CMS-10630 Grievance Recognition and Notification

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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:
		Recognizing complaints as grievances
		Initial and Annual Written Grievance Information
Scope:	Recognizing complaints as grievances: • 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 grievance sample selection. • The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab. Initial and Annual Written Grievance Information: • 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 grievance sample selection. • The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab.
Instructions:	General: • The review timeframe is the audit review period. Errors noted prior to 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. Recognizing complaints as grievances: • 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 the participant, participant's family members, or participant representative submitted a complaint verbally or in writing. • Respond to the questions in the Participant Impact tab. Initial and Annual Written Grievance Information: • 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 the participant was provided written information of the grievance process at the time of enrollment and on at least an annual basis. • Respond to the questions in the Participant Impact tab.
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: Recognizing complaints as grievances

Section 3 - This information is to be completed if the Impact Analysis is being requested for: Initial and Annual Written Grievance Information

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.

Did the participant, their family members, their designated representatives, or their caregivers express a complaint, either written or oral, expressing dissatisfaction with service delivery or the quality of care furnished during the audit review period? (Yes/No) If the auditor did not select Recognizing complaints as grievances on the instructions tab the PO may enter NA in all columns in Section 2. If the answer to this question is No enter NA in all remaining columns in section 2.

Enter the date of the complaint. MM/DD/YYYY

Describe the complaint.

Is there documentation that the complaint was processed as a grievance? (Yes/No)

Date the grievance was resolved. MM/DD/YYYY If the grievance was not resolved, enter Not Resolved. If the grievance was not processed as a grievance, enter NA

Date the participant, their family members, their designated representatives, or their caregivers were notified of the resolution of the grievance. MM/DD/YYYY If the participant/family member was not notified, enter Not Notified. If the grievance was not processed as a grievance, enter NA

If the compliant was not processed as a grievance, was the complaint resolved outside of the grievance process? (Yes/No) Enter NA, if the complaint was processed as a grievance.

If yes, what was the resolution? Enter NA if the complaint was not resolved outside of the grievance process.

If yes, when was it resolved? MM/DD/YYYY Enter NA if the complaint was not resolved outside of the grievance process.

Were there any negative participant outcomes as a result of the failure to recognize complaints as grievances? (Yes/No)

Did the PO give the participant written information on the grievance process in understandable language, upon enrollment? (Yes/No) Enter NA if the participant was not newly enrolled during the audit review period. If the auditor did not select Initial and Annual Written Grievance Information on the instructions tab the PO may enter NA in all columns in Section 3.

Did the PO give the participant written information on the grievance process in understandable language, on an annual basis? (Yes/No) Enter NA if the participant was disenrolled before written information could be provided annually.

Did the PO's written grievance information include all of the required information, identified in § 460.120(c)? (Yes/No)

Did the participant or participant representative file a grievance during the audit review period? (Yes/No)

Were there any negative participant outcomes as a result of the PO failing to give the participant written information on the grievance process? (Yes/No)

If the participant experienced any negative outcomes, please describe the 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 grievance, please enter the information in this column.