CMS-10630 Grievances Impact Analysis Template

OMB Control Number: 0938-TBD (Expires: TBD)
Date Identified
(MM/DD/YY)
(Completed By The
CMS Audit Lead)

Detailed Description of the Issue
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 Outreach and
Remediation Initiated
(MM/DD/YY)

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

Participant
First Name

Participant Last
Name

Participant ID

Date Complaint
Initially
Received.
(MM/DD/YY)

Date Grievance
Initiated.
(DD/MM/YY)

What, If Any, Issues
Were Not Resolved
During the
Grievance?

Were They Ever
Resolved? (Y/N)

If Yes, When (Provide
Date)?
(MM/DD/YY)

For Misclassified
Service Requests,
Was the Service
Request Ever
Processed? (Y/N)

If Yes, When (Provide
Date)?
(MM/DD/YY)

Was the Service
Request Approved?
(Y/N)

If Yes, When Was the
Service Provided?

Were There Any
Negative Outcomes?
(Y/N)

If Yes, What Were the
Negative Outcomes?

Did the PO Fail to
Provide Continued If Yes, What Care Was
Not Provided?
Care During Grievance
Process? (Y/N)

{Other Data
Requested}

{Other Data
Requested}

{Other Data
Requested}