(a) A family care home shall assure a care plan is developed for each resident in conjunction with the resident assessment to be completed within 30 days following admission according to Rule .0801 of this Section. The care plan shall be an individualized, written program of personal care for each resident.
(b) The care plan shall be revised as needed based on further assessments of the resident according to Rule .0801 of this Subchapter.
(c) The care plan shall include the following:
(1) a statement of the care or service to be provided based on the assessment or reassessment; and
(2) frequency of the service provision.
(d) The assessor shall sign the care plan upon its completion.
(e) The facility shall assure that the resident’s physician authorizes personal care services and certifies the following by signing and dating the care plan within 15 calendar days of completion of the assessment:
(1) the resident is under the physician’s care; and
(2) the resident has a medical diagnosis with associated physical or mental limitations that justify the personal care services specified in the care plan.
(f) The facility shall assure that the care plan for each resident who is under the care of a provider of mental health, developmental disabilities or substance abuse services includes resident specific instructions regarding how to contact that provider, including emergency contact. Whenever significant behavioral changes described in Rule .0801(c)(1)(D) of this Subchapter are identified, the facility shall refer the resident to a provider of mental health, developmental disabilities or substance abuse services in accordance with Rule .0801(d) of this Subchapter.