Editorial Note on Part 460
Editorial Note: Nomenclature changes to part 460 appear at 67 FR 61504, Oct. 1, 2002.

§ 460.104 Participant assessment. ( a ) *Initial comprehensive assessment* — ( 1 ) *Basic requirement.* The interdisciplinary team must conduct an initial in-person comprehensive assessment on each participant. The assessment must be completed in a timely manner in order to meet the requirements in paragraph (b) of this section.
( 2 ) *Members present.* As part of the initial comprehensive assessment, each of the following members of the interdisciplinary team must evaluate the participant in person and develop a discipline-specific assessment of the participant's health and social status: ( i ) Primary care provider
( ii ) Registered nurse.
( iii ) Master's-level social worker.
( iv ) Physical therapist.
( v ) Occupational therapist.
( vi ) Recreational therapist or activity coordinator.
( vii ) Dietitian.
( viii ) Home care coordinator.
( 3 ) *Additional professional disciplines.* At the recommendation of the interdisciplinary team, other professional disciplines (for example, speech-language pathology, dentistry, or audiology) may be included in the initial comprehensive assessment process.
( 4 ) *Initial comprehensive assessment criteria.* The initial in-person comprehensive assessment must at a minimum include the evaluation of: ( i ) Physical and cognitive function and ability.
( ii ) Medication use.
( iii ) Participant and caregiver preferences for care.
( iv ) Socialization and availability of family support.
( v ) Current health status and treatment needs.
( vi ) Nutritional status.
( vii ) Home environment, including home access and egress.
( viii ) Participant behavior.
( ix ) Psychosocial status.
( x ) Medical and dental status.
( xi ) Participant language.
( b ) *Development of plan of care.* Within 30 days of the date of enrollment, the interdisciplinary team must consolidate discipline-specific assessments into a single plan of care for each participant through team discussions and consensus of the entire interdisciplinary team. In developing the plan of care: ( 1 ) If the interdisciplinary team determines that certain services are not necessary to the care of a participant, the reasoning behind this determination must be documented in the plan of care.
( 2 ) Female participants must be informed that they are entitled to choose a qualified specialist for women's health services from the PACE organization's network to furnish routine or preventive women's health services.
( c ) *Semi-annual reassessment.* On at least a semi-annual basis, or more often if a participant's condition dictates, the following members of the interdisciplinary team must conduct an in-person reassessment: ( 1 ) Primary care provider.
( 2 ) Registered nurse.
( 3 ) Master's-level social worker.
( 4 ) Other team members that the primary care provider, registered nurse and Master's-level social worker determine are actively involved in the development or implementation of the participant's plan of care.
( d ) *Unscheduled reassessments.* In addition to semi-annual reassessments, unscheduled reassessments may be required based on the following: ( 1 ) *A change in participant status.* If the health or psychosocial status of a participant changes, the members of the interdisciplinary team listed in paragraph (c) of this section must conduct an in-person reassessment.
( 2 ) *In response to a service determination request.* In accordance with § 460.121(h), the PACE organization must conduct an in-person reassessment if it expects to deny or partially deny a service determination request, and may conduct reassessments as determined necessary for approved services.
( e ) *Changes to plan of care.* When the interdisciplinary team conducts semiannual or unscheduled reassessments, the interdisciplinary team must reevaluate and, if necessary, revise the plan of care in accordance with § 460.106(c) following the completion of all required assessments.
( f ) *Documentation.* Interdisciplinary team members must document all assessment and reassessment information in the participant's medical record.
[64 FR 66279, Nov. 24, 1999, as amended at 71 FR 71336, Dec. 8, 2006; 84 FR 25674, June 3, 2019; 86 FR 6132, Jan. 19, 2021; 89 FR 30845, Apr. 23, 2024]