As a CenterLight Program of All-Inclusive Care for the Elderly (PACE) provider, your commitment to participant safety and program integrity is essential. One of the most critical tools to ensure that we provide high quality care and meet participants' needs is incident reporting.
In order to ensure positive outcomes for those we serve, you must inform us immediately if you become aware of any change in condition or if there are any incidents that may threaten their health and safety.
The Centers for Medicare and Medicaid Services requires CenterLight Healthcare and other PACE organizations to report incidents that include:
Suspected elder abuse, neglect, or exploitation
Medication related events such as adverse drug reactions or medication administration errors
Injuries or new wounds, including burns and pressure injuries
Elopements
Falls with or without injury
Incident reporting isn’t just about checking boxes—it’s about protecting lives and improving care. If your protocol is to send a participant to the Emergency Room after a fall, or if there is another valid reason for sending them to the hospital for evaluation, please call CenterLight PACE so that we can be a part of the care coordination. Let’s keep our standards high and our reporting accurate and on time!
This blog post is written by Jocelyn Pappalardo, Director of Quality at CenterLight Healthcare PACE.
H3329 Blog_ForProviders_IncidentReporting Updated September 10, 2025
At CenterLight Healthcare Program of All-Inclusive Care for the Elderly (PACE), we believe that high-quality, participant-centered care is only possible through collaboration with our provider network. Our providers play a vital role in ensuring that care is not only compassionate and effective but also compliant with regulatory standards.
As part of our ongoing commitment to excellence in care coordination, regulatory compliance, and health outcomes, we rely on our provider network to submit timely, complete, and accurate medical records. Your diligence in documentation directly supports the delivery of safe, effective, and coordinated care—and it gets results.
Shared Success: Measurable Impact
Thanks to your continued efforts, CenterLight PACE achieved:
An 8% reduction in emergency room visits per 1,000 participants
A 5% reduction in hospital readmissions
These improvements, recorded from Q1 to Q2 of 2025,* reflect the power of strong provider collaboration and thorough medical documentation. They also ensure we meet key standards set by federal and state agencies, including Centers for Medicare and Medicaid Services (CMS) and New York State Department of Health (NYSDOH).
What to Include in Every Medical Record Submission
As the participant's consulting physician or primary care provider, you play an integral role as a member of their care team. One of our regulatory requirements as a PACE program is to have the CenterLight care team review and update the individualized plan of care minimally on a 6-month basis.
To support this goal, visit notes must be submitted to CenterLight PACE to ensure that our participants' visits to your office become part of their medical record.
Please ensure that each medical record submission includes the following components, when applicable:
Plan of Care
Nursing and physician progress notes detailing the participant’s response to treatment
Specialist evaluations and recommendations
Laboratory, radiological, and other test reports
Medication records, including medication administration records
Physician orders
Reports of contact with informal support (e.g., caregiver, legal guardian, or next of kin)
Hospital discharge summaries
Discharge summary and disenrollment justification
Advance directives
Documentation Guidelines
Submit medical record documentation monthly
Submit documentation after both scheduled and unscheduled assessments
Ensure all records are legible, clearly dated, and signed by the responsible clinician
Send records to: visitdocumentation@centerlight.org
CenterLight’s staff is HIPAA-trained and committed to upholding strict data privacy and security standards.
Thank you for you for helping us provide high-quality care to those we serve!
Your commitment to thorough documentation and timely communication helps us deliver exceptional care to our participants. Together, we are building a stronger, more responsive care network—one record at a time.
This blog post is written by Jocelyn Pappalardo, Director of Quality at CenterLight Healthcare PACE.
*CenterLight PACE participant data collected by the organization's Quality Department.
