CMS-10630 CAP Template

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Overview

Instructions
Corrective Action

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Sheet 1: Instructions

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.
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: Corrective Action

Audit Lead to Populate Column A PO may add additional rows if needed for multiple root causes	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.	Please identify the specific actions that will be taken to remediate any impacted participants, if remediation is possible.	What specific actions will be taken to address each cause and prevent future non-compliance.	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.	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.	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.	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.
Example: Wound care was not provided as ordered by the PCP.	The PCP incorrectly entered wound care orders into the EMR.	Provider EMR review of all participants receiving wound care to ensure orders are current and aligned with PCP plan of care.	Provider EMR Training	Medical Director	Every two weeks, Medical director will review 5 differing participant charts undergoing wound care to ensure PCP orders are correctly entered.	Quality Director, Executive Director	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.
Example: Wound care was not provided as ordered by the PCP.	PO was under the impression that wound care could be ordered by RNs.	Provider EMR review of all participants receiving wound care to ensure orders are current and aligned with PCP plan of care.	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.	1) Nursing Director 2) Nursing Director, Quality Director 3) Nursing Director, Medical Director	Every two weeks, Nursing Director will review 5 differing participant charts undergoing wound care to ensure nurses are effectuating PCP orders as written.	Quality Director, Executive Director	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.