transfer of, or changes to the license.

  No license granted shall be assignable or transferrable. A license shall apply only to the facility location described in the license application.

  Whenever ownership of an agency is transferred from the individual or entity named in the license application to any other individual or entity, written notification of change of ownership shall be made to the Office of Health Quality. The buyer shall notify the Office of Health Quality of the impending transfer and apply for a new license.

  Any license granted to the buyer shall be subject to the plan of correc- tion submitted by the previous owner as approved by the Office of Health Quality.

  The seller shall notify the Office of Health Quality at least thirty (30) days before the actual date of transfer.

  Upon receipt of the licensure application, a new license will be issued to be effective on the date of the change of ownership.

  The day after the change of ownership the obsolete license shall be mailed back to the Office of Health Quality.

  If the rehabilitation facility's name is changed, the Office of Health Quality shall be advised in writing and a new license shall be issued upon receipt of the licensure fee and application.

  Conditioning or revoking a license.

  Denial of application - suspension or revocation of license.

  An application for license may be denied or a previously issued license may be suspended or revoked for noncompliance with minimum standards as herein set forth when noncompli- ance jeopardizes the health, safety or welfare of patients.

  Suspension of admissions.

  The Office of Health Quality may suspend new admissions or re-admissions to rehabilitation facility when conditions in the facility are such that patient needs cannot safely be met.

  Conditions in a rehabilitation facility shall not jeopardize the patient's health and safety.

  Hearings.

  Any rehabilitation facility aggrieved by a decision of the Office of Health Quality may request a hearing by submitting a written request within ten (10) days of the date of the decision.

  Except in matters concerned with the spread of communicable disease as required in Section 5 (c)(i), the Senior Management Consultant of the Office of Health Quality shall present the preliminary decisions and reasons to the parties concerned and provide an opportunity for a hearing if a hearing is requested within ten (10) days.

  Hearings requested under the terms of these rules and regulations shall be held by the Office of Health Quality according to the provisions of the Wyoming Administrative Procedures Act at W.S. 16-3-113, and with the contested case rules and regulations of the Wyoming Department of Health.

  Posting of license.

  The current license issued by the Office of Health Quality shallbe displayed in a public area within the rehabilitation facility.

  Survey of the rehabilitation facility.

  The survey of rehabilitation facility programs shall be arranged by the Office of Health Quality. The survey shall be performed periodically. All records of the facility shall be made available to the surveyor.

  Requirements of the Office of Health Quality.

  The Office of Health Quality shall provide each rehabilitation facility with:

  A copy of these standards; and

  A copy of any deficiencies found.

  Voluntary Closure.

  If a rehabilitation facility voluntarily ceases to operate, they shall notify the Office of Health Quality in writing at least five working days prior to the closure.

  The first working day after the closure of the rehabilitation facility the license of the rehabilitation facility shall be returned to the Office of Health Quality.

  Section 6. Organization and Management.

  (a) Governing Body. The rehabilitation program shall have a governing body which has the legal authority and responsibility to operate the rehabilitation program. The governing body shall:

    (i) Obtain a fidelity bond for client protection arising from the want of honesty, integrity or fidelity of an employee. The bond shall consist of no less than $2500 and shall be aug- mented in relation to the number of employees.

  Central registry information can be obtained by contacting Department of Family Services at 307-777-5366. (This number may be subject to change.)

  Adopt, revise, and approve personnel policies; including:

  Frequency of evaluations;

  Insuring confidentiality of central registry information checks;

  Prepare an organizational chart that reflects the administrative control and lines of authority for the delegation of responsibility from management down to the client care level.

  The governing body shall ensure that all services provided are consistent with ac- cepted standards of practice.

  The governing body shall ensure adequate staffing to provide quality rehabilitation care.

  There must be policies and procedures for services offered, which shall be reviewed annually by the governing body.

  Ensure in accordance with the State Statute 25-2-910, there is an effective, ongoing, agency wide written quality improvement program which ensures and evaluates quality of care provided to all clients.

  Personnel Records.

  There shall be one person designated responsible for maintaining the confiden- tiality.

  Employee Health. The rehabilitation program shall:

  Develop policies and procedures for employee health, including a policy identifying communicable diseases that could put the client population at risk.

  Advanced Directives.

  The rehabilitation program shall adopt policies which assure that they provide information on advanced directives to clients. If the client's advanced directives are known they shall be followed by the rehabilitation facility.

  Notification. Prior to admission all perspective clients shall be notified if the rehabili- tation program is not Medicare/Medicaid certified.

  Section 7. Construction.

  At the time of initial licensure the rehabilitation facility shall meet the most current provisions of NFPA 101 Life Safety Code of the National Fire Protection Association.

  After initial licensure the rehabilitation facility will continue to be licensed under the same provisions of the NFPA 101 Life Safety Code as when they were initially licensed.

  For new construction the facility shall comply with the most current edition of the Guidelines for Construction and Equipment of Hospitals and Medical Facilities Chapter 10 Rehabilitation Facili- ties.

  For remodeling a portion of the rehabilitation facility, the facility must comply with the most current edition of the Guidelines for Construction and Equipment of Hospital and Medical Facilities Chapter 10 Rehabilitation Facilities.

  Plans must be submitted and approved by the Office of Health Quality.