Cal. Code Regs. Tit. 22, § 78303 - Basic Program Services: Assessment
(a) The multidisciplinary team shall be
composed of at least a staff or attending physician, a registered nurse, a
social worker, an occupational therapist and a physical therapist.
(b) The multidisciplinary team, in
collaboration with the participant or the participant's authorized
representative and the placement agency, if any, shall assess each
participant's need for services prior to the acceptance of that
participant.
(c) The
multidisciplinary team shall determine and document in the participant's health
record that:
(1) The amount of care,
supervision and type of services required by the participant are available in
the center.
(2) The participant is
ready and can benefit from the program the center has to
offer.
(d) A written
individualized plan of care shall be developed to meet the needs of each
participant and shall include but not be limited to:
(1) Scheduled days of attendance.
(2) Medical diagnoses.
(3) Prescribed medications and frequency of
administration.
(4) Specific
element of the service needed.
(5)
Individualized objectives, therapeutic goals and duration of each
service.
(6) An individualized
activity plan designed to meet the needs of the participant for social and
therapeutic recreational activities.
(7) Participation in specific group
activities.
(8) A plan for
transportation needs.
(9)
Therapeutic diet requirements and if indicated, the plan for dietary
counselling and education.
(10) A
plan for other services needed by the participant.
(11) Discharge planning.
(12) The signature of each member of the
multidisciplinary team including a physician.
(e) Prior to or at the time of the admission
of a participant, the program director shall obtain a written health assessment
of the participant which has been completed within 90 days by the participant's
physician or staff physician. The assessment shall be included in the
participant's health record and shall include at least the following:
(1) Previous medical history.
(2) Identification of any health condition
including communicable disease.
(3)
Identification of physical limitations including ambulatory status.
(4) Current diagnosis of any health problem
and the prescribed treatment.
(5)
Evidence of tuberculosis screening.
Notes
Note: Authority cited: Section 208(a), Health and Safety Code. Reference: Section 1580, Health and Safety Code; Section 14528, Welfare and Institutions Code.
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