42 CFR §456.380

1. (a)Before admission to an ICF or before authorization for payment, a physician must establish a written plan of care for each applicant or beneficiary.
2. (b)The plan of care must include—
   1. (1)Diagnoses, symptoms, complaints, and complications indicating the need for admission;
   2. (2)A description of the functional level of the individual;
   3. (3)Objectives;
   4. (4)Any orders for—
      1. (i)Medications;
      2. (ii)Treatments;
      3. (iii)Restorative and rehabilitative services;
      4. (iv)Activities;
      5. (v)Therapies;
      6. (vi)Social services;
      7. (vii)Diet; and
      8. (viii)Special procedures designed to meet the objectives of the plan of care;
   5. (5)Plans for continuing care, including review and modification of the plan of care; and
   6. (6)Plans for discharge.
3. (c)The team must review each plan of care at least every 90 days.