CMS Pub. 100-11, ch. 8, § 10.2

The PACE organization must establish, implement, and maintain documented internal

procedures governing the exchange of information between team members, contractors,

and participants and their caregivers consistent with the requirements for confidentiality

in 42 CFR § 460.200(e). The IDT approach involves timely and effective

communications, interactive problem-solving, and the exchange of information between

team members, contractors, participants and their caregivers in order to create mutual

goals for the participant, while maintaining participant confidentiality. See Chapter 12

Medical Records and Participant Information for further information. Each team member

is responsible for informing the IDT of the medical, functional, and psychosocial

condition of each participant in an ongoing manner.

[42 CFR § 460.102(d)(2)(i)]

The following questions should be answered during the team meetings:

• What information is shared? And when?

• What is the interaction of the other team members?

• When there is an initial or periodic assessment:

ο Does the team consider a home assessment by the therapist if the

participant has a functional disability or is compromised?

ο Does the team consider a plan of care for all of the diagnoses that

effect the participant’s health or well being?

ο Does the physician appear to be involved in the participant’s care in

other settings (inpatient or nursing facilities)?

ο Is there any contract staff providing care or services?

 Do they attend the meetings; if not, how is their input obtained?