Policies and Procedures Manual for Clinical Staff

1 Options For Rehab Policy and Procedure for clinical staff- PT,OT,ST

Options for Rehab (OFR)

Policies and Procedures Manual for Clinical Staff Physical Therapist (PT) Occupational Therapist (OT) Speech Therapist (ST)

Rev. May 2010 and 2/11 It is the responsibility of the clinical staff and independent contractors to familiarize themselves with the contents ofthis Manual. The review of this Manual shall be included in the new clinical staff and independent contractor’s orientation procedures. For independent contractors this Manual is intended as a general guide to the goals, policies, practices, and expectations of OFR to enhance quality of care between staff and independent contractors and is not intended to cover every situation or dictate actions which may arise during an individual clinical staff’s contractual employment at OFR. Further, this Manual is not a contractual employment agreement with OFR and should not

be deemed as such. Independent contractors should utilize this manual as a voluntary resource that can be utilized at the discretion of the independent contractor. At all times, the independent contractor as long as they are following the laws and regulations relating to their license and current and customary standards of care are free to accept or refuse each individual referral for client management and care, render actual home based client care at their own discretion, schedule the client according to their own desires in conjunction with the desire of the client, physician and insurers, at a site that is agreeable to themselves and the client. Scheduling, actual methods and direction of patient care, and site of the care to be provided is not controlled in any manner by OFR.


General Administrative Policies(PT/OT/ST):

Follow all OFR rules and regulations including, but not limited to the policies and procedures included in this Manual or the contractual agreement with OFR, and the State of California’s professional policies, procedures, regulations, and guidelines, and Medicare’s professional policies, procedures, regulations, and guidelines.

Prioritize and adjust current work schedule to accommodate new patient referrals based on an agreed geographic area of coverage with OFR and/or other contractual agreement criteria with OFR.

Attend a mandatory new clinical staff or independent contractor orientation prior to OFR referring a first patient to you. The orientation will include, but shall not be limited to, items in the contractual agreement with OFR, the policies and procedures outlined in this Manual and elsewhere, items in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) policy and procedure manual, OFRs billing and compensation procedures, and OFRs administrative staff procedures comprising Agency and OFR requirements of forms and other paperwork at each phase of patient care and OFRs electronic knowledgebase.

Attend in-services on practices and issues that deal with the disciplines available at OFR and the business and regulatory guidelines of health care delivery services. Everycalendar year, there will be a mandatory in-service on infection control, blood borne pathogens and other Occupational Safety and Health Administration (OSHA) or HIPPA required in-services. Included in this in-service will be new regulations, methods and review of established OFR policies and procedures.

OFR General Clinical Policies and Procedures (PT/OT/ST):

Follow OFR Core Values in the treatment and client management of all patients and contacts with referral sources. The OFR Core values for professional behavior are Accountability, Altruism, Compassion, Caring, Excellence, Integrity, Professional Duty, and Social Responsibility. See the Policy and Procedure Manual for a full description of these values.

Follow policiesfor the delivery ofall clinical treatments and care as required by your State Practice Act and all laws and regulations guiding your license. In addition Physical Therapists and Physical Therapy Assistants should follow care prescribed and outlined in the current edition of Guide to PhysicalTherapist Practice (APTA).

Develop and administer (or supervise administration of) therapy and rehab care plans for patients, wherein the care plans comprise a plan of treatment, the treatment goals,


the frequency of the treatment, the duration of the treatment, and the final outcome of the treatment. The process comprises of the following steps:

A. Referral: Make an initial contact with the patient to schedule an appointment for a first visit (initial evaluation or IE) upon receipt of a patient referral from OFR and within twenty-four (24) hours of the receipt of the referral; and Document the same in an OFR communication note.

B. Evaluation: Make an IE within seventy-two (72) hours from Start of Care (SOC) or within forty-eight (48) hours from referral from OFR, unless (A) safety has been identified as a concern or (B) you are the primary case manager. In these cases, the IE must be made within twenty-four (24) hours from referral from OFR. If, for some reason the IE cannot be made within the aforementioned specified time frames, the patient, OFR, and the patient's physician have to be notified (if necessary, OFR will refer the patient to another PT). Document any delays in service, the reason for the delay, and the notification of the delay to appropriate people (for example, OFR, patient, and patient’s physician). Complete an OFR initial evaluation, an OFR route sheet, and an OFR physician order for the IE (purpose and procedure to be mentioned in evaluation) and submit the pertinent paperwork of the IE to OFR within twenty-four (24) hours of the IE unless the evaluation cannot be completed because of pending orders or authorization. Initial Evaluation must include but is not limited to the following:

a. Client Examination which includes gathering a history of the current issue and past medical history, performing a systems review and performing necessary tests and measures.

b. Evaluation in which the therapist makes clinical judgments based on data gathered during the examination.

c. Determine Problems and Needs from Examination and Evaluation findings.

d. Develop Prognosis, Rehabilitation Potential, Plan of Care, and Goals including time frames to meet goals and specific interventions to be used, including their timing, frequency and duration.

1. The care plans are to be established in conjunction with patient/caregiver participation and consultation with the patient's physician. The care plans must be re-evaluated/examined at least every sixty (60) days or more often as necessary to insure the adequacy of the plans, patient/caregiver response, effectiveness of service, and appropriateness of continuing care. The care plans are used as a tool to provide timely instructions and interventions reflecting patient/caregiver initial needs, changes in needs, goals


and care to be provided; and the care plans and the documentation thereof must follow the initial baseline status of the patient.

e. Documentation is required of all Initial Evaluations, Plan of Care, Goals, Re-evaluations/examinations, and Rehabilitation Prognosis and Potential. Documentation is to include adequate objective and measurable baseline status and data. Functional limitations should be documented including problems contributing to the loss of function.

