CMS-10630 Clinical Appropriateness for Restraints Impact Analysis

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

Specific Type of Restraint Used.

List Other Methods Utilized by the PO
Prior to the Use of Restraint.

Reason the Use of Restraints was
Initiated and Were They Needed to
Ensure Participant's Safety and/or
Safety of Others

Which Members of the IDT
Completed Assessments?

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

Date(s) Restraint Was Utilized?
(MM/DD/YY)

Time(s) Restrain Was Initiated.
(HH:MM:SS)

Time the Restraint Was Discontinued.
(HH:MM:SS)

How Frequently Was the Participant
Monitored While Restrained?

How Frequently Was the Participant
Reassessed While Restrained?

IDT Members 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}