Crosswalk - Changes in 30-day ICR

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request
Title Page
Attachment I PACE Audit
Process and Data Request
Audit Purpose and General
Guidelines
Pre-Audit Identified Issues
of Non-Compliance

Original Language

Revised Language

2017

Removed specific year.

None.

Pre-Audit Identified Issues of Non-Compliance: POs will be
asked to provide a list of all identified issues of non-compliance
that occurred during the audit review period. This could include
issues that were self-identified by the PO (that may or may not
have been disclosed to CMS) or issues identified by CMS during
the course of the audit review period. Please do not include all
issues identified by your organization, just those that are relevant
to the areas being audited. Also, please exclude Level I and Level
II data that has already been reported to CMS.

Modified the title and text to
only include disclosed issues
previously reported to CMS.

Pre-Audit Disclosed Issues of Non-Compliance: POs will be
asked to provide a list of all disclosed issues of non-compliance that
are relevant to the elements being audited and may be detected
during the audit. A disclosed issue is one that has been reported to
CMS prior to the receipt of the audit start notice (which is also
known as the “engagement letter”). Issues identified by CMS or the
SAA through on-going monitoring or other account
management/oversight activities during the audit year are not
considered disclosed. POs should exclude Level I and Level II data
already reported to CMS.

Within 5 business days after receipt of the engagement letter, POs
must provide a description of each issue as well as the remediation
status (what was corrected and when) using the Pre-Audit Issue
Summary template (Attachment III). The PO’s Account Manager
will review the summary for accuracy and completeness.
CMS will consider an issue corrected if the PO can demonstrate
that correction or remediation was implemented prior to the
engagement letter being sent.
Issues that are reported as uncorrected may be cited as conditions
in the CMS audit report. Issues reported as corrected after the date
of the audit start notice will be treated as uncorrected issues.
Issues that are reported as corrected prior to the audit review
period will be assumed to be corrected. However, if the CMS
discovers during the audit that the issue was not actually corrected,
CMS may cite the applicable conditions in the audit report.
For issues that are reported as corrected during the audit review
period, CMS may validate correction during the audit. Auditors
will validate correction if it can be accomplished simply (e.g.,
observing a wound dressing, pulling a medical record, etc.). When
correction is validated the issue will be noted as an observation in
the organization’s audit report.

Page 1 of 25

Clarification or Change

POs must provide a description of each disclosed issue as well as the
status of correction and remediation using the Pre-Audit Issue
Summary template (Attachment III). This template is due within 5
business days after the receipt of the audit start notice. The PO’s
Account Manager will review Attachment III to validate that
“disclosed” issues were known to CMS prior to receipt of the audit
start notice.
When CMS determines that a disclosed issue was promptly
identified, corrected (or is actively undergoing correction), and the
risk to participants has been mitigated, CMS will not apply the ICAR
condition classification to that condition.

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request
Audit Purpose and General
Guidelines

Original Language

Clarification or Change

Revised Language

An impact analysis template must be submitted as requested by
CMS for any issue discovered during the audit that has potential
participant impact and may be cited as a condition of noncompliance. CMS may validate the accuracy of the IA
submission(s).

Clarified language
surrounding IA templates,
including an extended
timeframe for submitting IA
templates (10 business days).

Observations will be recorded in the draft and final reports, but
will not be scored and therefore will not be included in the
program area and audit scores.

Deleted the term “program
area” for clarity.

An impact analysis must be submitted as requested by CMS. The
impact analysis must identify all participants subjected to or
impacted by the issue of non-compliance. POs will have up to 10
business days to complete the requested impact analysis templates.
CMS may validate the accuracy of the impact analysis
submission(s). In the event an impact analysis cannot be produced,
CMS will report that the scope of non-compliance could not be fully
measured and impacted an unknown number of participants within
the PO.
Observations will be recorded in the draft and final reports, but will
not be scored and therefore will not be included in the audit scores.

CMS will provide daily updates regarding conditions discovered
that day (unless the case has been pended for further review).

Changed “the case” to “a
sample” for clarity.

CMS will provide daily updates regarding conditions discovered that
day (unless a sample has been pended for further review).

The PO is expected to provide accurate and timely universe and
documentation submissions within 30 calendar days of the
engagement letter date. CMS may request a revised universe if
data issues are identified. The resubmission request may occur
before and/or after the entrance conference depending on when the
issue is identified. POs will have a maximum of 3 attempts to
provide complete and accurate universes, whether these attempts
all occur prior to the entrance conference or they include
submissions prior to and after the entrance conference. When
multiple attempts are made, CMS will only use the last universe
submitted.

Deleted text for clarity.

The PO is expected to provide accurate and timely universe and
documentation submissions within 30 calendar days of the
engagement letter date. CMS may request a revised universe if data
issues are identified.

Impact Analysis (IA)

Attachment I PACE Audit
Process and Data Request
Audit Purpose and General
Guidelines
Calculation of Score
Attachment I PACE Audit
Process and Data Request
Audit Purpose and General
Guidelines
Informing PO of Results
Attachment I PACE Audit
Process and Data Request
Universe Preparation &
Submission
Responding to Universe
and Documentation
Requests

If the PO fails to provide accurate and timely universe
submissions after three attempts, CMS will document this as an
observation in the PO’s program audit report.

Page 2 of 25

Section in Current CMS10630 (08/16)

Original Language

Attachment I PACE Audit
Process and Data Request

•
•

Universe Preparation &
Submission

•

Completed PACE questionnaire (PACEQ)
The PO’s QAPI plan(s) that were in use during the audit
review period
PAC Minutes for the audit review period

Clarification or Change

Replaced old name with
updated/ corrected attachment
name and spelled out
acronyms.

Revised Language
•
•

•

Pull Universes and Submit
Documentation

Completed PACE Supplemental Questions (Attachment II)
The PO’s Quality Assessment and Performance
Improvement (QAPI) plan(s) that were in use during the
audit review period
Participant Advisory Committee (PAC) Minutes for the
audit review period

Documentation
Attachment I PACE Audit
Process and Data Request
Universe Preparation &
Submission

For the quality assessment universe, the PO should identify each
quality initiative that occurred and the corresponding data used in
the quality initiative during the audit review period. Data could
include examples such as hospitalizations, falls, grievances,
appeals, medical records, audits, etc.

Included a definition of
quality initiatives.

For the quality assessment universe, the PO should identify each
quality initiative that occurred and the corresponding data used in the
quality initiative during the audit review period. A quality initiative
is a set of data used to measure and identify areas of good or
problematic performance within a PACE organization. Data could
include examples such as hospitalizations, falls, grievances, appeals,
medical records, audits, etc.

The universes should be 1) all inclusive, regardless of whether the
request was determined to be approved, denied, or partially
approved and 2) submitted in the appropriate record layout as
described in Appendix A.

Replaced “partially approved”
with “partially denied” for
consistency.

