---
kind: "section"
citation: "42 C.F.R. § 460.104"
title: "42"
number: "460.104"
heading: "Participant assessment."
url: "https://uscodex.org/cfr/42/460.104"
---

# §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)](#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)](#c) of this section must conduct an in-person reassessment.
  - (2) **In response to a service determination request.** In accordance with [§ 460.121(h)](/cfr/42/460.121.md?p=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)](/cfr/42/460.106.md?p=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.

## Notes

### Amendments

[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]

### Authority

Authority: 42 U.S.C. 1302, 1395, 1395eee(f), and 1396u-4(f).

### Source

Source: 64 FR 66279, Nov. 24, 1999, unless otherwise noted.

### Amendments

[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]