1. (a) Before admission or no later than 2 days after admission of a recipient to a cost reimbursed hospital or hospital unit, the attending or staff physician shall establish, and include in the recipient’s medical record, an individual written plan of care.

2. (b) The plan of care must include:

   1. (1) Medical justification for admission and continued stay.
   2. (2) Diagnoses, symptoms, complaints and complications indicating the need for admission.
   3. (3) A description of the functional level of the individual.
   4. (4) Orders for medications, treatments, restorative and rehabilitative services, activities, therapies, social services and diet.
   5. (5) Plans for continuing care including review and modification of the plan of care.
   6. (6) Plans for discharge.
3. (c) The orders and activities shall be developed in accordance with physician’s instructions and be reviewed and revised as appropriate to treat the recipient’s condition.

Source

The provisions of this § 1163.476 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185.

Cross References

This section cited in 55 Pa. Code § 1163.457 (relating to payment policies relating to out-of-State hospitals); 55 Pa. Code § 1163.458 (relating to payment policies relating to same-calendar-day admissions and discharges); and 55 Pa. Code § 1163.473 (relating to hospital utilization review plan).