(b) A plan of care shall be developed within 10 days of admission to the agency and approved by the patient based on the comprehensive interdisciplinary patient assessment. The plan shall designate a professional person employed by the agency to be responsible for coordinating care which includes but is not limited to:

1. (1) coordination of all services provided directly or by contract to the patient by the agency, informal supports and other community resources to carry out the agency's plan of care;
2. (2) cooperation with other health, social and community organizations providing or coordinating care;
3. (3) consultation with the patient's authorized practitioner, the local social services representative and discharge planner, if applicable. If an authorized practitioner has referred a patient under a plan of care that cannot be completed until after an evaluation visit, the authorized practitioner shall be consulted to approve additions or modifications to the original plan; and
4. (4) responsibility for maintaining current clinical records, conducting case reviews and completing required patient-specific records and reports, as appropriate.

(e) The plan of care shall be reviewed as frequently as required by changing patient conditions but at least every 60 days.

1. (1) each review shall be documented in the clinical record; and
2. (2) agency professional personnel shall promptly alert the patient's authorized practitioner to any significant changes in the patient's condition that indicate a need to alter the plan of care.