100-11 Programs of All-Inclusive Care for the Elderly (PACE)Manual: Chapter 8 - IDT, Assessment & Care Planning

Programs of All-Inclusive Care for the
Elderly (PACE)
Chapter 8 – IDT, Assessment & Care Planning
Table of Contents
(Rev. 2, Issued: 06-09-11)
Transmittals for Chapter 8
10 - Introduction - Section 1 Interdisciplinary Team (IDT)
10.1 - Interdisciplinary Team Composition
10.2 - Basic Information for an Established IDT
10.3 - Requirements for the IDT
20 – Introduction - Section 2 Participant Assessment
20.1 - PACE Organization Responsibilities
20.2 - Timing of Assessments
20.3 - Pre-Enrollment
20.4 - Initial Assessment
20.5 - Assessment of Multiple New Participants
20.6 - Assessment Process
20.7 - Initial Assessment
20.8 - Semiannual Reassessments
20.9 - Annual Reassessments
20.10 - Periodic and Unscheduled Health Reassessments
20.11 - Recommendations for the Assessment Process
20.12 - Changes to Plan of Care and Documentation
30 - Introduction - Section 3 Care Planning

30.1 - PACE Care Planning Overview
30.2 - PACE Care Planning and the Interdisciplinary Team
30.3 - Plan of Care Development
30.4 - Single Plan of Care
30.5 - Participant/Caregiver Involvement in Care Planning Process
30.6 - Contents of the Care Plan
30.7 - Progress Notes
30.8 - Monitoring Participant Health Status
30.9 - Documentation of Plan of Care
30.10 - Plan of Care Revision
30.11 - Continuous Plan of Care Monitoring and Evaluation

10 - Introduction - Section 1 Interdisciplinary Team (IDT)
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The intent of this portion of the chapter is to clarify the regulatory requirements for the
Interdisciplinary Team (IDT) as defined by the PACE regulations. CMS developed a
guidance to provide an in-depth description of PACE care planning that provides
additional clarification regarding IDT requirements for the PACE program. Care
Planning Guidance for PACE Organizations, September 1, 2010 is available at:
http://www.cms.gov/PACE/09_AdditionalResources.asp#TopOfPage.
10.1 - Interdisciplinary Team Composition
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The IDT is critical to the success of the PACE program. Each of the eleven (11) IDT
roles must be fulfilled by specific individuals who are employed or contracted by the
PACE organization.
The IDT is composed of, but not limited to, at least the following members:
• 	Primary Care Physician;
• 	Registered Nurse;
• 	Master’s Level Social Worker;
• 	Physical Therapist;
• 	Occupational Therapist;
• 	Recreational Therapist or Activity Coordinator;
• 	Dietitian;
• 	PACE Center Manager;
• 	Home Care Coordinator;
• 	Personal Care Attendant or his or her representative;
• 	Driver or his or her representative.
The IDT members must be legally authorized (licensed, certified, registered) to practice
in the State in which they provide services and possess the ability to actively participate
as an effective member of the team in the development and monitoring of each
participant’s plan of care. The IDT members may be employed or contracted staff.

However, if the PACE organization uses contracted IDT members, they must meet the
same personnel requirements and perform the same responsibilities as employed IDT
members. All members of the IDT must primarily serve PACE participants. PACE
organizations may apply for a waiver to contract with community-based primary care
physicians when the organization can demonstrate that extenuating circumstances
warrant this arrangement. If CMS grants this waiver, and the community-based
physicians are contracted as the IDT physician, they must provide all the additional
services required in that role.
[42 CFR §§ 460.64, 460.102(b) and (d)(3); Section 903 of BIPA]
10.2 - Basic Information for an Established IDT
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The PACE organization must establish, implement, and maintain documented internal
procedures governing the exchange of information between team members, contractors,
and participants and their caregivers consistent with the requirements for confidentiality
in 42 CFR § 460.200(e). The IDT approach involves timely and effective
communications, interactive problem-solving, and the exchange of information between
team members, contractors, participants and their caregivers in order to create mutual
goals for the participant, while maintaining participant confidentiality. See Chapter 12
Medical Records and Participant Information for further information. Each team member
is responsible for informing the IDT of the medical, functional, and psychosocial
condition of each participant in an ongoing manner.
[42 CFR § 460.102(d)(2)(i)]
The following questions should be answered during the team meetings:
• 	What information is shared? And when?
• 	What is the interaction of the other team members?
• 	When there is an initial or periodic assessment:
ο 	Does the team consider a home assessment by the therapist if the
participant has a functional disability or is compromised?
ο 	Does the team consider a plan of care for all of the diagnoses that
effect the participant’s health or well being?
ο 	Does the physician appear to be involved in the participant’s care in
other settings (inpatient or nursing facilities)?
ο 	Is there any contract staff providing care or services?