C. Informed Consent (only if doing SOC): The therapy and rehab care plans must be explained to the patient/caregiver sotheycan b e e d u c a t e d about t h e t h e r a p y a n d r e h a b c a r e ortreatment and the risks and benefits of the treatment.Thepatient/caregiver haveadutytobe surethattheyunderstandtheinformationtheyhavebeengiven.Thelanguageofa consentformmay b e generalorspecific,statingthatthepatienthasbeeninformedofthe risks of the treatments and what alternative treatments are available; Components of the consent form to include the patient’s/caregiver’s capacity (or ability) to make the decision regarding the care plans; disclosure by the medical provider regarding information on the treatment, test or procedure in question, including the expected benefits and risks and the likelihood (or probability) that thebenefits and risks will occur; understanding by the patient/caregiver of the information they have been given; and voluntary grant of the consent by the patient/caregiver without coercionorduress; Only under certain conditions, there are exceptions to the informed consent rule which include an emergency in which medical care is needed immediately to prevent serious or irreversible harm to the patient and incompetenceinwhich a p at ien t /careg iv er isunabletogivepermission(ortorefuse permission) for testing or treatment; and Theconsentform must be signed by the patient/caregiver and keptwiththe patientcharts.

D. Interventions/Care Plan: Provide purposeful and skilled intervention in accordance with State Practice Act, Community Standards of Care, and all Legal and Professional Guidelines. Interventions are provided as specified by the evaluating therapist toward the planned goals. Interventions should be consistent with the diagnosis, prognosis, and evaluations findings. The therapist performs a re-examination/evaluation periodically or if there is a new clinical finding or lack of client progress. The Plan of Care/Intervention can be modified as appropriate based on re-examination/evaluation findings. Interventions


should include patient caregiver participation when applicable/appropriate. Interventions can be assigned to a Licensed Assistant by the evaluating therapist. Only those tasks that can be safely, effectively and competently demonstrated on a patient by an assistant should be delegated to the assistant.

E. Submission of Therapy and Rehab Care Plans: Complete an “admission packet” (including consent forms, medical sheets, and OASIS forms) for certain agencies (these packets will be given by OFR). Many of the forms in the “admission packet’ require patient/caregiver signatures. Accordingly, take the “admission packet”, if needed, to the IE; Communicate to OFR via phone, fax, or email the SOC, a plan of care (POC), and a frequency and duration of the therapy and rehab care plans (F+D) preferably on the date of the IE so that OFR can schedule a PTA to perform the follow-up treatments; and Mail, to OFR, the original SOC, POC, and F+D within twenty-four (24) hours of the IE.

F. Orders/Authorization: Contact the patient’s physician during or immediately following the IE to discuss the findings of the assessment and the proposed POC. Document all contacts or attempts to contact the physician in an OFR communication note. If there is difficulty in obtaining a physician approval and/or order which would delay further care and submission of the evaluation, assistance maybe requested from OFR; Complete an OFR request for authorization and submit to OFR the same with the initial evaluation if the patient is a managed care patient (HMO patient). If the requested authorization is not obtained from OFR in a timely manner, inform the patient and the patient’s physician of the delay in starting the care plans. Work closely with OFR to ensure appropriate authorization for visits. Maintain a record of the visits authorized and those made to ensure that all visits are covered and submitted for payment; Contact the patient's physician to report changes in the patient's condition and/or any need to change the care plans. All verbal orders, including changes in frequency and duration, must be documented in an OFR physician order form. Send the OFR physician order form to the physician for signature; and Submit an OFR missed visit form if for any reason an ordered visit is not made, including a refusal by the patient. Notify the patient’s physician of the missed visit or complete an OFR physician order form if as a result of the missed visit, the frequency changes and is not as ordered for the week.

G. Documentation: All patient care/interaction must be documented. Submit to OFR, at least twice (2x) a week, OFR route sheet(s) with appropriate OFR progress report(s), OFR communication note(s), OFR physician order(s), OFR case management calendar sheet, and any other


pertinent paperwork for each patient. F+D can be tracked and patient charts can be audited on the OFR case management calendar sheet. An audit must be made prior to discharge of patient to verify the F+D matches the physician’s order and patient visits.

H. Supervision of assigned PTA/COTA: Determine and assign if applicable and appropriate to a PTA or COTA as appropriate only those tasks that can be safely, effectively and competently demonstrated on a patient by an assistant. Supervise follow-up treatments based on the therapy and rehab care plans by an assigned Physical Therapist Assistant (PTA) or COTA as applicable. The supervision of the assigned COTA must follow the Occupational Therapy Board of California’s current Laws and Regulation Governing Occupational Therapy Assistants The supervision of the assigned PTA must follow the Physical Therapy Board of California’s current Laws and Regulation Governing Physical Therapy Assistants. The current Laws and Regulation Governing Physical Therapy Assistants maybe found at http://www.ptbc.ca.gov/laws_regs/laws_pt_asst.pdf. Be available to the assigned Assistant in-person or via phone and at all times while the assigned Assistant performs follow-up treatment based on the care plans; Perform a reassessment visit for each patient after every six (6) to eight (8) follow-up visits by the assigned Assistant and every thirty (30) days thereafter. Make additional reassessment visits based on the patient’s health condition; and Review, cosign, and date all patient documentation generated by the assigned Assistant within seven (7) days after the assigned Assistant starts the follow-up treatment based on the care plans. Conduct a weekly case conference via in-person or phone with the assigned Assistant for each patient. Thereafter, conduct a monthly scheduled case conference in-person or phone with the assigned Assistant for each patient. Document all case conference notes in the patient chart.

I. Recertification: Determine towards the end of the current POC period, if a patient will continue to need therapy beyond the end of the current POC period; Contact the patient’s physician with an OFR physician order to continue therapy if the patient needs therapy beyond the end of the current POC period; and Perform a complete assessment of the patient and submit a completed interim evaluation of the patient to OFR before the last day of the current POC period, if the patient will continue to need therapy beyond the end of the current POC period.

http://www.ptbc.ca.gov/laws_regs/laws_pt_asst.pdf


J. Discharge: The patient is discharged if treatment goals/outcomes are met, there is a change in medical status and the patient is unable to continue progress toward goals, the patient refuses care, the physician

requests discharge, the therapist feels the patient will no longer benefit from therapy, or financial/insurance resources request discharge. Summarize in a final OFR discharge summary and instructions, the degree to which the treatment goals have been met when the patient is discharged include number of visits, summary of interventions, comparison of discharge status to baseline status.