The universes should be 1) all inclusive, regardless of whether the
request was determined to be approved, denied, or partially denied
and 2) submitted in the appropriate record layout as described in
Appendix A.

No later than 72 hours following receipt of the request by the IDT.
The PO may extend the decision up to 5 days when applicable.

Clarified language to better
reflect the regulatory
requirement.

No later than 72 hours following the date the request was received by
the IDT. The PO may extend the decision up to 5 days when
applicable.

Pull Universes and Submit
Documentation
Data Universes
Attachment I PACE Audit
Process and Data Request
Universe Preparation &
Submission
Pull Universes and Submit
Documentation
Data Universes
Attachment I PACE Audit
Process and Data Request
Universe Preparation &
Submission
Submit Universes to CMS

Page 3 of 25

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request

Original Language

Clarification or Change

No later than 30 days from the date of receipt for standard appeals.
No more than 72 hours from receipt for expedited appeals.

Clarified language by adding
“of the appeal”.

None.

Added a fourth bullet called
“selecting samples” to clarify
CMS sampling process.

In sampling, CMS will select 30 targeted cases that appear
significant. CMS will attempt to ensure that the sample set is
representative of various types of service requests, grievances and
appeals. The sample set will be selected from the universe
categories as follows:

Added clarification on how
CMS will target samples.

Revised Language

No later than 30 days from the date of receipt for standard appeals.
No more than 72 hours from receipt of the appeal for expedited
appeals.

Universe Preparation &
Submission
Submit Universes to CMS
Attachment I PACE Audit
Process and Data Request

4.

Universe Preparation &
Submission

Attachment I PACE Audit
Process and Data Request
Audit Elements
Service Delivery Requests,
Appeals and Grievances
(SDAG)

Selecting Samples: Auditors will review the universes
collected from the PO and select samples in accordance
with the instructions noted below. For each element, the
selected samples will be given to the PO 1 business day
before the review of that element begins.

In sampling, CMS will select 30 targeted cases that appear
significant. CMS will attempt to ensure that the sample set is
representative of various types of service requests, grievances and
appeals. CMS will use the PAC Minutes, the On-Call Universe and
the List of Participant Medical Records in order to target samples for
review. The sample set will be selected from the universe categories
as follows:

Select Sample Cases
•
Attachment I PACE Audit
Process and Data Request

•

Audit Elements

•

Service Delivery Requests,
Appeals and Grievances
(SDAG)
Review Sample Case
Documentation
For Grievances

Page 4 of 25

Documentation showing resolution notification to the
beneficiary and/or their representative.
Copy of the written decision letter sent and
documentation of date/time letter was mailed.
If oral notification was given, copy of medical record
notes and/or documentation of call including date/time
stamp.

Changed “beneficiary” to
“participant”. Changed
“decision” to “resolution”.
Deleted “time stamp”.

•
•
•

Documentation showing resolution notification to the
participant and/or their representative.
Copy of the written resolution letter sent and
documentation of date/time letter was mailed.
If oral notification was given, copy of medical record notes
and/or other documentation of call including the date.

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request

Original Language

Clarification or Change

Revised Language

3.1.4 Did the PO provide the participant with a reasonable
opportunity to present evidence during their appeal?

Changed language to make it
plural.

3.1.4 Did the PO provide the participants with a reasonable
opportunity to present evidence during their appeals?

3.3.3 Did the PO process an appeal within 30 days, or, for
expedited appeals, within 72 hours?

Clarified language to include
“after the PO receives the
appeal”.

3.3.3 Did the PO process an appeal within 30 days, or, for expedited
appeals, within 72 hours after the PO receives the appeal?

In sampling, CMS will select 10 targeted medical records that
appear clinically significant. CMS will attempt to ensure that the
sample set is representative of various types of service requests
and care (e.g., hospitalizations, wound care, dialysis, social needs,
home bound, skilled nursing, etc.).

Added a sentence to clarify
CMS sampling process.

In sampling, CMS will select 10 targeted medical records that appear
clinically significant. CMS will attempt to ensure that the sample set
is representative of various types of service requests and care (e.g.,
hospitalizations, wound care, dialysis, social needs, home bound,
skilled nursing, etc.). CMS will also utilize the SDAG universes, the
On-Call Universe, and the PAC minutes in order to appropriately
target participants.

Audit Elements
Service Delivery Requests,
Appeals and Grievances
(SDAG)
Apply Compliance
Standard
Attachment I PACE Audit
Process and Data Request
Audit Elements
Service Delivery Requests,
Appeals and Grievances
(SDAG)
Apply Compliance
Standard
Attachment I PACE Audit
Process and Data Request
Audit Elements
Clinical Appropriateness &
Care Planning
Select Sample Cases

Page 5 of 25

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request

Original Language
•

Documentation that assessments were done in person
when applicable

Clarification or Change

Removed “when applicable”.
Added a period at the end of
the sentence.

Revised Language
•

Documentation that assessments were done in person.

Audit Elements
Clinical Appropriateness &
Care Planning
Review Sample Case
Documentation
Attachment I PACE Audit
Process and Data Request
Audit Elements
Clinical Appropriateness &
Care Planning

3.5 Did the PO develop and document an appropriate plan of
care for the participants?
3.5.1 Did the PO promptly and appropriately develop a plan of
care that meets the minimum requirements for each participant?
3.5.2 Did the PO appropriately evaluate and monitor the
participants’ plan of care?
3.5.3 Did the PO ensure that the appropriate IDT members were
involved in creating the plan of care?

Changed “plan of care” to
“care plan” for consistency.

3.5 Did the PO develop and document an appropriate care plan
for the participants?
3.5.1 Did the PO promptly and appropriately develop a care plan that
meets the minimum requirements for each participant?
3.5.2 Did the PO appropriately evaluate and monitor the participants’
care plan?
3.5.3 Did the PO ensure that the appropriate IDT members were
involved in creating the care plan?

3.5.4 Was an explanation of care plan changes given to the
participant, if appropriate?
3.5.5 Did the participant have a role in care plan decisions, if
appropriate?

Removed “if appropriate”
from the compliance
standards.

3.5.4 Was an explanation of care plan changes given to the
participant?
3.5.5 Did the participant have a role in care plan decisions?

Apply Compliance
Standard
Attachment I PACE Audit
Process and Data Request
Audit Elements
Clinical Appropriateness &
Care Planning
Apply Compliance
Standard

Page 6 of 25

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request
Audit Elements

Original Language

Clarification or Change

Revised Language

CMS will select a targeted sample of 10 personnel records. CMS
will attempt to ensure that the sample set is representative of
various types of employees, including part-time, full-time,
contract, etc.

Added “volunteers” to be
consistent with universe
description.

CMS will select a targeted sample of 10 personnel records. CMS will
attempt to ensure that the sample set is representative of various
types of employees, including part-time, full-time, contract,
volunteers, etc.

3.5.1 Were competency evaluations done for individuals
performing participant care

Added a question mark at the
end of the sentence.

