42 CFR 460.106 - Plan of care.
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(a) Basic requirement. The interdisciplinary team must promptly develop a comprehensive plan of care for each participant.
(1) Specify the care needed to meet the participant's medical, physical, emotional, and social needs, as identified in the initial comprehensive assessment.
(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.
Title 42 published on 2014-10-01
no entries appear in the Federal Register after this date.