Write an OFR physician order if the POC has been interrupted; Complete an OFR physician order documenting the circumstances leading to the discharge, the patient's condition on the last visit, and a summary of progress made toward meeting the treatment goals, if the discharge is unexpected or unplanned for some reason; and Complete a discharge/transfer summary within ten (10) days of discharge if you are the case manager.

OFR General Clinical Protocols PT/OT/ST:

A. Initial Evaluations Examination is required prior to any initial

evaluation and is always performed by a licensed therapist. A physician must have ordered therapy and a diagnosis is provided.

a. Obtain History/Past Medical History: Gather information from an interview of the patient, interview of the patient’s family or caregiver, review of the patient record or other sources.

b. Data obtained can consist of, but is not limited to the following: demographics, social information, employment, living environment, general health, medical/surgical history, current complaints, functional status, activity level, and medications.

c. Perform a systems Review. The systems review must include a review of the cardiovascular/pulmonary system, integumentary system, musculoskeletal system, neuromuscular system, and communication ability (including cognitive ability, learning barriers/styles, and language). The depth of the review of each area will depend on problems or impairments that are found and is up to the discretion of the evaluating therapist but should be consistent with the diagnosis and problems present. Proper attention to this area can also identify problems that require consultation with or referral to another provider

d. Tests and Measures are performed based on data gathered from the systems review. Problem areas require further investigation by using appropriate tests and measures. The evaluating therapist determines which tests and measures are necessary to contribute to and confirm decisions regarding the status and care


of the client. For example: The physical therapist may perform strength, ROM, functional mobility and sensation testing on a client. The occupational therapist may perform fine motor dexterity, strength, and activities of daily living testing on a client. The speech therapist may perform articulation and swallowing testing on a client. Adequate testing and data must be generated to properly

assess the client’s status. Some examples of tests and measures categories are aerobic capacity, arousal, attention, cognition, circulation, nerve integrity, body mechanics, gait, balance, etc. All therapists should assess and test patient safety at the initial evaluation and monitor on every visit. Safety issues should be addressed as soon as discovered. e. Evaluation of the data collected in which the patients problems

and needs are properly identified and specifically reporting the impact on the function of the client. Objective and Measurable Goals are identified, a time frame to achieve the goals and a rehabilitation prognosis and potential are indentified.

f. A Plan of Care /Intervention is established in accordance with customary practices, standards of care, and legal guidelines.

B. Interventions: a. Interventions should be purposeful and designed to produce

changes in the condition that are consistent to the diagnosis and prognosis. Specific frequency and duration of interventions are stipulated. Interventions always include client management, coordination of services, and documentation. Interventions can include but are not limited to the following:

i. Physical therapy: education, therapeutic exercises, functional training, manual therapy, physical agents and mechanical modalities and electrotherapeutic modalities.

ii. Occupational therapy: education, therapeutic exercises, functional ADL training, prescription/application/training in splints and assistive devices, physical agents and modalities.

iii. Speech Therapy: education, articulation training, swallowing training, communication exercises, and cognitive training.

b. Interventions should be performed always guided by a concern for patient safety and welfare. Always introduce yourself to the patient before treatment. Gain the confidence of the patient and explain all procedures to the patient before initiating. Be aware of any precautions or contraindications for any interventions and


verify that they do not conflict with any precautions with your patient. Inspect your equipment prior to use.

Inspect the treatment area for safety before beginning treatment. If the area is not safe for the patient OR for you do not begin treatment. The area should be warm and free of drafts. Avoid bright light in the patient’s eyes. Protect furniture, rugs, and bedding. Leave area neat- all materials put away. Be sure the patient is as comfortable as possible. Drape the patient if necessary and protect their privacy. Stay with the patient or within calling distance during treatment. Make necessary changes quickly and observe the effects of your treatment. Make proper records of all treatments and patients response to treatment.

C. Re-examination/Revaluation: The patient is reexamined/evaluated intermittently throughout the course of therapy to evaluate progress and to modify or redirect interventions. Indications for reexamination include new clinical findings or failure to respond to interventions.

C. Discharge: The patient is discharged if treatment goals/outcomes are met, the patient fails to make progress toward goals, there is a change in medical status and the patient is unable to continue progress toward goals, the patient refuses care, the physician requests discharge, the therapist feels the patient will no longer benefit from therapy (patient has reached highest potential), or financial/insurance resources request discharge. Summarize in a final OFR discharge summary and instructions, the degree to which the treatment goals have been met when the patient is discharged include number of visits, summary of interventions, comparison of discharge status to baseline status.

OFR Specific Clinical Physical Therapy Protocols:

Total Knee Arthroplasty Protocol- TKA: Objective: To standardize treatment progression and maintain quality of care between therapists and assure adherence to all precautions for TKA post surgical patients. At all times final determination of clinical direction and specific appropriate interventions are up to the treating therapist in consultation with the referring physician.


Goals: Decrease pain and edema. Improve strength, ROM and power. Restore joint arthrokinematics, joint stability and co-contraction. Return to full functional activities or performance. Indications for Referral: Stable individual, post total knee arthroplasty with loss of ROM, strength, and/or function. Contraindications: Uncontrolled infection, unstable knee, uncontrolled bleeding post operatively, DVT , unstable heart, lung or kidney condition. Referral: Referral will come directly from the surgical physician. Therapy will not be initiated until orders are received from the physician. Frequency: Pt will be seen at a frequency deemed appropriate by the evaluating therapist upon initial examination and evaluation of the client and upon communication/consultation with the physician. Evaluations of the patient: All patients will be evaluated by a licensed therapist before initiation of treatment intervention. A treatment plan will be set individually for each client. All evaluations will include but not be limited to the following: history, past medical history, medications, strength, ROM, edema, sensation/neurological status, circulatory status, integumentary examination, soft tissue examination, pain, safety/ fall risk assessment and functional limitations and symptoms. Individual Specific Precautions will be listed. General TKA precautions as per this protocol will be followed on all TKA clients unless specifically modified by the physician or evaluating therapist. Progression to each Rehabilitation Phase: Advancement to the next phase of rehabilitation is dependant on each individual client and the discretion of the treating therapist. The client should have made adequate progress and tolerance in the previous level of rehabilitation to advance to the next level. Discharge Criteria:The patient will be discharged from therapy if all goals are met, patient has met full rehab potential, patient is not progressing adequately toward goals or is unable to meet goals, patient is non compliant with therapy or refuses therapy, or if there is a decrease in medical status and patient is unable to continue or medical status requires discharge.

