CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

Audit Review Period:
Issue(s) of non-compliance:

Scope:

Auditors:
Select All that Apply

Issue
Unscheduled Assessments
Semiannual Assessments
Initial Assessments

Unscheduled Assessments:
• 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.
Semiannual Assessments:
• 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.
Initial Assessments:
• The scope of this Impact Analysis is limited to 50% of the participants newly 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:

General:
• 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.
• The review timeframe is the audit review period. Errors noted prior to the audit review period should not be included.
Unscheduled Assessments:
• Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab.
• Review the selected medical records to determine:
1. If the participant had a change in status; and
2. If all required IDT members completed assessments as required.
Semiannual Assessments:
• Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab.
• Review the selected medical records to determine if all required IDT members completed assessments as required.
Initial Assessments:
• Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab.
• Review the selected medical records to determine if all required IDT members completed assessments as required.

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)

General Information: This information is to be completed for all Impact Analyses
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)

This information is to be completed if the Impact Analysis is being requested for: Unscheduled Assessments
Did the participant experience a change in their health or psychosocial status
during the audit review period that required a change is status assessment?
(Yes/No)
If the auditor did not select Unscheduled Assessments on the instructions tab the
PO may enter NA in fields F-M.

When did the change in status occur. If there was
more than one change in status, use a new row for
each date.
MM/DD/YYYY

Is there documentation that assessments were completed by all
required IDT members (at a minimum this includes: PCP, RN and
MSW, and any other discipline determined to be actively involved in
the care plan) in response to the change in condition?
(Yes/No)

Enter the IDT members who did not complete
assessments.

Date the first change in status assessment was
completed.

Date the last change in status assessment was
completed.

Enter NA if the participant received all required
assessments.

MM/DD/YYYY

MM/DD/YYYY

Were all required assessments completed in-person?
(Yes/No)

Identify the assessments that were not completed inperson.
(PCP, RN, etc.)
Enter NA if participant had all assessments completed in
person.

If the answer to this question is No the PO may enter NA in fields G-M.

Pending OMB Approval (0938-New)

This information is to be completed if the Impact Analysis is being requested for: Semiannual Assessments
Should the participant have had a Semi-annual Assessment during the audit review
period?
(Yes/No)
If the auditor did not select Semiannual Assessments on the instructions tab the PO may
enter NA in fields N-W.

Did the participant have a Semi-annual
Assessment completed during the audit
review period?

For participants that should have had a semi-annual assessment completed,
which disciplines were actively involved in the development or
implementation of the participant's plan of care, at the time of assessment?

(Yes/No)

Identify all disciplines that apply.

List the IDT members who DID NOT complete assessments (at a minimum the Were all assessments completed inrequired disciplines include PCP, RN, MSW and any disciplines identified in
person?
the previous column).
(Yes/No)
Enter NA if the participant received all required semi-annual assessments.

If the answer to this question is No the PO may enter NA in fields O-W.

Pending OMB Approval (0938-New)

Identify the assessments that were not
completed in-person.

When should the assessments have been
completed?

(PCP, RN, etc.)

MM/DD/YYYY

Enter NA if all assessments were
completed in person.

When was the first assessment completed? When was the last assessment completed? Where did the participant reside at the time of the
assessments (e.g. home, SNF, ALF, hospital, etc.)?
MM/DD/YYYY
MM/DD/YYYY

This information is to be completed if the Impact Analysis is being requested for: Initial Assessments
Did the required IDT members complete all initial assessments (at a minimum this
includes PCP, RN, MSW, RD, HCC, RT/AC, PT and OT)?
(Yes/No)
If the auditor did not select Initial Assessments on the instructions tab the PO may
enter NA in fields X-AC.

List the IDT members who DID NOT complete assessments.

General Information: This information is to be completed for all Impact Analyses
Were all assessments completed inperson?
(Yes/No)

Identify any assessments not completed in- Were all assessments completed within 30 Date last initial assessment was completed. Optional: Please note, you do not have to complete this column.
person.
days of the participant's enrollment?
If there are any mitigating factors that you would like CMS to consider related to a specific participant, please enter the information
MM/DD/YYYY
(RN, MSW, etc.)
(Yes/No)
in this column.
Enter NA if all assessments were
completed in person.

If the answer to this question is Yes the PO may enter NA in fields Y-AC.

Pending OMB Approval (0938-New)