b) A case manager shall be designated for each participant. A case manager may serve one or more participants. The provision of services for each participant shall be organized through the case manager or case manager designee who shall:

1. 1) Assume responsibility for implementation of the rehabilitation plan;
2. 2) Assist the participant in becoming oriented to his/her program;
3. 3) Enable the program to proceed in an orderly, purposeful, and goal-oriented manner;
4. 4) Promote the program's responsiveness to the needs and preferences of the participant;
5. 5) Promote the participant's ongoing engagement in discussions of plans, goals and status;
6. 6) Participate consistently in team conferences concerning the participant;
7. 7) Maintain communication with family members, guardian (if designated), and funding source of the participant; and
8. 8) Facilitate the discharge process and arrangements for the discharge plan.

c) Functional outcome goals shall be established for each individual. The licensee shall provide those services that are indicated by the rehabilitation plan and consistent with the outcome goals and the overall needs of the individual. Services shall include, but not be limited to:

1. 1) Case management;
2. 2) Training and assistance with activities of daily living;
3. 3) Nursing consultation;
4. 4) Traditional therapies (physical, occupational, speech);
5. 5) Functional interventions in the residence and community (job placement, shopping, banking, recreation);
6. 6) Counseling;
7. 7) Self-management strategies;
8. 8) Productive or vocational activities; and
9. 9) Multiple opportunities for skill acquisition and practice throughout the day. (Section 35(4) of the Act)

d) The Program shall provide active and least restrictive treatment.

1. 1) The Program shall provide active treatment through the delivery of services that are intended to promote the personal autonomy or independence of all persons served. This shall be reflected in program philosophies or missions, as well as trainings, materials, practices, and staff performance appraisal systems.

2. 2) The Program shall deliver services in the least restrictive or intrusive manner possible and in a living situation that affords the greatest degree of autonomy possible for each person served.

   1. A) With respect to interventions, programs shall adopt a model for determining procedural restrictiveness and shall demonstrate or justify in each situation that less restrictive procedures have been tried or considered prior to implementing any procedure that could impinge on an individual's rights.
   2. B) Clinical documentation shall reflect that persons are treated in or are being prepared to reside in the least restrictive living arrangements possible, considering their existing strengths and needs.

e) Day treatment or individualized outpatient services shall be provided for persons who reside in their own home (Section 35(4) of the Act) at the request of a physician or funding agency and shall meet the following criteria:

1. 1) Assessment need be completed only for the specific service, or services, to be provided by the Model.
2. 2) The rehabilitation team for the participant receiving outpatient services shall include the participant, the participant's representative, if desired, and those therapists providing services.
3. 3) Each service provided shall develop treatment goals for the participant.