Protocol: Phase 1-Post Operative Day 1 through Day 5

1. Perform Initial Evaluation. Educate patient, family, caregiver, and/or significant others regarding diagnosis, rehabilitation plan and potential, rehabilitation progression, and all precautions.

2. Perform patient self care instructions; bed mobility, transfers in/out bed, up/down from toilet, on/off commode, and car transfers.


3. Perform gait training instruction with appropriate device level and unlevel surface.

4. Include safety training and fall risk reduction training. This will include but is not limited to the following; removal of throw rugs, adequate lighting, removal of electrical cords through pathways, no gait on wet floors, use of safety belt, etc.

5. Instruct family/caregivers if appropriate on all assistance of patient as needed for home safety and care

6. Instruct patient in all precautions related to their status i.e.: signs and symptoms of inappropriate swelling, pain, circulation, DVT, infection, erythema, drainage, etc. Instruct in Weight bearing status- unless otherwise specified by the physician; cemented knee WBAT, uncemented knee TDWB until 6 weeks post-op. Knee immobilizer is to be on for all gait and transfers until therapist clears patient to remove. Active, passive and resisted ROM is allowed immediately- but gradual progression is expected in all areas. Goal is 0-110 degrees ROM by week 3 post operatively. Pt may gain greater flexion actively- but passive ROM is never applied greater then 110 degrees and caution should be taken not to overload the joint with strengthening. Generally no greater then 5# weight is used on a TKA. Caution should be used at all times with torsional knee stresses. Massage to the knee or LE is contraindicated at this time. Instruct the patient in general care of the wound. Keep clean and dry, contact MD immediately if signs or symptoms of infection occur.

7. Instruct the patient in hip, knee, and ankle strengthening all muscle groups. Ankle Pumps, Quad sets, Glut sets, Hams sets, SLR, Drakes, SAQ, prone or standing hip extension and knee flexion, sidelying or supine hip abduction and adduction. Stretches should include HS and hip flexor stretches, gastroc soleus stretches, knee self active and passive flexion and extension ROM techniques. Stationary bicycling with no resistance could be implemented 5-10 minutes.

8. Utilize Ice for inflammation -10 minutes. 9. Utilize EMS or biofeedback if needed for stimulation of VMO. 10. Instruct pt on positioning to prevent contracture and elevation and ankle

pumps to control edema. 11. If CPM is present, verify proper set up, educate patient in use. Pt should

begin wit 0-40 degrees and progress 5-10 degrees each day, use as tolerated for 5-

20 hours a day. Instruct in observing for and preventing pressure sores.

Phase 2-Post Operative Day 6 through Day 21 1. Continue and progress with all necessary interventions from Phase 1.

Progress to more aggressive active and passive ROM, and gently progressing


strength exercises if appropriate. If patient is not making adequate ROM progress, contractures are forming PT PROM may be initiated.

2. Soft tissue and Myofascial release may be initiated – respecting the incision.

3. Joint mobilization could be implemented.

4. Begin step ups, mini squats, single and double leg balance activities.

5. Progress with gait activities, increasing difficulty, work on increasing independence, decreasing deviations, increase stability and decrease need for assistive device as appropriate.

6. Continually assess home safety/community safety, wound status and overall patient progress. By 3 weeks post –operative- patient should be able to obtain 0-110 degrees of ROM and gait should be independent with appropriate device for limited community gait.

Phase 3-Post Operative Day 21- through Week 8 1. Continue and progress with all necessary interventions from Phase 1 and 2.

More aggressive active and passive ROM, and progressive strengthening can occur. If patient is not making adequate ROM progress and contractures are forming PT PROM may be more aggressive. Educate family/caregivers with assist in this if appropriate and if static stretches have not been implemented-

they can be implemented here.

2. Bicycle or walking for cardiovascular can be progressed to 20 minutes if appropriate.

3. Progress with all balance, proprioceptive, dynamic and functional activity to return pt to previous functional abilities.

4. Active- ROM goal is 0-125, though some patients can obtain full flexion. Passive ROM is not applied past 110 degrees.

Total Hip Arthroplasty Protocol- THA: Objective: To standardize treatment progression and maintain quality of care between therapists and assure adherence to all precautions for THA post surgical patients. At all times final determination of clinical direction and specific appropriate interventions are up to the treating therapist in consultation with the referring physician. Goals: Decrease pain and edema. Improve strength, ROM and power. Restore joint arthrokinematics, joint stability and co-contraction. Return to full functional activities or performance.


Indications for Referral: Stable individual, post total hip arthroplasty with loss of ROM, strength, and/or function. Contraindications: Uncontrolled infection, unstable hip, uncontrolled bleeding post operatively, DVT , unstable heart, lung or kidney condition. Referral: Referral will come directly from the surgical physician. Therapy will not be initiated until orders are received from the physician. Frequency: Pt will be seen at a frequency deemed appropriate by the evaluating therapist upon initial examination and evaluation of the client and upon communication/consultation with the physician. Evaluations of the patient: All patients will be evaluated by a licensed therapist before initiation of treatment intervention. A treatment plan will be set individually for each client. All evaluations will include but not be limited to the following: history, past medical history, medications, strength, ROM, edema, sensation/neurological status, circulatory status, integumentary examination, soft tissue examination, pain, safety/ fall risk assessment and functional limitations and symptoms. Individual Specific Precautions will be listed. General THA precautions as per this protocol will be followed on all THA clients unless specifically modified by the physician or evaluating therapist. Progression to each Rehabilitation Phase: Advancement to the next phase of rehabilitation is dependant on each individual client and the discretion of the treating therapist. The client should have made adequate progress and tolerance in the previous level of rehabilitation to advance to the next level. Discharge Criteria:The patient will be discharged from therapy if all goals are met, patient has met full rehab potential, patient is not progressing adequately toward goals or is unable to meet goals, patient is non compliant with therapy or refuses therapy, or if there is a decrease in medical status and patient is unable to continue or medical status requires discharge.