 	Do they attend the meetings; if not, how is their input obtained?
10.3 - Requirements for the IDT
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
PACE organizations must establish an IDT at each center to comprehensively assess and
meet the individual needs of each participant and assign each participant to an IDT
functioning at the PACE center that the participant attends. The IDT is responsible for the
initial and periodic assessments, plan of care, and coordination of 24-hour care delivery.
Each team member is responsible for: (1) regularly informing the IDT of the medical,
functional, and psychosocial condition of each participant; (2) remaining alert to pertinent
input from other team members, participants, and caregivers; and (3) documenting
changes of a participant’s condition in the participant’s medical record consistent with
documentation policies established by the medical director. Additionally, IDT members
must serve primarily PACE participants.
As part of the initial assessment, eight of the eleven IDT members (Primary Care
Physician, Registered Nurse, Master’s Level Social Worker, Physical Therapist,
Occupational Therapist, Home Care Coordinator, Dietitian, and Recreational Therapist or
Activity Coordinator) evaluate the participant in person, at appropriate intervals and
develop a discipline-specific assessment of the participant’s health and social status. At
the recommendation of individual team members, other professional disciplines (e.g.,
Speech-Language Pathology, Dentistry, or Audiology) may be included in the
comprehensive assessment process.
[42 CFR §§ 460.102(a) and (d), 460.104(a); 71 FR 71288 (Dec. 8, 2006)]
20 - Introduction - Section 2 Participant Assessment
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
This portion of Chapter 8 focuses on Participant Assessment Requirements and providing
additional guidance related to the participant assessments.
20.1 - PACE Organization Responsibilities
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The PACE organization must have a care management strategy to address the major
health needs of the participant for the interim period between official enrollment and
initial comprehensive assessment leading to the development of the initial care plan. The
interim care management strategy may be documented in the discipline-specific progress
notes or other section of the medical record identified by the organization and
documented in policy and procedures.
PACE organizations must have policies and procedures that delineate how the IDT will
operate, how they will conduct participant assessments, and how they will incorporate the
results of assessments into a continuously updated care plan for each participant.

Specifically, the policies and procedures must address, at a minimum, the following
elements:
• 	The mechanisms and timeframes for IDT interaction;
• 	The organization’s process for initial assessment includes:
ο 	Discipline-specific assessment information and at what intervals
assessments are made;
ο 	Criteria to determine when additional disciplines (e.g., Speech Therapist,
medical specialists, clinical pharmacists, dentists, etc.) would be included
in the assessment;
ο 	Required elements of the initial and periodic assessments, i.e., physical
and cognitive function and ability, medication use, participant preferences
for care, socialization and availability of family support, current health
status and treatment needs, nutritional status, participant behavior,
psychosocial status, medical and dental status, and participant language;
ο 	Home assessment including home access and egress, ability to perform
ADLs in the home environment, need for assistive devices, ability to
summon immediate emergency assistance, relationship with co-habitants
and neighbors;
ο 	Identification of conditions that overlap disciplines (e.g., blindness,
deafness, psycho-behavioral problems, etc.) and require interdisciplinary
interventions and measurable outcomes;
• 	The process for reassessments includes:
ο 	Frequency at which scheduled reassessments are performed;
ο 	Circumstances that would prompt an unscheduled reassessment (e.g.,
significant change in health status);
ο 	Persons performing the reassessment;
ο 	Process for communicating the compiled reassessment information to the
team;
ο 	Process for resolving participant requests for reassessments in a timely
manner;
• 	Team roles and functions;

