CMS-10630 Clinical Appropriateness for Care Planning Impact Analys

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 # of Individuals Impacted
(e.g. participants) 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)

Was This the Initial Plan of Care,
Semiannual Revision to the Plan of
Care, Annual Revision to the Plan
of Care, or Unscheduled Revision
to the Plan of Care?

If Applicable, Date of the Previous
Plan of Care Revision
(MM/DD/YY)

Did the Plan of Care Require a
Revision?
(Y/N)

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

IDT Members (Disciplines) Actively
Involved in the Development and
Implementation of the
Participant's Plan of Care at the
Time of the Assessment.

IDT Members (Disciplines) Who
Completed an Assessment.

Date the IDT Members (Disciplines)
Completed the Assessments
(Identify Assessment Date by
Discipline)
(MM/DD/YY)

Was There a Change in the
Participant's Status? (Y/N)

If Yes, Describe the Change in the
Participant's Status.

Reason Assessments Were
Delayed or Not Completed.

Did the Plan of Care Specify the
Care Needed to Meet the
Participant's Medical, Physical,
Emotional and Social Needs? (Y/N)

Did the Plan of Care Identify
Measurable Outcomes to Be
Achieved?
(Y/N)

Did the IDT Develop, Review and
Reevaluate the Plan of Care in
Collaboration With the Participant
or Caregiver, or Both, to Ensure
That There is Agreement With the
Plan of Care and That the
Participant's Concerns Were
Addressed?

WereThere Any
Negative Participant
Outcomes?
(Y/N)

If Yes,
Describe the
Negative
Outcomes.

{Other Data
Requested}

{Other Data
Requested}

{Other Data
Requested}