(a) Within thirty (30) days of the admission of a resident to a facility, the facility shall prepare an individual service plan setting forth the:

1. (1) Needs of the resident to be treated by the facility;
2. (2) Services to be provided by the facility to meet those needs; and
3. (3) Timetable for meeting those needs.

(b) The individual service plan shall be developed as follows:

1. (1) Upon admission, the facility shall appoint a member of the facility’s staff who shall serve as program manager in the development and implementation of the individual service plan;
2. (2) The facility shall review all information concerning the resident received upon referral of the resident to the facility;
3. (3) The facility shall evaluate the resident’s physical, psychological, social, familial, vocational, and educational status;
4. (4) The facility, with input from the resident and the resident’s sponsor, shall develop the goals to be achieved by the treatment supplied by the facility; and

5. (5)

   1. (A) The facility shall evaluate the services needed to achieve those goals.
   2. (B) Commonly utilized services that should be considered included but are not limited to:

(i) Advocacy;

1. (ii) Alcoholism and drug abuse treatment services;

   1. (iii) Audiology;

      1. (iv) Chaplaincy;
      2. (v) Dentistry;
      3. (vi) Dietary/nutrition;
      4. (vii) Driver training;
      5. (viii) Education;
      6. (ix) Independent living skills instruction;
      7. (x) Interpretive services for those who are deaf or hearing impaired;
      8. (xi) Job placement;
      9. (xii) Manual communication instruction;
      10. (xiii) Medication management;
      11. (xiv) Mobility instruction for those who are blind or visually impaired;
      12. (xv) Nursing;
      13. (xvi) Occupational skills training;
      14. (xvii) Occupational therapy; (xviii) Orthotics;
      15. (xix) Pharmacy;
      16. (xx) Physical therapy;
      17. (xxi) Physician;
      18. (xxii) Prosthetics; (xxiii) Psychological evaluation and treatment;
      19. (xxiv) Recreational;
      20. (xxv) Rehabilitation counseling;
      21. (xxvi) Rehabilitation engineering; (xxvii) Residential; (xxviii) Social casework or group work;
      22. (xxix) Specialized services for those who are deaf and blind;
      23. (xxx) Speech-language pathology;
      24. (xxxi) Transportation; (xxxii) Vocational evaluation; and (xxxiii) Work adjustment.
      25. (c) Based on the review and assessment required by paragraph.
      26. (d) The facility shall develop an individual service plan containing statements of:
2. (1) The resident's goals;
3. (2) The treatment or services to be provided;
4. (3) The specific goals to be obtained from each service;
5. (4) The time intervals at which treatment or service outcomes will be reviewed;
6. (5) The anticipated time frames for the attainment of each of the resident’s specified goals; and
7. (6) The measures to be used to assess the effects of treatment or services.

(e)

1. (1) The resident's individual service plan shall be in writing.
2. (2) A copy of the individual service plan shall be provided and explained to the resident and the resident’s sponsor.
3. (3) A copy of the individual service plan shall be maintained in the resident’s records at the facility.

(f) The facility shall review and revise the resident’s individual service plan upon a substantial change in the resident’s needs and no less often than quarterly to determine:

1. (1) The resident’s current physical, psychological, social, familial, vocational, and educational status;
2. (2) The resident’s attainment of the goals previously established;
3. (3) Any changes in the goals of the individual service plan; and
4. (4) Any changes in the services to be provided to achieve those goals.

(g) A single program manager shall be designated for each resident and shall:

1. (1) Be responsible for the resident during the implementation of the individual service plan;
2. (2) Ensure that the resident is adequately oriented to his or her individual service plan;
3. (3) Ensure that the individual service plan proceeds in an orderly and goal-directed manner;
4. (4) Encourage the resident’s participation in the program;
5. (5) Ensure that the resident and the resident’s sponsor are involved on an ongoing basis in evaluation and revision of the individual service plan;
6. (6) Participate in staff conferences concerning the resident; and
7. (7) Ensure that the discharge decision and arrangements for follow-up and appropriate support services are made.

(h)

1. (1) Conferences of the facility staff shall be held at least monthly to:

   1. (A) Review the progress of the resident;
   2. (B) Develop further plans; and
   3. (C) Maintain integrated and coordinated services.
2. (2) The resident and the resident’s sponsor shall be allowed to provide input into these conferences.