Patient Care Plan. A health care team, consisting of at least the physician, nurse practitioner, or physician assistant responsible for the patient's end-stage renal disease care, a nurse responsible for nursing services, a social worker, and a dietitian, shall develop an individualized care plan for each patient. The patient or health care decision maker shall be involved in developing the care plan. The health care team shall review the patient care plan: At least monthly for a patient whose condition has not stabilized, as determined by a physician's assessment of the patient's laboratory values and physical condition; or Annually for a patient whose condition has stabilized. The health care team shall revise the patient care plan as necessary to ensure that it meets the patient's ongoing needs.