N.Y. Comp. Codes R. & Regs. tit. 10 § 766.3 : DEPARTMENT OF HEALTH — Medical Facilities — State Hospital Code — Certified Home Health Agencies and Licensed Home Care Services Agencies — Licensed Home Care Services Agencies-minimum Standards — Plan of care

The governing authority or operator shall ensure that:

(a) all patients are accepted for health care services only after a determination has been made by a registered professional nurse or by an individual directly supervised by a registered professional nurse that the patient's needs can be safely and adequately met by the agency;
(b) a plan of care is established for each patient based on a professional assessment of the patient's needs and includes pertinent diagnosis, prognosis, need for palliative care, mental status, frequency of each service to be provided, medications, treatments, diet regimens, functional limitations and rehabilitation potential;
(c) orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency and duration of such services; and
(d) the plan of care is reviewed and revised as frequently as necessary to reflect the changing care needs of the patient, but no less frequently than every six months;
(1) each review shall be documented in the clinical record; and
(2) agency professional personnel shall promptly alert the patient's authorized practitioner and other affected care providers to any significant changes in the patient's condition that indicate a need to alter the plan of care.

N.Y. Comp. Codes R. & Regs. Tit. 10 § 766.3