H3329 Blog_ForProviders_VisitNotes Updated July 15, 2025
When you partner with CenterLight Healthcare Program of All-Inclusive Care for the Elderly (PACE), you enjoy a host of benefits for your practice, while helping your patients live safely and independently in their homes. PACE is an integrated model of care where older adults 55+ with long term care needs can enjoy access to all the care they require, including medical care; rehabilitation; social work, nutrition, and recreation services; prescription and over-the-counter medications; and home care.*
With CenterLight PACE, you remain the Primary Care Provider (PCP) and share the responsibility of patient care with our Interdisciplinary Team (IDT) which includes, but is not limited to, Nurses, Rehab Therapists, Social Workers, Dietitians, and Therapeutic Recreation Specialists. Some participants (individuals enrolled in PACE) may receive primary care services from us, but a large number keeps their existing doctors. We work with community providers, meet those we serve where they are, and integrate with their ecosystem. So when our doctors and the rest of the IDT encounter your patient throughout their healthcare journey, we address their immediate needs and strive to communicate, collaborate, and be true partners in care to you. As majority of PACE participants are frail older adults with complex medical and social needs, we count on having an effective and efficient relationship with our primary care partners to accomplish our shared goal of providing high quality services that help improve their quality of life.
Benefits for Your Medical Practice
One payor source: no need to bill fee-for-service Medicaid for Part B deductible and cost shares.
IDT develops, coordinates, and carries out an individualized plan of care and provides health education to participants and/or caregivers.
Transportation coordination for medical appointments reduces no-shows.
Improved engagement with participants who do not come frequently to their regular primary care appointments.
Access to homebound participants through the IDT.
Social worker helps with entitlements and behavioral health issues.
Collaboration with a pharmacist to assist with medication review and reconciliation.
An opportunity to grow your practice as we grow our membership.
PACE Model of Care: Proven Results
Through continuous collaboration between the participants’ primary care provider and the CenterLight PACE IDT, participants benefit from high quality, holistic care. IDT involvement helps prevent unnecessary hospitalizations, achieve high quality outcomes, and helps improve social determinants of health outcomes. The charts below illustrate how PACE outcomes compare with national averages.
Working Together to Provide High Quality Care
One of CenterLight’s core responsibilities is to ensure care coordination and delivery of services to our participants. Our participants’ consulting physician or primary care provider play an integral role as a member of their care team.
The CenterLight IDT provides wrap around services (urgent care access, chronic illness management, transition of care support, palliative care, and more) to your patient and functions as an extension to your team.
We collaborate with you when there is a change in a participant’s status and to closely monitor their condition. We are your eyes and ears when you can’t see them, and we strive to make our interactions brief, efficient and beneficial, and avoid adding unnecessary burden on you.
Medical encounter notes are required to ensure that the participant’s visit to your office becomes part of their medical records.
As part of PACE regulatory requirements, CenterLight participants are required to have semiannual and annual assessments done by members of their IDT. Most of these assessments may be done at the PACE Center. The nurse and physical/occupational therapist must do assessments and safety evaluations in the home twice a year.
Please check back soon for more articles about how we can work together to provide high quality care to those we serve.
This blog post is written by Ziad Farah, MD, MBA, Chief Medical Officer at CenterLight Healthcare PACE.
H3329 ForProvidersBlog Approved 10292024 Last Updated September 4, 2024
The participant may be liable for the costs of unauthorized or out-of-PACE program agreement services. Upon enrollment, the PACE program will be the participant’s sole service provider. Participants will have access to all services needed as identified by the Interdisciplinary Team, but not to a specific provider of these services.
CenterLight Healthcare has an approved PACE contract with the Centers for Medicare and Medicaid Services (CMS) and NY State Department of Health (NYSDOH). Enrollment in CenterLight Healthcare PACE depends on renewal of its contract with CMS and NYSDOH. Participants may be fully and personally liable for the cost of unauthorized or out-of-PACE program agreement services. Upon enrollment, the PACE program will be the participant’s sole service provider. Participants will have access to all services needed as identified by the Interdisciplinary Team, but not to a specific provider of these services. Please contact us for more information.
