(1) any new/revised policies have been provided to the governing body;

(2) any new/revised policies have been distributed to staff, and, when applicable, staff have been advised or trained regarding their responsibilities; and

(3) staff are knowledgeable regarding their responsibilities under any new/revised policies/procedures.

(1) the adequacy of the record and the appropriateness of the services delivered relative to the person's comprehensive functional assessment;

(2) integration of all services provided at the day treatment facility;

(3) coordination of day treatment services with the person's services provided in a certified residence;

(4) reviews and assessments are present; and

(5) the appropriate notifications have been made.

(1) such reassessments of the person's capabilities, capacities, needs, and preferences as may be indicated;

(2) participation by the person, the person's correspondent (which includes invitation, if not actual attendance), and advocate (if appropriate), unless the person is an adult capable of objecting to such participation and has so objected;

(3) review of a person's comprehensive functional assessment for relevancy, updating it as necessary, and revising the individual program plan as appropriate;

(4) a review of the outcome of the services delivered;

(5) establishment of modified or new outcomes, if need or preference is indicated;

(6) a listing of all parties who attended the review, by name and title or role; and

(7) notification, at least semi-annually, of the person's status and progress sent to the person's correspondent and the certified residential facility, if applicable, unless the person is an adult with the capacity to object to such notification and does object.

(1) the advisability of continued receipt of day treatment services; or

(2) the advisability and availability of alternative services; and

(3) how the person may exercise his or her civil and legal rights.

(1) the establishment of review criteria developed for monitoring and assessing the appropriateness of treatment and clinical performance;

(2) regularly scheduled reviews of clinical records, complaints, suggestions from persons served, their correspondents and/or advocates, reported incidents or allegations of abuse, and other documents pertinent to problem identification;

(3) documentation of all quality assurance activities, including but not limited to the findings, recommendations, and actions taken to resolve identified problems; and

(4) the timely implementation of corrective actions and periodic assessments of the results of such actions with adjustments, as appropriate.

(1) identification information about the person and his or her family, and services received outside of the day treatment facility (including identification of practitioner or responsible entity);

(2) source of referral, date service commenced, and the name of the party responsible for treatment coordination;

(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) reports of all known, recent (i.e., within the last year) diagnostic examinations and assessments, including findings and conclusions, regardless of source, including reports of any special studies and/or laboratory procedures performed at the day treatment facility's recommendation;

(5) the individual written plan of services for all services being recommended and delivered by the facility; and

(6) treatment notes signed by the professional staff member or treatment coordinator making the note.

(1) progress notes describing the person's response in terms of the established objectives;

(2) written notations regarding significant changes in the person's performance, attitudes, feelings and physical condition;

(3) summaries specific to the person's goals and objectives prepared or reviewed and approved by qualified professionals providing or supervising services and reviewed by the treatment coordinator of the person's program plan; or a summarization, by the treatment coordinator, of all services being provided to the person;

(4) an activity and attendance schedule for each person;

(5) identification of the staff members responsible for providing each service; and

(6) at the time of discharge, a plan by which the person will be discharged to a facility or services more consistent with the person's needs and/or preferences. The plan shall include specific identification of any services needed and/or desired by the person.

(1) the person has been adjudicated incompetent under State law; and

(2) there is a demonstrable need for the information and it may be reasonably expected to not be detrimental to the person; or

(3) the person is under the age of 18.

(1) a preliminary screening, based on task oriented observations or a review by qualified professionals of the person's clinical records obtained from another appropriate source, was completed to the extent necessary to support admission to the facility, and included a preliminary appraisal or determination of the person's capabilities, capacities, and needs in the areas of communication, mobility, learning, independent living, self-care, health care and self-direction; and

(2) within 90 days of admission, this preliminary screening information has been fully verified by assessments (see glossary), and documented in the person's individual program plan.