Section 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.(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 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.(3) Master's-level social worker.(5) Occupational therapist.(6) Recreational therapist or activity coordinator.(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.(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 following for each participant: (i)Assessments and plan of care. The initial assessment, periodic reassessments, and plan of care.(ii)Coordination of care. Coordination and implementation of 24-hour care delivery that meets participant needs across all care settings, including but not limited to the following:(A) Ordering, approving, or authorizing all necessary care.(B) Communicating all necessary care and relevant instructions for care.(C) Ensuring care is implemented as it was ordered, approved, or authorized by the IDT.(D) Monitoring and evaluating the participant's condition to ensure that the care provided is effective and meets the participant's needs.(E) Promptly modifying care when the IDT determines the participant's needs are not met in order to provide safe, appropriate, and effective care to the participant.(iii)Documenting recommended services. 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) .(iv)Consideration of recommended services. The interdisciplinary team must review, assess, and act on recommendations from emergency or urgent care providers, employees, and contractors, including medical specialists. Specifically, the interdisciplinary team must ensure the following requirements are met: (A) The appropriate member(s) of the interdisciplinary team must review all recommendations from hospitals, emergency departments, and urgent care providers and determine if the recommended services are necessary to meet the participant's medical, physical, social, or emotional needs as expeditiously as the participant's health condition requires, but no later than 48 hours from the time of the participant's discharge.(B) The appropriate member(s) of the interdisciplinary team must review all recommendations from other employees and contractors and determine if the recommended services are necessary to meet the participant's medical, physical, social, or emotional needs as expeditiously as the participant's health condition requires, but no later than 7 calendar days from the date the recommendation was made.(C) If recommendations are authorized or approved by the interdisciplinary team or a member of the interdisciplinary team, the services must be promptly arranged and furnished under § 460.98(c) .(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: (G) Designated representatives.(iii) Documenting changes of a participant's condition in the participant's medical record consistent with documentation polices established by the medical director.(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) .64 FR 66279, Nov. 24, 1999, as amended at 67 FR 61506 , Oct. 1, 2002; 71 FR 71334 , 71336, Dec. 8, 2006; 84 FR 25674 , June 3, 2019; 86 FR 6132 , Jan. 21, 2021 84 FR 25674 , 8/2/2019; 86 FR 6132 , 3/22/2021; 89 FR 30845 , 6/3/2024