42 CFR §441.155

1. (a)“Individual plan of care” means a written plan developed for each beneficiary in accordance with §§ 456.180 and 456.181 of this chapter, to improve his condition to the extent that inpatient care is no longer necessary.
2. (b)The plan of care must—
   1. (1)Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the beneficiary's situation and reflects the need for inpatient psychiatric care;
   2. (2)Be developed by a team of professionals specified under § 441.156 in consultation with the beneficiary; and his parents, legal guardians, or others in whose care he will be released after discharge;
   3. (3)State treatment objectives;
   4. (4)Prescribe an integrated program of therapies, activities, and experiences designed to meet the objectives; and
   5. (5)Include, at an appropriate time, post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the beneficiary's family, school, and community upon discharge.
3. (c)The plan must be reviewed every 30 days by the team specified in § 441.156 to—
   1. (1)Determine that services being provided are or were required on an inpatient basis, and
   2. (2)Recommend changes in the plan as indicated by the beneficiary's overall adjustment as an inpatient.
4. (d)The development and review of the plan of care as specified in this section satisfies the utilization control requirements for—
   1. (1)Recertification under §§ 456.60(b), 456.160(b), and 456.360(b) of this subchapter; and
   2. (2)Establishment and periodic review of the plan of care under §§ 456.80, 456.180, and 456.380 of this subchapter.