M2-Standards_of_Assessment-INST.ppt PDF

Standards of Assessment RCTX 3254 East Carolina University   “MINIMUM level of performance determined to be acceptable” (burlingame and Blaschko, 2002)  Sources Standards  Regulations  Voluntary  Profe...

Standards of Assessment RCTX 3254 East Carolina University   “MINIMUM level of performance determined to be acceptable” (burlingame and Blaschko, 2002)  Sources Standards  Regulations  Voluntary  Professional Organizations  Site-specific or Agency   Laws enacted by any level of government Regulations   Licensed recreational therapist. – A person who holds a license pursuant to this Chapter as a recreational therapist. A person licensed as a 'Recreational Therapist' under this Chapter may practice in clinical, residential, educational, and community settings and may: NC  a. Conduct an individualized patient or client assessment for the purpose of collecting Recreation systematic, comprehensive, and accurate data necessary to determine a course of action and al Therapy subsequent individualized treatment plan.  b. Plan and develop the Licensure individualized treatment plan that identifies a patient or client's goals, objectives, and treatment intervention strategies. Act (NC Bill  c. Implement the individualized treatment plan that is consistent with the overall 613) patient or client treatment program.  d. Systematically evaluate and compare the patient or client's response to the individualized treatment plan and suggest modifications as appropriate. NC Legislature Website   Appendix A State Operations Manual  Quality Assurance  Ongoing assessment Discharge planning  Assessment related to ct activity on hospital swing bed  IRF-PAI  Facilities with >75% ct w/ amputation, brain injury, Federal burns, congenital deformity, hip fracture, major multiple Standards trauma, neurological disorders, SCI, stroke, polyarthritis  normative data, diagnostic data, functional ability using the 18 items of the FIM  FIM items must measure performance, not capacity!  ICF-MR  Assessment & tx goals not listed by profession   Minimum expectations for performance Voluntary  Private enforcement   Minimum performance expectations supported by a professional organization Professional  Professional certification lost or challenged if standard unmet   Standard 1. Assessment. The therapeutic recreation specialist conducts an individualized assessment to collect systematic comprehensive and accurate data necessary to determine a course of action and subsequent individualized treatment ATRA plan. Under the clinical supervision of the Assessment therapeutic recreation specialist, the therapeutic Standard recreation assistant aids in collecting systematic, comprehensive and accurate data necessary to determine a course of action and subsequent individualized treatment plan. (ATRA website)  12 professional standards developed to provide a written description of recreational therapy practice.  Assures the systematic provision of QUALITY recreational therapy services.  ATRA Standards of Practice  1.2.1. The Recreational Therapist receives and responds to requests, including referrals and physician orders, for recreational therapy assessment and treatment in a timely manner, consistent with the process defined in the written plan of operation.  1.2.2. The Recreational Therapist informs the participant of his/her responsibility in the assessment and seeks collaboration in the process. Seeks others if patient’s condition does not permit.  ATRA Standards of Practice  1.2.3. The Recreational Therapist uses standardized assessment procedures as appropriate, including: structured interview, direct observation, performance testing, standardized testing, information from others, and/or record review.  1.2.4. The Recreational Therapist provides a summary of the assessment process and analysis of assessment data that contains information relative to the patient’s/client’s strengths, patient’s/client’s limitations in the following areas: physical, cognitive, social and behavioral/emotional, as related to functional independence in life activities.  ATRA Standards of Practice  1.2.5. Based upon the analysis of assessment data, recreational therapist formulates clinical impressions and recommendations for treatment, referral for other services, or no service at all.  1.2.6. Recreational Therapist reports assessment findings to appropriate individuals including the treatment team, patient/client or family and/or significant others.  ATRA Standards of Practice  1.2.7. Recreational Therapist documents all relevant information regarding the assessment process within the patient/client record.  1.3.1. The participant/client/family/significant understand the process used to request that recreational therapy assessment and treatment be initiated, including when referrals and physician orders are needed  ATRA Standards of Practice  1.3.2. The participant/client/family/significant others participates in the assessment process as appropriate.  1.3.3. The participant/client/family/significant others complies with the assessment process  1.3.4. The participant/client/family/significant others benefits from the assessment process and does not incur adverse consequences due to participation in the assessment.  ATRA Standards of Practice  Assessment Audit & Evaluation  Management Audit  Documentation Audit  Conducting the ATRA SOP Assessment Audit  Internal  Staff/Supervisors  External:  “Swap with a Buddy”  “Fund a Buddy”  Find a University (HINT: ECU RT Graduate Program)  Recent Change to ATRA Standards “The recreational therapist receives and responds, consistent with regulatory requirements for the setting, to referrals and physician orders for assessment and treatment and conducts an individualized assessment to collect systematic, comprehensive and accurate data necessary to determine a course of action and subsequent individualized treatment plan.”  Recent ATRA Standard Standard 1: – If an agency is under a regulatory body (e.g., CMS), then recreational therapy services are ONLY provided with a physicians order or referral. – If an agency is not aligned with a regulatory body (like CMS), then the agency must use procedures from their Policies & Procedures indicating HOW RT services are initiated. Individual Education Plan (IEP) Council on Aging – Referral for Medicaid Waiver   Minimum of care outlined in each facility’s policy and procedure manual  Often changes according to feedback Site-specific from personnel or change in agency policies or Agency  More specific than professional standards  Often more stringent than regulatory standards  Never LESS stringent   Time frame of completion (24-72 hours)  Process of document production  e-charts or hard copies Site-specific  Placement in chart Standards  Notation in progress note  Documenting refusal of assessment  Areas of assessment