28 Pa. Code § 131.23
There shall be a current written plan of care for each patient receiving treatment, based on the direction of the attending physician and on the rehabilitation potential of the patient. The plan of care shall state the needs and limitations of the patient as well as the goals of the treatment program for that patient. Because the patient should be an active participant in his treatment program, the prescribing physician or the person providing the service, or both, should discuss the treatment goals and the capabilities of the rehabilitative service with the patient or his family, or both. The prescribing physician, or the person providing the service, or both, should participate in planning for the discharge and followup care of the patient, whenever indicated. The patient or his family, or both, should receive the written instructions that are necessary for the appropriate aftercare of the patient.
28 Pa. Code § 131.23