Protocol: Phase 1-Post Operative Day 1 through Day 5

1. Perform Initial Evaluation. Educate patient, family, caregiver, and/or significant others regarding diagnosis, rehabilitation plan and potential, rehabilitation progression, and all precautions. 2. Perform patient self care instructions; bed mobility, transfers in/out bed,

up/down from toilet, on/off commode, and car transfers. 3. Perform gait training instruction with appropriate device level and unlevel surface.


4. Include safety training and fall risk reduction training. This will include but is not limited to the following; removal of throw rugs, adequate lighting, removal of electrical cords through pathways, no gait on wet floors, use of safety belt, etc. 5. Instruct family/caregivers if appropriate on all assistance of patient as needed for home safety and care 6. Instruct patient in all precautions related to their status i.e.: signs and symptoms of inappropriate swelling, pain, circulation, DVT, infection, erythema, drainage, etc. Instruct in Weight bearing status- unless otherwise specified by the physician; cemented hip WBAT, uncemented hip TDWB until 6 weeks post-op. Active, passive and resisted ROM is allowed immediately- but gradual progression is expected in all areas. For 6 weeks pt cannot flex hip greater then 90 degrees, Adduct or Internally rotate hip past neutral. Caution should be taken not to overload the joint with strengthening. Generally no greater then 5# weight is used on a THA. Massage to the hip or LE is contraindicated at this time. Instruct the patient in general care of the wound. Keep clean and dry, contact MD immediately if signs or symptoms of infection occur. 7. Instruct the patient in hip, knee, and ankle strengthening all muscle groups. Ankle Pumps, Quad sets, Glut sets, Hams sets, SLR, Drakes, SAQ, standing hip extension and knee flexion, supine hip abduction and adduction(to neutral). Stretches (active and self passive) should include heel slides with no hip flexion greater then 90 degrees, gastroc soleus stretches and supine hip external rotation. 8. Utilize Ice for inflammation -10 minutes. 9. Instruct pt on positioning to prevent contracture 10. Instruct in observing for and preventing pressure sores.

Phase 2-Post Operative Day 6 through week 6 1. Continue and progress with all necessary interventions from Phase 1. Gently progress ROM, and gently progressing strength can occur in this phase. If patient is not making adequate ROM progress, contractures are forming PT gentle PROM may be initiated. Goal by the end of phase 2 is hip flexion to 90 degrees, hip abduction to 30 degrees or equal to uninvolved, and hip external rotation 45 degrees or equal to uninvolved. 2. Joint mobilization could be implemented. 3. Begin step ups, mini squats, single and double leg balance activities. Progress

with sidelying hip Abduction and Adduction, prone hip extensions, lunges or any necessary strengthening within precautions.

4. Progress with gait activities, increasing difficulty, work on increasing independence, decreasing deviations, increase stability and decrease need for assistive device as appropriate.

5. Continually assess home safety/community safety, wound status, patient observance of precautions and overall patient progress. By 6 weeks post –


operative- gait should be independent with appropriate device for community gait.

6. Patient may begin stationary bike 5-10 minutes within THA precautions now.

Phase 3-Post Operative Week 7 1. Continue and progress with all necessary interventions from Phase 1 and 2. Pt can now flex, adduct, and internally rotate hip gradually toward full ROM. More aggressive active and passive ROM is allowed, and progressive strengthening can occur. If patient is not making adequate ROM progress and contractures are forming PT PROM may be more aggressive. Educate family/caregivers with assist in this if appropriate. 2. Bicycle or walking for cardiovascular can be progressed to full tolerance now. 3. Progress with all balance, proprioceptive, dynamic and functional activity to

return pt to previous functional abilities. 4. Goals are full hip ROM, strength, independent gait without device, full

function if appropriate for the individual patient.

Neurological Protocol: Objective: To standardize treatment progression and maintain quality of care between therapists and assure adherence to all precautions for neurological patients. At all times final determination of clinical direction and specific appropriate interventions are up to the treating therapist in consultation with the referring physician. Goals: Improve sensory, strength, ROM, power, coordination, balance, transfers, cognition, gait, and function to patients highest possible level. Where full recovery is not imminent or probable teach patient compensatory techniques to allow highest possible function and quality of life. Educate caregivers in assist of patient as needed. Recommend/Obtain any needed assistive equipment and train in use. Indications for Referral: Individual suffering neuromuscular loss with stable medical status allowing participation in rehabilitation. Examples include; CVA, brain tumor, head injury diagnoses. Contraindications: Unstable heart, lung or kidney condition, unstable vital signs, DVT, progressively deteriorating status or symptoms.


Referral: Referral will come directly from the physician. Therapy will not be initiated until orders are received from the physician. Frequency: Pt will be seen at a frequency deemed appropriate by the evaluating therapist upon initial examination and evaluation of the client and upon communication/consultation with the physician. Evaluations of the patient: All patients will be evaluated by a licensed therapist before initiation of treatment intervention. A treatment plan will be set individually for each client. All evaluations will include but not be limited to the following: history, past medical history, medications, strength, ROM, sensation, neurological status (ie.: tone, reflex, neglect, etc), vital signs, soft tissue and joint examination, cognition/orientation, skin/integumentary, edema, safety/ fall risk assessment and functional limitations and symptoms. Determine previous level of function. Individual Specific Precautions will be listed. General precautions as per this protocol will be followed on all clients unless specifically modified by the physician or evaluating therapist. Progression to each Rehabilitation Phase: Advancement to the next phase of rehabilitation is dependant on each individual client and the discretion of the treating therapist. The client should have made adequate progress and tolerance in the previous level of rehabilitation to advance to the next level. Discharge Criteria:The patient will be discharged from therapy if all goals are met, patient has met full rehab potential, patient is not progressing adequately toward goals or is unable to meet goals, patient is non compliant with therapy or refuses therapy, or if there is a decrease in medical status and patient is unable to continue or medical status requires discharge.

