CMS-10630 Clinical Appropriateness for Assessments Impact Analysis

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

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)

Type of Assessment.

IDT Members (Disciplines) Actively
Dates the IDT Members Completed
Involved in the Development and
Their Initial Assessments (Identify
Implementation of the Participant's
Assessment Date by Discipline).
Plan of Care at the Time of the
(MM/DD/YY)
Assessment.

IDT Members (Disciplines) Who
Completed an Assessment.

Were Any Assessments NOT
Completed? (Y/N)

Which Assessments Were NOT
Completed?

Reason Assessments Were Delayed
or Not Completed.

Were Assessments Completed in
Person? (Y/N)

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

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

Were Any Assessments NOT
Documented? (Y/N)

Which Assessments Were NOT
Documented?

If Applicable, Was the Service
Approved or Denied?

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

Date the Initial Plan of Care Was
Completed?
(MM/DD/YY)

Were There Any
If Yes, Describe
Negative Participant the Negative
Outcomes? (Y/N)
Outcomes.

{Other Date as
Requested}

{Other Date as
Requested}

{Other Date as
Requested}