Enrollment is not the end of the records problem for a PACE organization. It is where the problem changes shape. Before enrollment the interdisciplinary team is assembling a history from organizations the applicant used to see. After enrollment the participant keeps being seen elsewhere, by the hospital, the emergency department and the twenty-six contracted specialties, and every one of those visits produces a document the team is required to review on a clock, act on, and file in a record the state and CMS will read. This article is about those clocks, that record, and what the auditors found when they opened it.
The sequence before enrollment, and the 30-day plan-of-care clock that starts on the first of the month, is in the PACE intake timeline. Nothing there is repeated here.
Care outside the center is the normal case
A PACE organization is responsible for care “across all care settings, 24 hours a day, every day of the year” (42 CFR 460.98(a)), and services “must be furnished in at least the PACE center, the home, and inpatient facilities” (460.98(b)(2)). The organization must hold a written contract with every outside provider of care it does not furnish itself, including, at a minimum, twenty-six named medical specialties, from anesthesiology to urology (460.70(a)). Emergency providers are the exception: no contract is required (460.70(a)), which is also why the hospital is the one outside provider the organization has no paper with.
How often does a participant leave the center for care? The one recent federal figure is RTI International’s study for ASPE of every full-benefit dual-eligible beneficiary in 2021, 48,143 of them in PACE. In that year 26.45 percent of PACE participants had at least one inpatient hospitalization and 30.76 percent had at least one emergency department visit. Adjusted for age, comorbidity and state, PACE participants were less likely than matched Medicare Advantage enrollees to be hospitalized (odds ratio 0.951) and less likely to visit an ED (0.760); the unadjusted rate is the highest of the plan types because PACE enrolls the frailest people. The older measure, from Segelman and colleagues in 2014, is 539 hospitalizations per 1,000 person-years with a 30-day readmission rate of 19.3 percent and “considerable variation” between sites. Take either figure and the arithmetic is the same: a program of 300 participants should expect a hospital discharge summary to arrive, or fail to arrive, most weeks of the year, and specialist consult notes every day.
The three clocks that start when the participant comes back
CMS’s 2024 PACE rule put day counts on what the team must do with those documents. All three are in the current text of 42 CFR Part 460.
| Clock | What must happen | Rule |
|---|---|---|
| 48 hours from discharge | The appropriate team members “must review all recommendations from hospitals, emergency departments, and urgent care providers and determine if the recommended services are necessary” | 460.102(d)(1)(iv)(A) |
| 7 calendar days from the recommendation | The same review for “all recommendations from other employees and contractors”, which includes every contracted specialist | 460.102(d)(1)(iv)(B) |
| 14 calendar days from hospital discharge | A reevaluation of, and if necessary revisions to, the plan of care, when the participant was hospitalized within 14 days of a change in status | 460.106(b)(3)(ii) |
The first two are review clocks, and each one starts on a document the organization does not write. The 48 hours start “from the time of the participant’s discharge”, whether or not the discharge summary has been sent; the 7 days start “from the date the recommendation was made”, whether or not the consult note has been received. A recommendation the team approves must then be arranged “no later than 7 calendar days after the date the interdisciplinary team or member of the interdisciplinary team first approves the service” (460.98(c)(2)). Every one of those recommendations, and the reason for any that is not approved, has to be documented in the medical record (460.102(d)(1)(iii), 460.210(b)(4) and (b)(5)).
The third clock is the one most programs know as “the 14 days”. A change in participant status, as the rule defines it, is “a major decline or improvement” that “has an impact on more than one area of the participant’s health status and requires interdisciplinary team review or revision of the care plan” (460.106(a)(1)). It triggers an in-person reassessment by the primary care provider, the registered nurse and the social worker (460.104(d)(1)), and the plan of care must then be re-evaluated within 14 calendar days of when the organization “determines, or should have determined” the change occurred (460.106(b)(3)(i)). When the change puts the participant in a hospital, the clock moves to 14 days from the discharge date. “Should have determined” is doing real work in that sentence: a change the team learns about late, because the document that recorded it arrived late, is still measured from when the team should have known.
