Section 5320.52. Review and periodic reexamination

The interdisciplinary treatment team shall review treatment plans at least every 30 days or more frequently as the resident’s condition changes. A report of the review and findings and the resident’s progress toward meeting program goals and objectives shall be documented by the interdisciplinary team in the resident’s record.

(1) The interdisciplinary treatment team shall maintain a record of each reexamination and review to include:

(i) A report of the reexamination.

(ii) A brief description of the treatment provided to the person during the period preceding the reexamination and the results of that treatment.

(iii) Continuation or revision of the individual treatment plan for the next period.

(iv) Criteria for discharge and recommendation for discharge if these criteria have been met.

(2) Changes to the treatment plan and the reasons for the changes shall be made by the interdisciplinary treatment team and recorded in the resident’s record as a progress note or on another form specifically designed for that purpose.

(3) The record shall include information required by § 5100.16 (relating to review and periodic reexamination).

(4) Reassessment of each resident’s mental, physical and social needs, including a mobility assessment as follows:

(i) Annually.

(ii) If the condition of the resident materially changes prior to the annual assessment.

(iii) At the request of the county administrator or the Department if there is cause to believe that an additional assessment is required.