42 CFR § 460.102 - Interdisciplinary team.
(a)Basic requirement. A PACE organization must meet the following requirements:
(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.
(2) Each primary care physician 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 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.
(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).