42 CFR 460.102 - Interdisciplinary team.
(a) Basic requirement. A PACE organization must meet the following requirements:
(1) Establish an interdisciplinary team at each Pace center to comprehensively assess and meet the individual needs of each participant.
(2) Assign each participant to an interdisciplinary team functioning at the PACE center that the participant attends.
(b) Composition of interdisciplinary team. The interdisciplinary team must be composed of at least the following members:
(1) Primary care physician.
(2) Registered nurse.
(3) Master's-level social worker.
(4) Physical therapist.
(5) Occupational therapist.
(6) Recreational therapist or activity coordinator.
(8) PACE center manager.
(9) Home care coordinator.
(10) Personal care attendant or his or her representative.
(11) Driver or his or her representative.
(c) Primary care physician. (1) Primary medical care must be furnished to a participant by a PACE primary care physician.
(2) Each primary care physician is responsible for the following:
(i) Managing a participant's medical situations.
(ii) Overseeing a participant's use of medical specialists and inpatient care.
(d) Responsibilities of interdisciplinary team. (1) The interdisciplinary team is responsible for the initial assessment, periodic reassessments, plan of care, and coordination of 24 hour care delivery.
(2) Each team member is responsible for the following:
(i) Regularly informing the interdisciplinary team of the medical, functional, and psychosocial condition of each participant.
(ii) Remaining alert to pertinent input from other team members, participants, and caregivers.
(iii) Documenting changes of a participant's condition in the participant's medical record consistent with documentation polices established by the medical director.
(3) The members of the interdisciplinary team must serve primarily PACE participants.
(e) Exchange of information between team members. 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 § 460.200(e).