456.380—Individual written plan of care.
(a)
Before admission to an ICF or before authorization for payment, a physician must establish a written plan of care for each applicant or recipient.
(b)
The plan of care must include—
(1)
Diagnoses, symptoms, complaints, and complications indicating the need for admission;
(2)
A description of the functional level of the individual;
(iii)
Restorative and rehabilitative services;
(viii)
Special procedures designed to meet the objectives of the plan of care;
(5)
Plans for continuing care, including review and modification of the plan of care; and
(c)
The team must review each plan of care at least every 90 days.