§ 456.180 Individual written plan of care.

(a) Before admission to a mental hospital or before authorization for payment, the attending physician or staff 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; (3) Objectives; (4) Any orders for— (i) Medications; (ii) Treatments; (iii) Restorative and rehabilitative services; (iv) Activities; (v) Therapies; (vi) Social services; (vii) Diet; and (viii) Special procedures recommended for the health and safety of the patient; (5) Plans for continuing care, including review and modification to the plan of care; and (6) Plans for discharge. (c) The attending or staff physician and other personnel involved in the beneficiary's care must review each plan of care at least every 90 days.