Current through Register Vol. 46, No. 39, September 25, 2024
(a) Each individual of a specialty hospital
shall have an individual program plan which describes for the individual his or
her medical treatment for health-related problems and active programming for
developmental disability(ies).
(b)
Programming and treatment shall be directed at those aspects of the
health-related conditions and developmental disability necessitating the
restrictiveness of the specialty hospital placement. The type and duration of
programming and treatment shall be structured to enable the individual's
movement to a less restrictive environment as quickly as possible with regard
for each individual's disabilities.
(c) Each individual program shall state the
conditions requiring admission to a specialty hospital, the course of treatment
and programs prescribed for these conditions and the anticipated outcomes of
treatment and programs.
(d) The
individual program plan shall be developed and implemented by an
interdisciplinary team (see section
680.13 of
this Part) including the providers of medical treatment and active programming
and direct care staff. One member of this team who is a qualified intellectual
disability professional (see section
680.13)
shall serve as individual coordinator (see section
680.13) with
primary responsibility for implementation of the individual program plan,
coordination of its components and for arranging movement of the client to a
less restrictive environment as soon as the individual's needs
permit.
(e) Active programming is
to take place in a setting separate from the individual's living and sleeping
areas unless it is necessitated because of an individual's health care
problem(s) and prescribed by a physician (see section
680.13 under
"Professional Staff").
(f) The
combination of goal-oriented health care, medical treatment and active
programming, excluding recreation, shall be at least six hours per day, five
days per week in the manner recommended by each individual's interdisciplinary
team. The medical treatment and active programming for these conditions
necessitating admission to the specialty hospital shall be provided with the
frequency and duration prescribed by the individual's I.T. Thus, a person may
receive more than six hours of medical treatment and structured programming per
day, but can only receive less than six hours per day if a physician has
certified in writing that such activities would be medically harmful to the
individual. For Willowbrook class members, approval of the programming
exemption must be obtained from the professional advisory board.
(g) Each individual program plan shall
specify the conditions to be treated, and the anticipated preventive and/or
restorative outcomes resulting from the various therapeutic interventions to be
used. The individual program plan shall be written and maintained in the
manner, frequency and format prescribed by OPWDD and shall contain the
following components:
(1) the goals and long-
and short-term objectives established to attain or maintain the optimal level
of health, self-care, communication, learning, mobility, recreation and
capacity for independent living of which the individual is presently or
potentially capable;
(2) service
plans for each mandatory and selective service which combine into an integrated
program of individually designed activities, experiences and programs necessary
to achieve each individual's objectives. These plans shall contain, as
appropriate, specific individual medical prescriptions or written direction
from the interdisciplinary team for all necessary services;
(3) progress notes describing the
individual's response to programs and services;
(4) an activity schedule for each individual
which includes all programs, services and leisure time activities prescribed by
the interdisciplinary team; and
(5)
identification of the person responsible for providing each program or
service.
(h) Review of
each individual program plan shall be performed as follows:
(1) At least monthly a member or members of
the interdisciplinary team shall review the individual's response to the
individual program plan to determine any necessary modifications. Written
documentation of such reviews shall be maintained in the individual's
record.
(2) At least quarterly, the
interdisciplinary team shall collectively review and evaluate each person's
individual program plan. This review shall describe the improvement or lack of
improvement in those conditions for which the individual was admitted and
additionally include:
(i) such reassessments
of the individual's condition, assets or disabilities as may be indicated prior
to the interdisciplinary team's review conference;
(ii) participation by the individual and his
or her correspondent, unless the individual is an adult competent to object and
objects to such participation;
(iii) input and relevant participation from
professional and nonprofessional staff providing services to the
individual;
(iv) a review of the
individual's response to the active programming provided during the previous
quarter; and
(v) establishment of
modified or new long- and short-range objectives, as appropriate.
(3) At least quarterly, the
individual coordinator shall send written notification of the individual's
medical condition and progress in programs and services to the individual's
correspondent.
