CMS Pub. 100-11, ch. 8, § 20.7

The initial comprehensive health assessment must be conducted in person by eight of the

eleven IDT members for each new participant. Each IDT member uses a discipline-specific standardized health risk assessment form developed or adopted by the PACE

organization. When completed, the discipline-specific health risk assessment form is filed

in the medical record section designated by PACE organization policy, for example, in a

separate tab containing all discipline-specific assessments; or, in the respective discipline

section of the medical record along with the discipline-specific progress notes. CMS

expects clinical documentation to meet professional health information management

standards. Specifically, clinical documentation must: a) identify and communicate

patients’ problems, needs and strengths; b) monitor their condition on an ongoing basis;

and c) record treatment and response to treatment for each participant. PACE

organizations must periodically review medical records to assure that clinical

documentation reflects good clinical practice and conforms to high standards of

communicating clear, complete, and accurate information at the level expected from

trained and licensed health care professionals. Good clinical practice dictates not only the

documentation of treatment and services, but also the outcomes and efficacy in resolving

the problem. Further information regarding medical records can be found in Chapter 12.

A comprehensive assessment criterion includes, but is not limited to, the following:

• Physical and cognitive function and ability;

• Medication use;

• Participant and caregiver preferences for care;

• Socialization and availability of family support;

• Current health status and treatment needs;

• Nutritional status;

• Home environment, including home access and egress;

• Participant behavior;

• Psychosocial status;

• Medical and dental status;

• Participant language and cultural needs.

[42 CFR §§ 460 Preamble Discussion, 460.104(a)(2) and (4); 71 FR 71311 (Dec. 8,

2006)]