(a) Core diagnostic and evaluation services are mandatory for each person admitted to the clinic for the comprehensive evaluation; these services are available discretely for any person admitted for a particular diagnostic and evaluation service under subparagraph (a)(4)(ii) of section 676.5 of this Part. It shall be mandatory that each person receiving the package of core diagnostic and evaluation services shall also have the services specified in subdivisions (e) and (f) of this section.

1. (1) Admission and screening devices shall be provided by the admission committee covering such items as:

   1. (i) visits by the health care professional staff to the person, when required, to determine appropriateness of receiving services at the diagnostic and research clinic and/or referral of the person and family to other appropriate agencies;
   2. (ii) background information on the person: name, address, referring agent, reason for referral, tentative diagnosis, symptomatology, activity of daily life;
   3. (iii) prenatal history;
   4. (iv) perinatal history;
   5. (v) delivery;
   6. (vi) developmental history;
   7. (vii) past medical history;
   8. (viii) family history; and
   9. (ix) social service history including familial relations and financial factors, capacity for independent living and self-direction, need for self-care, personal care services and person's level of interpersonal functioning.

2. (2) General medical examination shall be performed by a physician on duty and shall include such items as:

   1. (i) physical development, including height, weight, head and chest circumferences, special facial features and vital signs; and
   2. (ii) general appearance, including skull, facial features, eyes, ears, nose, philtrum, mouth, lips, alveolar dentition, palate, gingiva, pharynx, chin, neck, thorax, lungs, heart, abdomen, primary and secondary sex characteristics, skeletal features, dermatoglyphics and integument.

3. (3) Neurological or pediatric neurological examination shall be performed by a neurologist or a pediatric neurologist and shall include at least the following items:

   1. (i) estimated mental status;
   2. (ii) cranial nerves (including assessment of visual and auditory acuity), function;
   3. (iii) motor system, including reflexes;
   4. (iv) coordination system; and
   5. (v) sensory system.

4. (4) Psychological examination shall be provided or supervised by a licensed psychologist and shall include:

   1. (i) required psychological tests, provided as a minimum to all persons admitted for comprehensive diagnosis and evaluation, including measurement of:

      1. (a) intelligence;
      2. (b) adaptive behavior;
      3. (c) personality;
      4. (d) aptitude/achievement;
      5. (e) communication skills (receptive and expressive);
      6. (f) perceptual motor skills; and
      7. (g) emotional development.

   2. (ii) additional psychological tests, provided to persons, if needed, in conjunction with related specialized clinical laboratory services and/or other optional services for purposes of differential diagnosis, including use of measurement instruments for:

      1. (a) neuropsychological functions entailing a comprehensive assessment of the functional ramifications of neurological impairment;
      2. (b) conceptual skills;
      3. (c) memory;
      4. (d) sensorimotor skills;
      5. (e) special abilities and disabilities; and
      6. (f) educational performance.
5. (5) Nursing evaluation shall be conducted by a registered nurse and shall assess each person's need for nursing care and shall include a review of the person's medication history.
6. (6) Nutritional evaluations shall assess the person's need for services related to special diet related to appropriate growth or maintenance and/or treatment of digestive and related systems' disorders and/or metabolic disturbances, e.g., diabetes mellitus, aminoacidopathies, etc.

7. (7) Audiological evaluations shall assess:

   1. (i) outer, middle and inner ear function;
   2. (ii) auditory acuity; and
   3. (iii) site of lesion determination in cases of auditory dysfunction.

8. (8) Ophthalmological evaluation shall assess:

   1. (i) visual acuity, including binocular function;
   2. (ii) visual field;
   3. (iii) color vision function;
   4. (iv) ocular transparency with use of slit lamp microscopy, if needed;
   5. (v) intra-ocular pressure;
   6. (vi) cornea sensitivity;
   7. (vii) pupillary function;
   8. (viii) retinal integrity via funduscopy;
   9. (ix) ocular motility;
   10. (x) presence or absence of refractive errors; and
   11. (xi) the ocular adnexae (glands, lids, etc.).

(b) Optional specialized clinical laboratory and medically related services are clinical laboratory assessments performed or supervised by licensed professionals. The following lists the most general areas of specialized clinical laboratory services provided at the diagnostic and research clinic. The clinic shall be responsible for developing a complete list of all specialized clinical laboratory tests and this list shall be included in the clinic's policies and procedures manual. Such list shall be reviewed by the clinic, at least annually, and shall be available for review by appropriate agencies. This Part mandates that each person receiving any or all of the specialized clinical laboratory services, listed herein, shall also be provided with the services specified in subdivisions (e) and (f) of this section. A certified anesthesiologist shall be available to administer general anesthesia to a person with developmental disabilities who may require such a service in the course of the delivery of any of the following specialized assessments:

1. (1) Neuroradiology services shall refer to computerized transaxial tomography (CTT scan) and shall be used, when appropriate, for the purpose of detecting structural abnormalities in the brain or body.

