R432-152-11. Individual Program Plan

(1) Each client shall have an individual program plan developed by an interdisciplinary team that represents the professions, disciplines or service areas that are relevant to:

(a) identifying the client's needs, as described by the comprehensive functional assessments required in R432-152-12(4); and

(b) designing programs that meet the client's needs.

(2) Interdisciplinary team meetings shall include the following participants:

(a) representatives of other agencies who may serve the client; and

(b) the client and the client's legal guardian unless participation is unobtainable or inappropriate.

(3) Within 30 days after admission, the interdisciplinary team shall prepare for each client an individual program plan that states the specific objectives necessary to meet the client's needs, as identified by the comprehensive assessment required by R432-152-12, and the planned sequence for dealing with those objectives.

(a) The program objectives shall:

(i) be stated separately, in terms of a single behavioral outcome;

(ii) be assigned projected completion dates;

(iii) be expressed in behavioral terms that provide measurable indices of performance;

(iv) be organized to reflect a developmental progression appropriate to the individual; and

(v) be assigned priorities.

(b) Each written training program designed to implement the objectives in the individual program plan shall specify:

(i) the methods to be used;

(ii) the schedule for use of the method;

(iii) the person responsible for the program;

(iv) the type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives;

(v) the inappropriate client behavior, if applicable; and

(vi) provision for the appropriate expression of behavior and the replacement of inappropriate behavior, if applicable, with behavior that is adaptive or appropriate.

(c) The individual program plan shall also:

(i) describe relevant interventions to support the individual toward independence;

(ii) identify the location where program strategy information, which shall be accessible to any person responsible for implementation, can be found;

(iii) include, for those clients who lack them, training in personal skills essential for privacy and independence, including toilet training, personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs, until it has been demonstrated that the client is developmentally incapable of acquiring them;

(iv) identify mechanical supports, if needed, to achieve proper body position, balance, or alignment, including the reason for each support, the situations in which each is to be applied, and a schedule for the use of each support;

(v) provide that clients who have multiple disabling conditions spend a major portion of each waking day out of bed and outside the bedroom area, moving about by various methods and devices whenever possible; and

(vi) include opportunities for client choice and self-management.

(4) A copy of each client's individual program plan shall be made available to all relevant staff, staff of other agencies who work with the client or legal guardian.

(5) As soon as the interdisciplinary team has formulated a client's individual program plan, each client shall receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.

(a) The facility shall develop an active treatment schedule that outlines the current active treatment program and that is readily available for review by relevant staff.

(b) Except for those facets of the individual program plan that may be implemented only by licensed personnel, each client's individual program plan shall be implemented by all staff who work with the client.

(6) The facility must document, in measurable terms, data and significant events relative to the accomplishment of the criteria specified in individual client program plans.

(7) The individual program plan shall be reviewed at least by the qualified mental retardation professional and revised as necessary; including situations in which the client:

(a) has successfully completed an objective or objectives identified in the individual program plan;

(b) is regressing or losing skills already gained;

(c) is failing to progress toward identified objectives after reasonable efforts have been made; or

(d) is being considered for training towards new objectives.