Authority: IC 16-28-1-7

Affected: IC 16-28-5-1

Sec. 35. (a) The facility must develop a written comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.

(b) The care plan must describe the following:

1. (1) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
2. (2) Any services that would otherwise be required, but are not provided due to the resident's exercise of rights, including the right to refuse treatment.

(c) A comprehensive care plan must be:

1. (1) developed within seven (7) days after the completion of the comprehensive assessment; and

2. (2) prepared by an interdisciplinary team that includes:

   1. (A) the attending physician;
   2. (B) a registered nurse with responsibility for the resident; and
   3. (C) other appropriate staff in disciplines as determined by the resident's needs;
3. and to the extent practicable with the participation of the resident and the resident's family.

(d) The written care plan shall indicate the following:

1. (1) Resident care priorities.

2. (2) Plans of action to achieve identified goals as follows:

   1. (A) For each goal, the disciplines responsible for assisting in achieving these goals.
   2. (B) Periodically reviewed and revised at a care plan conference by a team of qualified persons, with the participation of the resident and the resident's family to the extent practicable, after each assessment or assessment review.

(e) Documentation of care plan reviews shall indicate the date of the review and the initials of each reviewer present and that the goals and approaches have been updated in accordance with the resident's condition.

(f) The resident's care plan shall be available for use by all personnel caring for the resident.

(g) The services provided or arranged by the facility must:

1. (1) meet professional standards of quality; and
2. (2) be provided by qualified persons in accordance with each resident's written care plan.

(h) For purposes of IC 16-28-5-1, a breach of:

1. (1) subsection (a), (b), (f), or (g) is a deficiency; and
2. (2) subsection (c), (d), or (e) is a noncompliance.

(Indiana Department of Health; 410 IAC 16.2-3.1-35; filed Jan 10, 1997, 4:00 p.m.: 20 IR 1554, eff Apr 1, 1997; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; readopted filed Sep 11, 2013, 3:19 p.m.: 20131009-IR-410130346RFA; readopted filed Nov 13, 2019, 3:14 p.m.: 20191211-IR-410190391RFA; readopted filed Nov 14, 2025, 11:18 a.m.: 20251210-IR-410240588RFA)