(4) Prior to
discharge or for an extended stay beyond six months and performed in accordance
with individual need, an interdisciplinary team, consisting of individuals who
are representative of the professions or services included in this Part (that
are relevant in each particular case), including direct care staff, shall
conduct a comprehensive reassessment (based upon individual assessments) of
each individual, covering self-care, health, communication, learning, mobility
and capacity for independent living.
(5) At least quarterly, the interdisciplinary
team shall collectively review the status of each individual, including
consideration of the following:
(i) the
advisability of continued residence at the specialty hospital and alternative
programs; and
(ii) review of the
need for guardianship and how the individual may exercise his or her civil and
legal rights when the person legally becomes an adult.
(i) The individual's individual
program plan and program shall be periodically monitored by OPWDD to ensure:
(1) the adequacy of the record and the
appropriateness of the services delivered;
(2) integration of all programs and services
provided to each individual;
(3)
required reviews and assessments are accomplished as prescribed in this Part;
and
(4) the notifications required
in paragraph (h)(3) of this section are made.
(j) The specialty hospital shall maintain the
following system of records:
(1) Individual
record. The specialty hospital shall maintain a comprehensive record for each
person. Each record shall be organized in the manner and contain the
information prescribed by OPWDD. Each individual's record shall contain the
following types of information:
(i)
identification information;
(ii)
admission information, including the individual's medical and developmental
history, and documentation of the commissioner's prior approval of
admission;
(iii) a current
individual program plan (as specified in subdivisions [a] through [i] of this
section);
(iv) copies of
assessments, reassessments, progress notes and previous individual program
plans;
(v) service plans,
description of treatments provided and medications administered;
(vi) reports of illness or injury including
the date and time of occurrence and action taken regarding each
occurrence;
(vii) summary of
findings, progress and plans when the individual is discharged.
(2) Record of program operations.
The administrator shall maintain or cause to be maintained the following
records of program operations:
(i) a
chronological admission and discharge register which is a daily alphabetical
listing of individuals admitted and discharged from the specialty hospital by
name of individual, including referral and/or placement information;
(ii) a daily census record including daily
census and cumulative census for each month and year;
(iii) notation of all accident and incident
reports;
(iv) fire drill
records;
(v) dietary service
record;
(vi) records that document
compliance with sanitation, health and environmental safety codes including
written reports of inspections by State and local authorities having primary
jurisdiction and records of action taken on their recommendations;
(vii) copies of all transfer and affiliation
agreements;
(viii) a copy of the
emergency disaster plan;
(ix) a
master plan for staffing;
(x) a
personnel record for each staff member including all available pre-employment
information and, for professional staff, a copy of the current registration and
license or certificate.
(3) Confidentiality.
(i) The individual and his or her
correspondent shall have access to the total record upon request unless
proscribed by order of the court, or unless the person is an adult and objects
to the correspondent's having access to the record.
(ii) The staff of the specialty hospital
shall keep all medical, social, personal and financial information about an
individual confidential and make it available only to persons authorized by law
or by the commissioner.
(iii) The
individual record is the property of the specialty hospital, which shall
protect it from loss, damage, tampering or use by unauthorized
individuals.
(iv) The specialty
hospital shall obtain written consent of the individual, or the individual's
next of kin or guardian before releasing information to persons who are not
otherwise authorized to receive it.
(v) The specialty hospital shall have the
individual's record available in his or her living unit.
(4) Central record service.
(i) The specialty hospital shall maintain a
centrally administered record service for the collection and release of
individual information.
(ii) The
specialty hospital shall make records readily accessible to authorized
personnel.
(iii) The specialty
hospital shall retain all clinically oriented individual records in accordance
with OPWDD's Manual of Policy and Procedures.
(iv) The specialty hospital shall submit any
data or information contained in the individual records, the record of program
operations or any other agency records to the commissioner upon request. Such
requested information shall be submitted in the format and manner prescribed by
OPWDD.
