PreAuditIssueSummary - Track Changes version

Instructions:

• Enter responses to each question in Pre-Audit Issue Summary tab of this document.
• Only include issues of non-compliance that occurred during the data collection period. The data collection period begins 6 months prior to the date of the
audit engagement letter and, for the purposes of this document, ends on the date of the audit engagement letter. For example, an audit engagement letter is
issued on March 3, 2026. The audit review period for this audit is September 3, 2025 2023, through March 3, 2026.
• Only include issues of non-compliance that were disclosed to the PACE organization's CMS account manager prior to the date of the audit
engagement letter.
• Do not include Quality data already reported to CMS.
• Do not include data that is not relevant to the audit elements included in the audit protocol.
• Do not include issues discovered during routine CMS and SAA monitoring and account management. This includes information discovered
during account management calls and information discovered during SAA audits.

Due Date:

This document must be completed and submitted to HPMS within 5 business days following the issuance of the audit engagement letter.

Issue
number

Description of the non-compliance
(explain what happened and what the non-compliance was)

Number of participants Date non-compliance
identified
impacted
Enter unknown if the
impact is unknown

Pending OMB Approval (0938-New)

MM/DD/YYYY

Was the non-compliance disclosed to
the CMS account manager prior to the
date of the Audit Engagement Letter?
Yes/No

Date non-compliance disclosed to
CMS
MM/DD/YYYY

To whom the noncompliance was
disclosed at CMS
(first and last name)

Pending OMB Approval (0938-New)

Root cause analysis of the non-compliance
(explain why it happened)

Pending OMB Approval (0938-New)

How was the non-compliance discovered?

Was the non-compliance fully Describe how the non-compliance
was remediated (corrected).
remediated?
(e.g. was the non-compliance fully
corrected)?

Date system/operational
remediation initiated
MM/DD/YYYY

Yes/No

Pending OMB Approval (0938-New)

Date system/operational
remediation completed
MM/DD/YYYY

Description of remediation for negatively
impacted participants

Date participant remediation
initiated MM/DD/YYYY

Date participant remediation
completed MM/DD/YYYY

Enter NA if participant
remediation was not initiated.

Enter NA if participant
remediation was not initiated.

Pending OMB Approval (0938-New)

If remediation or correction was not If remediation or correction was not
completed, has the risk to
completed, when is the anticipated
participants been mitigated?
completion date?

If the risk to participants has been
mitigated please explain.

Pending OMB Approval (0938-New)