3.5.1 Were competency evaluations done for individuals performing
participant care?

CMS will observe 3 to 5 participants while onsite, one that
receives care from home, and at least one that receives care at the
center. CMS may observe more participants while onsite if an
issue is noted that warrants additional review.

Modified language for clarity
and readability.

CMS will observe 3 to 5 participants while onsite, including at least
one who receives care from home and one who receives care at the
center. CMS may observe more participants while onsite if an issue
is noted that warrants additional review.

Review Sample Case Documentation: The PO should be able to
provide the following access to CMS auditors:
•
A private area (can be the clinic) to view a
participant receiving care,
•
A home visit of a willing participant,
•
A visit to an outside facility (such as a SNF), if
applicable,
•
At least one transportation vehicle used to transport
participants to and from the center,
•
Any emergency equipment the center has available.

Changed title to include “and
Observations”. Added
“willing” into first bullet.
Added a bullet for IDT
observations.

Review Sample Case Documentation and Observations: The PO
should be able to provide the following access to CMS auditors:
•
A private area (can be the clinic) to view a willing
participant receiving care,
•
A home visit of a willing participant,
•
A visit to an outside facility (such as a SNF), if
applicable,
•
At least one transportation vehicle used to transport
participants to and from the center,
•
Any emergency equipment the center has available.
•
An IDT meeting for CMS observation.

Personnel Records
Select Sample Cases
Attachment I PACE Audit
Process and Data Request
Audit Elements
Personnel Records
Apply Compliance
Standard
Attachment I PACE Audit
Process and Data Request
Audit Elements
Onsite Review
Select Participants for
Observation
Attachment I PACE Audit
Process and Data Request
Audit Elements
Onsite Review

Page 7 of 25

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request

Original Language

Clarification or Change

Revised Language

3.1 Does the PO have a method of communicating between the
van and the PACE organization?

Changed “organization” to
“center” to align with
regulation.

3.1 Does the PO have a method of communicating between the van
and the PACE center?

3.3.1 Has the PACE organization appropriately established an
interdisciplinary team at each PACE center?

Changed “PACE
organization” to “PO” and
“interdisciplinary team” to
“IDT” for consistency.

3.3.1 Has the PO appropriately established an IDT at each PACE
center?

3.5 Does the PO follow appropriate infection control standards
when providing care?
3.5.1 Did they wash/ sanitize hands as appropriate?
3.5.2 Did they don and doff personal protective equipment as
appropriate?
3.5.3 Did they follow aseptic technique, if applicable?

Changed “they” to
“personnel” and removed
compliance standard 3.5.3.

3.5 Does the PO follow appropriate infection control standards
when providing care?
3.5.1 Did personnel wash/ sanitize hands as appropriate?
3.5.2 Did personnel don and doff personal protective equipment as
appropriate?

3.7.3 During an assessment or treatment, were any progress notes
appropriately documented?

Removed “any” for clarity.

3.7.3 During an assessment or treatment, were progress notes
appropriately documented?

Audit Elements
Onsite Review
Apply Compliance
Standard
Attachment I PACE Audit
Process and Data Request
Audit Elements
Onsite Review
Apply Compliance
Standard
Attachment I PACE Audit
Process and Data Request
Audit Elements
Onsite Review
Apply Compliance
Standard
Attachment I PACE Audit
Process and Data Request
Audit Elements
Onsite Review
Apply Compliance
Standard

Page 8 of 25

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request

Original Language

Clarification or Change

Revised Language

3.8 Does the PO follow their dietary care plans by providing food
in the form necessary for participant’s needs?

Removed “their” for clarity.

3.8 Does the PO follow dietary care plans by providing food in the
form necessary for participant’s needs?

If CMS auditors determine that requirements are not met while
conducting the onsite review, conditions (findings) are cited. If
CMS requirements are met, no conditions (findings) are cited.

Added the first sentence for
consistency with other
elements.

CMS will conduct onsite observations. If CMS auditors determine
that requirements are not met while conducting the onsite review,
conditions (findings) are cited. If CMS requirements are met, no
conditions (findings) are cited.

CMS will select two tracers, using the quality assessment
universe, appeals and grievances documentation, onsite interviews
and discussions with the PO, a review of participant medical
records, etc. to determine the effectiveness of the POs quality
assessment and performance improvement (QAPI) program.

Changed “quality assessment
universe” to “Quality
Assessment Initiatives
Records” universe for
consistency.

CMS will select two tracers, using the Quality Assessment Initiatives
Records universe, appeals and grievances documentation, onsite
interviews and discussions with the PO, a review of participant
medical records, etc. to determine the effectiveness of the POs
quality assessment and performance improvement (QAPI) program.

CMS will use the tracer to assess whether CMS requirements are
met. If CMS requirements are not met, conditions (findings) are
cited.

Changed “tracer” to “tracers”
for consistency.

CMS will use the tracers to assess whether CMS requirements are
met. If CMS requirements are not met, conditions (findings) are
cited.

Audit Elements
Onsite Review
Apply Compliance
Standard
Attachment I PACE Audit
Process and Data Request
Audit Elements
Onsite Review
Onsite Review Results
Attachment I PACE Audit
Process and Data Request
Audit Elements
Quality Assessment
Select Sample Cases
Attachment I PACE Audit
Process and Data Request
Audit Elements
Quality Assessment
Sample Case Results

Page 9 of 25

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request
Table 1 –
Column ID F
Column ID N
Column ID O
Column ID Q
Column ID S
Column ID U
Attachment I PACE Audit
Process and Data Request
Table 1 – Column ID L

Attachment I PACE Audit
Process and Data Request
Table 1 –
Column ID

Page 10 of 25

Original Language

Field Name:
Field Name:
Field Name:
Field Name:
Field Name:
Field Name:

Time Service Delivery Request Received
Date of Decision
Time of Decision
Time of Oral Notification
Time of Written Notification
Quality Analysis

Column ID L
Field Name: Request Disposition
Field Length: 10
Field Description: Provide the request disposition for the service
delivery request. Valid fields include: Approved or Denied.
Field Name and Column ID:
Column ID G: Category of the Request
Column ID H: Description of the Request
Column ID I: Date(s) Assessment(s) Performed
Column ID J: Discipline(s) Performing Assessment(s)
Column ID K: Assessment(s) In Person
Column ID M: Extension
Column ID P: Date of Oral Notification
Column ID R: Date of Written Notification
Column ID T: Date service provided

Clarification or Change

Revised Language

Deleted these columns from
the record layout.

None.

Changed Column ID.
Changed field length from 10
to 16. Changed field
description to include
“partially denied” as an
option.
Changed Column ID.

