California Code of Regulations
Title 22 - Social Security
Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies
Chapter 3 - Skilled Nursing Facilities
Article 4 - Optional Services
Section 72413 - Occupational Therapy Service Unit-Services

Universal Citation: 22 CA Code of Regs 72413

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) "Occupational therapy service" means those services ordered by the licensed healthcare practitioner acting within the scope of his or professional licensure in which selected purposeful activity is used as treatment in the rehabilitation of persons with a physical or mental disability.

(b) Occupational therapy services shall include but not be limited to:

(1) Assisting the licensed healthcare practitioner acting within the scope of his or her professional licensure in an evaluation of a patient's level of function by applying diagnostic and prognostic tests.

(2) Conducting and preparing written initial and continuing assessment of the patient's condition and modifying treatment goals under the order of a licensed healthcare practitioner acting within the scope of his or her professional licensure, consistent with identified needs of the patient.

(3) Decreasing or eliminating disability during patient's initial phase of recovery following injury or illness.

(4) Increasing or maintaining a patient's capability for independence.

(5) Enhancing a patient's physical, emotional and social well-being.

(6) Developing function to a maximum level.

(7) Guiding patients in their use of therapeutic, creative and self-care activities.

(c) An occupational therapy service unit shall meet the following requirements:

(1) Patient health records shall contain pertinent information and signed orders for treatment.

(2) Notes shall be written and entered in the patient's health record after completion of each procedure. The note shall indicate the procedure(s) performed, the reaction of the patient to the procedure(s) and shall be signed by the occupational therapist.

(3) Initial and continuing assessment, development of a treatment plan and discharge summary shall be written and entered in each patient's health record.

(4) Individual progress notes shall be written and signed at least weekly by the occupational therapist.

1. Amendment of subsections (a) and (b)(1)-(2) and NOTE filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).

Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1276, 1316.5, 131050, 131051 and 131052, Health and Safety Code.

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