In facilities with an organized speech language pathology/audiology services department, the following shall apply:

1. (1) Speech pathology/audiology services shall be under the direction of a physician member of the medical staff;
2. (2) Speech pathology/audiology services shall be supervised by a therapist who is currently licensed;
3. (3) There shall be sufficient supportive personnel to provide authorized speech pathology/audiology services;

4. (4) There shall be documentation, verified by the physician director, of who may:

   1. (A) Perform special procedures; and
   2. (B) Give patient instructions;

5. (5)

   1. (A) Policies and procedures shall have evidence of ongoing review and/or revision.

   2. (B) The first page of each manual shall have the:

      1. (i) Annual review date; and
      2. (ii) Signature of the department supervisor and/or person or persons conducting the review;

6. (6) There shall be written policies and procedures that shall include:

   1. (A) Job descriptions for every type of employee;
   2. (B) Orientation procedures for new employees;
   3. (C) Infection prevention and control measures;
   4. (D) A listing of services/treatments available to the medical staff; and
   5. (E) Safety practices;

7. (7)

   1. (A) Equipment shall be in good repair and under the control of the therapist supervisor.
   2. (B) Documentation of preventive maintenance shall be maintained for the life of each piece of equipment;
8. (8) Current reference material shall be available for the department;

9. (9)

   1. (A) Clinically relevant educational programs shall be conducted on a regularly scheduled basis at not less than twelve (12) per year.

   2. (B) There shall be evidence of:

      1. (i) Program dates;
      2. (ii) Attendance; and
      3. (iii) Subject matter;
10. (10) All speech pathology/audiology prescriptions/work requests shall be authorized by a written and signed physician’s order;

11. (11) Speech pathology/audiology services records for each patient shall include:

    1. (A) Current written plan of care;
    2. (B) Statement of treatment objectives;
    3. (C) Statement of patient’s short-term and long-term rehabilitation potential;
    4. (D) Justification of any continued rehabilitation care; and
    5. (E) Documentation of progress notes following treatment given to patients;
12. (12) All speech pathology/audiology personnel shall maintain competency in life support measures;
13. (13) There shall be an ongoing QA/PI program; and
14. (14) Contracted speech pathology/audiology services shall be under current agreement and the contractor shall fulfill all requirements of this section.

Codification Notes: “QA/PI” means quality assurance/performance improvement.