.22 Care Planning.

A. Individualized Plan of Care.

(1) There shall be an individualized plan of care completed for each participant within 30 days following admission.

(2) The participant shall participate in the development of the plan of care, along with the multidisciplinary team, unless the center documents the reasons why the participant is unable or unwilling to participate.

(3) The plan of care shall be consistent with the comprehensive assessment and shall include a problem list.

(4) A registered nurse shall update the plan of care within 7 calendar days of a participant's change in status, but not less than semiannually.

(5) The participant's plan of care shall be based on the comprehensive assessment that is completed by registered nurse as described in Regulation .21 of this chapter.

(6) The plan of care shall include:

(a) Orders by a Health care provider;

(b) All pertinent diagnoses;

(c) Frequency and types of services required;

(d) Treatment goals for each type of service ordered;

(e) Rehabilitation, services, and prognosis;

(f) Functional and cognitive limitations;

(g) Level of activity permitted;

(h) Diet;

(i) Medication and treatment or treatments;

(j) Measurable goals for each problem or need that is identified;

(k) Goals that are realistic, practical, and tailored to the desired outcome for the participant; and

(l) Approaches to accomplishing each goal.

(7) The multidisciplinary team shall document all components of the participant's care plan in the participant's medical record;

(8) The center shall give family members, and others designated by the individual with proper consent or responsible parties, an opportunity to participate in the care plan meeting.

B. Attendance and Unscheduled Absences.

(1) Staff shall maintain daily records on each participant's attended days of care.

(2) When a participant is absent on a scheduled day, staff shall investigate on the day of the occurrence to learn the reason for the absence and document the reason.

(3) The center shall have documentation that:

(a) Absences are reviewed on at least a 30-day basis; and

(b) Appropriate action has been taken.