Column ID K
Field Name: Request Disposition
Field Length: 16
Field Description: Provide the request disposition for the service
delivery request. Valid fields include: Approved, Denied or Partially
Denied.
Field Name and Column ID:
Column ID F: Category of the Request
Column ID G: Description of the Request
Column ID H: Date(s) Assessment(s) Performed
Column ID I: Discipline(s) Performing Assessment(s)
Column ID J: Assessment(s) In Person
Column ID L: Extension
Column ID M: Date of Oral Notification
Column ID N: Date of Written Notification
Column ID O: Date service provided

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request
Table 2 –

Original Language
•

Submit cases based on the date the PACE organization’s
decision was rendered or should have been rendered (the
date the request was initiated may fall outside of the
review period).

Clarification or Change

Changed “PACE
organization’s” to “PO’s”.

Revised Language
•

Submit cases based on the date the PO’s decision was
rendered or should have been rendered (the date the
request was initiated may fall outside of the review
period).

Introduction Text
Attachment I PACE Audit
Process and Data Request

Field Name: Reviewer
Field Name: Date of Decision
Field Name: Time of Decision

Deleted these columns from
the record layout.

None.

Table 2 – Column ID F

Field Length: 8
Field Description: Provide the time the appeal was received by
the PO. Submit in HH:MM:SS format (e.g. 23:54:23). Enter NA
for an appeal that was not expedited.

Changed field length to 5.
Changed field description to
no longer request seconds for
time.

Field Length: 5
Field Description: Provide the time the appeal was received by the
PO. Submit in HH:MM format (e.g. 23:54). Enter NA for an appeal
that was not expedited.

Attachment I PACE Audit
Process and Data Request

Field Description: Provide a description of the issue and, for
denials, an explanation of why the decision was denied.

Changed “the decision” to
“the appeal”.

Field Description: Provide a description of the issue and, for
denials, an explanation of why the appeal was denied.

Column ID L
Field Name: Request Disposition
Field Length: 10
Field Description: Provide the request disposition for the appeal.
Valid fields include: Approved or Denied.

Changed Column ID.
Changed field length from 10
to 16. Changed field
description to include
“partially denied” as an
option.

Column ID K
Field Name: Request Disposition
Field Length: 16
Field Description: Provide the request disposition for the appeal.
Valid fields include: Approved, Denied or Partially Denied.

Table 2 –
Column ID K
Column ID M
Column ID N
Attachment I PACE Audit
Process and Data Request

Table 2 – Column ID J

Attachment I PACE Audit
Process and Data Request
Table 2 – Column ID L

Page 11 of 25

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request
Table 2 – Column ID P

Attachment I PACE Audit
Process and Data Request
Table 2 – Column ID R

Attachment I PACE Audit
Process and Data Request

Original Language

Clarification or Change

Revised Language

Column ID P
Field Name: Time of Oral Notification
Field Length: 8
Field Description: Time the PO provided oral notification of the
decision to the participant or caregiver. Submit in HH:MM:SS
format (e.g. 23:59:59). Enter NA if no oral notification was
provided.
Column ID R
Field Name: Time of Written Notification
Field Length: 8
Field Description: Time the PO provided written notification of
the decision to the participant or caregiver. Submit in HH:MM:SS
format (e.g. 23:59:59). Enter NA if no oral notification was
provided.
Column ID T
Field Description: Yes (Y) / No (N) indicator on whether an
analysis of this appeal was included in your QAPI program?

Changed Column ID.
Changed field length from 8
to 5. Changed field
description to no longer
request seconds for time and
also added an option for NA if
the request was not expedited.
Changed Column ID.
Changed field length from 8
to 5. Changed field
description to no longer
request seconds for time and
also added an option for NA if
the request was not expedited.
Changed Column ID. Added
“particular” into the field
description.

Column ID M
Field Name: Time of Oral Notification
Field Length: 5
Field Description: Time the PO provided oral notification of the
decision to the participant or caregiver. Submit in HH:MM format
(e.g. 23:59). Enter NA if no oral notification was provided or if the
request was not expedited.
Column ID O
Field Name: Time of Written Notification
Field Length: 5
Field Description: Time the PO provided written notification of the
decision to the participant or caregiver. Submit in HH:MM format
(e.g. 23:59). Enter NA if no written notification was provided or if
the request was not expedited.
Column ID Q
Field Description: Yes (Y) / No (N) indicator on whether an
analysis of this particular appeal was included in your QAPI
program?

Field Name and Column ID:

Changed Column ID.

Field Name and Column ID:

Table 2 – Column ID T
Attachment I PACE Audit
Process and Data Request

Column ID O: Date of Oral Notification
Column ID Q: Date of Written Notification
Column ID S: Date service provided

Table 2 –

Column ID L: Date of Oral Notification
Column ID M: Date of Written Notification
Column ID P: Date service provided

Column ID
Attachment I PACE Audit
Process and Data Request
Table 3 – Column ID L

Page 12 of 25

Field Description: Yes (Y) / No (N) indicator on whether an
analysis of this grievance was included in your QAPI program?

Added “particular” into the
field description.

Field Description: Yes (Y) / No (N) indicator on whether an
analysis of this particular grievance was included in your QAPI
program?

Section in Current CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request
Table 4 –
Column ID J
Column ID K
Column ID L
Column ID M
Attachment I PACE Audit
Process and Data Request

Original Language

Field Name:
Field Name:
Field Name:
Field Name:

Background Check
Excluded Provider List
Competency Evaluations
OSHA Training

Field Length: 1
Field Description: Yes (Y) / No (N) indicator of whether the
employee is licensed for their job with the PACE organization.

Table 4 – Column ID I

Attachment I PACE Audit
Process and Data Request

•

Include all participants enrolled in the PACE
organization at some point during the audit period.

Clarification or Change

Revised Language

Deleted these columns from
the record layout.

None.

Changed field length to 2.
Changed “PACE
organization” to “PO” and
changed field description to
include an option for NA
when the position does not
require a license.
Changed “PACE
organization” to “PO” for
consistency.

Field Length: 2
Field Description: Yes (Y) / No (N) indicator of whether the
employee is licensed for their job with the PO. Enter NA if the
employee’s position for not require a license.

Deleted these columns from
the record layout.

None.

Changed Column ID.
Changed field description to
include guidance on what sort
of admissions should be
included.

Column ID I
Field Description: Provide the number of skilled nursing facility/
nursing facility admissions that occurred during the audit review
period. This should include all SNF/NF admissions for any cause,
including admission as a result of a request for services.

•

Include all participants enrolled in the PO at some point
during the audit period.

Table 5 –
Introductory Text
Attachment I PACE Audit
Process and Data Request
Table 5 –
Column ID H
Column ID J
Column ID Q
Column ID U
Column ID Z
Column ID AP
Attachment I PACE Audit
Process and Data Request
Table 5 – Column ID K

Page 13 of 25

Field Name:
Field Name:
Field Name:
Field Name:
Field Name:
Field Name:

Most recent date of Hospitalization
Most recent date of Emergency Room Visit
Number of Falls Reported as a Level I Event
List of Infections
Ambulation
Quality Analysis

Column ID K
Field Description: Provide the number of skilled nursing facility/
nursing facility admissions that occurred during the audit review
period.

