Compilation of Rules and Regulations of the State of Georgia
Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH
Chapter 111-8 - HEALTHCARE FACILITY REGULATION
Subject 111-8-71 - TRAUMATIC BRAIN INJURY FACILITIES
Rule 111-8-71-.09 - Client Assessment and Individual Program Planning

Universal Citation: GA Rules and Regs r 111-8-71-.09

Current through Rules and Regulations filed through September 23, 2024

(1) Written policies and procedures shall be established and implemented to provide for a complete, written assessment of the client within four weeks following admission. The purpose of the assessment shall be to determine client rehabilitation potential or need for ongoing lifetime support and the facility's ability to deliver appropriate treatment and rehabilitative care, or support to the client.

(2) The assessment shall be performed under the supervision of the program manager in collaboration with the rehabilitation professionals that provide therapies and services in the facility. The assessment must also include documentation of contact and input from the client's physician, previous rehabilitation providers and facilities, and rehabilitation professionals previously involved in the client's treatment and rehabilitative care. The assessment must identify the client's rehabilitation potential and behavioral, cognitive, educational, emotional, functional, medical, nursing, sociological, and vocational characteristics and needs. Whenever feasible, clients, families, and guardians or representatives should participate in assessments.

(3) An individual, written program plan shall be developed for each client, with his participation, by professional staff that participated in the assessment. The plan shall be based on the characteristics and needs identified in the assessment. The plan shall include specific goals oriented towards outcomes to achieve independence for the client.

(a) An individual case manager shall be assigned primary responsibility for managing the client's program plans.

(b) Program plans shall be reviewed by the case manager in collaboration with the client and other appropriate professional staff at least monthly and modified as needed.

(c) When transfer or discharge is planned, a discharge summary shall be included in the program plan. The summary must contain the reason for referral or discharge, the diagnosis, the client's functional limitations, the services that were provided, the outcomes of the services, and any recommendations of the case manager or professional staff. A facility shall provide every client at least ten days prior notification of transfer or discharge, provided, however, that an emergency transfer shall be done and notification given as soon as practical.

O.C.G.A. § 31-7-2.1.

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