Protocol: Phase 1- PRECAUTIONS: Assess vital signs. Do not initiate upright activities until third day after onset OR until BP is stable. Monitor BP, HR and signs of distress throughout treatment sessions. If patient becomes more confused or disoriented, has undue fatigue, deterioration of overall status or symptoms, unstable blood pressure or heart rate then therapist should take the action as they feel appropriate based on the symptoms noted. This could include, report to physician and have physician examine prior to continuing any further treatment or refer to 911, urgent care or physician. Avoid moderate elevation in BP and avoid Valsalva with patient during all rehabilitation. Utilize extreme caution until you have verified patient’s safety judgment and awareness of injury. The patient may not be fully aware of their deficits initially and can move unexpectedly. Protect the patient at all times.


1. Perform Initial Evaluation. Educate patient, family, caregiver, and/or significant others regarding diagnosis, rehabilitation plan and potential, rehabilitation progression, and all precautions.

2. Identify equipment/assistive device needs and order as appropriate. 3. Perform patient self care instructions/training as appropriate ie.: bed mobility,

transfers in/out bed, up/down from toilet, on/off commode, shower/tub and car transfers.

4. Perform gait training instruction if appropriate with appropriate device level and unlevel surface.

5. Include safety training and fall risk reduction training. This will include but is not limited to the following; removal of throw rugs, adequate lighting, removal of electrical cords through pathways, no gait on wet floors, use of safety belt, etc.

6. Instruct family/caregivers if appropriate on all assistance and education regarding patient as needed for home safety and care

7. Instruct patient and caregivers in all precautions related to their particular status

8. Begin therapeutic exercises and neuromuscular facilitation techniques as appropriate for patients physical status addressing problem areas and concerns. For example: fine and gross motor coordination, strength, ROM, tone facilitation or inhibition, balance, bed mobility, function, etc).

9. Instruct patient and caregivers on positioning to prevent contracture including tone inhibiting positions if spasticity is present; protect flaccid extremities and Instruct in observing for and preventing pressure sores.

Phase 2- 1. Continue and progress with all necessary interventions from Phase 1. Progress with all transfer, bed mobility, and gait issues toward more independent status as appropriate. Increased difficulty with therapeutic exercises are appropriate, follow all precautions from phase 1. If vitals signs (BP and HR) have been stable for 3 weeks with progressive activity there is no need to continually monitor. But, if new moderately stressful activity is to be implemented resume monitor of vitals to be sure you are within the precautions. 2. Soft tissue and Myofascial release may be initiated if needed for tone issues. If not already done, verify need for bracing/splinting as appropriate. 3. Joint mobilization could be implemented. 4. Progress with gait activities, increasing difficulty, work on increasing independence, decreasing deviations, increase stability and decrease need for assistance and/or assistive device as appropriate. If appropriate more high level balance, gait and coordination skills can be implemented. 5. Continually assess home safety/community safety, and overall patient

progress.


Phase 3- 1. Continue and progress with all necessary interventions from Phase 1 and 2. Progressive strengthening and therapeutic exercises can occur. Continue to address any ROM issues, be sure to monitor for contractures. Continue with all precautions from phase 1. 2. Bicycle or walking for cardiovascular training can be initiated here if

appropriate , begin gradually, monitor BP and HR. 3. Progress with all balance, proprioceptive, dynamic and functional activity to

return pt to previous or highest functional abilities possible for this individual patient. Implement Return to Work or Hobby retraining if appropriate.

Cardiac/Pulmonary Protocol: Objective: To standardize treatment progression and maintain quality of care between therapists and assure adherence to all precautions for cardiac/pulmonary patients. At all times final determination of clinical direction and specific appropriate interventions are up to the treating therapist in consultation with the referring physician. Goals: Improve competence of cardiovascular and pulmonary systems. Improve, strength, ROM, endurance, transfers, gait, and functional ability/tolerance to highest possible level within individual limitations. Educate caregivers in assist of patient as needed. Recommend/Obtain any needed assistive equipment and train in use. Indications for Referral: Individual suffering cardiovascular/pulmonary loss with stable medical status allowing participation in rehabilitation. Examples include; s/p MI, s/p CABG, pacemaker implant, COPD. Contraindications: Unstable heart, lung or kidney condition, unstable vital signs, DVT, indications of continued ischemia, left ventricular failure, serious circulatory impairment, important dysrrhythmias, conduction defects, severe pleurisy or pericarditis. RHR greater then 110 bpm or less then 50bpm unless medication induced. Resting BP greater then 155/100 or less then 90/50. Overt CHF, Recent PE or thrombophlebitis, unstable angina, uncontrolled DM, uncontrolled or high rate arrhythmias, nd severe heart block, Referral: Referral will come directly from the physician. Therapy will not be initiated until orders are received from the physician. Frequency: Pt will be seen at a frequency deemed appropriate by the evaluating


therapist upon initial examination and evaluation of the client and upon communication/consultation with the physician. Evaluations of the patient: All patients will be evaluated by a licensed therapist before initiation of treatment intervention. A treatment plan will be set individually for each client. All evaluations will include but not be limited to the following: history, past medical history, medications, strength, ROM, sensation, cardiac status (ie.: results of stress testing, EKG’s, cardiac function tests, etc), vital signs and responses to activity, respiratory function (ie: chest expansion, SOB, breathing patterns) soft tissue examination, skin/integumentary, pain, circulatory status (ie; edema, pulses, venous distention) cognition, endurance, safety/ fall risk assessment and functional limitations and symptoms. Determine previous functional ability. Individual Specific Precautions will be listed. General precautions as per this protocol will be followed on all clients unless specifically modified by the physician or evaluating therapist. Progression to each Rehabilitation Phase: Advancement to the next phase of rehabilitation is dependant on each individual client and the discretion of the treating therapist. The client should have made adequate progress and tolerance in the previous level of rehabilitation to advance to the next level. Discharge Criteria:The patient will be discharged from therapy if all goals are met, patient has met full rehab potential, patient is not progressing adequately toward goals or is unable to meet goals, patient is non compliant with therapy or refuses therapy, or if there is a decrease in medical status and patient is unable to continue or medical status requires discharge.

