(a) The multidisciplinary health team conducting an assessment shall consist of at least the individual’s personal physician or a staff physician, or both, a registered nurse, and a social worker.
(b) For the initial assessment, the multidisciplinary health team shall also include a physical therapist and an occupational therapist. In addition, when the need is identified by a physician or nurse, qualified consultants with skills in recreational therapy, speech language pathology, or dietary assessment shall serve as team members.
(c) The multidisciplinary team described in subdivision (b) shall conduct an initial assessment. At the time of reassessment, if an individual plan of care has been developed by the physical therapist or the occupational therapist, they shall reassess the participant to determine any ongoing or different needs for physical therapy or occupational therapy services. If it is determined that no further physical therapy or occupational therapy is needed, the physical therapist and the occupational therapist shall not be required to sign the treatment plan. For further reassessments, the nurse or physician shall determine if the physical therapist or occupational therapist is needed.
(d) The assessment team shall:
(1) Determine the medical, psychosocial, and functional status of each participant.
(2) Develop an individualized plan of care, including goals, objectives, and services designed to meet the needs of the person, which shall be signed by each member of the multidisciplinary team, except that the signature of only one physician member of the team shall be required.
(3) At least biannually reassess the participant’s individualized plan care and make any necessary adjustments to the plan.
(4) If the initial assessment or any subsequent reassessment shows that restorative therapy is needed, acute rehabilitative treatment shall be provided by the appropriate licensed or certified personnel.
(5) If the initial assessment or any subsequent reassessment shows that restorative therapy is not needed, the multidisciplinary team shall determine whether the participant requires maintenance program services and if the team finds that the participant requires these services, the multidisciplinary team shall develop an individual maintenance program as part of the plan of care.
(Amended by Stats. 1991, Ch. 985, Sec. 5.)