Form CMS-10630 Clinical Appropriateness for IDT Documentation Impact An

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 Outreach and
Remediation Initiated
(MM/DD/YY)

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

Participant First
Name

Participant Last
Name

Participant ID

If Hospitalized, Most Recent Date of
Hospitalization.
(MM/DD/YY)

If Participant Went to the Emergency
Room, Most Recent Date of
Emergency Room Visit. (MM/DD/YY)

Describe the Change in the
Participant's Condition.

Did the Change Require an
Assessment by One or More
Members of the IDT?
(Y/N)

IDT Members Who Completes
Assessments.

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

Were Assessments Completed in
Person?
(Y/N)

Did the Change Require an Update/
Revision to the Plan of Care?
(Y/N)

Was the Participant's Plan of Care
Updated/ Revised?
(Y/N)

Date the Plan of Care Was or Should
Have been Completed or Revised by
the IDT.
(MM/DD/YY)

If the Change in the Participant's
Condition Did NOT Require an
Assessment Was a Progress Note
Documented?
(Y/N)

IDT Member Who Completed
Progress Notes?

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

If Yes, Describe the Negative
Outcomes.

{Other Data
Requested}

{Other Data
Requested}

{Other Data
Requested}