Protocol: Phase 1 HHS unmonitored-Day 1 post event to Day 8 PRECAUTIONS: See contraindications listed earlier in protocol. This program is performed in the home setting. Patients cannot be on a cardiac monitor while performing this program. Cardiac patients must be cleared to perform therapy unmonitored in the home setting. If activity is to be increased while assessing on a cardiac monitor – the patient must be referred to an in or out – patient cardiac rehabilitation monitored program. Patient is at risk of an event with this program and there is no crash cart or code blue immediately available. If an event occurs, emergency medical system- 911 is activated and CPR is initiated if appropriate. In addition, the following precautions may apply depending on the individual patient situation. 1. Discontinue exercise if HR increased > 30 bpm over RHR, or exceeds 110 bpm in a s/p MI patient or 120bpm in a post cardiac surgery patient. 2. Discontinue exercise if HR decreases 10bpm or more with activity,


3. Discontinue exercise if systolic BP is decreased more then 20mmHg with activity or exceeds 160mmHg, diastolic BP drops below 50 or exceeds 110mmHg, pulse pressure (difference between systolic and diastolic blood pressure) drops to 20mmHg or less. 4. Discontinue exercise if signs or symptoms of angina, undue dyspnea, excessive fatigue, mental confusion, dizziness, leg claudication, development of bilateral ankle edema, pallor, cold sweat, ataxia, cyanosis, neck vein distention, crepitant rales, or SOB greater then 3 at rest, or 5 with activity occur. 5. For cardiac patients determine starting MET level of ADL and therapy activity based on patients MET level by their report just prior to DC home and current evaluation findings. Generally, Day 1 post event, pt should have been on MET level 1 activity in the hospital. MET level would be gradually progressed every 2 days by .5 MET level x 8 days. By Day 8 pt can generally be working at MET level 4. In addition, note the following list of generalized cardiac patient precautions. 1. Wait 1 to 2 hours after a meal before exercising. 2. Following exercise take a warm or tepid shower. Too hot of a shower can cause a sudden drop in blood pressure stressing the heart. 3. In high altitude exercise is more difficult, so expect a higher heart rate with less activity if exercising in high altitude. 4. Do not perform isometric exercises or Valsalva, those exercises will raise the blood pressure. Avoid hand held weights- instead strap weights on at wrists. 5. Upper extremity exercise is more challenging then lower extremity on the heart. Use extra care when utilizing upper extremity exercises. 6. Progress slowly and gradually with an exercise program. Progress intensity, duration, and frequency of exercise separately from each other (not all at one time). 7. Determine target heart rate for aerobic training sessions and activity and do not exercise above that level. 8. Always warm up prior to exercise and cool down after exercise. 8. Discontinue exercise immediately and refer to physician if any of the following conditions develop during or following exercise: a. pain in chest, jaw, teeth, neck, or arm b. significant difficulty breathing

c. Irregular heart rate persisting during or after exercise d. light headedness or fainting e. disabling musculoskeletal discomfort or swelling

f. constant lethargy, malaise, or uncoordinated gait with weakness after exercise.

g. unexplained weight loss h. persistent nausea or vomiting occurring after exercise. Protocol:


1. Perform Initial Evaluation. Assess vital signs. Monitor BP, HR, SOB, pulse oximetry, RPE and signs of distress throughout every treatment session as appropriate. Monitor appropriate vital signs at rest, after warm up, at peak aerobic, prior to cool down, and 5 minutes after conclusion of cool down. Educate patient, family, caregiver, and/or significant others regarding diagnosis, rehabilitation plan and potential, rehabilitation progression, and all precautions. 2. Identify equipment/assistive device needs and order as appropriate. 3. Each session should be structured in 4 general phases

a. warm up exercises b. functional or aerobic target exercises (specific frequency , duration and intensity) c. cool down exercises d. patient education.

Vitals and signs/ symptoms are monitored throughout the session. 4. Perform patient self care instructions as appropriate ie.: bed mobility, transfers in/out bed, up/down from toilet, on/off commode, shower/tub and car transfers. 5. Perform gait training and/or aerobic activity instruction if appropriate with appropriate device level and unlevel surface. 6. Include safety training and fall risk reduction training. This will include but is not limited to the following; removal of throw rugs, adequate lighting, removal of electrical cords through pathways, no gait on wet floors, use of safety belt, etc. 7. Instruct family/caregivers if appropriate on all assistance and education regarding patient as needed for home safety and care 8. Instruct patient and caregivers in all precautions related to their particular status 9. Therapeutic exercises and techniques should address the patients physical needs addressing problem areas and concerns. For example: Perform UE arom for warm ups, LE arom for cool down exercises for cardiac patients with general deconditioning and deep breathing and diaphragm exercises for pulmonary patients. 10. Begin patient education such as: self pulse monitoring, principles of exercise

and conditioning, aerobic program information, principles of warm up and cool down, general and specific exercise cardiac precautions, risk factor reduction program, energy conservation techniques, environmental control, anxiety control, pacing of activity, diaphragm and pursed lip breathing as appropriate for the cardiac or pulmonary patient.

Phase 2- Day 8 post event 1. Continue and progress with all necessary interventions from Phase 1. Progression to phase 2 is allowed only if vital signs are stable and patient tolerance is acceptable. 2. Progress with all transfer, bed mobility, gait issues toward more independent status as appropriate. Increased difficulty with therapeutic exercises, including progression to weights are appropriate, follow all precautions from phase 1.


3. Continue with aerobic advancement with goal towards 20-30 minutes aerobic session. Maintain MET level at 4.0. Aerobic activity can include but is not limited to walking, stationary bicycle, and stair climbing. 4. Continually assess home safety/community safety, and overall patient

progress. 5. Progress functional activity to return pt to previous or highest functional

abilities possible for this individual patient. Implement Return to Work or Hobby retraining if appropriate.