Current Section in CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request
Table 5 – Column ID O

Attachment I PACE Audit
Process and Data Request
Table 5 – Column ID R
Attachment I PACE Audit
Process and Data Request
Table 5 – Column ID S

Attachment I PACE Audit
Process and Data Request
Table 5 – Column ID T

Attachment I PACE Audit
Process and Data Request
Table 5 – Column ID V

Page 14 of 25

Original Language

Clarification or Change

Revised Language

Column ID O
Field Length: 15
Field Description: Provide information on how often the
participant currently attends the center. Enter both the number of
days each week (e.g., 1, 3, 5) as well as whether attendance is full
days or partial days (e.g., 3 Full, 2 Partial).

Changed Column ID. Changed
field length to 1. Changed field
description to only ask for the
number of days a week the
participant attends the center.

Column ID M
Field Length: 1
Field Description: Provide information on how often the
participant currently attends the center. Enter the number of days
each week (e.g., 1, 3, 5).

Column ID R
Field Description: Provide the number of falls a participant had
during the audit review period that were reported as a level II
event.

Changed Column ID. Changed
field description to capitalize
“level”.

Column ID O
Field Description: Provide the number of falls a participant had
during the audit review period that were reported as a Level II
event.

Column ID S
Field Name: Currently recovering from a fall reported as either a
Level I or Level II event
Field Length: 3
Field Description: Yes (Y) / No (N) indicator on whether the
participant is still recovering from a fall that was reported as either
a Level I or Level II event?

Changed Column ID. Changed
field name to delete reference
to Level I. Changed field
length to 2. Changed field
description to delete reference
to Level I and add an option for
NA.

Column ID T
Field Description: Provide the number of infections the
participant had during the audit review period. This includes all
types of infections. Enter NA if the participant did not have an
infection during the audit review period.

Changed Column ID. Changed
field description to include
guidance on how to identify
infections.

Column ID V
Field Name: Number of Pressure Ulcers
Field Length: 3
Field Description: Provide the number of pressure ulcers that the
participant had during the audit review period. Only include
pressure ulcers that are staged II or above. Enter NA if the
participant did not have any pressure ulcers during the audit
review period.

Changed Column ID. Changed
field name to delete reference
to numbers. Changed field
length to 1. Changed field
description to request
information in a yes/no format.

Column ID P
Field Name: Currently recovering from a fall reported as a Level
II event
Field Length: 2
Field Description: Yes (Y) / No (N) indicator on whether the
participant is still recovering from a fall that was reported as a
Level II event? Enter NA if the participant did not have a fall
reported as a Level II event.
Column ID Q
Field Description: Provide the number of infections the
participant had during the audit review period. This includes all
types of infections as defined by your infection control plan.
Enter NA if the participant did not have an infection during the
audit review period.
Column ID R
Field Name: Pressure Ulcers
Field Length: 1
Field Description: Yes (Y) / No (N) indicator on whether the
participant has had one or more pressure ulcer(s) during the audit
review period. Only include pressure ulcers that are staged II or
above.

Current Section in CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request
Table 5 – Column ID W
Attachment I PACE Audit
Process and Data Request
Table 5 – Column ID AA
Attachment I PACE Audit
Process and Data Request
Table 5 – Column ID AI

Attachment I PACE Audit
Process and Data Request

Original Language

Column ID S
Field Length: 1
Field Description: Yes (Y) / No (N) indicator on whether the
participant is currently receiving treatment for a pressure ulcer
staged II or above?
Column ID V
Field Description: Yes (Y) / No (N) indicator on whether the
participant experienced significant unanticipated weight loss at
any time during the audit review period?

Column ID AI
Field Length: 500
Field Description: If the participant has received skilled
therapy during the audit review period, please provide a
brief description of that therapy (e.g., PT for leg, OT,
etc.). Include all types of skilled therapy received. Enter
NA if the participant did not receive skilled therapy
during the audit review period.
Column ID AL
Field Description: Yes (Y) / No (N) indicator on whether the
participant used oxygen during the audit review period?

Changed Column ID. Changed
field length to 1. Changed field
description to ask for
information in a yes or no
format.

Column ID AD
Field Length: 1
Field Description: Yes (Y) / No (N) indicator on whether the
participant has ever received skilled therapy during the audit
review period. Include all types of skilled therapy received.

Changed Column ID. Changed
field description to clarify what
we consider oxygen use for
purposes of audit.

Column ID AG
Field Description: Yes (Y) / No (N) indicator on whether the
participant regularly used oxygen (as indicated by the care plan)
during the audit review period (not as a result of an acute event)?

Column ID AN
Field Description: Yes (Y) / No (N) indicator on whether the
participant has impaired vision?

Changed Column ID. Changed
field description to clarify what
we consider impaired vision for
purposes of audit.

Column ID AI
Field Description: Yes (Y) / No (N) indicator on whether the
participant has impaired vision (i.e, blind or vision is severely
impaired without corrective lenses)?

Column ID AO
Field Description: Yes (Y) / No (N) indicator on whether the
participant has impaired hearing?

Changed Column ID. Changed
field description to clarify what
we consider impaired hearing
for purposes of audit.

Column ID AJ
Field Description: Yes (Y) / No (N) indicator on whether the
participant has impaired hearing (i.e., deaf or hearing is severely
impaired without an assistive hearing device)?

Column ID AA
Field Description: Yes (Y) / No (N) indicator on whether the
participant experienced significant weight loss at any time during
the audit review period?

Table 5 – Column ID AN
Attachment I PACE Audit
Process and Data Request
Table 5 – Column ID AO

Page 15 of 25

Revised Language

Changed Column ID. Added a
field length of 1. Changed
field description to clarify
treatment for pressure ulcers
staged II or above.
Changed Column ID. Changed
field description to clarify that
we are requesting on
unanticipated weight loss.

Column ID W
Field Length: (none)
Field Description: Yes (Y) / No (N) indicator on whether the
participant is currently receiving treatment for a pressure ulcer?

Table 5 – Column ID AL
Attachment I PACE Audit
Process and Data Request

Clarification or Change

Current Section in CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request
Table 5 –
Column ID

Attachment I PACE Audit
Process and Data Request

Original Language

Field Name and Column ID:

Clarification or Change

Changed Column ID.

