CMS Pub. 100-11, ch. 8, § 20.1

The PACE organization must have a care management strategy to address the major

health needs of the participant for the interim period between official enrollment and

initial comprehensive assessment leading to the development of the initial care plan. The

interim care management strategy may be documented in the discipline-specific progress

notes or other section of the medical record identified by the organization and

documented in policy and procedures.

PACE organizations must have policies and procedures that delineate how the IDT will

operate, how they will conduct participant assessments, and how they will incorporate the

results of assessments into a continuously updated care plan for each participant.

Specifically, the policies and procedures must address, at a minimum, the following

elements:

• The mechanisms and timeframes for IDT interaction;

• The organization’s process for initial assessment includes:

ο Discipline-specific assessment information and at what intervals

assessments are made;

ο Criteria to determine when additional disciplines (e.g., Speech Therapist,

medical specialists, clinical pharmacists, dentists, etc.) would be included

in the assessment;

ο Required elements of the initial and periodic assessments, i.e., physical

and cognitive function and ability, medication use, participant preferences

for care, socialization and availability of family support, current health

status and treatment needs, nutritional status, participant behavior,

psychosocial status, medical and dental status, and participant language;

ο Home assessment including home access and egress, ability to perform

ADLs in the home environment, need for assistive devices, ability to

summon immediate emergency assistance, relationship with co-habitants

and neighbors;

ο Identification of conditions that overlap disciplines (e.g., blindness,

deafness, psycho-behavioral problems, etc.) and require interdisciplinary

interventions and measurable outcomes;

• The process for reassessments includes:

ο Frequency at which scheduled reassessments are performed;

ο Circumstances that would prompt an unscheduled reassessment (e.g.,

significant change in health status);

ο Persons performing the reassessment;

ο Process for communicating the compiled reassessment information to the

team;

ο Process for resolving participant requests for reassessments in a timely

manner;

• Team roles and functions;

• Timeline;

• Documentation of resolution.

[42 CFR §§ 460 Preamble Discussion, 460.102, 460.104(d); 71 FR 71331 (Dec. 8, 2006)]