1. (a) An adult day health care program care plan based on the comprehensive assessment required by this Part, and, when applicable, a transfer or discharge plan, is developed for each registrant and is in place within five visits or within 30 days after registration, whichever is earlier. The adult day health care program and the referring managed long term care plan or care coordination model must be sure to coordinate with each other regarding the development of a registrant’s care plan.

2. (b) Each registrant's care plan must include:

   1. (1) designation of a professional person to be responsible for coordinating the care plan;
   2. (2) the registrant's pertinent diagnoses, including mental status, types of equipment and services required, case management, frequency of planned visits, prognosis, rehabilitation potential, functional limitations, planned activities, nutritional requirements, medications and treatments, necessary measures to protect against injury, instructions for discharge or referral if applicable, orders for therapy services, including the specific procedures and modalities to be used and the amount, frequency and duration of such services, and any other appropriate item;
   3. (3) the medical and nursing goals and limitations anticipated for the registrant and, as appropriate, the nutritional, social, rehabilitative and leisure time goals and limitations;
   4. (4) the registrant's potential for remaining in the community; and
   5. (5) a description of all services to be provided to the registrant by the program, informal supports and other community resources pursuant to the care plan, and how such services will be coordinated;
3. (c) Development and modification of the care plan is coordinated with other health care providers outside the program who are involved in the registrant's care.

4. (d) The responsible persons, with the appropriate participation of consultants in the medical, social, paramedical and related fields involved in the registrant's care, must:

   1. (1) record in the clinical record changes in the registrant's status which require alterations in the registrant care plan;
   2. (2) modify the care plan accordingly;
   3. (3) review the care plan at least once every six months and whenever the registrant's condition warrants and document each such review in the clinical record; and
   4. (4) promptly alert the registrant's authorized practitioner of any significant changes in the registrant's condition which indicate a need to revise the care plan.

The operator must ensure that: