CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

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Overview

Instructions
Detailed Sample Information
Root Cause Analysis
Participant Impact

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Sheet 1: Instructions

Audit Review Period:
Issue(s) of non-compliance:	Auditors: Select All that Apply	Issue
		Unscheduled Assessments
		Semiannual Assessments
		Initial Assessments
Scope:	Unscheduled Assessments: • The scope of this Impact Analysis is no more than 50% of the participants enrolled during the audit review period who were not included in the provision of services sample selection. • The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab. Semiannual Assessments: • The scope of this Impact Analysis is limited to 50% of the participants enrolled during the audit review period who were not included in the provision of services sample selection. • The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab. Initial Assessments: • The scope of this Impact Analysis is limited to 50% of the participants newly enrolled during the audit review period who were not included in the provision of services sample selection. • The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab.
Instructions:	General: • After completing the Impact Analysis, if any changes need to be made to the Root Cause Analysis, please update the RCA tab. • The review timeframe is the audit review period. Errors noted prior to the audit review period should not be included. Unscheduled Assessments: • Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab. • Review the selected medical records to determine: 1. If the participant had a change in status; and 2. If all required IDT members completed assessments as required. Semiannual Assessments: • Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab. • Review the selected medical records to determine if all required IDT members completed assessments as required. Initial Assessments: • Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab. • Review the selected medical records to determine if all required IDT members completed assessments as required.
Impact Analysis Due Date:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1327. This information collection will allow CMS to conduct comprehensive reviews of PACE organizations to ensure compliance with regulatory requirements. The time required to complete this information collection is estimated at 780 per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory per CMS’s authority under Section 1894 and 1934 of the Social Security Act and implementing regulations at 42 CFR § 460.190 and 460.194, which state that CMS, in conjunction with the State Administering Agency (SAA), audit PACE organizations (POs) annually for the first 3 contract years (during the trial period), and then on an ongoing basis following the trial period. Additionally, per § 460.200(a) PACE organizations are required to collect data, maintain records, and submit reports as required by CMS and the State administering agency. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Sheet 2: Detailed Sample Information

Tracking ID Number	Brief Description Of Issue (Completed By The CMS Audit Lead)	Type of Issue Identified (Completed By The CMS Audit Lead) (Applies to condition 1P.02 Only. For all other conditions enter N/A)	Detailed Description of the Issue (Explain what happened)
		x

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Sheet 3: Root Cause Analysis

Date Identified (MM/DD/YY) (Completed By The CMS Audit Lead)

Brief Description Of Issue (Completed By The CMS Audit Lead)

Condition Language (Completed By The CMS Audit Lead)

Root Cause Analysis for the Issue (Explain why it happened)

Methodology - Describe the process that was undertaken to determine the # of individuals (e.g. participants) impacted

# of Individuals Impacted

Action Taken to Resolve System/ Operational Issues

Date System/ Operational Remediation Initiated (MM/DD/YY)

Date System/ Operational Remediation Completed (MM/DD/YY)

Actions Taken to Resolve Negatively Impacted Individuals Including Outreach Description and Status

Date Individual Outreach and Remediation Initiated (MM/DD/YY)

Date Individual Outreach and Remediation Completed (MM/DD/YY)

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Sheet 4: Participant Impact

Section 1 - General Information: This information is to be completed for all Impact Analyses

Section 2 - This information is to be completed if the Impact Analysis is being requested for: Unscheduled Assessments

Section 3 - This information is to be completed if the Impact Analysis is being requested for: Semiannual Assessments

Section 4 - This information is to be completed if the Impact Analysis is being requested for: Initial Assessments

Section 5 - General Information: This information is to be completed for all Impact Analyses

Participant First Name

Participant Last Name

Medicare Beneficiary Identifier

Participant ID

Date of Enrollment MM/DD/YYYY

Date of Disenrollment MM/DD/YYYY Enter NA if the participant is still enrolled.

Were all change in status assessments completed, as required, during the audit review period? Enter NA if the participant did not have a change in status during the audit review period. (Yes/No/NA) If the auditor did not select Unscheduled Assessments on the instructions tab the PO may enter NA in all columns in Section 2. If the answer to this question is NA, enter NA in all remaining columns in Section 2.

When did the change in status occur? If there was more than one change in status, use a new row for each date. MM/DD/YYYY

Identify the IDT disciplines who did not complete assessments. (PCP, RN, etc.) The required disciplines are the PCP, RN, MSW, and other team members they determine are actively involved in the development or implementation of the participant's plan of care. Enter NA if all required unscheduled assessments were completed.

Identify the IDT disciplines who did not complete in-person assessments. (PCP, RN, etc.) The required disciplines are the PCP, RN, MSW, and other team members they determine are actively involved in the development or implementation of the participant's plan of care. Enter NA if all assessments were completed in-person.

Identify the IDT disciplines who did not complete assessments before the reevaluation of the participant's care plan was completed. (PCP, RN, etc.) The required disciplines are the PCP, RN, MSW, and other team members they determine are actively involved in the development or implementation of the participant's plan of care. Enter NA if all assessments were completed before the reevaluation of the participant's care plan was completed.

Were all semi-annual assessments completed, as required, during the audit review period? Enter NA if semi-annual assessments were not required during the audit review period. (Yes/No/NA) If the auditor did not select Semiannual Assessments on the instructions tab the PO may enter NA in all columns in Section 3. If the answer to this question is NA, enter NA in all remaining columns in Section 3.

Did the PCP, RN, and MSW determine that any other IDT disciplines were actively involved in the development or implementation of the participant's plan of care? If yes, list the disciplines as determined by the PCP, RN, and MSW. If no, enter NA.

Identify the IDT disciplines who did not complete assessments. (PCP, RN, etc.) At a minimum the required disciplines include PCP, RN, MSW and any disciplines identified in column M. Enter NA if all required semi-annual assessments were completed.

Identify the IDT disciplines who did not complete in-person assessments. (PCP, RN, etc.) At a minimum the required disciplines include PCP, RN, MSW and any disciplines identified in column M. Enter NA if all assessments were completed in-person.

Identify the IDT disciplines who did not complete assessments before the reevaluation of the participant's care plan was completed. (PCP, RN, etc.) At a minimum the required disciplines include PCP, RN, MSW and any disciplines identified in column M. Enter NA if all assessments were completed before the reevaluation of the participant's care plan was completed.

Were all initial assessments completed, as required, during the audit review period? Enter NA if the participant's enrollment date was prior to the start of the audit review period. (Yes/No/NA) If the auditor did not select Initial Assessments on the instructions tab the PO may enter NA in all columns in Section 4. If the answer to this question is NA, enter NA in all remaining columns in Section 4.

Identify the IDT disciplines who did not complete assessments. (PCP, RN, etc.) Enter NA if all required initial assessments were completed.

Identify the IDT disciplines who did not complete in-person assessments. (PCP, RN, etc.) Enter NA if all assessments were completed in-person.

Identify the IDT disciplines who did not complete assessments within 30 days of the participant's enrollment. (PCP, RN, etc.) Enter NA if all assessments were completed within 30 days of enrollment.

Identify the IDT disciplines who did not complete assessments before the completion of the participant's initial care plan. (PCP, RN, etc.) Enter NA if all assessments were completed before the completion of the participant's initial care plan.

Optional: Please note, you do not have to complete this column. If there are any mitigating factors that you would like CMS to consider related to a specific participant, please enter the information in this column.