2. (2) Genetic services shall be used when there are indications of genetic disorders, and may be provided alone or in conjunction with genetic counseling. Genetic services may include:

   1. (i) diagnosis of chromosomal abnormalities; and
   2. (ii) diagnosis of genetically determined metabolic disorders.

3. (3) Electrophysiological services shall include electrophysiological tests used to determine if functional deficiencies exist in the central or peripheral nervous system. Such procedures may include but not be limited to:

   1. (i) electroencephalography (EEG);
   2. (ii) cortical and brainstem evoked potentials—graphic documentation of central nervous system activity in response to sensory stimulation;
   3. (iii) electronystagmography—graphic documentation of extra-ocular muscle response to inner ear stimulation;
   4. (iv) electroretinography—determination of retinal function to light of varying wave lengths, often done in conjunction with visual evoked potentials based initially on ophthalmological examination;
   5. (v) electromyography—graphic documentation of somatic muscle activities;
   6. (vi) nerve conduction velocity determinations—graphic documentation of peripheral nerve (sensory or motor) propagation; and
   7. (vii) sleep recording (cortical activity and related physiologic functions as related to the sleep-wake cycle by either direct recording or telemetry).

4. (4) Biochemical, immunological and virological services shall be made as indicated by the symptomatology and medical history of the individuals. This may require collection of urine, withdrawal of blood, biopsies of the skin, muscle, bone marrow, kidney, liver, peripheral nerve or brain, and/or use of cultured fibroblasts and long-term lymphoid cell lines derived from skin and lymphocytes, respectively. A variety of biochemical tests may be authorized, including:

   1. (i) enzymatic assays as well as diagnosis, screening, and quantification of amino acids, organic acids, lipids, saccharides, polysaccharides and other constituents of body fluids;
   2. (ii) virological tests; e.g., tests for German measles, measles, and herpes simplex viruses;
   3. (iii) virus isolation tests from suspected slow virus infections; and
   4. (iv) immunological tests, including tests for antibodies.
5. (5) Neuro-ophthalmological services shall be provided by a qualified neuro-ophthalmologist and shall be made when there are indications that visual dysfunctions are more serious than refractive errors. The neuro-ophthalmologist shall be consulted, if required, to synthesize and augment clinical data elicited by other clinicians who have assessed the person's visual function.
6. (6) Psychophysiological services shall be used to measure autonomic activity during rest and in response to sensory stimulation (e.g., heart period, skin conductance and respiration), and may be coordinated with any electrophysiological services that may be administered for the person.
7. (7) Neuropharmacological services shall be provided to persons in need of assessment of the effects of anticonvulsant drug concentrations and other appropriate xenobiotic agents. This may include frequent sampling in conjunction with sleep-wake monitoring of central nervous system activity by direct recording or telemetry for prolonged time periods.
8. (8) Neuroendocrinological services shall include tests on endocrine function as related to central nervous system state, and may include sleep-wake monitoring of nervous system activity by direct recording or telemetry for prolonged time periods.
9. (9) Histopathological services shall be used to diagnose tissues using technologies that may include an electron microscope and/or histochemical analysis. This may require biopsies of the skin, bone marrow, liver, kidney, peripheral nerve, muscle and brain, as well as morphologic studies of blood cells or cultured fibroblasts.

(c) Other optional diagnostic and evaluation services may be provided to individuals, if needed. If any of the following services are provided, however, the individual receiving such services shall also receive the services specified in subdivisions (e) and (f) of this section.

1. (1) Dental evaluations shall be conducted or supervised by a licensed dentist to assess the person's intra- and extra-oral condition and the person's immediate and continuing dental and oral hygiene needs.

2. (2) Psychiatric examination shall be conducted by a licensed psychiatrist for individuals in need of such an assessment, and may include assessments of:

   1. (i) mental status;
   2. (ii) cognitive/affective functioning; and
   3. (iii) familial/personal/socio-cultural factors.

3. (3) Physiatry evaluations may include assessments of:

   1. (i) sensory integration;
   2. (ii) appropriateness of prosthetic devices;
   3. (iii) fine and gross motor functions inclusive of gait, posture, stance, range of motion and balance; and

   4. (iv) appropriate use of physical modalities for habilitation and treatment.

      (d) Other optional services.

      Clinicians delivering any of the following services to persons admitted to the clinic shall be responsible to develop a diagnostic and evaluation summary as specified in subdivision (e) of this section. Such clinicians shall also be responsible to participate in the interdisciplinary team planning process and the development of the person's recommended treatment plan as specified in subdivision (f) of this section.

4. (1) Nutritional services shall be provided to each person staying at the diagnostic and research clinic for evaluation for any period that extends through a meal time, including persons admitted to the clinic's residential unit (i.e., the ICF/DD for overnight stays.

