CMS-10630 Personnel Impact Analysis Template

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
Date Individual
Outreach and
Outreach and
Remediation Initiated Remediation Completed
(MM/DD/YY)
(MM/DD/YY)

Employee First Employee Last
Name
Name

Job Title

Job Description

Date of Hire
(MM/DD/YY)

Date of
Termination
(MM/DD/YY)

Type of
Employment

Direct
Participant
Contact (Y/N)

License (Y/N)

Was a Background Check
Was the Employee Ran
Were Competency
Performed on the
Through the OIG Excluded Evaluations Conducted for
Employee Prior to Hiring?
Provider List? (Y/N)
the Employee? (Y/N)
(Y/N)

Was OSHA Training
Provided to the
Employee? (Y/N)

For Those Staff That Have direct
Participant Contact, Was the
Individual Medically Cleared for
Communicable Diseases Before
Engaging in Direct Participant
Contact? (Y/N)

{Other Data Requested}

{Other Data
Requested}

{Other Data
Requested}