CMS-10630 Clinical Appropriateness for Transportation Impact Analy

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

C

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

Were Assessments
Completed by
Members of the IDT?
(Y/N)

IDT Members Who
Completed Assessments.

Were There Any Missed
Appointments, Center
Attendance, Etc.? (Y/N)

If Yes, When Were the
Missed Appointments,
Center Attendance, Etc.?

Number of Vehicles
Available to Provide
Transportation at the
Time That the
Appointments, Center
Attendance, Etc. Were
Missed.

Were Any Vehicles
Available That Were
Accessible to the
Participant? (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}