CAPTemplate - Track Change

OMB Control Number: 0938-1327 (Expires: 11/30/2025)

Condition: Audit Lead will populate the condition number and Language

Needed Corrective Action Language: Audit Lead will populate

Scope:

Non-compliance identified during this audit was based on a review of a subset of participants and may not be fully representative
of all types of non-compliance during the audit review period. The corrective action plan must fully address all non-compliance
present during the audit review period (whether identified by the CMS audit team or by other means).

PO Instructions: Respond to the relevant questions in the Corrective Action Tab. Please provide a response in each column related to the noncompliance listed in the corresponding row. If noncompliance has
more than one root cause, please add an additional row such that each row is in relation to a single root cause. Please note that the level of detail necessary to ensure complete and accurate CAPs will be
dependant on each individual issue contributing to the non-compliance identified during the audit. The examples provided in tab 2 are intended to serve as a guide and represent the minimum amount of
information necessary to fully address the non-compliance.
• Corrective Action tab:
* Column A - Will be completed by the audit lead.
* Column B - PO will enter each root cause for each issue identified in Column A. If more than one root cause exists for an issue in Column A, please insert an additional row. Please see the example for more
than one root cause included in the Corrective Action tab.
* Columns C-H - The PO will enter details relating to the Corrective Action of each root cause identified in Column B.
Potential Types of Non-Compliance

Non-Compliance Identified During Audit (Enter X if identified during the audit)

Corrective Action Plan Submission to CMS Due Date:
Full Implementation Date: CMS expects that PACE organizations correct non-compliance as expeditiously as possible. The PO must plan to achieve regulatory compliance no later than 60 days after CAP
acceptance. Failure to correct non-compliance identified during an audit may result in a compliance or enforcement action referral.

Audit Lead to Populate Column A
PO may add additional rows if needed for multiple root causes

Example: Wound care was not provided as ordered by the PCP.

Example : Wound care was not provided as ordered by the PCP.

Pending OMB Approval (0938-New)

Please describe the cause(s) that led to the non-compliance.
If more than one root cause exists for an issue in Column A, please
enter each root cause in a new row by inserting an additional rows.

The PCP incorrectly entered wound care orders into the EMR.

PO was under the impression that wound care could be ordered by
RNs.

Pending OMB Approval (0938-New)

Please identify the specific actions that will be taken to remediate
any impacted participants, if remediation is possible.

Provider EMR review of all participants receiving wound care to
ensure orders are current and aligned with PCP plan of care.
Provider EMR review of all participants receiving wound care to
ensure orders are current and aligned with PCP plan of care.

Pending OMB Approval (0938-New)

What specific actions will be taken to address each cause and
prevent future non-compliance.

Provider EMR Training

1) RN Scope training
2) Wound care policy updates to include all wound care orders will
require PCP order or co-signature prior to being executed by nursing
staff.
3) Policy update indicating verbal orders will not be utilized.

Pending OMB Approval (0938-New)

Please identify the staff responsible for the implementation of the
corrective action plan. If multiple actions/changes will be
implemented, please identify the staff responsible for
implementing each action/change.
Medical Director

1) Nursing Director
2) Nursing Director, Quality Director
3) Nursing Director, Medical Director

Pending OMB Approval (0938-New)

Please identify the specific, objective, and measurable monitoring
activities the PO will undertake to evaluate the effectiveness of the
changes implemented to prevent future non-compliance. If multiple
monitoring activities will be implemented, please identify each
monitoring activity.
Every two weeks, Medical director will review 5 differing participant
charts undergoing wound care to ensure PCP orders are correctly
entered.
Every two weeks, Nursing Director will review 5 differing participant
charts undergoing wound care to ensure nurses are effectuating PCP
orders as written.

Pending OMB Approval (0938-New)

Please identify the staff responsible for monitoring and evaluating
the effectiveness of the CAP. If multiple actions/changes will be
implemented, please identify the staff responsible for monitoring
each action/change.
Quality Director, Executive Director

Quality Director, Executive Director

Pending OMB Approval (0938-New)

Please describe how the CAP will be integrated into the PO’s
compliance and/or quality program in order to ensure compliance
with CMS requirements. If multiple actions/changes will be
implemented, please describe how each action/change will be
integrated into the PO’s compliance program.
Results will be collected, aggregated and analyzed and maintained in
ongoing quality review. Results will be reported in monthly quality
meeting and quarterly calls with BOD.
Results will be collected, aggregated and analyzed and maintained in
ongoing quality review. Results will be reported in monthly quality
meeting and quarterly calls with BOD.

Pending OMB Approval (0938-New)