42 CFR § 460.102 - Interdisciplinary team.
(a) Basic requirement. A PACE organization must meet the following requirements:
(1) Establish an interdisciplinary team, composed of members that fill the roles described in paragraph (b) of this section, at each PACE center to comprehensively assess and meet the individual needs of each participant.
(b) Composition of interdisciplinary team. The interdisciplinary team must be composed of members qualified to fill, at minimum, the following roles, in accordance with CMS guidelines. One individual may fill two separate roles on the interdisciplinary team where the individual meets applicable state licensure requirements and is qualified to fill the two roles and able to provide appropriate care to meet the needs of participants.
(1) Primary care provider.
(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 provider.
(1) Primary medical care must be furnished to a participant by any of the following:
(i) A primary care physician.
(ii) A community-based physician.
(iii) A physician assistant who is licensed in the State and practices within his or her scope of practice as defined by State laws with regard to oversight, practice authority and prescriptive authority.
(iv) A nurse practitioner who is licensed in the State and practices within his or her scope of practice as defined by State laws with regard to oversight, practice authority and prescriptive authority.
(2) Each primary care provider is responsible for the following:
(i) Managing a participant's medical situations.
(d) Responsibilities of interdisciplinary team.
(1) The interdisciplinary team is responsible for the following:
(i) The initial assessment, periodic reassessments, plan of care, and coordination of 24-hour care delivery.
(ii) Documenting all recommendations for care or services and the reason(s) for not approving or providing recommended care or services, if applicable, in accordance with § 460.210(b).
(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 any individual with direct knowledge of or contact with the participant, including the following:
(A) Other team members.
(G) Designated representatives.
(e) Team member qualifications. The PACE organization must ensure that all members of the interdisciplinary team have appropriate licenses or certifications under State law, act within the scope of practice as defined by State laws, and meet the requirements set forth in § 460.71.
(f) 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).