1. (a) An ICF/IID 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. (1) information identifying the recipient;
   2. (2) a list of the members of the interdisciplinary team organized under 7 AAC 140.605;
   3. (3) a prioritized summary of the presenting problems and needs as identified during the evaluation;
   4. (4) a description of the functional level of the recipient;
   5. (5) diagnoses, symptoms, complaints, and complications indicating the need for admission or continued stay;
   6. (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. (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. (8) reasons why alternative placement is not feasible or appropriate;
   9. (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. (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. (11) signatures of the following individuals, indicating review and approval:

       1. (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;
       2. (B) at least one physician or qualified intellectual disability professional;
       3. (C) those participating members of the interdisciplinary team organized under 7 AAC 140.605 who have reviewed and approved the plan.

2. (b) An ICF/IID must provide

   1. (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. (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.
3. (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.

(Eff. 2/1/2010, Register 193)