Column ID I: Number of Emergency Room Visits
Column ID L: Currently in SNF/NF
Column ID M: Received Home Care
Column ID N: Currently Receiving Home Care
Column ID P: Transportation Services Provided
Column ID X: Incontinent
Column ID Y: Indwelling Catheter
Column ID AB: Mechanically Altered Diet
Column ID AC: Parenteral or Enteral Feeding
Column ID AD: Dementia
Column ID AE: Psychoactive Medications
Column ID AF: Restraints
Column ID AG: Assistance with Administering Medications
Column ID AH: Pain Management
Column ID AJ: Currently Receiving Skilled Therapy
Column ID AK: Functional Decline
Column ID AM: Dialysis

Revised Language

Field Name and Column ID:
Column ID H: Number of Emergency Room Visits
Column ID J: Currently in SNF/NF
Column ID K: Received Home Care
Column ID L: Currently Receiving Home Care
Column ID N: Transportation Services Provided
Column ID T: Incontinent
Column ID U: Indwelling Catheter
Column ID W: Mechanically Altered Diet
Column ID X: Parenteral or Enteral Feeding
Column ID Y: Dementia
Column ID Z: Psychoactive Medications
Column ID AA: Restraints
Column ID AB: Assistance with Administering Medications
Column ID AC: Pain Management
Column ID AE: Currently Receiving Skilled Therapy
Column ID AF: Functional Decline
Column ID AH: Dialysis

Field Description: Provide the date the quality initiative was
concluded. Submit in format CCYY/MM/DD (e.g. 2017/02/01).

Added an option for NA when
the quality initiative is ongoing.

Field Description: Provide the date the quality initiative was
concluded. Submit in format CCYY/MM/DD (e.g. 2017/02/01).
Enter NA if the quality initiative has not concluded (it is ongoing).

Field Length: 1
Field Description: Yes (Y) / No (N) indicator on whether the
PO implemented any corrective actions as a result of the
quality initiative?

Changed field length to 2.
Added an option for NA when
no corrective action was
necessary.

Field Length: 2
Field Description: Yes (Y) / No (N) indicator on whether the PO
implemented any corrective actions as a result of the quality
initiative? Enter NA if no corrective action was necessary.

Field Name: Date of Corrective Action Implementation
Field Description: Provide the date the PO implemented
corrective action as a result of the quality initiative. Submit in
format CCYY/MM/DD (e.g., 2017/02/01).

Changed field name to clarify
intention. Clarified field
description for what we are
requesting and added an option
for NA.

Field Name: Start Date of Corrective Action Implementation
Field Description: Provide the date the PO began implementing
corrective action as a result of the quality initiative. Submit in
format CCYY/MM/DD (e.g., 2017/02/01). Enter NA if no
corrective action was necessary.

Table 6 – Column ID H
Attachment I PACE Audit
Process and Data Request
Table 6 – Column ID K
Attachment I PACE Audit
Process and Data Request
Table 6 – Column ID L

Page 16 of 25

Current Section in CMS10630 (08/16)
Attachment I PACE Audit
Process and Data Request

Original Language
•

Include all after hour calls received by the PACE
organization.

Clarification or Change

Changed “PACE organization”
to “PO” for consistency.

Revised Language
•

Include all after hour calls received by the PO.

Table 7 –
Introductory Text
Attachment I PACE Audit
Process and Data Request

None.

Created a new field for
participant ID.

Field Name: PO Follow-up
Field Name: Date of PO Follow-up

Deleted these columns from the
record layout.

Column ID E
Field Length: 8
Field Description: Provide the time the call was received. Submit
in HH:MM:SS format (e.g. 23:54:23).

Changed Column ID. Changed
field length to 5. Change field
description to remove seconds
from the time.

Column ID F
Field Length: 5
Field Description: Provide the time the call was received.
Submit in HH:MM format (e.g. 23:54).

Field Name and Column ID:

Changed Column ID.

Field Name and Column ID:

Table 7 – New field
Attachment I PACE Audit
Process and Data Request

Column ID C
Field Name: Participant ID
Field Length: 25
Field Description: The identification number the PO uses to
identify the participant.
None.

Table 7 –
Column ID H
Column ID I
Attachment I PACE Audit
Process and Data Request
Table 6 – Column ID E
Attachment I PACE Audit
Process and Data Request
Table 5 –
Column ID

Page 17 of 25

Column ID C:
Column ID D:
Column ID F:
Column ID G:

Caller Information
Date of Call
Call Description/ Reason for Call
Response to Call

Column ID D:
Column ID E:
Column ID G:
Column ID H:

Caller Information
Date of Call
Call Description/ Reason for Call
Response to Call

Current Section in CMS10630 (08/16)

Original Language

Clarification or Change

Attachments II PACE
Supplemental Questions

None.

Added a question regarding
receipt of service delivery
requests.

Attachment I – PACE
Audit Process and Data
Request

None

Added a field and added
instructions on populating yes
or no in fields.

Appeal Impact Analysis
Template
Participant Impact Tab
Attachment I – PACE
Audit Process and Data
Request

Did the PO notify the participant regarding the extension?
Was the participant a Medicaid participant?
Was the reviewer involved in the initial decision?
Were there any negative outcomes caused by the failure to provide
the service?
Has the participant appealed again? (Medicare or Medicaid/SAA
process)
None

Added a new impact analysis
template for personnel
conditions.

Personnel Impact Analysis
Template
Personnel Impact Tab

Attachment I – PACE
Audit Process and Data
Request

None

Clinical Appropriateness
Impact Analysis
Template_Assessments

Dates the IDT members completed their initial assessments
(Identify assessment date by discipline)(HH:MM:SS)
Were any assessments not completed?
Were assessments completed in person?
Was there a change in the participant’s status?
Were any assessments not documented?
Were there any negative participant outcomes?

Participant Impact Tab

Page 18 of 25

None

Added two impact analysis
fields and added clarification
on how to populate fields with
yes or no. Also corrected an
error from entering time to
entering dates.

Revised Language

9. Please describe when your organization deems a service
delivery request as received by the IDT. Please attach the portion
of the policy or procedure that discusses receipt of a service
delivery request.
Was the Reviewer an Impartial Third Party that was Appropriately
Credentialed? (Y/N)
Did the PO notify the participant regarding the extension? (Y/N)
Was the participant a Medicaid participant? (Y/N)
Was the reviewer involved in the initial decision? (Y/N)
Were there any negative outcomes caused by the failure to provide
the service? (Y/N)
Has the participant appealed again? (Medicare or Medicaid/SAA
process) (Y/N)
Employee First Name
Employee Last 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 performed on the employee prior to hire?
Was the employee run through the OIG excluded provider list?
(Y/N)
Were competency evaluations conducted for the employee? (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)
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)
Dates the IDT members completed their initial assessments
(Identify assessment date by discipline)(MM/DD/YY)
Were any assessments not completed? (Y/N)
Were assessments completed in person? (Y/N)
Was there a change in the participant’s status? (Y/N)
Were any assessments not documented? (Y/N)
Were there any negative participant outcomes? (Y/N)

Current Section in CMS10630 (08/16)

Original Language

Attachment I – PACE
Audit Process and Data
Request

None

Clinical Appropriateness
Impact Analysis
Template_Care Plan

Did the plan of care require a revision?
Was there a change in the participant’s status?
Did the plan of care specify the care needed to meet the
participant’s medical, physical, emotional and social needs?

