(1) A plan of care is a written plan of supports and interventions based on an assessment of the status and needs of a recipient. The plan of care describes the needs of the recipient and the services available through the program and otherwise that are to be made available to the recipient in order to maintain the recipient at home and in the community.

(2) The services that a recipient may receive through the program and the amount, scope and duration of those services must be specifically authorized in writing through an individual plan of care for the person.

(3) The plan of care is initially developed upon the person's entry into the program. The plan must be reviewed and, if necessary, revised at intervals of at least 6 months beginning with the date of the initial plan of care.

(4) Each plan of care is developed, reviewed and revised by the case management team.

(5) The case management team in developing the plan of care consults with the recipient or the recipient's legal representative, with treating and other appropriate health care professionals and others who have knowledge of the recipient's needs.

(6) Each plan of care must include the following:

(a) diagnosis, symptoms, complaints and complications indicating the need for services;

(b) a description of the recipient's functional level;

(c) objectives;

(d) any orders for:

(i) medication;

(ii) treatments;

(iii) restorative and rehabilitative services;

(iv) activities;

(v) therapies;

(vi) social services;

(vii) diet; and

(viii) other special procedures recommended for the health and safety of the recipient to meet the objectives of the plan of care.

(e) the specific services to be provided, the frequency of the services, and the type of provider to provide them;

(f) the projected annualized costs of each service; and

(g) names and signatures of all persons who have participated in developing the plan of care (including the recipient, unless the recipient's inability to participate is documented) which will verify participation, agreement with the plan of care, and acknowledgement of the confidential nature of the information presented and discussed.

(7) The case management team must provide a copy of the plan to the recipient.

(8) Plan of care approval is based on:

(a) completeness of plan;

(b) consistency of plan with screening criteria; and

(c) feasibility of service provision, including cost-effectiveness of plan as provided for in ARM 37.40.1421.