CMS-10630 Clinical Appropriateness for Infections 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

Type(s) of
Infection(s).

Date(s) the Infection(s)
Were Identified.
(MM/DD/YY)

Source of the
Measure(s) Taken
Measure(s) Taken
Where Did the Participant
Infection(s) (e.g. Food
Prior to the Date(s) the After the Date(s) the
Contract the Illness (e.g.
Infection(s) Were
Infection(s) Were
Bourne Illness, Hospital
PACE Center, Home,
Identified to Control
Idenfied to Prevent
Acquired, Outbreak in
Nursing Facility, etc.)?
the Infection(s)
Infection(s)
PACE Center).

Were Any Local, State,
or Federal Agencies
Notified of the
Infection(s)? (Y/N)

Were Incident(s) of
Infection
Investigated? (Y/N)

Were Incident(s) of Infection
Analyzed? (Y/N)

Were Any Trends
Identified? (Y/N)

Were There Any
Negative Outcomes?
(Y/N)

If Yes, What Were the
Negative Outcomes?

{Other Data
Requested}

{Other Data
Requested}

{Other Data Requested}