   1. (i) Meals provided to such persons during the day at the clinic or while staying at the ICF/DD shall comply with the person's dietary and medical needs.
   2. (ii) Persons shall be supervised during meal times to ensure that they receive adequate amounts of food and fluid at proper temperatures.

   3. (iii) The clinic shall maintain sanitary standards and comply with appropriate State and local regulations. Such standards shall include, but not be limited to:

      1. (a) following effective procedures for cleaning all equipment, work and eating areas;
      2. (b) providing hand-washing facilities, including hot and cold water, soap and paper towels;
      3. (c) ensuring that personnel having symptoms of communicable diseases or open wounds are not permitted to participate in food preparation or service; and
      4. (d) equipping dining areas with tables, chairs, eating utensils and dishes designed to meet the developmental needs of each person.
5. (2) Living environment services shall be provided to each person staying at the clinic's residential unit (i.e., the ICF/DD) in the manner appropriate to the person's needs.
6. (3) Nursing services shall be available to each person admitted to the diagnostic and research clinic if such a service is needed to facilitate the person's evaluation. Nursing services shall be provided to persons admitted to the clinic's residential unit for overnight stays.
7. (4) Self-care services, if required, shall be provided to each person admitted to the diagnostic and research clinic for residential and nonresidential visits so that each person's hygiene, personal care, and adaptive behavioral needs are attended to during the person's stay at the clinic and the clinic's residential unit.
8. (5) Autopsy services shall be available at the clinic for deceased individuals with developmental disabilities in order to determine the etiology of the disorder that contributed to the person's death and to counsel their family so as to minimize the risk or prevent the occurrence of disabilities in future offspring. Such autopsy services shall be performed by a forensic pathologist licensed in the State of New York.

9. (6) Genetic counseling services shall be provided to persons with developmental disabilities and/or their families to minimize the risk or progression of a disability or to prevent its occurrence. Such counseling shall be conducted by a genetic counselor licensed in the State of New York.

   (e) Mandatory diagnostic and evaluation service summary.

10. (1) Each physician, lab technician or any other clinician performing an evaluation service in any of the areas above in subdivision (a), (b), (c) or (d) of this section shall also be responsible to prepare a written summary of his or her findings for each individual examined.

11. (2) This requirement shall apply regardless of the category under which the person has been admitted or regardless of the services the person has received while at the clinic.

    (f) Mandatory recommended treatment plan, conference and referral.

12. (1) Each person admitted to the clinic for any or all of the services specified in subdivision (a), (b), (c) or (d) of this section shall be afforded, in addition to a discipline summary stipulated in subdivision (e), an interdisciplinary team treatment planning conference conducted by the professionals who have assessed the person with developmental disabilities in specific disciplines. This group of professionals, working as an interdisciplinary team, shall develop an individualized recommended treatment plan for the person and shall follow the provisions in paragraphs (2) through (7) of this subdivision in so doing.
13. (2) Each recommended treatment plan shall include the diagnostic and evaluation service summaries written by each clinician evaluating the person with developmental disabilities.

14. (3) During the interdisciplinary team conference, each professional's findings in their particular disciplines shall be coordinated and integrated so that a single and unified profile of the person emerges. This unified profile shall include at least written statements concerning the person's:

    1. (i) etiology;
    2. (ii) symptomatology;
    3. (iii) classification according to activities of daily life;
    4. (iv) central nervous system process;
    5. (v) functional and behavioral skills and deficits; or
    6. (vi) diagnostic conclusion.
15. (4) Based on this unified profile, the interdisciplinary team shall develop a written recommended treatment plan in which the team states the person's behavioral and/or medical goals and short-range objectives, methods of intervention and correlative services oriented toward ameliorating the effects of the person's developmental disability(ies).
16. (5) The interdisciplinary team may also recommend that the person should receive additional services at another specialized diagnostic and evaluation program. Such a recommendation shall be written in the person's recommended treatment plan.

17. (6) The interdisciplinary team may recommend that the person should revisit the diagnostic and research clinic for follow-up, corollary, or supplemental service(s).

    1. (i) Date, time and service required shall be specified in the individual's recommended treatment plan.
    2. (ii) Each time the person revisits the clinic, a specific evaluation shall be written in the area(s) in which the person is assessed and included in the individual's recommended treatment plan; and the interdisciplinary team shall again meet to discuss the care that that person has been receiving, update the overall recommended treatment plan, and either change their recommendation for treatment or renew their recommendation of the course of action outlined in the treatment plan.
18. (7) The interdisciplinary team, after developing the recommended treatment plan, shall discuss and explain their findings and their recommendations, if possible, with the person, the person's correspondent, the referral agency or person, and if appropriate, with the individual's service coordinator assigned to the person at a program or residence serving that person.
19. (8) A complete copy of the individual's recommended treatment plan shall be given to the person or agency that originally referred the person to the clinic so that the recommended treatment plan can be acted upon.