Section 220.2000  Individual Rehabilitation Plan

a)         Within 10 days after the completion of the assessment conducted pursuant to Section 220.1900 of this Part, the results of the assessment shall be used to revise the individualized rehabilitation plan, designed by the rehabilitation team, that establishes goals and objectives that incorporate the unique strengths, abilities, and preferences of the person served and relates to the services and environment to which the person will be discharged.  The design of individualized program plans shall be consistent with the outcome goals that are established for each resident.  (Section 35(4) of the Act)

b)         The individual rehabilitation plan shall include, at a minimum:

1)         The desired outcome goals for the program;

2)         Identification of targeted objectives to achieve the outcome goals;

3)         Services needed to support the targeted objectives;

4)         Anticipated times frames for accomplishing the goals and objectives; and

5)         Persons responsible for implementing the rehabilitation plan.

c)         The licensee shall define the members of the rehabilitation team who will develop and review the rehabilitation plan.  The members of the rehabilitation team shall include, at a minimum:

1)         The participant;

2)         Participant representative, if he/she chooses to participate, and any other persons chosen by the participant;

3)         A person assigned to coordinate services for the person (case manager or designee);

4)         A nurse; and

5)         Persons providing services for the participant, based on the assessment.

d)         The rehabilitation team shall meet at least every 30 days to implement and modify, as needed, the rehabilitation plan and discharge plan.

e)         The case manager or case manager designee shall ensure that the rehabilitation plan is implemented and that the appropriate services are coordinated to ensure that the rehabilitation plan is followed.