What the record has to hold
The duty to keep these documents sits on the organization, not on the hospital or the specialist. 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 it must contain:
- “A summary of emergency care and other inpatient or long-term care services” (460.210(b)(2)(i))
- “Services furnished by contractors and their reports” (460.210(b)(2)(iii))
- “All recommendations for services made by employees or contractors of the PACE organization, including specialists”, and the reasons for any not approved or provided (460.210(b)(4), (b)(5))
- “Laboratory, radiological and other test reports” (460.210(b)(7))
- “Hospital discharge summaries, if applicable” (460.210(b)(9))
The contracting rule is weaker than people assume. 460.70 requires the contractor to agree to “submit reports required by the PACE organization” (460.70(d)(5)(v)) and requires the organization to “designate an official liaison to coordinate activities between contractors and the organization” (460.70(b)(3)). It does not say that the contractor must send the medical record, in those words, and it says nothing at all about the hospital, which has no contract. What the organization is required to do is “document, track and monitor the provision of services across all care settings in order to ensure the interdisciplinary team remains alert to the participant’s medical, physical, emotional, and social needs” (460.98(b)(4)), and to “implement, coordinate, and monitor the plan of care regardless of whether the services are furnished by PACE employees or contractors, across all care settings” (460.106(d)(1)). Each team member is responsible for “remaining alert to pertinent input from any individual with direct knowledge of or contact with the participant”, a list that names contractors and specialists (460.102(d)(2)(ii)). The regulation puts the retrieval burden on the team, and then audits the team on it.
What CMS reads
The CMS PACE Audit Protocol is explicit about the documents the auditors open. CMS selects “up to 25 targeted medical records” that “appear clinically significant”, chosen to represent “hospitalizations, wound care, dialysis, social needs, home bound, skilled nursing care” among other needs, and gives the organization the list “1 hour prior to the start of the review of medical records”. The record review covers coordination of care “between the IDT and contracted individuals and entities”, and the list of what CMS reads includes:
- “Specialist records”
- “Hospital discharge summaries”
- “Summaries of other inpatient and long-term care services, including documentation of coordination of care with nursing facilities, assisted living facilities, and other sub-acute facilities”
- “Laboratory results” and “Diagnostic testing results”
- “All information related to coordination of participant care including communication between the PO and the participant, their designated representatives, their caregivers, hospitals, nursing facilities, assisted living facilities, other sub-acute facilities, specialists, other contractors”
The compliance questions follow the clocks word for word. Item 3.2.13 asks whether hospital, ED and urgent care recommendations were reviewed “no later than 48 hours from the time of the participant’s discharge”; 3.2.14 asks the same of contractor recommendations at 7 calendar days; 3.2.5 asks whether the team “remain[ed] alert to pertinent input” from specialists and contractors; 3.4.2 asks whether the record held its required content. The universe the organization submits before the audit, the List of Participant Medical Records, carries columns for hospital admissions, 30-day readmissions, ER visits and specialist use per participant, so the sample is drawn from exactly the participants whose records have the most outside paper in them.
What California found
California’s Department of Health Care Services publishes its PACE corrective action plans, and the routine audits of 2023 to 2025 and the complaint investigations into 2026 are a catalogue of the failure this article is about. The findings are quoted as DHCS wrote them. Participants are numbered in the reports and are not named here.
The recommendation never reached the plan. Neighborhood Healthcare PACE in Riverside, reviewed in October 2024, “was unable to monitor and track specialist recommendation” for one participant, and “was unable to effectuate MD order, specialist treatment, consultation, and/or referral expeditiously” for four others, cited under 460.98(b)(4) and (c)(4). Center for Elders’ Independence in Oakland, reviewed June 2024, was cited on the same two paragraphs for a pulmonology consult, a kidney ultrasound, a neurology consult, ophthalmology consults and an echo Doppler, a hematology consult and an abdominal ultrasound, and for neurology and nephrology follow-ups the organization “was unable to monitor and track”. Providence PACE in Napa, reviewed October 2024, was cited for two fecal immunochemical tests ordered and not tracked.
