CMS-10630 Clinical Appropriateness for Comprehensive Care Impact A

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
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

Was There a Service
Delivery Request by the
Participant/ Caregiver/
Participant
Representative?
(Y/N)

Were the Assessments Documented
in the Medical Record?
(Y/N)

List Each Type of Service NOT
Provided by the PO.

Date the Services Should Have
Started?
(MM/DD/YY)

How Long Were Services NOT
Provided?

In What Setting(s) Would the
Services Have Been Provided?

Reason the Services Were NOT
Provided.

Was the Service a Medicare Covered
Service?
(Y/N)

Were There any Negative
Participant Outcomes?
(Y/N)

If Yes, Describe the Negative
Outcomes.

{Other Data Requested}

{Other Data
Requested}

{Other Data
Requested}