The Essential Physical
Therapy Private Practice
Policy & Procedure Manual
NANCY BECKLEY & ASSOCIATES LLC
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2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information in
this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized for
your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
A. The Content is intended to serve as a concise initial reference and NOT as a
complete reference source. The Content does NOT include information concerning
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2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information in
this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized for
your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Terms & Conditions
Authorization and Restrictions
The purchaser of the “The Essential Physical Therapy Private Practice Policies &
Procedures” (Manual) is authorized to duplicate materials in the following manner subject
to the Single Licensing Agreement.
The purchaser may:
• Duplicate and/or print the Adobe Acrobat (PDF) documents including all policies
and procedures provided in this format for your own use within the original
purchaser’s private practice. You must purchase a copy of the Manual for each
separate private practice entity. For purposes of this authorization, a private
practice is defined as private practice and all enrolled locations. If you own, or
participate in another private practice entity, another Manual must be purchased if
you choose to use it in that practice. Please contact us directly to clarify whether
this authorization will be extended or whether additional copies will be required.
• Modify the policies and procedures and documents that have been included in
(Word 2016) to include language specific to your own practice and for any future
changes in law, regulation, and accreditation standards.
• Incorporate excerpts from the Manual into the policies and procedures of your own
practice.
• Insert your practice logo in any document headers.
The purchaser may not:
• Reproduce and/or distribute, in whole or in part, any portion of this manual for
sale, redistribution or inclusion in other printed text without prior written consent
of the author above and beyond the authorization described above, whether or not
such activities are for profit.
• Reproduce and/or distribute, in whole or in part, any portion of this manual for use
in educational activities, seminars or educational publications without the prior
written consent of the author above and beyond the authorization described
above, whether or not such activities are for profit.
• Incorporate, in whole or in part, any portion of this manual into other documents,
manuscripts, or texts without prior written approval of the author.
• Purchase this manual for use as a consultant with more than one client. If you are a
consultant, please contact us for a licensing arrangement.
Page 3 of 5
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information in
this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized for
your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Introduction
Thank you for purchasing The Essential Physical Therapy Private Practice Policy and
Procedure Manual. (“Manual”)
This Manual was developed using current resources and includes references to both
compliance obligations and clinical practice responsibilities. The information is believed to
be current at the time of publication and is intended to assist with the development of
policies and procedures for your practice.
As you review and revise the documents provided, we strongly recommend that you
additionally review and incorporate state specific laws and regulations as it relates to the
practice and oversight of Physical Therapy. This Manual includes general personnel
Policies. It is our experience that in addition to federal laws governing employment, there
are also state laws governing personnel and employment that should be incorporated into
your final version of this Manual. We recommend the use of experienced consultants who
specialize in the areas of human resources, information technology, and other areas
impacted by specific state laws, and the services that you offer.
The Manual is intended to serve as a foundation for policies and procedures specific to
your Therapy Practice. Given varying state requirements the Manual does not include
reference to “all” state regulations. As such we again recommend that you review state
requirements that are applicable to services provided in your Practice.
All Books in this Manual are provided both in Adobe PDF and Word 2016. You may edit
documents in Word based on your acceptance of the Single Use License Agreement and
the Terms & Conditions Authorization and Restrictions included herein.
Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy
and regulatory information in this book. NBA makes no real or implied guarantee that by
using this book and sample policies that you will meet all legal and regulatory requirements
and will not accept responsibility for any liability, loss or damage resulting from use of this
sample document. As with any model policy, the document should be carefully reviewed
and customized for your organization. No information provided in this document should be
used as a substitute for the advice of competent legal counsel.
We encourage you to access and utilize other resources from our website:
https://NancyBeckley.com/Store
We wish you success in using this Manual to create your own “Best Practice” policies.
Thank you for choosing our product.
Page 4 of 5
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information in
this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized for
your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
How This Manual is Organized
This focus and organization of this Manual is based upon a “Best Practice” approach to
address the needs of the Therapy Practice. The Manual is written in Book format with a
less formal approach, allowing for flexibility in customization.
