(a) The operator shall:

1. (1) develop a comprehensive care plan based on the comprehensive assessment required by this Part and, when applicable, a transfer or discharge plan, for each registrant within five visits or within 30 days after registration, whichever is earlier. The adult day health care program and the referring managed care organization or care coordination model must be sure to coordinate with each other regarding the development of a registrant’s comprehensive care plan;
2. (2) designate staff members to ensure the completion of the comprehensive care plan with the participation of consultants in the medical, social, paramedical and related fields as appropriate;

3. (3) ensure that the comprehensive registrant care plan includes for each registrant:

   1. (i) designation of a professional person to be responsible for coordinating the comprehensive care plan;
   2. (ii) the registrant’s pertinent diagnoses, including mental health 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. (iii) the medical and nursing goals and limitations anticipated for each registrant and, as appropriate, the nutritional, social, rehabilitative and leisure time goals and limitations;
   4. (iv) the registrant's potential for remaining in the community;
   5. (v) transportation arrangements; and
   6. (vi) a description of all services to be provided to the registrant by the program, informal supports and other community resources pursuant to the comprehensive care plan, and how such services will be coordinated;
4. (4) ensure that development and modification of the comprehensive care plan is coordinated with other health care providers outside the program who are involved in the registrant's care.

(b) Designated staff members, with the participation of consultants in the medical, social, paramedical and related fields, as appropriate, shall:

1. (1) record in the clinical record changes in the registrant's status which require alterations in the registrant comprehensive care plan;
2. (2) modify the comprehensive care plan accordingly;
3. (3) review the comprehensive 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 comprehensive care plan.