§ 460.106 Plan of care.

(a) Definition and basic requirements—(1) Definition. For purposes of this section, a “change in participant's status” means a major decline or improvement in a participant's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the participant's health status and requires interdisciplinary team review or revision of the care plan, or both.

(2) Basic requirements. (i) The interdisciplinary team members specified in § 460.102(b) must develop, evaluate, and if necessary, revise a comprehensive person-centered plan of care for each participant.

(ii) Each plan of care must do all of the following:

(A) Take into consideration the most current assessment findings.

(B) Identify the services to be furnished to attain or maintain the participant's highest practicable level of well-being.

(b) Timeframes for developing, evaluating, and revising plan of care. (1) Initial plan of care. The interdisciplinary team must complete the initial plan of care within 30 calendar days of the participant's date of enrollment.