A. An interdisciplinary team shall complete a resident specific care plan for each resident within 7 calendar days following completion of all assessments.
B. A care plan under this regulation shall be based upon assessments conducted at the following times:
(3) Quarterly; and
(4) Significant change in the resident's condition.
C. A facility shall give a family member or resident's representative 7 calendar days advance notice, in writing, of the location, date, and time of the care planning conference for a resident for whom a family member or representative is interested. The notification shall include an invitation for the family member or resident's representative to attend the conference.
D. The facility shall hold the care planning conference not later than 7 calendar days after completion of the assessment, but may hold the conference earlier if agreed to by the resident, a family member, or a resident's representative.
E. Organization of Care Plan.
(1) Problems and needs shall be identified, based upon the interdisciplinary assessment. The care plan shall address all of the resident's special care requirements necessary to improve or maintain the resident's status. The interdisciplinary team shall incorporate resident input into the care plan.
(2) The team shall establish goals for each problem or need identified. The goal shall be realistic, practical, and tailored to the resident's needs. Goal outcome shall be measurable in time or degree, or both.
(3) Approaches to accomplishing each goal shall be established. Approaches shall communicate the work to be done, by whom it is to be done, and how frequently it is to be performed.
F. Disciplines shall update the care plans as the resident's assessment warrants, but not less than quarterly.
G. Availability of Resident Care Plan. Resident care plans shall be readily available for use by all health care personnel.