This Manual is organized into 4 Books:
1. Administration & Compliance
2. Environment & Safety
3. Patient Care & Quality
4. Personnel & Human Resources
Each Book contains Chapters which can be used as a stand-alone policies to address a
specific area of need or when combined with current policies to assist you in achieving a
Compliance-oriented framework to your Therapy Practice policies and procedures.
This Manual is not intended, nor will it meet Medicare Certification or Accreditation
requirements for Hospitals, Skilled Nursing Facilities, Rehab Agencies, CORFs, or Home
Health Agencies. We have not provided references or citations to Medicare Conditions of
Participation, or Accreditation Standards.
About Your Downloaded Product
All of our products are downloadable products only. When you downloaded this product
from our website, you have downloaded the full manual in PDF format and individual files,
organized in Chapters in Word 2016 format.
Page 5 of 5
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information in
this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized for
your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Administration & Compliance
1
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Administration ...................................................................................................................... 6
Mission, Vision and Values ......................................................................................................... 6
Governing Body and Bylaws ....................................................................................................... 6
Organization Structure................................................................................................................ 7
Licensure and Certification ......................................................................................................... 7
Policies and Procedures .............................................................................................................. 8
Ethics ........................................................................................................................................... 8
Conflict of Interest ...................................................................................................................... 9
Confidentiality of Proprietary Business Information .................................................................. 9
Compensation Arrangement with Referral Sources (Physicians) ............................................. 10
Contract Management and Oversight ...................................................................................... 11
Document retention, Preservation, and Destruction of Clinical and Business Records .......... 11
Hours of Operation ................................................................................................................... 14
Keys and Access Controls .......................................................................................................... 14
Building and Equipment Leases ................................................................................................ 15
Incident Reporting .................................................................................................................... 15
Open Lines of Communication.................................................................................................. 16
External Communications .................................................................................................... 17
Publishing and Media Communications ................................................................................... 17
Advertising and Sponsorships ................................................................................................... 17
Clinical Operations .............................................................................................................. 18
Nondiscrimination and Accessibility in Clinical Operations...................................................... 18
Notice of Nondiscrimination and Accessibility ...................................................................... 18
[COMPANY] shall provide free aids and services to people with disabilities to communicate
effectively, such as: ................................................................................................................... 18
Scheduling of Federal Healthcare Program Patients ................................................................ 19
Cash and Wellness Services: Collection of Payment................................................................ 19
Compliance ......................................................................................................................... 20
Compliance Program Administration ....................................................................................... 20
Compliance - Standards, Policies and Procedures .................................................................... 21
2
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Compliance - Screening and Evaluation ................................................................................... 21
Compliance Communication, Education, and Training ............................................................ 22
Compliance - Monitoring, Auditing, and Reporting.................................................................. 22
Compliance - Discipline for Non-Compliance ........................................................................... 23
Compliance - Investigations and Remedial Measures .............................................................. 23
Compliance - Fraud, Waste, and Abuse Prevention ................................................................. 27
Compliance Risk Assessment .................................................................................................... 28
Compliance – Red Envelope Policy ........................................................................................... 28
Federal Health Care Programs ............................................................................................. 30
Medicare Enrollment ................................................................................................................ 30
Medicare Services and Use of Space Regulations .................................................................... 30
Compliance with Medicare Coverage, Billing and Payment ..................................................... 30
Referral Source Education Spending ........................................................................................ 31
Finance ............................................................................................................................... 32
Generally Accepted Accounting Principles ............................................................................... 32
Payroll, Schedule, Deductions, Overtime, Compensation ........................................................ 32
Expense and Mileage Reimbursement ..................................................................................... 32
Use of a Company Credit Card .................................................................................................. 32
Professional & Business Courtesies .......................................................................................... 33
Contract and Invoice Billing ...................................................................................................... 36
Cash Billing (Collection)............................................................................................................. 36
Cash Management/Debt Management .................................................................................... 37
Billing Oversight ........................................................................................................................ 37
Accounts Receivable (Collections) Resolutions ........................................................................ 38
Benefits Verification.................................................................................................................. 39
Patient Financial Hardship ........................................................................................................ 39
Payment Plan ............................................................................................................................ 40
Collection of Patient Responsibility .......................................................................................... 41
Submission of Unresolved Patient Balances to a Collection Agency ........................................ 41