• 	Timeline;
• 	Documentation of resolution.
[42 CFR §§ 460 Preamble Discussion, 460.102, 460.104(d); 71 FR 71331 (Dec. 8, 2006)]
20.2 - Timing of Assessments
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
20.3 - Pre-Enrollment
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The IDT must perform any pre-enrollment assessments in person, and cannot substitute
assessments completed by non-PACE community providers or reports contained in
copied medical records. The PACE organization also cannot supplant the initial
comprehensive assessments with any pre-enrollment screening undertaken to determine a
prospective enrollee’s suitability for PACE services as well as eligibility for PACE
enrollment.
CMS recognizes that some PACE organizations may choose to perform some or all IDT
assessments prior to enrollment, and allows pre-enrollment assessments to fulfill the
initial assessments requirement when certain contingencies are met:
• 	The health status of the enrolled participant has not changed since the pre-
enrollment assessments;
• 	If the participant’s health status has changed, the participant is reassessed per
42 CFR § 460.104 and an initial care plan developed per 42 CFR § 460.106.
The Medicare Health Outcomes Survey-Modified (HOS-M) assesses annually the frailty
of the population in PACE organizations in order to adjust plan payment rates. Initial
eligibility for payment purposes is based on community-residing participants who do not
have end-stage renal disease (ESRD) and are 55 or over. Refer to Chapter 10 of this
PACE Manual for more information regarding HOS-M.
[42 CFR § 460.180]
20.4 - Initial Assessment
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
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)]
20.5 - Assessment of Multiple New Participants
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
When a PACE organization enrolls three or more new PACE participants in one month,
the organization may conduct the initial comprehensive assessment for the new PACE
participants over a four-week (i.e., twenty business days) time period in which the IDT
identifies and prioritizes the assessments by highest acuity of care (i.e., sickest first).
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, 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 delay of care plan
development. Following completion of the assessments for an individual participant, the
IDT will promptly consolidate the discipline-specific results into a single plan of care.
20.6 - Assessment Process
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
20.7 - Initial Assessment
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
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)]
20.8 - Semiannual Reassessments
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The IDT primary care physician, registered nurse, master’s level social worker, and
recreational therapist/activity coordinator must all, at a minimum, conduct periodic health
reassessments on a semiannual basis. Other IDT members or specialty practitioners
actively involved in the development or implementation of the participant’s care plan
must also conduct the semiannual reassessment. The pertinent practitioners conduct the
reassessment in person, and meet to consolidate the reassessment findings into the care
plan. At least semi-annually, the IDT must reevaluate the plan of care, including defined
outcomes, and make changes as necessary.

