A. An interdisciplinary team shall complete or revise as necessary a resident-specific care plan for each resident within 7 calendar days following completion of assessments, including:
(1) Admission assessment;
(2) Annual assessment;
(3) Quarterly assessment; and
(4) Significant change in the residentís condition.
B. Care Plan Meeting. The nursing home shall, with the residentís consent:
(1) Give an interested and appropriate family member or residentís representative 7 calendar days advance notice, in writing, of the location, date, and time of a care planning conference for a resident;
(2) Strive to accommodate the schedules of invited family members and residentís representatives when scheduling care plan meetings; and
(3) Include an invitation for the family member or residentís representative to attend the conference.
C. The nursing home shall hold the care planning conference not later than 7 calendar days after completing the assessment, but may hold the conference sooner if agreed to by the resident, a family member, or a residentís representative.
D. Organization of Care Plan.
(1) Residentís problems and needs shall be identified, based upon the interdisciplinary assessment. The care plan shall address all of the residentís special care requirements necessary to improve or maintain the residentís status. The interdisciplinary team shall incorporate resident input into the care plan.
(2) The team shall establish goals for each problem or need identified, or a combination thereof. The goals shall be realistic, practical, and tailored to the residentís needs. Goal outcomes shall be measurable in time or degree, or both.
(3) Approaches to accomplishing each goal shall be established. Approaches shall indicate the work to be done, who is to do it, and how frequently it is to be done.
E. Disciplines shall update the care plans as the resident's assessment warrants, but not less than quarterly.
F. Availability of Resident Care Plan. Resident care plans shall be readily available for use by all health care personnel.