US · guidance
CMS Pub. 100-11, ch. 8, § 30.4
Single Plan of Care
The IDT will promptly consolidate the eight discipline-specific assessments into a single
individualized plan of care for each participant. The full IDT team collectively develops
the care plan through discussion and consensus at a formal care planning meeting. The
IDT must implement, coordinate, and monitor the plan of care whether the services are
furnished by PACE employees or contractors. When goals and interventions for a
particular problem are overlapping, the team may decide to combine actions into team
interventions and outcomes to achieve a single goal. They may conversely find that a
problem is unique and needs to be addressed by a specific discipline. Whether a problem
manifests as multi-faceted or singular in nature, the IDT incorporates the problems into a
single plan of care that is collectively monitored and evaluated by the team. Although the
PACE center director, driver, and personal care attendant do not perform assessments,
they contribute valuable information about participants and should be included in care
planning discussions.
[42 CFR §§ 460.104(b); 460.106]
History
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
0f82bd70582aac9b2cf428183c1f7fbb1c9c73702e9c53d8f456fb85831371cb
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