Small Balances........................................................................................................................... 42
3
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Overpayment Refunds .............................................................................................................. 42
Antitrust .................................................................................................................................... 42
Annual Budgeting ...................................................................................................................... 43
Medical and Billing Record Request Invoicing .......................................................................... 43
Biller Education and Training .................................................................................................... 45
HIPAA Privacy...................................................................................................................... 46
Confidentiality of Protected Health Information...................................................................... 46
Privacy - Administrative Requirements .................................................................................... 46
Privacy - Business Associates .................................................................................................... 48
Privacy - Permitted Uses and Disclosures ................................................................................. 49
Privacy - Uses and Disclosures - Authorization and Minimum Necessary................................ 53
Privacy - Amendment of Protected Health Information .......................................................... 55
Privacy - Disclosure and Accounting ......................................................................................... 56
Privacy - Notices and Other Individual Rights........................................................................... 56
Privacy - Response to Privacy Breach ....................................................................................... 58
Privacy - Business Associate Agreement Template .................................................................. 62
HIPAA Security .................................................................................................................... 63
Security Administrative - Assigned Security Responsibility ...................................................... 63
Security Administrative – Business Associate Written Contract .............................................. 63
Security Administrative – Corrective Action & Sanctions ......................................................... 63
[OPTIONAL] Security Administrative - Credit Card Processing and Payment Card Industry Data
Seurity Standard (PCI DSS) ........................................................................................................ 64
Security Administrative - Data Backup Plan ............................................................................. 67
Security Administrative - Disaster Recovery Plan ..................................................................... 67
Security Administrative - Emergency Mode Operation and Recovery ..................................... 68
Security Administrative - System Activity Review .................................................................... 68
Security Administrative - Login Monitoring .............................................................................. 69
Security Administrative - Password Management ................................................................... 69
Security Administrative - Protection from Malicious Software ................................................ 69
Security Administrative - Response and Reporting .................................................................. 70
4
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Security Administrative - Risk Assessment ............................................................................... 70
Security Administrative - Risk Management ............................................................................ 71
Security Administrative - Security Reminders .......................................................................... 72
Security Administrative - Technical and Non-Technical Evaluations........................................ 72
Security Administrative - Workforce Authorization ................................................................. 72
Security Physical - Access and Validation ................................................................................. 72
Security Physical – Accountability ............................................................................................ 73
Security Physical - Contingency Safeguards ............................................................................. 73
Security Physical - Data Backup and StoragE ............................................................................ 74
Security Physical - Disposal or Reuse of Device Media ePHI .................................................... 74
Security Physical - Security Maintenance Record ..................................................................... 74
Security Physical - Workstation Use ......................................................................................... 74
Security Technical - Audit Controls ........................................................................................... 75
Security Technical - Automatic Logoff ...................................................................................... 75
Security Technical - Emergency Access .................................................................................... 75
Security Technical – Encryption ................................................................................................ 75
Security Technical - Integrity Controls ...................................................................................... 76
Security Technical - Mechanism to Authenticate ePHI ............................................................ 76
Security Technical - User Identification and Authentication .................................................... 76
5
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Environment & Safety
1
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Contents
Emergency Preparedness....................................................................................................... 3
Emergency Preparedness ........................................................................................................... 3
Emergency Preparedness Risk Assessment ................................................................................ 3
Emergency Preparedness Communication Plan ......................................................................... 3
Emergency Preparedness Training and Testing .......................................................................... 4
Fire Prevention, Drills, & “RACE” ................................................................................................ 4
Emerging Infectious Diseases and Pandemic Declarations ........................................................ 5
Sheltering in Place....................................................................................................................... 6
Maintenance & Cleanliness.................................................................................................... 8
Environmental Health ................................................................................................................. 8
Safety .......................................................................................................................................... 8
Therapy Equipment Maintenance .............................................................................................. 9
Housekeeping ............................................................................................................................. 9
Infection Control ................................................................................................................. 10
Infection Control ....................................................................................................................... 10
Aseptic and Isolation Techniques ............................................................................................. 10
Blood Borne Pathogen Exposure Control ................................................................................. 12
Linens ........................................................................................................................................ 13
2
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Patient Care & Quality
1
