CMS Pub. 100-11, ch. 8, § 20.4

The interdisciplinary team (IDT) must conduct an initial, in person comprehensive

assessment for each PACE participant. The initial assessment must be completed

promptly following enrollment with individual team members’ assessments scheduled at

appropriate intervals taking into account the participant’s level of health. If the

comprehensive assessment cannot be completed by the effective date of enrollment, the

organization must explicitly document the reason for the delay in the progress notes and

care plan and perform the comprehensive assessment within a few days.

CMS believes timely health assessments and care planning are imperative to sustain

continuity of care. Therefore, if essential members of the IDT or other identified

healthcare experts required to complete the initial comprehensive assessment are not

available to conduct the assessment in the established time frame due to prolonged

absence (vacant IDT position, extended leave, or illness lasting three or more weeks), the

remaining IDT members should develop the care plan and revise it as soon as the missing

required initial health assessment is completed, and document in the progress notes the

reason for the delay in developing a complete care plan.

[42 CFR § 460.104(a)]