§ 2380.181. Assessment.
(a) Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.
(b) If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section.
(c) The assessment shall be based on assessment instruments, interviews, progress notes and observations.
(d) The program specialist shall sign and date the assessment.
(e) The assessment must include the following information:
(1) Functional strengths, needs and preferences of the individual.
(2) The likes, dislikes and interests of the individual, including vocational and employment interests.
(3) The individuals current level of performance and progress in the following areas:
(i) Acquisition of functional skills.
(iii) Personal adjustment.
(iv) Personal needs with or without assistance from others.
(4) The individuals need for supervision.
(5) The individuals ability to self-administer medications.
(6) The individuals ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.
(7) The individuals knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.
(8) The individuals ability to evacuate in the event of a fire.
(9) Documentation of the individuals disability, including functional and medical limitations.
(10) A lifetime medical history.
(11) Psychological evaluations, if applicable.
(12) Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.
(13) The individuals progress over the last 365 calendar days and current level in the following areas:
(ii) Motor and communication skills.
(iii) Personal adjustment.
(14) The individuals knowledge of water safety and ability to swim.
(f) The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.
The provisions of this § 2380.181 issued under sections 911 and 1021 of the Human Services Code (62 P.S. § § 911 and 1021); amended under sections 201(2), 403(b), 403.1(a) and (b), 911 and 1021 of the Human Services Code (62 P.S. § § 201(2), 403(b), 403.1(a) and (b), 911 and 1021); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)).
The provisions of this § 2380.181 adopted August 27, 2010, effective August 28, 2010, 40 Pa.B. 4935; amended October 4, 2019, effective in 120 days, 49 Pa.B. 5777. Immediately preceding text appears at serial pages (352113) to (352114) and (381387).
This section cited in 55 Pa. Code § 2380.173 (relating to content of records).
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