Home Safety/Fall Risk Protocol: Objective: To standardize treatment progression and maintain quality of care between therapists and assure adherence to all precautions for home safety /fall risk for all appropriate patients. At all times final determination of clinical direction and specific appropriate interventions are up to the treating therapist in consultation with the referring physician. Goals: Identify fall and safety risk factors in the home. Implement patient and caregiver training and strategies and identify proper equipment needs to improve home safety and prevent falls and other injuries. Recommend equipment and train in use. Indications for Referral: Any client referred for Home Health Service Rehabilitation Services. Contraindications: Unstable medical condition. Referral: Referral will come directly from the physician. Therapy will not be initiated until orders are received from the physician. Frequency: Pt will be seen at a frequency deemed appropriate by the evaluating therapist upon initial examination and evaluation of the client and upon communication/consultation with the physician. Evaluations of the patient: All patients will be evaluated by a licensed therapist before initiation of treatment intervention. A treatment plan will be set individually for each client. All evaluations will include but not be limited to the following: history, past medical history, medications, strength, ROM, sensation/neurological status, circulatory status, integumentary examination, pain, gait, transfer, and mobility ability, high level balance and coordination, safety/ fall risk assessment and functional limitations and symptoms. Determine previous functional level and obtain detailed history of any falls or near falls prior


to this condition onset and since this condition onset. Individual Specific Precautions will be listed. Progression to each Rehabilitation Phase: Advancement to the next phase of rehabilitation is dependant on each individual client and the discretion of the treating therapist. The client should have made adequate progress and tolerance in the previous level of rehabilitation to advance to the next level. Discharge Criteria:The patient will be discharged from therapy if all goals are met, patient has met full rehab potential, patient is not progressing adequately toward goals or is unable to meet goals, patient is non compliant with therapy or refuses therapy, or if there is a decrease in medical status and patient is unable to continue or medical status requires discharge.

Protocol: Phase 1-Post Onset Day 1

1. Perform Initial Evaluation. Therapist should perform standard examination and evaluation of the patient based on their diagnosis/condition including all aspects to determining safe mobility and self care in and throughout the home, bathroom, kitchen, etc. There are many tests that can be used for gait integrity but some standardized tests can provide excellent objective and measurable data. Some form of standardized test should be utilized to test gait/mobility. Examples are: Time Up and Go Test (TUG), Fast Evaluation of Mobility, Balance and Fear (FEMBAF). Tinetti assessment tool, Motor assessment Scale (MAS), Fugi-Meyer assessment (FMA) Physical Performance Test (PPT-8), or the 6 minute walk test. In addition the therapist should assess the following areas as is appropriate for the individual situation:

a. Structure: Type of structure patient is residing in ie.: apartment, senior complex, house, one level, two level, stairs/elevator/ramp.

b. Barriers: Width of doors, width of hallways, width of entrance, number of steps into home or inside home, width and height of steps. Are emergency exits marked. If there is an elevator in the building are the controls reachable. Is a ramp available, can one be installed, what is the grade of the ramp.

c. Handrails: Are there handrails at steps, ramp, or bathroom. What is the location, is it possible to install handrails.

d. Floor coverings : Is their carpeting- loose or tacked down. Any areas of poor repair? Is their tile, linoleum, throw rugs? Can you easily see a transition of height or from floor to rug?

e. Obstacles: Are there loose electric or oxygen cords, clutter, loose objects/toys on the floors or in doors. Is furniture arranged for easy maneuverability? Are pets or small children underfoot? Is the area well lit?

f. Bathroom: Is it a tub or shower, what is the access to the shower, can patient maneuver between sink, toilet, and tub. Are there grab rails, non slip surfaces or bath mats, is there a shower or tub chair, is there a hand held shower


attachment, does patient need an elevated toilet seat, can patient reach the sink?

g. Kitchen: Can patient reach counter tops, sink, appliances, or table. Can patient prepare meals safely, maneuver around kitchen with objects.

h. Bedroom: What is the height of the bed, can patient reach in/out of dresser and closet for clothes. Is a chair needed in bedroom for easier dressing. Is a bedside commode needed. Is there adequate lighting, free of clutter and cords, easy access to phone at night?

i. Living Room: Assess as other rooms and check if there is an comfortable place pt can access to relax during the day. It is important to encourage the patient to be out of bed if possible during the day.

j. Other: Is there access to the garage and car. Can patient gain access to the exit and entrance of the house safely. Can patient lock and unlock door, close and open doors.

k. Self Care: When assessing self care such as bathroom, kitchen, gait , transfer

safety remember to look at smaller details such as ability to turn on/off lights, do laundry, meal preparation, turn TV on/off, or access computer. Look at proper shoes and clothing, safety if patient is in a hurry or has bouts of dizziness. What is the patient’s safety judgment?

l. Home assistance: Is family or caregiver available, what hours, what is their knowledge level, are they capable of assistance. Are there social issues that could affect safety.

2. Educate patient, family, caregiver, and/or significant others regarding

diagnosis, rehabilitation plan and potential, rehabilitation progression, and all precautions related to their issues/status. Include home safety training and fall risk reduction training based on evaluation findings. This will include but is not limited to the following; removal of throw rugs, adequate lighting, removal of electrical cords through pathways, no gait on wet floors, use of safety belt, etc.

3. Perform patient self care instructions; bed mobility, transfers in/out bed, up/down from toilet, on/off commode, and car transfers.

4. Perform gait training instruction with appropriate device level and unlevel surface.

5. Identify any equipment needs, recommend as appropriate. 6. Implement appropriate rehabilitation program ie.: education, therapeutic exercise, modalities, etc to correct or minimize deficits relating to safety as appropriate to orders, diagnosis, and findings. For example: strength training for weakness causing decreased safety with gait. 7, Train caregivers in assistance of patient as needed.

Phase 2-


1. Continually assess home safety as per phase 1. 2. Assess community mobility and safety as appropriate and applicable.

Documents

Policies and Procedures Manual for Clinical Staff