(1) Each client must have an individual treatment 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 (3) ; and
(b) designing programs that meet the client's needs.
(2) Appropriate facility staff must participate in interdisciplinary team meetings. Participation by other agencies serving the client is encouraged. Participation by the client or the client's legal guardian is required unless that participation is unobtainable or inappropriate.
(3) Within 30 days after admission, the interdisciplinary team must perform accurate assessments or reassessments as needed to supplement the preliminary evaluation conducted prior to admission. The comprehensive functional assessment must take into consideration the client's age (for example a young adult, an elderly person) and the implications for treatment and habilitation at each stage, as applicable, and must:
(a) identify the presenting problems and disabilities and where possible, their causes;
(b) identify the client's specific developmental strengths;
(c) identify the client's specific developmental and behavioral management needs;
(d) identify the client's need for services without regard to the actual availability of the services needed; and
(e) include physical development and health, nutritional status, sensory motor development, affective development, speech and language development and auditory functioning, cognitive development, social development, adaptive behaviors or independent living skills necessary for the client to be able to function in the community, and as applicable, vocational skills.
(4) Within 30 days after admission, the interdisciplinary team must prepare for each client an individual treatment plan that states the specific objectives necessary to meet the client's needs, as identified by the comprehensive assessment required by (3) , and the planned sequence for dealing with those objectives. These objectives must be:
(a) stated separately, in terms of a single behavioral outcome;
(b) assigned projected completion dates;
(c) expressed in behavioral terms that provide measurable indices of performance;
(d) organized to reflect a developmental progression appropriate to the individual; and
(e) assigned priorities.
(5) Each written training program designed to implement the objectives in the individual treatment plan must specify:
(a) the methods to be used;
(b) the schedule for use of the method;
(c) the person responsible for the program;
(d) the type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives;
(e) the inappropriate client behavior(s) , if applicable; and
(f) provision for the appropriate expression of behavior and the replacement of inappropriate behavior, if applicable, with behavior that is adaptive or appropriate.
(6) The individual treatment plan must also:
(a) describe relevant interventions to support the individual toward independence;
(b) identify the location where program strategy information (which must be accessible to any person responsible for implementation) can be found;
(c) include, for each client who lacks them, training in personal skills essential for privacy and independence (including, but not limited to, 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;
(d) identify mechanical supports, if needed, to achieve proper body position, balance, or alignment. The plan must specify the reason for each support, the situations in which each is to be applied, and a schedule for the use of each support;
(e) provide that each client who has 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
(f) include opportunities for client choice and self-management.
(7) Relevant portions of each client's individual treatment plan must be made available to appropriate staff, including staff of other agencies who work with the client and to the client or legal guardian.