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Clinical Operations ................................................................................................................ 3
Patient Admission and Consent .................................................................................................. 3
Patient Rights and Responsibilities ............................................................................................. 3
Patient Attendance, Cancellation and No-Show/ Fee Policy ...................................................... 3
Contract for Therapy Services ..................................................................................................... 4
Program Evaluation & Data Analysis .......................................................................................... 4
Quality: Internal Clinical Review ................................................................................................. 4
[OPTIONAL] Aquatic Therapy Compliance with Regulations ...................................................... 5
Aquatic Therapy in a Community Pool ....................................................................................... 5
Quality Outcomes Measures: Collecting and Reporting ............................................................ 6
Clinical Services ..................................................................................................................... 7
Therapy Disciplines ..................................................................................................................... 7
Clinical Services, Interventions and Speciaty Programs ............................................................. 7
Therapy Documentation ............................................................................................................. 8
Therapy Coding & Billing ............................................................................................................. 8
Therapy Documentation Timeliness ........................................................................................... 9
Abandoned Therapy Documentation ....................................................................................... 10
Patient Personal Belongings and Private Dressing Accomodations ......................................... 11
Emergency Care - Patient Emergency....................................................................................... 11
Abuse, Neglect, and Exploitation .............................................................................................. 11
2
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Personnel & Human Resources
1
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Personnel & Human Resources – Disclaimer .......................................................................... 4
Benefits ................................................................................................................................. 5
Compensation ............................................................................................................................. 5
Employee Time Off ..................................................................................................................... 5
Health Insurance ......................................................................................................................... 6
Employee Assistance Program .................................................................................................... 6
Retirement Plan .......................................................................................................................... 6
Clinical Continuing Education ..................................................................................................... 6
Employee Verification ........................................................................................................... 7
Contingent Offers of Employment .............................................................................................. 7
Background Checks for Employees and Applicants .................................................................... 7
Employee – Communicable Diseases ......................................................................................... 9
Immigration Law Compliance ..................................................................................................... 9
Licensure of Personnel ................................................................................................................ 9
Federal and State Program Exclusion Screening ...................................................................... 10
Hire/[iNSERT fREQUENCY] Education and Training .................................................................. 10
Employment Agreement ...................................................................................................... 12
Employee Personnel File & Records ......................................................................................... 12
Job Descriptions ........................................................................................................................ 12
Employee Orientation ............................................................................................................... 12
Performance Reviews ............................................................................................................... 12
Discipline & Response ............................................................................................................... 13
Employee Duty to Self-Report .................................................................................................. 13
Employee Resignation............................................................................................................... 13
Employee Termination.............................................................................................................. 14
Nepotism ................................................................................................................................... 14
Outside Employment/Moonlighting ......................................................................................... 14
Employment Rights ............................................................................................................. 15
Employment At Will .................................................................................................................. 15
Equal Employment Opportunity ............................................................................................... 15
2
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.
Meal and Break Periods ............................................................................................................ 15
Harassment ............................................................................................................................... 15
Fit for Duty .......................................................................................................................... 16
AttendancE ................................................................................................................................ 16
Employee - Drug Testing and Screening ................................................................................... 16
Risk Management................................................................................................................ 17
Bring Your Own Device (BYOD) ................................................................................................. 17
Personal Use of Company Equipment and Resources .............................................................. 17
Acceptable Use of Email ........................................................................................................... 17
Social Media ........................................................................................................................ 19
Social Media, Networking, and Electronic Communications .................................................... 19
3
2020 ©Nancy Beckley & Associates LLC. All Rights Reserved. Nancy Beckley & Associates (NBA) has taken a great deal of care to include current policy and regulatory information
in this book. NBA makes no real or implied guarantee that by using this book and sample policies that you will meet all legal and regulatory requirements and will not accept
responsibility for any liability, loss or damage resulting from use of this sample document. As with any model policy, the document should be carefully reviewed and customized
for your organization. No information provided in this document should be used as a substitute for the advice of competent legal counsel.