(a) To supplement the core services required in § 11.123 (relating to core services), centers should consider providing the following specialized services:

1. (1) Physical therapy.

   1. (i) Physical therapy services are provided to restore or maintain maximum mobility, with programs for restoration and maintenance of muscle function.

   2. (ii) The services may range from consultation regarding group exercise to one-on-one skilled restorative therapy. Based on a physical therapy assessment, the plan of care and physician’s orders, the services include the following:

      1. (A) Assessment of the client’s mobility level, strength, range of motion, endurance, balance, gait, ability to transfer, coordination, posture and pain level.
      2. (B) Provision of treatment to relieve pain, and develop, restore or maintain functioning.
      3. (C) Assistance to achieve and maintain maximum performance using physical means such as active or passive exercise, massage, heat, moist heat, ultrasound, hydrotherapy and ice.
      4. (D) Establishment of a maintenance program and provision of written and verbal instructions to the center staff persons and the family/caregiver to assist the client with implementation.
      5. (E) Recommendation of adaptive or assistive devices.
      6. (F) Training other staff persons to lift, move and otherwise assist the client.
      7. (G) Evaluation of the home for environmental barriers and changes needed for greater client independence.
      8. (H) Provision of skilled rehabilitation services when indicated.
      9. (I) Assistance in obtaining assistive ambulatory devices, such as canes, walkers, crutches, wheelchairs, leg braces and prosthetic devices.
      10. (J) Physical therapy procedures including ambulation, gait training, active and passive exercises, orthotics training, prosthesis training, massage and neuromuscular reeducation.

2. (2) Occupational therapy. Occupational therapy services are services designed to increase physical status and independence in activities of daily living and to prevent further deterioration. The intensity of services provided may range from consultation for group services to one-on-one acute rehabilitative therapy. Depending on the occupational therapy assessment, plan of care and physician orders, occupational therapy services include the following:

   1. (i) Administering diagnostic and prognostic tests to determine integrity of upper extremities, ability to transfer, range of motion, balance, strength and coordination, endurance, activities of daily living and cognitive-perceptual functioning.
   2. (ii) Teaching clients adaptive techniques to overcome barriers and impediments in activities of daily living.
   3. (iii) Teaching and training staff persons in the use of therapeutic, creative and self-care activities to improve or maintain the client’s capacity for self-care and independence, and increase the range of motion, strength and coordination.
   4. (iv) Training the client in the use of supportive and adaptive equipment and assistive devices.
   5. (v) Evaluating the home for environmental barriers and recommending changes for greater client independence.
   6. (vi) Providing restorative therapy when indicated, establishing a maintenance program when needed to prevent deterioration and providing written and verbal instructions to center staff persons and the family/caregiver to assist the client with implementation.

   7. (vii) Occupational therapy procedures, including:

      1. (A) Training or retraining in activities of daily living.
      2. (B) Training in work simplification.
      3. (C) Exercises and graded activities to improve strength and range of motion.
      4. (D) Sensory stimulation techniques to minimize sensory deficits.
      5. (E) Coordination activities to promote increased manual dexterity.
      6. (F) Evaluation and provision of needed slings or splints to increase or maintain functional use of upper extremities.

3. (3) Speech therapy. Speech services are provided to restore impaired speech and language disorders due to stroke, laryngectomy, head trauma and neurological diseases. Speech therapy services, when indicated by the plan of care, the speech therapist’s assessment and physician orders, include the following:

   1. (i) The establishment of a treatment program to improve communication ability and correct disorders.
   2. (ii) The provision of written and verbal instruction to center staff persons and family members in methods to assist the client to improve and correct speech disorders.

   3. (iii) Speech therapy procedures, including the following:

      1. (A) Auditory comprehension tasks.
      2. (B) Visual or reading comprehension tasks, or both.
      3. (C) Language intelligibility tasks.
      4. (D) Language expression tasks.
      5. (E) Training involving the use of alternative communication devices.

4. (4) Medical services.

   1. (i) Medical services by a staff physician, the client’s personal physician or a certified registered nurse practitioner (CRNP) are provided or arranged by an older adult daily living center providing nursing or physical, speech or occupational therapy.
   2. (ii) Medical services may be direct, indirect or a combination of both. Centers may have a physician or CRNP on a part-time basis who serves as a consultant and authorizes the medical plan of care. The physician may also serve as medical director or directly provide hands-on assessment or treatment, or both. Medical services may also be provided by the client’s personal physician who is contacted when changes or emergencies occur, provides medical assessment and treatment, is informed on a regular basis of the client’s status and retains primary responsibility for medical care. In centers where a medical director or consultant is available to act as a member of the team and authorize care, information is usually supplied to the personal physician, who may still provide the ongoing medical treatment.