None

Clarification or Change

Added two impact analysis
fields and added clarification
on how to populate fields with
yes or no.

Participant Impact Tab

Attachment I – PACE
Audit Process and Data
Request
Clinical Appropriateness
Impact Analysis
Template_IDT
Documentation

Did the plan of care identify measurable outcomes to be
achieved?
Were there any negative participant outcomes?
None.
None.

Added two impact analysis
fields and added clarification
on how to populate fields with
yes or no.

Did the change require an assessment by one or more members of
the IDT?
Were the assessments documented in the medical record?
Were assessments completed in person?
Did the change require an update/ revision to the plan of care?

Participant Impact Tab

Attachment I – PACE
Audit Process and Data
Request
Clinical Appropriateness
Impact Analysis
Template_Med Rec
Documentation
Participant Impact Tab

Page 19 of 25

Was the participant’s plan of care updated/ revised?
If the change in the participant’s condition did not require an
assessment, was a progress note documented?
Were there any negative participant outcomes?
None.
None.
Was the information lost, deleted, destroyed, etc.?
Action taken by PO to recover loss, if any?
Were there any negative outcomes?

Added two impact analysis
fields and added clarification
on how to populate fields with
yes or no.

Revised Language

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)
Did the plan of care require a revision? (Y/N)
Was there a change in the participant’s status? (Y/N)
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)
Were there any negative participant outcomes? (Y/N)
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)
Did the change require an assessment by one or more members of
the IDT? (Y/N)
Were the assessments documented in the medical record? (Y/N)
Were assessments completed in person? (Y/N)
Did the change require an update/ revision to the plan of care?
(Y/N)
Was the participant’s plan of care updated/ revised? (Y/N)
If the change in the participant’s condition did not require an
assessment, was a progress note documented? (Y/N)
Were there any negative participant outcomes? (Y/N)
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 the information lost, deleted, destroyed, etc.? (Y/N)
Action taken by PO to recover loss, if any? (Y/N)
Were there any negative outcomes? (Y/N)

Current Section in CMS10630 (08/16)
Attachment I – PACE
Audit Process and Data
Request
Clinical Appropriateness
Impact Analysis
Template_Emergency
Participant Impact Tab

Attachment I – PACE
Audit Process and Data
Request
Clinical Appropriateness
Impact Analysis
Template_Comp Care
Participant Impact Tab
Attachment I – PACE
Audit Process and Data
Request
Clinical Appropriateness
Impact Analysis
Template_Infections
Participant Impact Tab

Page 20 of 25

Original Language

None.

Clarification or Change

Revised Language

Added four impact analysis
fields and added clarification
on how to populate fields with
yes or no.

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)
Did the participant or caregiver contact the PO before
seeking emergency care? (Y/N)
Was emergency care provided? (Y/N)
Was the participant held harmless for utilization of
emergency care services? (Y/N)
Other data requested
Other data requested

Was there a service delivery request by the participant/
caregiver/ participant representative?
Were the assessments documented in the medical record?
Was the service a Medicare covered service?
Were there any negative participant outcomes?

Added clarification on how to
populate fields with yes or no.

Was there a service delivery request by the participant/
caregiver/ participant representative? (Y/N)
Were the assessments documented in the medical record? (Y/N)
Was the service a Medicare covered service? (Y/N)
Were there any negative participant outcomes? (Y/N)

Were any local, state, or federal agencies notified of the
infection(s)?
Were incidents of infection investigated?
Were incidents of infection analyzed?
Were any trends identified?
Were there any negative outcomes?

Added clarification on how to
populate fields with yes or no.

Were any local, state, or federal agencies notified of the
infection(s)? (Y/N)
Were incidents of infection investigated? (Y/N)
Were incidents of infection analyzed? (Y/N)
Were any trends identified? (Y/N)
Were there any negative outcomes? (Y/N)

None.
Did the participant or caregiver contact the PO before
seeking emergency care?
Was emergency care provided?
Was the participant held harmless for utilization of
emergency care services?
None.
None.

Current Section in CMS10630 (08/16)
Attachment I – PACE
Audit Process and Data
Request

Original Language

Clarification or Change

Revised Language

Were there any negative outcomes?

Added clarification on how to
populate a field with yes or no.

Were there any negative outcomes? (Y/N)

Were assessments documented in the medical record?
Were there any negative outcomes?

Added clarification on how to
populate fields with yes or no.

Were assessments documented in the medical record? (Y/N)
Were there any negative outcomes? (Y/N)

Were assessments completed by members of the IDT?
Were there any missed appointments, center attendance, etc?

Added clarification on how to
populate fields with yes or no.

Were assessments completed by members of the IDT? (Y/N)
Were there any missed appointments, center attendance, etc?
(Y/N)
Were any vehicles available that were accessible to the
participant? (Y/N)
Were there any negative outcomes? (Y/N)

Added clarification on how to
populate fields with yes or no.

Were they ever resolved? (Y/N)
For misclassified service requests, was the service request ever
processed? (Y/N)
Was the service request approved? (Y/N)
Were there any negative outcomes? (Y/N)
Did the PO fail to provide continued care during the grievance
process? (Y/N)

Clinical Appropriateness
Impact Analysis
Template_Providers
Participant Impact Tab
Attachment I – PACE
Audit Process and Data
Request
Clinical Appropriateness
Impact Analysis
Template_Restraints
Participant Impact Tab
Attachment I – PACE
Audit Process and Data
Request
Clinical Appropriateness
Impact Analysis
Template_Transportation
Participant Impact Tab
Attachment I – PACE
Audit Process and Data
Request
Grievance Impact Analysis
Template
Participant Impact Tab

Page 21 of 25

Were any vehicles available that were accessible to the
participant?
Were there any negative outcomes?

Were they ever resolved?
For misclassified service requests, was the service request ever
processed?
Was the service request approved?
Were there any negative outcomes?
Did the PO fail to provide continued care during the grievance
process?

Current Section in CMS10630 (08/16)

Attachment I – PACE
Audit Process and Data
Request

Original Language

Clarification or Change

Revised Language

Was appeal language included in the letter?
Did the participant appeal?
Was the approved service added to the care plan?
Was emergency care provided?

Added clarification on how to
populate fields with yes or no.

Was appeal language included in the letter? (Y/N)
Did the participant appeal? (Y/N)
Was the approved service added to the care plan? (Y/N)
Was emergency care provided? (Y/N)

None.

Added a total number of POs.

There are currently 119 POs.

Information collected from the POs for use in the audit is obtained
electronically via Secure File Transfer Protocol (SFTP) or
electronically through Health Plan Management System (HPMS).
HPMS is a system that was developed and is maintained by CMS
and that all POs have access too. This system is also secure,
requiring users to request and gain access via CMS personnel and
then must create and maintain a secure user id and password.

Deleted the reference to the
“SFTP” as PACE audits will
only use HPMS for file
transfers in 2017.

