CMS-10630 Root Cause Analysis Template

OMB Control Number: 0938-TBD (Expires: TBD)
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)

Detailed Description of the Issue
(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
Date System/ Operational Remediation Actions Taken to Resolve Negatively Impacted Individuals
Initiated
Completed (MM/DD/YY)
Including Outreach Description and Status
(MM/DD/YY)

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

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