CMS Pub. 100-11, ch. 8, § 10.3

PACE organizations must establish an IDT at each center to comprehensively assess and

meet the individual needs of each participant and assign each participant to an IDT

functioning at the PACE center that the participant attends. The IDT is responsible for the

initial and periodic assessments, plan of care, and coordination of 24-hour care delivery.

Each team member is responsible for: (1) regularly informing the IDT of the medical,

functional, and psychosocial condition of each participant; (2) remaining alert to pertinent

input from other team members, participants, and caregivers; and (3) documenting

changes of a participant’s condition in the participant’s medical record consistent with

documentation policies established by the medical director. Additionally, IDT members

must serve primarily PACE participants.

As part of the initial assessment, eight of the eleven IDT members (Primary Care

Physician, Registered Nurse, Master’s Level Social Worker, Physical Therapist,

Occupational Therapist, Home Care Coordinator, Dietitian, and Recreational Therapist or

Activity Coordinator) evaluate the participant in person, at appropriate intervals and

develop a discipline-specific assessment of the participant’s health and social status. At

the recommendation of individual team members, other professional disciplines (e.g.,

Speech-Language Pathology, Dentistry, or Audiology) may be included in the

comprehensive assessment process.

[42 CFR §§ 460.102(a) and (d), 460.104(a); 71 FR 71288 (Dec. 8, 2006)]