There is no published PACE intake checklist. The regulation lists what the medical record must contain, what the assessment must evaluate and what the enrollment agreement must say; the states each name a form; CMS’s manual adds a few lines of guidance. Nobody has put them in one list with the rule beside each item and a column for who holds the document. This is that list.
The clocks these documents run against are in the PACE intake timeline and are not repeated. One framing point first, because the title of this article can mislead: the initial comprehensive assessment under 42 CFR 460.104 is performed after enrollment. CMS’s PACE Manual says it is done “independent of any pre-enrollment screening by the IDT” and “must be completed promptly following enrollment”, and the plan of care it feeds is due within 30 days of the enrollment date. “Before the initial comprehensive assessment” therefore means: gathered during intake and the pre-enrollment screening, in the file on the day the eight disciplines start.
What the rule says must be in the record
42 CFR 460.210 requires “a single, comprehensive medical record for each participant” that is complete, accurately documented, readily accessible, systematically organized and available to all staff. “At a minimum, the medical record must contain the following”, and the list is fifteen items:
- Appropriate identifying information
- Documentation of all services furnished, including a summary of emergency care and other inpatient or long-term care services, services furnished by employees of the PACE center, and services furnished by contractors and their reports
- Interdisciplinary assessments, reassessments, plans of care, treatment, and progress notes that include the participant’s response to treatment
- All recommendations for services made by employees or contractors of the PACE organization, including specialists
- If a recommended service is not approved or provided, the reasons
- Original documentation of written communications described in 460.200(d)(2)
- Laboratory, radiological and other test reports
- Medication records
- Hospital discharge summaries, if applicable
- Reports of contact with informal support (for example, caregiver, legal guardian, or next of kin)
- Enrollment Agreement
- Physician orders
- Discharge summary and disenrollment justification, if applicable
- Advance directives, if applicable
- A signed release permitting disclosure of personal information
Six of those are generated by the organization itself over time (2, 3, 4, 5, 6, 13). The other nine have to be in hand at or near intake, and five of the nine (7, 8, 9, 12, 14) originate with someone other than the organization or the applicant.
What the assessment has to evaluate
Under 460.104(a)(4), the initial in-person comprehensive assessment “must at a minimum include the evaluation of” eleven things: physical and cognitive function and ability; medication use; participant and caregiver preferences for care; socialization and availability of family support; current health status and treatment needs; nutritional status; home environment, including home access and egress; participant behavior; psychosocial status; medical and dental status; and participant language. Each of the eight disciplines (primary care provider, registered nurse, master’s-level social worker, physical therapist, occupational therapist, recreational therapist or activity coordinator, dietitian, home care coordinator) must “evaluate the participant in person and develop a discipline-specific assessment”.
In person is the rule, and CMS’s manual draws the line that matters for a checklist: the team “cannot substitute assessments completed by non-PACE community providers or reports contained in copied medical records”. The outside record does not replace the assessment. It is what “medication use”, “current health status and treatment needs” and “medical and dental status” are evaluated against, because none of the three can be assessed from the participant’s recollection alone.
The checklist
Each row names the document, who has it before the organization does, and the rule or form that makes it necessary. “Prior provider” means a hospital, physician, specialist, pharmacy or facility the applicant used before PACE.
| Document | Who holds it | Why it is needed |
|---|---|---|
| Signed release for medical and financial information and Medicare and Medicaid eligibility status | The applicant signs it; the organization keeps it | 460.152(a)(2) requires it at intake; 460.210(b)(15) requires it in the record |
| Enrollment agreement: name, sex and date of birth, Medicare and Medicaid status and numbers, other insurance, premiums, conditions of enrollment and disenrollment, the authorization for information exchange with CMS and the state, effective date, signature | The applicant and the organization | 460.154, items (a) to (t); 460.210(b)(11) |
| Proof of age 55 or over and of residence in the service area | The applicant | 460.150(b)(1) and (b)(3) |
| The state’s nursing facility level of care determination | The state administering agency or its delegate, from the organization’s and the physician’s inputs | 460.150(b)(2); 460.152(a)(3); renewed at least annually under 460.160(b) |
| The physician’s certification of level of care, with diagnoses | A prior provider: the applicant’s own physician | State rule; see the state table below |
| The Medicaid financial application, where the applicant is not already enrolled | The applicant, with the organization’s help | 460.152(a)(1) requires the premium and spenddown consequences to be explained; the application itself is the state’s |
| The organization’s own assessment that the applicant can live safely in the community, including the care support network and the home | The organization | 460.150(c)(1); 460.152(a)(4); documented if enrollment is denied, 460.152(b)(3) |
| Medication records: the current list as prior providers and the pharmacy hold it | Prior providers | 460.210(b)(8); the “medication use” domain, 460.104(a)(4)(ii) |
| Hospital discharge summaries, and a summary of emergency and inpatient care | Prior providers: the hospital, the skilled nursing facility | 460.210(b)(9) and (b)(2)(i), “if applicable” |
| Laboratory, radiology and other test reports | Prior providers | 460.210(b)(7); the “current health status” and “medical and dental status” domains |
| Physician orders in force at intake | Prior providers until the organization’s primary care provider writes new ones | 460.210(b)(12) |
| Advance directives | The applicant, or a prior provider’s chart | 460.210(b)(14), “if applicable” |
| Caregiver, guardian or next-of-kin contacts; power of attorney or guardianship papers where they exist | The applicant and family | 460.210(b)(10); the “availability of family support” and “preferences for care” domains, 460.104(a)(4)(iii) and (iv) |
| The eight discipline-specific assessments, and the plan of care within 30 days of enrollment | The organization’s interdisciplinary team | 460.104(a)(2), (b) and (f); 460.210(b)(3) |
| An interim care management strategy for the gap between enrollment and the initial assessment | The organization | CMS PACE Manual chapter 8, §20.1: guidance, not regulation |
What the state wants from the physician
The federal rule says the state determines level of care and says nothing about how. Each state does it with a form, and for most of them the form is signed by a physician the organization does not employ. That is the one document in the checklist with a hard expiry and a named signer, and the one a program most often waits on.
