(g) Each individual program plan shall specify the conditions to be treated, and the anticipated preventive and/or restorative outcomes resulting from the various therapeutic interventions to be used. The individual program plan shall be written and maintained in the manner, frequency and format prescribed by OPWDD and shall contain the following components:

1. (1) the goals and long- and short-term objectives established to attain or maintain the optimal level of health, self-care, communication, learning, mobility, recreation and capacity for independent living of which the individual is presently or potentially capable;
2. (2) service plans for each mandatory and selective service which combine into an integrated program of individually designed activities, experiences and programs necessary to achieve each individual's objectives. These plans shall contain, as appropriate, specific individual medical prescriptions or written direction from the interdisciplinary team for all necessary services;
3. (3) progress notes describing the individual's response to programs and services;
4. (4) an activity schedule for each individual which includes all programs, services and leisure time activities prescribed by the interdisciplinary team; and
5. (5) identification of the person responsible for providing each program or service.

(h) Review of each individual program plan shall be performed as follows:

1. (1) At least monthly a member or members of the interdisciplinary team shall review the individual's response to the individual program plan to determine any necessary modifications. Written documentation of such reviews shall be maintained in the individual's record.

2. (2) At least quarterly, the interdisciplinary team shall collectively review and evaluate each person's individual program plan. This review shall describe the improvement or lack of improvement in those conditions for which the individual was admitted and additionally include:

   1. (i) such reassessments of the individual's condition, assets or disabilities as may be indicated prior to the interdisciplinary team's review conference;
   2. (ii) participation by the individual and his or her correspondent, unless the individual is an adult competent to object and objects to such participation;
   3. (iii) input and relevant participation from professional and nonprofessional staff providing services to the individual;
   4. (iv) a review of the individual's response to the active programming provided during the previous quarter; and
   5. (v) establishment of modified or new long- and short-range objectives, as appropriate.
3. (3) At least quarterly, the individual coordinator shall send written notification of the individual's medical condition and progress in programs and services to the individual's correspondent.
4. (4) Prior to discharge or for an extended stay beyond six months and performed in accordance with individual need, an interdisciplinary team, consisting of individuals who are representative of the professions or services included in this Part (that are relevant in each particular case), including direct care staff, shall conduct a comprehensive reassessment (based upon individual assessments) of each individual, covering self-care, health, communication, learning, mobility and capacity for independent living.

5. (5) At least quarterly, the interdisciplinary team shall collectively review the status of each individual, including consideration of the following:

   1. (i) the advisability of continued residence at the specialty hospital and alternative programs; and
   2. (ii) review of the need for guardianship and how the individual may exercise his or her civil and legal rights when the person legally becomes an adult.

(i) The individual's individual program plan and program shall be periodically monitored by OPWDD to ensure:

1. (1) the adequacy of the record and the appropriateness of the services delivered;
2. (2) integration of all programs and services provided to each individual;
3. (3) required reviews and assessments are accomplished as prescribed in this Part; and
4. (4) the notifications required in paragraph (h)(3) of this section are made.

(j) The specialty hospital shall maintain the following system of records:

1. (1) Individual record. The specialty hospital shall maintain a comprehensive record for each person. Each record shall be organized in the manner and contain the information prescribed by OPWDD. Each individual's record shall contain the following types of information:

   1. (i) identification information;
   2. (ii) admission information, including the individual's medical and developmental history, and documentation of the commissioner's prior approval of admission;
   3. (iii) a current individual program plan (as specified in subdivisions [a] through [i] of this section);
   4. (iv) copies of assessments, reassessments, progress notes and previous individual program plans;
   5. (v) service plans, description of treatments provided and medications administered;
   6. (vi) reports of illness or injury including the date and time of occurrence and action taken regarding each occurrence;
   7. (vii) summary of findings, progress and plans when the individual is discharged.

2. (2) Record of program operations. The administrator shall maintain or cause to be maintained the following records of program operations:

   1. (i) a chronological admission and discharge register which is a daily alphabetical listing of individuals admitted and discharged from the specialty hospital by name of individual, including referral and/or placement information;
   2. (ii) a daily census record including daily census and cumulative census for each month and year;
   3. (iii) notation of all accident and incident reports;
   4. (iv) fire drill records;
   5. (v) dietary service record;
   6. (vi) records that document compliance with sanitation, health and environmental safety codes including written reports of inspections by State and local authorities having primary jurisdiction and records of action taken on their recommendations;
   7. (vii) copies of all transfer and affiliation agreements;
   8. (viii) a copy of the emergency disaster plan;
   9. (ix) a master plan for staffing;
   10. (x) a personnel record for each staff member including all available pre-employment information and, for professional staff, a copy of the current registration and license or certificate.

3. (3) Confidentiality.

   1. (i) The individual and his or her correspondent shall have access to the total record upon request unless proscribed by order of the court, or unless the person is an adult and objects to the correspondent's having access to the record.
   2. (ii) The staff of the specialty hospital shall keep all medical, social, personal and financial information about an individual confidential and make it available only to persons authorized by law or by the commissioner.
   3. (iii) The individual record is the property of the specialty hospital, which shall protect it from loss, damage, tampering or use by unauthorized individuals.
   4. (iv) The specialty hospital shall obtain written consent of the individual, or the individual's next of kin or guardian before releasing information to persons who are not otherwise authorized to receive it.
   5. (v) The specialty hospital shall have the individual's record available in his or her living unit.

4. (4) Central record service.

   1. (i) The specialty hospital shall maintain a centrally administered record service for the collection and release of individual information.
   2. (ii) The specialty hospital shall make records readily accessible to authorized personnel.
   3. (iii) The specialty hospital shall retain all clinically oriented individual records in accordance with OPWDD's Manual of Policy and Procedures.
   4. (iv) The specialty hospital shall submit any data or information contained in the individual records, the record of program operations or any other agency records to the commissioner upon request. Such requested information shall be submitted in the format and manner prescribed by OPWDD.