[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

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

[CITE: 42CFR460.106]



[Page 446]

 

                         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 

 

                         Subpart F_PACE Services

 

Sec.  460.106  Plan of care.



    (a) Basic requirement. The interdisciplinary team must promptly 

develop a comprehensive plan of care for each participant.

    (b) Content of plan of care. The plan of care must meet the 

following requirements:

    (1) Specify the care needed to meet the participant's medical, 

physical, emotional, and social needs, as identified in the initial 

comprehensive assessment.

    (2) Identify measurable outcomes to be achieved.

    (c) Implementation of the plan of care. (1) The team must implement, 

coordinate, and monitor the plan of care whether the services are 

furnished by PACE employees or contractors.

    (2) The team must continuously monitor the participant's health and 

psychosocial status, as well as the effectiveness of the plan of care, 

through the provision of services, informal observation, input from 

participants or caregivers, and communications among members of the 

interdisciplinary team and other providers.

    (d) Evaluation of plan of care. On at least a semi-annual basis, the 

interdisciplinary team must reevaluate the plan of care, including 

defined outcomes, and make changes as necessary.

    (e) Participant and caregiver involvement in plan of care. The team 

must develop, review, and reevaluate the plan of care in collaboration 

with the participant or caregiver, or both, to ensure that there is 

agreement with the plan of care and that the participant's concerns are 

addressed.

    (f) Documentation. The team must document the plan of care, and any 

changes made to it, in the participant's medical record.