Information collected from the POs for use in the audit is obtained
electronically through Health Plan Management System (HPMS).
HPMS is a system that was developed and is maintained by CMS
and that all POs have access too. This system is also secure,
requiring users to request and gain access via CMS personnel and
then must create and maintain a secure user id and password.

The 2017 protocol, provided in this package will also be published
a 60-day and subsequent 30-day Federal Register comment period.
This package can be updated with specific dates when publication
dates are known.

Deleted reference to 2017.
Provided specific dates for
previous 60 day comment
period.

The audit protocol, provided in this package was published for a
60-day Federal Register comment period on August 5, 2016 and
will be posted for a subsequent 30-day comment period. This
package can be updated with specific dates when publication dates
are known.

For each PACE organization we estimate an average of 100 hours
for administrative and systemic work, 40 hours prior to the audit
start to assemble and review the information for completeness, 40
hours for the actual administration of the audit, and 20 hours to
review and respond to the draft audit report. We believe an
additional 80 hours is spend on corrective action and audit close
out activities. This is a total of approximately 180 hours for each
PO. The average number of POs that will receive an audit
annually is 72.

Adjusted the burden for POs
based on comments received.

Additionally, for each PO that receives an audit in 2017, we
estimate an average of 80 hours prior to the audit start to assemble
and review the information for completeness, 40 hours for the
actual administration of the audit, and 40 hours to review and
respond to the draft audit report. We believe an additional 80
hours is spend on corrective action and audit close out activities.
This is a total of approximately 240 hours for each PO. The
average number of POs that will receive an audit annually is 72.

Service Delivery Impact
Analysis Template
Participant Impact Tab
CMS-10630_Supporting
Statement A
Background
CMS-10630_Supporting
Statement A
Justification
Improved Information
Technology
CMS-10630_Supporting
Statement A
Justification
Federal Register
CMS-10630_Supporting
Statement A
Justification
Burden Estimate
Trial Year and Routine
Audits

Page 22 of 25

Current Section in CMS10630 (08/16)
CMS-10630_Supporting
Statement A

Original Language

Clarification or Change

Revised Language

None.

Added a new section to include
costs to POs for building a
system for capturing, tracking
and submitting data.

One-Time Burden to Build Systems
We believe there will be a one-time burden of $38,430 for each of
the 119 POs to implement systems to capture, track and submit
data as requested by CMS. This estimate includes building or
creating systems to capture data in each of the seven requested
universes. Specifically, we believe it will take 75 hours for a PO
to build the service delivery requests universe, 40 hours to build
the appeals universe, 75 hours for the grievance universe, 40 hours
for the personnel universe, 100 hours for the quality assessment
universe, 250 hours for the participant universe, and 50 hours for
the on-call universe. This is a total of approximately 630 hours to
build the universes included in the PACE protocol. With an
estimated hourly wage of 61 dollars, times 630 hours per PO, this
is a one-time estimate of $38,430 per PO.

Only used if a deficiency is cited during the audit. Response time
can vary based on the size of the impact. It is usually 3 to 5 days.

Changed response time to 10
days.

Only used if a deficiency is cited during the audit. Response time
can vary based on the size of the impact. It is usually 10 days.

None.

Created a personnel impact
analysis and included it as an
attachment.

Total audit hours (72 x 180) = 12,960
Average hourly wage = $61 per hour
Total Cost of Collection Effort = $790,560

Adjusted total costs to account
for increased audit hours.

Document Title: Personnel Impact Analysis
Description: Personnel Impact Analysis Template
Purpose: To assess impact on personnel
Respondents: PACE organizations
Reporting Frequency: We audit approximately 72 PACE
organizations annually
Time Per Response: Only used if a deficiency is cited during the
audit. Response time can vary based on the size of the impact. It
is usually 10 days.
Total audit hours (72 x 240) = 17,280
Average hourly wage = $61 per hour
Total Cost of Audit (17,280 x 61) = $1,054,080
One-time Implementation Cost (119 x 38,430) = $4,573,170
Total Cost of Collection Effort (Total Cost of Audit + One-Time
Implementation Cost) = $5,627,250

Justification
Burden Estimate
One-Time Burden To Build
Systems (New)

CMS-10630_Supporting
Statement A
Attachments
All IA templates
CMS-10630_Supporting
Statement A
Attachments
Personnel Impact Analysis

CMS-10630_Supporting
Statement A
Justification
Burden Estimate
Calculation of Total Audit
Hours and Approximate
Cost

Page 23 of 25

Current Section in CMS10630 (08/16)
CMS-10630_Supporting
Statement A
Justification

Original Language

Clarification or Change

Revised Language

For each audit we estimate an average of 200 hours for
administrative and systemic work, 80 hours prior to the audit start
to review the information for completeness and prepare for audit,
40 hours for the actual administration of the audit, and 80 hours to
review audit documentation, discuss findings, and draft the report.

Removed part of the first
sentence for clarity.

For each audit we estimate 80 hours prior to the audit start to
review the information for completeness and prepare for audit, 40
hours for the actual administration of the audit, and 80 hours to
review audit documentation, discuss findings, and draft the report.

None.

Added a new section to
highlight contractor costs for
the government, and added
those costs into the total
government costs.

Contractor Costs
CMS has two audit support contractors that perform a variety of
duties beyond just the performance of the audit. The duties
performed related to this collection effort include performing team
lead duties, acting as the documenter (i.e., documenting all audit
findings) for each audit team, providing clinicians for portions of
the audit, receiving, and analyzing and ensuring completeness of
all audit data collected from POs. Based on invoices received by
the government, each audit costs CMS approximately $23,000 in
contracted resources. Contractors assist with approximately 20
PACE audits each year.

Burden Estimate
Costs to Federal
Government
CMS-10630_Supporting
Statement A
Justification
Burden Estimate
Costs to Federal
Government
Contractor Costs

Consequently, the total cost to the government in contracted
resources is as follows:
$23,000 per audit x 20 audits = $460,000.
Adding up the costs to the government of staff time, travel and
contractor costs we can estimate total cost to the government as
follows:
Government Staff Cost
Contractor Costs:
Total Cost:
Attachment III_Pre-Audit
Issue Summary
Column D

Page 24 of 25

How was the issue discovered (e.g. CMS discovered issue, selfidentified, etc)?

Removed example.

$1,679,212.80
$460,000
$2,139,212.80

How was the issue discovered?

Current Section in CMS10630 (08/16)

Original Language

Clarification or Change

Revised Language

Attachment III_Pre-Audit
Issue Summary

Column G: Was the issue previously disclosed to CMS (e.g.,
Account Manager disclosure)? Y/N)

Removed column since we are
only requesting disclosed
issues.

None.

Column G
Attachment III_Pre-Audit
Issue Summary

Column I: To whom the issue was disclosed at CMS

Column shifted and clarified
that we want the person in
CMS that the issue was
disclosed.

Column H: To whom the issue was disclosed at CMS
(first and last name)

Column I

Page 25 of 25