(c) OPWDD shall verify that since the last survey:

1. (1) any new/revised policies have been approved by the governing body;
2. (2) said new/revised policies have been distributed to staff, and they have been advised or trained regarding their responsibilities; and
3. (3) said staff are knowledgeable regarding their responsibilities under any new/revised policies/procedures.

(i) OPWDD shall verify when services have been delivered by students-in-training that:

1. (1) the facility's plan for supervision of the service where it is delivered, has been implemented consistently and appropriately;
2. (2) persons receiving services from students-in-training have been so advised and that recipients rejecting such services have not had their rights to services compromised; and
3. (3) no more than 15 percent of a facility's total billed for units of service are delivered by students-in-training.

(j) OPWDD shall verify that there is a clinical record maintained in a confidential manner for each person admitted to the facility which contains at least:

1. (1) identification information about the applicant/service recipient and his or her family and services received outside of the clinic (including identification of practitioner or responsible entity);
2. (2) source of referral, date commencing service/treatment, and the name of the party responsible for treatment coordination;
3. (3) initial, interim, and/or final diagnosis(es), as applicable, set forth in appropriate official terminology, including those related to the person's developmental disability, other mental disability(ies) if present, and medical condition/diagnoses;
4. (4) reports of all known, recent (i.e., within the last two years) diagnostic examinations and assessments including findings and conclusions, regardless of source, including reports of any special studies and/or laboratory procedures performed at the clinic's recommendation;
5. (5) the individual written plan of services for all treatments being recommended and delivered by the clinic; and
6. (6) treatment notes signed by the professional staff member or treatment coordinator making the note.

(k) There shall be a written plan of services which also documents that the outcomes and/or course of treatment has been reviewed as to the achievement of said outcomes and the need for continued course of treatment pursuant to the following schedule:

1. (1) as specified by the treating physician or dentist, for medical or dental treatment; and
2. (2) at least semi-annually by the treating practitioner or treatment coordinator in consultation with the person receiving the service and/or his/her collaterals (unless the person is an adult, has the capacity to object, and does so object to the provision of such services), for all other ongoing rehabilitation/habilitation services (see section 679.3[j][2] of this Part) or health care services (see section 679.3[j][4] of this Part) of six months or longer duration.

(l) OPWDD shall verify that there is a licensed physician or dentist, as appropriate, assigned responsibilities as the medical director for the facility who shall:

1. (1) if a physician, be board certified by the American Board of Medical Specialties in pediatrics, adult medicine, neurology, family practice medicine, or internal medicine, or be eligible for said certification. Given documentation of the unique or specialized needs of the majority of persons to be served, the clinic, subsequent to OPWDD approval, may employ a candidate with or eligible for an alternative board certified specialization such as psychiatry; or
2. (2) if a dentist, be board certified in an appropriate specialty (if engaging in any amount of specialized dental practice under the clinic treatment facility's auspices), or be eligible for said certification; and
3. (3) be qualified pursuant to agency policy for the position by training, experience, and administrative ability.

(m) OPWDD shall verify that the written plan for the facility's quality assurance program describes the program's objectives, organization, responsibilities of all staff members, scope of the program and procedures for overseeing the effectiveness of monitoring, assessment and problem-solving activities and that the plan has been implemented. The quality assurance process shall define methods for the identification and selection of clinical and administrative problems to be reviewed, and include:

1. (1) the establishment of review criteria developed in accordance with current standards of professional practice for monitoring and assessing the appropriateness of treatment and clinical performance;
2. (2) regularly scheduled reviews of clinical records, complaints, suggestions from persons served and their collaterals, reported incidents or allegations of abuse, and other documents pertinent to problem identification;
3. (3) documentation of all quality assurance activities, including but not limited to the findings, recommendations, and actions taken to resolve identified problems; and
4. (4) the timely implementation of corrective actions and periodic assessments of the results of such actions with adjustments, as appropriate.

(n) OPWDD shall verify that the clinic's administration has reported the findings, conclusions, recommendations, and actions taken as a part of the quality assurance program to the governing body. OPWDD shall verify, that when problems have been identified, the outcomes of the quality assurance program have resulted in one or more of all of the following:

1. (1) changes in the treatments/services received by persons who have been admitted;
2. (2) improvements in the efficiency and effectiveness of service delivery;
3. (3) revision or development of facility policies/procedures; and/or
4. (4) changes in the granting or renewing of staff privileges, as appropriate.