Form CMS-10525 Level Two Conference Call Worksheet

LEVEL TWO CONFERENCE CALL WORKSHEET

INSTRUCTIONS: The organization must prepare a case presentation for discussion on the conference call. This worksheet is provided to aid in the documentation of the information to be presented during the conference call and provided within the notification email. It is highly recommended that this worksheet is used for this purpose.

Age and gender:

Enrollment Date:

Participant’s current status:

Significant diagnoses:

Summary of the care history

Summary of the event

Immediate actions taken

IDT team’s main concerns related to participant prior to event:

Precipitating/contributing factors:

Participant’s involvement/actions surrounding the event

Participant’s degree of involvement in PACE program:

Working relationship with contracted facility, contracted services (if applicable):

Compliance with organization’s established policies and procedures:

Identification of risk points and their potential contribution to the event:

As appropriate, proposed improvements in policies, training, procedures, systems, processes, physical plant, staffing levels, Etc. to reduce future risks

Initial improvements:

Additional improvements:

Quality improvement project initiated:

Example April 28, 2014