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for privacy and independence (including, but not limited to, toilet training, personal hygiene,

dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs),

until it has been demonstrated that the client is developmentally incapable of acquiring them.

Guidance §483.440(c)(6)(iii)

All clients who lack the skills listed within this standard have associated training programs

developed to meet their needs according to prioritization. These programs are consistently

implemented in both formal and informal settings.

“Developmentally incapable” is a decision made by the IDT that means a client does not have

the capacity to acquire certain skill sets. The decision must be based on an assessment of the

client’s strengths, needs, and functional limitations.

The determination of developmental incapability must be accompanied by written evidence

supporting this determination.

Such evidence may include training programs which failed after many different strategies were

tried, or physical limitations that preclude the acquisition of the skill. Examples are:

1) Eye contact program was attempted using seven different methods over a two year

period;

2) An client has two frozen elbow joints which do not allow her to get her hands to her

mouth and consequently she will not be trained on any hand to mouth skills; and

3) Some clients may have insufficient neuromuscular and sensory control to ever be totally

independent in toileting skills.

Toilet scheduling alone without any plan to progress would not be considered a toilet training

program.

The components of functional skills “training” as used in this regulation means aggressive

implementation of a systematic program of formal and informal techniques, which are:

• targeted toward assisting the client achieving the measurable behavioral level of skill

competency specified in IPP objectives;

• implemented at natural occurrences of activity and training programs; ( e.g.: an

objective for a client to increase grasping may be implemented as easily in the workshop

with a built up tool as in the bathroom with a toothbrush);

• conducted by all personnel involved with the client including those outside the home

such as in day programs; and

• carried out in conversation and interaction with the client appropriate to the situation.

§483.440(c)(6)(iv) Identify mechanical supports, if needed, to achieve proper body position,

balance, or alignment. The plan must specify

Guidance §483.440(c)(6)(iv)

The use of mechanical supports are based upon an individual assessment and fitting.

Mechanical devices are used to support a client's proper body position or alignment and may be

essential to prevent contractures or deformities. However, mechanical supports restrict

movement and the client should be released from the support periodically for exercise and free

movement. Mechanical supports may not be used as a substitute for programs or therapy. For

example, the use of a bolster to position a client upright in a sitting position without any

indication there has been an assessment for the need for muscle re-training may be an

indication of a mechanical device in lieu of programming. Some supports allow movement and

provide opportunity for more increased functioning. Some examples of devices used as

mechanical supports include splints, wedges, bolsters, lap trays, etc.

Wheelchairs are not generally used to position or align the body and would not alone constitute

a mechanical support. However, adaptations to a wheelchair which facilitate correct body

alignment by inhibiting reflexive, involuntary motor activity are mechanical supports and should

be included in the plan for the client.