42 C.F.R. § 456.380 – Individual written plan of care.

(a) Before admission to an ICF or before authorization for payment, a physician must establish a written plan of care for each applicant or beneficiary.
(b) The plan of care must include—
1. (1) Diagnoses, symptoms, complaints, and complications indicating the need for admission;
2. (2) A description of the functional level of the individual;
3. (3) Objectives;
4. (4) Any orders for—
  1. (i) Medications;
  2. (ii) Treatments;
  3. (iii) Restorative and rehabilitative services;
  4. (iv) Activities;
  5. (v) Therapies;
  6. (vi) Social services;
  7. (vii) Diet; and
  8. (viii) Special procedures designed to meet the objectives of the plan of care;
5. (5) Plans for continuing care, including review and modification of the plan of care; and
6. (6) Plans for discharge.
(c) The team must review each plan of care at least every 90 days.