[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR460.104]



[Page 431-432]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 460_PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)--Table 

of Contents

 

                         Subpart F_PACE Services

 

Sec. 460.104  Participant assessment.



    (a) Initial comprehensive assessment--(1) Basic requirement. The 

interdisciplinary team must conduct an initial comprehensive assessment 

on each participant. The assessment must be completed promptly following 

enrollment.

    (2) As part of the initial comprehensive assessment, each of the 

following members of the interdisciplinary team must evaluate the 

participant in person, at appropriate intervals, and develop a 

discipline-specific assessment of the participant's health and social 

status:

    (i) Primary care physician.

    (ii) Registered nurse.

    (iii) Social worker.

    (iv) Physical therapist or occupational therapist, or both.

    (v) Recreational therapist or activity coordinator.

    (vi) Dietitian.

    (vii) Home care coordinator.

    (3) At the recommendation of individual team members, other 

professional disciplines (for example, speech-language pathology, 

dentistry, or audiology) may be included in the comprehensive assessment 

process.

    (4) Comprehensive assessment criteria. The comprehensive assessment 

must include, but is not limited to, the following:

    (i) Physical and cognitive function and ability.

    (ii) Medication use.

    (iii) Participant and caregiver preferences for care.

    (iv) Socialization and availability of family support.

    (v) Current health status and treatment needs.

    (vi) Nutritional status.

    (vii) Home environment, including home access and egress.

    (viii) Participant behavior.

    (ix) Psychosocial status.

    (x) Medical and dental status.

    (xi) Participant language.

    (b) Development of plan of care. The interdisciplinary team must 

promptly consolidate discipline-specific assessments into a single plan 

of care for each participant through discussion in team meetings and 

consensus of the entire interdisciplinary team. In developing the plan 

of care, female participants must be informed that they are entitled to 

choose a qualified specialist for women's health services from the PACE 

organization's network to furnish routine or preventive women's health 

services.

    (c) Periodic reassessment--(1) Semiannual reassessment. On at least 

a semiannual basis, or more often if a participant's condition dictates, 

the following members of the interdisciplinary team must conduct an in-

person reassessment:

    (i) Primary care physician.

    (ii) Registered nurse.

    (iii) Social worker.

    (iv) Recreational therapist or activity coordinator.

    (v) Other team members actively involved in the development or 

implementation of the participant's plan of care, for example, home care 

coordinator, physical therapist, occupational therapist, or dietitian.

    (2) Annual reassessment. On at least an annual basis, the following 

members of the interdisciplinary team must conduct an in-person 

reassessment:

    (i) Physical therapist or occupational therapist, or both.

    (ii) Dietitian.

    (iii) Home care coordinator.



[[Page 432]]



    (3) Reassessment based on change in participant status or at the 

request of the participant or designated representative. If the health 

or psychosocial status of a participant changes or if a participant (or 

his or her designated representative) believes that the participant 

needs to initiate, eliminate, or continue a particular service, the 

members of the interdisciplinary team, listed in paragraph (a)(2) of 

this section, must conduct an in-person reassessment.

    (i) The PACE organization must have explicit procedures for timely 

resolution of requests by a participant or his or her designated 

representative to initiate, eliminate, or continue a particular service.

    (ii) Except as provided in paragraph (c)(3)(iii) of this section, 

the interdisciplinary team must notify the participant or designated 

representative of its decision to approve or deny the request from the 

participant or designated representative as expeditiously as the 

participant's condition requires, but no later than 72 hours after the 

date the interdisciplinary team receives the request for reassessment.

    (iii) The interdisciplinary team may extend the 72-hour timeframe 

for notifying the participant or designated representative of its 

decision to approve or deny the request by no more than 5 additional 

days for either of the following reasons:

    (A) The participant or designated representative requests the 

extension.

    (B) The team documents its need for additional information and how 

the delay is in the interest of the participant.

    (iv) The PACE organization must explain any denial of a request to 

the participant or the participant's designated representative orally 

and in writing. The PACE organization must provide the specific reasons 

for the denial in understandable language.

    (v) If the participant or designated representative is dissatisfied 

with the decision on the request, the PACE organization is responsible 

for the following:

    (A) Informing the participant or designated representative of his or 

her right to appeal the decision as specified in Sec. 460.122.

    (B) Describing both the standard and expedited appeals processes, 

including the right to, and conditions for, obtaining expedited 

consideration of an appeal of a denial of services as specified in Sec. 

460.122.

    (C) Describing the right to, and conditions for, continuation of 

appealed services through the period of an appeal as specified in Sec. 

460.122(e).

    (D) If the interdisciplinary team fails to provide the participant 

with timely notice of the resolution of the request or does not furnish 

the services required by the revised plan of care, this failure 

constitutes an adverse decision, and the participant's request must be 

automatically processed by the PACE organization as an appeal in 

accordance with Sec. 460.122.

    (d) Changes to plan of care. Team members who conduct a reassessment 

must meet the following requirements:

    (1) Reevaluate the participant's plan of care.

    (2) Discuss any changes in the plan with the interdisciplinary team.

    (3) Obtain approval of the revised plan from the interdisciplinary 

team and the participant (or designated representative).

    (4) Furnish any services included in the revised plan of care as a 

result of a reassessment to the participant as expeditiously as the 

participant's health condition requires.

    (e) Documentation. Interdisciplinary team members must document all 

assessment and reassessment information in the participant's medical 

record.