42 CFR 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 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;
(4) Any orders for -
(iii) Restorative and rehabilitative services;
(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.
(c) The team must review each plan of care at least every 90 days.