CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

Audit Review Period:
Issue of non-compliance:

IDT remaining alert to pertinent input

Scope:

• The scope of this Impact Analysis is limited to 50% of the participants enrolled during the audit review period who were not included in the provision of
services sample selection.
• The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab.

Instructions:

• Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab.
• Review documentation during the audit review period identified in this tab (Instructions).
• Determine if the IDT did not remain alert to any pertinent input from other team members, participants, and caregivers.
• Respond to the questions in the participant impact tab.
• After completing the Impact Analysis, if any changes need to be made to the Root Cause Analysis, please update the changes in the RCA tab.

Impact Analysis Due Date:

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)

Pending OMB Approval (0938-New)

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

Pending OMB Approval (0938-New)

# of Individuals
Impacted

Action Taken to Resolve System/
Operational Issues

Date System/ Operational Remediation Date System/ Operational Remediation Actions Taken to Resolve Negatively Impacted Individuals Date Individual Outreach and Remediation
Completed (MM/DD/YY)
Including Outreach Description and Status
Initiated
Initiated
(MM/DD/YY)
(MM/DD/YY)

Pending OMB Approval (0938-New)

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

Participant First Name

Participant Last Name

Participant ID

Date of Enrollment

Date of Disenrollment

MM/DD/YYYY

MM/DD/YYYY

Pending OMB Approval (0938-New)

Reason for Disenrollment

During the audit review period, did any PO employee, contracted
employee, or contractor fail to communicate pertinent
information regarding the participant's medical, functional, or
psychosocial condition to members of the IDT?
(Yes/No)

Please provide a brief description of the pertinent information that was not communicated
to the appropriate IDT member(s).

When did someone at the PO first become aware of the
issue (it was first discovered or documented)?

(This includes information that was not communicated at all, and delayed communication of MM/DD/YYYY
pertinent information)

If NO, the PO may enter NA in all remaining fields.

Pending OMB Approval (0938-New)

Who reported the issue initially
(participant, caregiver, SW, PCA, SNF staff, etc.)?

Which staff member received the initial report
(PCP, NP, RN, SW, OT, PT, Dietitian, HCC, RT, PCA, Driver, Center
Manager)?

Where was the initial report documented
(progress notes, on-call log, etc.)?

Pending OMB Approval (0938-New)

Was the information communicated to the appropriate
members of the IDT at some point (even if delayed)?

Date the information was communicated to the
appropriate members of the IDT.

(Yes/No)

MM/DD/YYYY

Did the communication issue cause a
delay in or failure to: assess the
participant, provide necessary care
and/or services, provide access to
emergency care, etc.?

Enter NA if the information was never communicated to
(Yes/No)
the appropriate IDT members.

Pending OMB Approval (0938-New)

If the communication issue caused a delay in or failure to: assess the participant, provide
necessary care and/or services, provide access to emergency care, etc., please describe
the care and/or services that were not provided or were delayed.
Enter NA if Not Applicable

Were the services delayed or not provided?
Enter Delayed or Not Provided
Enter NA if Not Applicable

If delayed, what date did the participant receive the
appropriate care and/or services.

What documentation or evidence does the PO have to
demonstrate that the services were provided?

Enter Date

(i.e., progress note in the medical record, record from a
specialist, etc.).

Enter Not Provided if the services were never provided.
Enter NA if Not Applicable

Pending OMB Approval (0938-New)

If the participant experienced negative outcomes, did they occur, in some
part, as a result of the failure to provide or a delay in the provision of care
and/or services?

If yes, describe the negative outcomes.
Enter NA if Not Applicable

(Yes/No)

Pending OMB Approval (0938-New)

Optional: Please note, you do not have to complete this column.
If there are any mitigating factors that you would like CMS to consider related to a
specific participant, please enter the information in this column.

Pending OMB Approval (0938-New)