public sectors and from multiple settings of care. Such scan shall include a review of the following: (i) The process of eliciting and documenting patient (and, where relevant and appropriate, family caregiver or legally authorized representative) goals, preferences, and values regarding care and treatment, including the articulation of goals for end-of-life care that adequately reflect how the patient wants to live. (ii) The effectiveness, patient-centeredness (and, where relevant, family caregiver-centeredness), and adequacy of care plans, including documentation of individual goals, preferences, and values. (iii) Agreement and consistency among— (I) the patient’s goals, preferences, and values