Intervals 	Performed 	Minimum disciplines involved
Semi-
annual
• 	In-person
• 	At least every 6 months
• 	More often if participant’s
condition dictates
• 	PCP, RN, SW, Recreational
Therapist or Activity Coordinator
• 	Other team members actively
involved in development or
implementation of Plan of Care
[42 CFR §§ 460.104(c)(1); 460.106(d)]
20.9 - Annual Reassessments
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The physical therapist, occupational therapist, dietitian, and home care coordinator, at a
minimum, must conduct, on at least an annual basis, an in person reassessment. Other
pertinent IDT members or specialty practitioners actively involved in the participant’s
care plan should also conduct an in-person annual reassessment. The IDT members who
do the periodic reassessment must meet to consolidate the findings into the revised care
plan.
Intervals 	Performed 	Minimum disciplines involved
Annual 	• 	In-person
• 	At least annually
• 	More often if participant’s
condition dictates
• 	PT, OT, Dietitian, Homecare
Coordinator
[42 CFR § 460.104(c)]
20.10 - Periodic and Unscheduled Health Reassessments
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
In addition to the semiannual and annual reassessments described above, two situations
should trigger participant reassessment. First, if a participant experiences a significant
change in health or psychosocial status, the eight IDT members (primary care physician,
registered nurse, master’s level social worker, physical therapist, occupational therapist,
recreational therapist or activity coordinator, dietitian, and home care coordinator) must
conduct an in-person reassessment. Secondly, when a participant or his or her designated
representative believes that the participant needs to initiate, eliminate, or continue a
particular service, the IDT members will determine the pertinent practitioners to conduct
the in-person reassessment. 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. The IDT 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 IDT receives the request for
reassessment. However, the IDT 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 if the participant or designated representative requests the
extension or the IDT documents its need for additional information and how the delay is
in the interest of the participant. The PACE organization must explain any denial of a
request to the participant or designated representative orally and in writing. The PACE
organization must provide the specific reasons for the denial in understandable language.
The PACE organization is responsible for: (1) informing the participant or designated
representative of his or her right to appeal the decision; (2) 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; and (3) describing the right
to, and conditions for, continuation of appealed services through the period of an appeal.
If the IDT 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 42 CFR § 460.122.
Intervals 	Performed 	Minimum Disciplines Involved
Unscheduled 	• 	In-person
• 	Change in participant status
(health or psychosocial)
• 	At the request of the
participant or designated
representative
• 	PCP, RN, SW, Recreational
Therapist/Activity Coordinator,
PT, OT, Dietitian, and/or
Homecare Coordinator as needed
• 	Other team members actively
involved in development or
implementation of POC
[42 CFR § 460.104(d)]
20.11 - Recommendations for the Assessment Process
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
20.12 - Changes to Plan of Care and Documentation
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Team members who conduct a reassessment must meet the following requirements:
• 	Reevaluate the participant’s plan of care;
• 	Discuss any changes in the plan with the IDT;
• 	Obtain approval of the revised plan from the IDT and the participant (or
designated representative); and
• 	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.

IDT members must document all assessment and reassessment information in the
participant’s medical record.
[42 CFR § 460.104(e) and (f)]
30 - Introduction - Section 3 - Care Planning
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
30.1 - PACE Care Planning Overview
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
PACE care planning is the process by which a participant’s IDT holistically assesses the
participant’s medical, functional, psychosocial, and cognitive needs, and develops a
single comprehensive plan of care to address the identified needs. The IDT members who
conduct the extensive discipline-specific assessments collectively discuss the
participant’s identified needs and design and monitor the individualized care plan.
[42 CFR §§ 460.104; 460.106(b)]
30.2 - PACE Care Planning and the Interdisciplinary Team
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
PACE care planning is the responsibility of the IDT members that deliver direct care to
participants in the PACE center they attend and/or in alternative settings such as their
homes or inpatient facilities when dictated by their healthcare needs. A key component of
the PACE model is IDT members’ identification of participant needs in all care domains
(medical, psychosocial, physical, cognitive, functional, and end-of-life), and the IDT’s
coordinated response to these needs. Each member of the team acts within his/her
authorized scope of practice, in accordance with participant preferences, working in
unison with other IDT members to meet the identified needs and achieve each
participant’s optimal outcomes. Optimal outcomes will differ for each participant, but the
plan of care is the roadmap to meet the participant- and team-defined outcomes as
measured after implementation of focused interventions over a prescribed period of time.
Each participant is assigned, at enrollment, to an IDT team that operates at the PACE
center the participant attends. The intent of having this broad-based team is to maximize
the expert services dedicated to the holistic care of each participant.
[42 CFR §§ 460.104; 460.106]
30.3 - Plan of Care Development
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
30.4 - Single Plan of Care
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)

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]
30.5 - Participant/Caregiver Involvement in Care Planning Process
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The IDT 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. The IDT may subsequently need to
reconvene to incorporate information obtained from the participant and/or caregiver
related to care plan changes requested by the participant.
[42 CFR § 460.106(e)]
30.6 - Contents of the Care Plan
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The initial care plan must specify the care needed to meet the participant’s medical,
functional, emotional, social, and cognitive needs identified in the initial comprehensive
health assessment. For each need identified, the plan must state the problem,
interventions to resolve or mitigate the problem, the measurable outcomes to be achieved
by the interventions, the anticipated time lines in which to achieve the desired outcomes,
and the staff responsible for conducting the interventions and monitoring the outcomes.
All care plans should include the aforementioned basic five components; however,
experienced PACE organizations may design more sophisticated care plan models that
incorporate these five basic components with other features such as long-term and short-
term goals that enhance care management.
The PACE plan of care is the IDT’s framework for managing the overall health status of
each participant. The problems identified in the initial health risk assessment and the
IDT’s coordination of care will be the plan’s focus. In general, the plan includes:

