CMS-10630 Arranging Services

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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:
		Arranging the Dispensing of Medications
		Arranging the Delivery of All Other Services
Scope:	• 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.
Instructions:	General: • Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab. • Respond to the questions in the Participant Impact tab. • The review timeframe is the audit review period. Errors noted before or after the audit review period should not be included. • After completing the Impact Analysis, if any changes need to be made to the Root Cause Analysis, please update the RCA tab. Arranging the Dispensing of Medications: • Review the selected medical records to determine if the dispensing of medications were arranged and scheduled within the required timeframe. Arranging the Delivery of All Other Services: • Review the selected medical records to determine if the delivery of all other services were arranged or scheduled within the required timeframe.
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: Arranging the Dispensing of Medications

Section 3 - This information is to be completed if the Impact Analysis is being requested for: Arranging the Delivery of All Other Services

Section 4 - 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.

Arranging the Dispensing of Medications Did the PO arrange and/or schedule the dispensing of medications as expeditiously as the participant's condition requires, but no later than 24 hours after a primary care provider ordered the medication? (Yes/No) If Yes, enter NA for all remaining columns in Section 2. If the auditor did not select Arranging the Dispensing of Medications on the instructions tab the PO may enter NA in all columns in Section 2.

Medications Enter each medication that was not arranged and/or scheduled within 24 hours in a new row. Only include medications that were not arranged or scheduled within 24 hours from the time the PCP ordered the medication. Please note: Impact analyses will be returned for correction if each service is not listed in a new row.

Date of Order MM/DD/YYYY

Time of Order HH:MM AM/PM

Date Dispensing was Arranged and/or Scheduled MM/DD/YYYY Enter NA if dispensing of the medication was never arranged and/or scheduled.

Time Dispensing was Arranged and/or Scheduled HH:MM AM/PM Enter NA if dispensing of the medication was never arranged and/or scheduled.

Was the medication provided? (Yes/No)

Date the medication was provided? MM/DD/YYYY Enter NA if the medication was not provided.

If the participant experienced negative outcomes, did they occur, in some part, as a result of a failure to arrange or schedule the dispensing of the medication within 24 hours from the time the PCP ordered the medication? (Yes/No)

Arranging the Delivery of All Other Services Did the PO arrange and/or schedule the delivery of all other IDT approved services, other than medications, as expeditiously as the participant's health condition requires, but no later than 7 calendar days after the date the IDT or member of the IDT first approved the service? ‘IDT approved services,’ means the service was determined necessary by the IDT or an IDT member, approved by IDT, ordered by a PACE PCP, or care planned. (Yes/No) If Yes, enter NA for all remaining columns in Section 3. If the auditor did not select Arranging the Delivery of All Other Services on the instructions tab the PO may enter NA in all columns in Section 3.

Services Enter each service that was not arranged and/or scheduled within 7 calendar days in a new row. Only include services that were not arranged or scheduled within 7 calendar days from the date they were first approved by the IDT. Please note: Impact analyses will be returned for correction if each service is not listed in a new row.

Routine/Preventative Services Was the service a routine or preventative service that the PO was unable to schedule due to circumstances beyond the control of the PO? (Yes/No) If the response to this question is Yes, enter NA in all remaining columns in Section 3.

Date Service Approved MM/DD/YYYY

Date Delivery of the Service was Arranged and/or Scheduled MM/DD/YYYY Enter NA if delivery of the service was never arranged and/or scheduled.

Was the service provided? (Yes/No)

Date the service was provided? MM/DD/YYYY Enter NA if the service was not provided.

If the participant experienced negative outcomes, did they occur, in some part, as a result of a failure to arrange or schedule the delivery of the service within 7 calendar days from the date the IDT fist approved the service? (Yes/No)

If the participant experienced any negative outcomes, please describe the negative outcomes. Enter NA if there were no negative outcomes.

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 appeal, please enter the information in this column.