Nursing homes and healthcare facilities must develop a comprehensive care plan within seven days of the completion of the comprehensive assessment and review and revise the care plan after each assessment. The interdisciplinary team must include the attending physician, a registered nurse and nurse aide with responsibility for the resident, a member of the food and nutrition services staff, and to the extent possible, the resident and resident representative, if applicable. If the attending physician is unable to participate, they can delegate to an NPP or arrange alternative methods of providing input. Other appropriate staff or professionals must also be involved based on the resident's needs. Residents and their representatives must be given the opportunity to participate in the development, review and revision of the care plan and must be provided with advance notice of care planning conferences. If the inclusion of the resident and/or resident representative is not practicable, documentation of the reasons must be included in the medical record. Facilities must facilitate the residents' and if applicable, the resident representatives' participation in the care planning process. The resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident. Nursing homes and healthcare facilities must take these new actions to ensure timely completion and IDT and resident involvement in the development of the Comprehensive Care Plan.

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