| State | The instrument | What the rule says |
|---|---|---|
| Pennsylvania | Form MA 570, the Physician Certification Form, with the Functional Eligibility Determination | OLTL Bulletin 59-20-03 (2020): the MA 570 “must be current (not more than one year old) and may only be signed by a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)” licensed in Pennsylvania or a bordering state; the state “will not accept an MA 570 signed by a physician in training, physician assistant or certified registered nurse practitioner”. The form asks the physician to “list all diagnoses with ICD codes related to patient’s need for care” and to check exactly one level of care |
| Colorado | The Professional Medical Information Page (PMIP), with the case management agency’s LTSS assessment | The PACE and CMA Handbook (November 2023): the PMIP is “signed by the individual’s physician”, and for new enrollees its “signature date must be prior to and no earlier than six months from the Certification Start Date and no later than 90 days from the LTSS Assessment date”. The applicant also signs a release “to allow PO and CMA to access financial and medical records” |
| Florida | Form 5000-3008, the Medical Certification for Medicaid Long-term Care Services, with a CARES in-person visit | The ADRC mails the form; the applicant’s “medical provider (Florida licensed physician, Advanced Practice Registered Nurse or Physician Assistant)” completes it; “the completed form must be returned to the ADRC, or the individual will not move forward” |
| California | The nursing facility level of care determination form | DHCS Policy Letter 02-14: organizations “must conduct an assessment for each beneficiary to determine if they meet the NFLOC requirements prior to enrollment”, on the form, “submitted electronically to the PACE LOC Review Inbox” for a DHCS nurse’s review |
| Michigan | The online Nursing Facility Level of Care Determination (LOCD) | The Medicaid Provider Manual: conducted “within fourteen (14) calendar days from the date of enrollment” by “a health professional (physician, registered nurse, licensed practical nurse, clinical social worker (BSW or MSW), or physician assistant) representing the proposed provider” |
| Ohio | The Department of Aging’s assessment, on an ODM-approved tool, with PASRR | OAC 173-50-03 (June 2026): the Department “is responsible for the level-of-care assessment” and “may delegate this responsibility”; OAC 5160-3-08 rests the criteria on the tool and, for cognitive impairment, a diagnosis “by a physician” |
| Louisiana | The LOCET telephone screening, then the interRAI Home Care assessment | Medicaid’s PACE chapter: “the PACE applicant must receive a face-to-face assessment to determine NFLOC criteria prior to PACE enrollment”, by OAAS-certified assessors, who may be PACE staff |
| Oklahoma | The UCAT Part III, by a nurse, in the home | OAC 317:35-18-5: the nurse “sends the UCAT, Part III to the designated OHCA nurse staff member for review and level of care determination” |
Pennsylvania’s and Colorado’s forms both ask the physician for the diagnoses behind the need for care; Florida’s asks the medical provider to certify it; Louisiana’s safety criteria rest on a physician who “has documented” the condition. Each of those is a document the physician writes from the chart, which means the chart has to be current with the hospital, the specialists and the pharmacy before the form is worth signing. A physician who signs an MA 570 from a chart that is missing the last admission certifies a level of care from last year’s picture.
What the rule does not say
Nothing in 42 CFR Part 460 or the CMS manual requires a PACE organization to request or obtain records from prior providers. The release at 460.152(a)(2) is permission, not a duty. The record “must contain” discharge summaries, test reports, medication records and advance directives, but four of those carry “if applicable”, and 460.210(c) on transfer of records is about sending copies “between treatment facilities”, not collecting them at intake. The assessment domains require the evaluation of medication use and health status; the rule leaves it to the team to find out what they are.
So the retrieval is the organization’s choice and the record’s completeness is the organization’s obligation, and the two meet at the first assessment visit. Vivlio’s own intake checklist, written from what PACE teams ask for, is the operational version of this article: the last six to twelve months of progress notes, the last two or three office visits, the history and physical, specialist consults, physical and occupational therapy notes, cognitive scores, discharge summaries, imaging, labs from the last six months, the medication list, behavioral health. None of those lookback windows is in a rule. They are what an interdisciplinary team needs to evaluate the eleven domains in person without starting from the kitchen drawer, and the rule’s “if applicable” is doing a lot of work for a population in which every one of them usually applies.
PACE intake records is the page about retrieving all of it at once, through the national record networks on the release the applicant has already signed, organized by section before the first visit. The initial comprehensive assessment, PACE enrollment and the level-of-care form carry the regulation text behind the rows above.
