(a) An ICF/MR
shall maintain a clinical record of services provided to a recipient. The
clinical record must include the evaluation required in
7
AAC 140.600(b) (1). The clinical
record must also include a written, individualized habilitative plan of care
that includes
(1) information identifying the
recipient;
(2) a list of the
members of the interdisciplinary team organized under
7
AAC 140.605;
(3) a prioritized summary of the presenting
problems and needs as identified during the evaluation;
(4) a description of the functional level of
the recipient;
(5) diagnoses,
symptoms, complaints, and complications indicating the need for admission or
continued stay;
(6) clearly stated
measurable goals or behaviorally stated objectives derived from the evaluation
and designed to attain or maintain the optimal physical, intellectual, social,
or vocational functioning of which the recipient is presently or potentially
capable;
(7) orders, as
appropriate, for services that are individually designed to accomplish the
stated goals and objectives, including medications, treatment, habilitation
services, nutrition services, social services, therapies, experiences,
activities, and any special procedures; in this paragraph, "habilitation
services" has the meaning given in
7
AAC 130.319;
(8) reasons why alternative placement is not
feasible or appropriate;
(9) a plan
for discharge and for care following discharge to assure the maximum
development of self-help and living skills; that plan must include provision
for appropriate services, protective supervision, and other follow-up services
in the recipient's new environment;
(10) documentation that the recipient or the
recipient's representative actively participated in the development of the
habilitative plan of care, or if active involvement is not possible, a
statement of the reasons for the lack of participation; and
(11) signatures of the following individuals,
indicating review and approval:
(A) the
recipient or the recipient's representative, unless the recipient or the
recipient's representative is not willing or able to participate as described
in (10) of this subsection;
(B) at
least one physician or qualified mental retardation professional;
(C) those participating members of the
interdisciplinary team organized under
7
AAC 140.605 who have reviewed and approved the
plan.
(b) An
ICF/MR must provide
(1) a protected
residential setting, individualized ongoing evaluation, planning, 24-hour
supervision, and coordination and integration of health and habilitative
services to help a recipient reach maximum functioning capability;
and
(2) in accordance with the
recipient's habilitative plan of care, regular participation by the recipient
in professionally developed and supervised activities, experiences, or
therapies, including recreation and day programming.
(c) At least once a year, the
interdisciplinary team assigned under
7
AAC 140.605 shall perform a medical, social, and
psychological reevaluation, including a review of the recipient's progress
toward meeting the goals and objectives stated in the recipient's habilitative
plan of care, the appropriateness of that plan of care, an assessment of the
continuing need for institutional care, and consideration of alternate methods
of care.