• 	Active chronic problems for which the IDT members have designed
interventions that they will be monitoring and evaluating over a set time
frame. When the IDT members achieve the care goals for an active problem,
they may classify the problem as maintenance care. Maintenance care may be
addressed in the care plan or in the discipline-specific progress notes
depending on the organization’s policy;
• 	Problems that cross domains of care and require interdisciplinary
coordination;
• 	Exacerbation of problems that were previously controlled and/or classified as
maintenance care, but disease progression and/or other intervening conditions
resulted in a change that now requires team monitoring and evaluation of
interventions;
• 	Significant changes that indicate a decline or improvement in health status
that:
ο 	Will not normally resolve without intervention by providers, require
standard disease-related clinical interventions, or are not self-limiting;
ο 	Impacts more than one area of the patient’s health status; and
ο 	Requires interdisciplinary review and/or revision of the care plan.
Each PACE organization must define what care is integrated into the participant’s plan of
care, and what discipline-specific care is appropriately documented and monitored by the
respective discipline specialist in the progress notes.
As PACE organizations develop care planning policy and procedures that unequivocally
define what problems are incorporated in the single care plan versus which problems may
be documented solely in discipline-specific progress notes, the following criteria are
suggested:
• 	Long-standing stability (e.g., controlled over several months or years) versus
liability (e.g., uncontrolled or prone to exacerbations);
• 	Brevity of therapeutic regimen to achieve resolution (e.g., brief regimen of
one-two weeks) versus chronicity of therapeutic regimen with uncertain
course until resolution (e.g., repeated changes in therapeutic agents to achieve
resolution);
• 	Maintenance condition monitored by a sole discipline versus active condition
that has potential to result in a change in health status, change in medication,
or expanded therapeutics requiring interdisciplinary monitoring;

• 	Stable residential, social network and caregiver support versus residential or
psychosocial transitions requiring interdisciplinary monitoring.
[42 CFR § 460.106(b)]
30.7 – Progress Notes
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Progress notes detail the care delivered by practitioners performing within their scope of
practice as they manage day-to-day participant encounters or follow up on care provided
during previous encounters. Progress notes may be formatted as the traditional “SOAPE”
note commonly used by many clinical professionals, a narrative description of care
rendered, or other format designed for narrative text entry in an electronic medical
record. The progress note format is prescribed in the PACE organization’s policy and
procedures for medical record documentation.
The progress note not only gives sufficient information to enable other providers to know
what care has been given, but also explains the details of the encounter and the clinical
judgment applied so that subsequent care enhances therapy without redundancy or
contravention. For example, a progress note would refer to subjective information
reported by the participant (e.g., complaints, concerns, effectiveness of ongoing therapy,
etc.), objective findings noted by the provider (e.g., vital signs, weight, examination of
body systems, random blood sugar test, etc.), the assessment of the findings (e.g.,
diagnosis, presumptive condition, etc.), the therapeutic approach taken (e.g., medication,
procedure, lifestyle activity, self-management strategy, etc.), and a discussion about how
the participant was educated about the treatment approach and agreement/disagreement
with the treatment planned (e.g., demonstration of self-management technique, discussion
about disease stages, explanation of medication side effects, etc.). A narrative progress
note may document an exchange between providers (e.g., documentation of a discussion
with the hospitalist managing the case of a hospitalized participant, summary of a
meeting with a nursing facility’s care planning team for a participant placed in a skilled
nursing facility, description of a home care coordinator’s visit to the contracted home
care facility to review contractor records, etc.) or between IDT members and the
participant’s family or other caregivers (e.g., discussion of a proposed change in a
participant’s care plan, discussion of a grievance filed by the participant and/or family,
etc.). Consider the following three examples.
In example 1, the physician or mid-level practitioner (nurse practitioner or physician
assistant) documents in a medical “SOAPE” note the subjective complaints, objective
measurement of vital signs and a body system-by-system assessment, existing or new
diagnoses, therapeutics, orders for diagnostic tests or specialty services, and participant
education for a participant’s chronic care visit to manage multiple co-morbid chronic
conditions.
In example 2, the registered nurse documents in the nursing “SOAPE” notes subjective
complaints, vital signs, the wound appearance (depth, width, color, drainage, degree of

