In facilities with organized recreational therapy services, the following shall apply:

1. (1) Recreational therapy services shall be under the direction of a physician member of the medical staff;
2. (2) Recreational therapy services shall be supervised by a therapist with current certification;
3. (3) There shall be sufficient recreational therapy supportive staff to provide authorized recreational therapy 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) The policy and procedure manual shall have evidence of ongoing review and/or revision.

   2. (B) The first page of the 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;
   2. (B) Infection prevention and control measures;
   3. (C) Recreational therapy services provided and a list of services shall be made available to the medical staff;
   4. (D) Orientation practices for new employees and volunteer personnel;
   5. (E) Assembly, operation, and maintenance of all equipment;
   6. (F) Safety practices;
   7. (G) Security of supplies and tools; and
   8. (H) Activities off campus;

7. (7)

   1. (A) All equipment, tools, and machines shall be:

      1. (i) In good repair; and
      2. (ii) 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 fewer 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 recreational therapy prescriptions/work requests shall be authorized by a written and signed physician's order and shall include:

    1. (A) Identification of the patient;
    2. (B) Date;
    3. (C) Physician's name;
    4. (D) Type, frequency, and duration of treatment; and
    5. (E) Originating signature;

11. (11) Recreational therapy service records for each patient shall include:

    1. (A) Current written plan of care;

    2. (B) Documentation of:

       1. (i) Attendance by the therapist in team meetings; and
       2. (ii) The contribution by the therapist to the treatment plan;
    3. (C) Statement of treatment objectives;
    4. (D) Statement of patient's short-term and long-term rehabilitation potential;
    5. (E) Record of daily activity participation;
    6. (F) Justification of any continued rehabilitation care; and
    7. (G) Progress notes;
12. (12) All recreational therapy personnel shall maintain competency in life support measures;
13. (13) There shall be an ongoing QA/PI program;
14. (14) If food and/or nutritional service functions are offered, infection prevention and control, storage and supervision shall be coordinated with the dietary department of the facility; and
15. (15) Contracted recreational therapy 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.