CMS-10630 Service Delivery Impact Analysis Template

OMB Control Number: 0938-TBD (Expires: TBD)
Detailed Description of the Issue
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)

(Explain what happened)
(Remaining fields to be Completed by PACE
Organization)

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
Date Individual
Outreach and
Outreach and
Remediation Initiated Remediation Completed
(MM/DD/YY)
(MM/DD/YY)

Participant
First Name

Participant Last
Name

Participant ID

Reason for Extension

Explain Why the
Extension Was Beneficial
to Participant

Notification of Extension
Given to Participant?

Was Appeal Language
Included in the Letter?
(Y/N)

Did the Participant
Appeal? (Y/N)

Date of the Appeal
Request
(MM/DD/YY)

Was the Approved
Service Added to
the Care Plan? (Y/N)

If Yes, Provide the
Date it Was Added.
(MM/DD/YY)

Was Emergency Care
Provided? (Y/N)

When Was
Emergency Care
Provided?

{Other Data
Requested}

{Other Data
Requested}

{Other Data
Requested}