(1) Based on the initial resident's needs assessment, an initial service plan shall be developed for all category A residents within 24 hours of admission. The initial service plan shall be reviewed or modified within 60 days of admission to assure the service plan accurately reflects the resident's needs and preferences.
(2) The service plan shall include a written description of:
(a) what the service is;
(b) who will provide the service;
(c) when the service is performed;
(d) where and how often the service is provided;
(e) changes in service and the reasons for those changes;
(f) if applicable, the desired outcome;
(g) an emergency contact with phone number; and
(h) the prospective resident's practitioner's name, address, and telephone number and whether there are any health care decision making instruments in effect if applicable.
(3) The resident service plan shall be reviewed and updated annually, or at any time the resident has a significant change.
(4) A copy of the resident service plan shall be given to the resident or resident's legal representative and be made part of the resident file.