Section 455IAC2-19-1. Coordination of services and plan of care

   (a) As follows, the case manager shall create a plan of care for the individual that shall:

(1) Consist of a formal description of goals, objectives, and strategies, including the following:

(A) Desired outcomes.

(B) Persons responsible for implementation.

(2) Be designed to enhance independence.

  (b) The provider shall assess the appropriateness of an individual's goals at least once every ninety (90) days as described in 455 IAC 2-17-6.

  (c) All entities responsible for providing service to an individual shall do the following:

(1) Coordinate the services provided to an individual.

(2) Share documentation regarding the individual's well-being, as required by the individual's care plan.

(Division of Aging; 455 IAC 2-19-1; filed Sep 1, 2006, 8:20 a.m.: 20060927-IR-460050119FRA; errata filed Aug 25, 2011, 1:41 p.m.: 20110914-IR-455110468ACA; readopted filed Nov 2, 2012, 8:32 a.m.: 20121121-IR-455120508RFA) NOTE: Transferred from the Division of Disability and Rehabilitative Services (460 IAC 1.2-19-1) to the Division of Aging (455 IAC 2-19-1) by P.L.153-2011, SECTION 21, effective July 1, 2011.