The specialist wrote; the primary care provider did not act. At InnovAge Sacramento, reviewed jointly by CMS and DHCS in October 2023, the primary care provider “did not address the phosphorus level per nephrologist’s recommendation”, “did not order the podiatry follow-up consultation as recommended by the podiatrist”, “did not address the biopsy per dermatologist recommendations”, and for one participant an orthopedic “consultation result /recommendation (surgery) on 03/30/2023 continuous to be delayed /pending for over 6 months at the time of audit fieldwork”. Redwood Coast PACE in Eureka, in a complaint investigation closed in February 2026, “failed to act on the dermatology specialist recommendations”, cited under the 2024 rule’s 460.102(d)(1)(iv).
The emergency department recommendation and the 48 hours. AltaMed PACE in Los Angeles, in a complaint investigation with a letter dated December 2025, was found to have “failed to effectuate medical doctor (MD) order, specialist treatment, consultation, and/or referral expeditiously” on an “Emergency department doctor’s recommendation during post fall assessment” and a “Stat CT head without IV contrast”, and the complaint itself was summarized by DHCS as “Not assessed after Emergency Department visit for fall on 5/5/25 and no follow- up on facial laceration”.
The result was not in the record. Neighborhood Healthcare “was unable to provide EKG results” for one participant, cited under 460.210(a)(2). InnovAge Sacramento “failed to maintain a medical record that was complete, accurate and/or available to all staff”. Providence “was unable to demonstrate accurate documentation” of a participant’s allergies.
The pre-enrollment consult that was never carried forward. North East Medical Services PACE in Daly City, reviewed September 2024, “was unable to follow through on a recommendation from a Specialty consult prior to enrollment. Colonoscopy and/or Colon Ca screening were not ordered for the participant since enrollment”, and for another participant a mammogram “recommended prior to the participants enrollment on 11/1/23” was never ordered after it. The outside record the intake team gathered contained a recommendation; the team that inherited the participant did not.
The clocks. Neighborhood “was unable to complete MD and RN semi-annual reassessment within timely manner” (460.104(c)); Center for Elders’ Independence missed the 180-day plan of care for a participant whose “Care plan due 9/21/23. Not completed until 11-9-23” (460.106(b)(2)).
And one finding about the referral system itself. The DHCS Audits & Investigations Focused Medical Review of InnovAge Inland Empire, covering 2023, concluded that “The PO did not document nor track all denied specialty referrals across all care settings”, and said why it matters: “Without tracking specialty referrals, the PO risks delaying medically necessary care for participants. This can potentially worsen a participant’s health outcome by delaying the diagnosis and treatment of serious conditions.”
Searched across the twenty-four reports on the DHCS index, no finding uses the words “discharge summary not obtained” or “reassessment after a change in condition not done”. The findings are framed one step downstream: a recommendation not tracked, a result the organization could not produce, a participant not assessed after the ED, a clock missed. That is what the failure looks like from the auditor’s chair. The document that did not arrive, or arrived and was not read, is the step before every one of them.
Why the document is late, and what to do about it
None of this is particular to PACE. Kripalani and colleagues’ 2007 systematic review of hospital-to-primary-care handoffs found that a discharge summary was available at the first post-discharge visit in 12 to 34 percent of cases and still only 51 to 77 percent at four weeks, and that the summaries that did arrive were missing diagnostic test results 33 to 63 percent of the time, pending results 65 percent of the time, discharge medications 2 to 40 percent, and follow-up plans 2 to 43 percent. That is the general condition of the document the 48-hour clock runs on. A PACE team has a tighter deadline than the primary care physicians in those studies and the same fax machine.
The mechanisms a team has are the ones the rule names: the contractor liaison, the contract clause requiring reports, the participant’s signed release, and whatever the hospital’s medical records department will send on request. Each one works per document, per provider, after the fact. The team learns that a hospitalization happened, then asks for the summary, then waits, while the 48 hours and the 14 days run.
The alternative is to stop asking per document. A participant’s outside record, retrieved through the national record networks on the treatment purpose the organization already holds, includes the hospital’s discharge documents and the specialist’s notes as soon as the sending organization files them, from every organization that participates, not only the ones the team thought to ask. Organized into one record, by section and by date, it is the “single, comprehensive medical record” 460.210 describes, with the discharge summary and the consult report in it before the clock expires rather than after. PACE intake records describes the same retrieval at the front of the process; the point of this article is that the process never ends. The interdisciplinary team, the plan of care and the discharge summary carry the regulation text behind it.