granulation, warmth/coolness, etc.), nursing diagnosis, and sterile or non-sterile technique
used when packing and dressing a decubitus ulcer during a skilled nursing visit for
wound care.
In example 3, the physical therapist documents in the physical therapy narrative progress
note a participant’s self-report of walker use in the home, results of range of motion and
strength measurement, and performance of strength-building exercises during a therapy
session. Progress notes summarize the chronological clinical care and underlying clinical
judgment applied by the individual clinician.
30.8 - Monitoring Participant Health Status
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The IDT members must continuously monitor the participant’s medical, functional,
emotional, social, and cognitive status. IDT members monitor health status by direct
observation when providing services, informal observation in the PACE center or
alternative settings, self-report by participants, feedback from caregivers, reports from
network providers, or communication among IDT members. When significant health or
psychosocial status changes occur, the eight IDT members must reassess the participant
and initiate or expand an already scheduled care planning meeting to discuss the
significant change(s), the reassessment results, and, if warranted, revise the participant’s
care plan following the discussion. Significant changes are defined as a “decline” or
“improvement” in the last assessed health status that meets all three conditions:
• 	Will not normally resolve without intervention by staff or by implementing
standard disease-related clinical interventions and is consequently not “self-
limiting”;
• 	Impacts more than one domain of the participant’s health;
• 	Requires interdisciplinary review and/or revision of the care plan.
[42 CFR §§ 460.104(d)(1) and (e); 460.106(c)(2)]
30.9 - Documentation of Plan of Care
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The IDT members consolidate the contents of the PACE care plan into a single
comprehensive document that is filed in the care plan section of the participant’s medical
record. The care plan clearly displays, at a minimum, the problem being addressed,
interventions, measurable outcomes, time lines, and persons responsible for each
intervention. It is continuously updated as the team monitors the participant’s health
status.
[42 CFR § 460.106(f)]

30.10 - Plan of Care Revision
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The PACE care plan is continuously updated as the team monitors the participant’s health
status. The IDT members must minimally reevaluate the single comprehensive plan of
care for each participant on a semiannual basis. The team should conduct the reevaluation
in collaboration with the participant and caregivers whenever feasible. Involvement of the
participant and caregivers in care planning assures that the participant’s care preferences
are addressed and informed participation in care is maximized.
Updates are made directly to the care plan in a way that preserves the history of care and
enables the team to trace the effectiveness of interventions over time. New problems are
added as they are identified, and resolved problems may be retained for monitoring or
relocated to the discipline-specific progress notes if the team classifies it as maintenance
care. The rationale for eliminating or relocating a resolved problem to maintenance care
in the progress notes section must be documented in the care plan.
[42 CFR §§ 460.104(c)(1) and (e); 460.106(d)]
30.11 - Continuous Plan of Care Monitoring and Evaluation
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
An integral part of implementing the care plan is the IDT’s continuous monitoring of the
participant’s health and psychosocial status as well as the effectiveness of the plan of
care. Continuous monitoring is achieved through the assessment/reassessment of
participant needs, provision of services, formal evaluation of the efficacy of services
provided, informal observation, input from participants or caregivers, and communication
among IDT members and all other providers. Timely, accurate, and complete written and
verbal communication among PACE stakeholders is paramount to quality and safe
participant care. The interdisciplinary care team approach and the perpetual care planning
process are the gold standards that make PACE an effective model for the care of frail
elders.
[42 CFR § 460.106(c)(2)]
To obtain more information pertaining to the Care Planning Guidance, visit
http://www.cms.gov/pace/.

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date CR#
R2PACE 06/09/2011 	Initial Publication of Manual 	06/03/2011 NA
R1_SO 06/03/2011 	Initial Publication of Manual - Rescinded and
replaced by Transmittal 2
06/03/2011 NA
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