(a) Basic requirement. Within 30 days of the date of enrollment, the interdisciplinary team members specified in §460.104(a)(2) must develop a comprehensive plan of care for each participant based on the initial comprehensive assessment findings.

(b) Content of plan of care. The plan of care must meet the following requirements:

(1) Specify the care needed to meet the participant's medical, physical, emotional, and social needs, as identified in the initial comprehensive assessment.

(2) Identify measurable outcomes to be achieved.

(3) Utilize the most appropriate interventions for each care need that advances the participant toward a measurable goal and outcome.

(4) Identify each intervention and how it will be implemented.

(5) Identify how each intervention will be evaluated to determine progress in reaching specified goals and desired outcomes.

(c) Implementation of the plan of care.

(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.

(f) Documentation. The team must document the plan of care, and any changes made to it, in the participant's medical record.

[64 FR 66279, Nov. 24, 1999, as amended at 84 FR 25675, June 3, 2019]