42 CFR 456.380 : Public Health (Part 1 To Parts 1009-1099) — (§ 430.0 To Part 481) — Centers For Medicare & Medicaid Services, Department Of Health And Human Services (Continued) (§ 430.0 To Part 481) — Medical Assistance Programs (§ 430.0 To § 456.725) — Utilization Control (§ 456.1 To § 456.725) — Utilization Control: Intermediate Care Facilities (§ 456.350 To § 456.438) — Plan Of Care (§ 456.380 And § 456.381) — Individual written plan of care.

4 Aug 2016

(a) Before admission to an ICF or before authorization for payment, a physician must establish a written plan of care for each applicant or beneficiary.

(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;

(3) Objectives;

(4) Any orders for -

(i) Medications;

(ii) Treatments;

(iii) Restorative and rehabilitative services;

(iv) Activities;

(v) Therapies;

(vi) Social services;

(vii) Diet; and

(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

(6) Plans for discharge.

42 CFR 456.380