Section 270.1900  Comprehensive Care Plan

a)         The results of the assessment shall be used to develop a comprehensive care plan within three days of completing the patient assessment for each patient, which includes measurable objectives and timetables to meet a patient's medical, nursing, mental and psychosocial needs that were identified in the assessment.  The comprehensive care plan shall include a discharge plan.

b)         The licensee shall establish a policy that defines the members of the interdisciplinary team who will develop and periodically review the comprehensive care plan at a team conference.  Team members shall include at least the following:

1)         Patient;

2)         Patient's representative, if he/she chooses to participate;

3)         Patient's Program Manager;

4)         Registered nurse; and

5)         Physician.

c)         The comprehensive care plan shall be implemented.

d)         The facility shall develop a comprehensive care plan evaluation component to measure a patient's progress and the need for revised objectives.

e)         The comprehensive care plan shall be reviewed and revised by the interdisciplinary team as frequently as needed by the patient.  A full care plan conference shall be held by the interdisciplinary team at least every 21 days.