Ill. Admin. Code tit. 77, § 270.1900 – Comprehensive Care Plan

a) The results of the assessment shall be used to develop a comprehensive care plan within three days of completing the patient assessment for each patient, which includes measurable objectives and timetables to meet a patient's medical, nursing, mental and psychosocial needs that were identified in the assessment. The comprehensive care plan shall include a discharge plan.
b) The licensee shall establish a policy that defines the members of the interdisciplinary team who will develop and periodically review the comprehensive care plan at a team conference. Team members shall include at least the following:
1. 1) Patient;
2. 2) Patient's representative, if he/she chooses to participate;
3. 3) Patient's Program Manager;
4. 4) Registered nurse; and
5. 5) Physician.
c) The comprehensive care plan shall be implemented.
d) The facility shall develop a comprehensive care plan evaluation component to measure a patient's progress and the need for revised objectives.
e) The comprehensive care plan shall be reviewed and revised by the interdisciplinary team as frequently as needed by the patient. A full care plan conference shall be held by the interdisciplinary team at least every 21 days.