CMS-10630 Summary of any pre-audit issues

Instructions:

• Enter responses to each question in Pre-Audit Issue Summary tab of this document.
• Only include issues of non-compliance that occurred during the audit review/data collection period. The audit review/data collection period begins 6 months
prior to the date of the audit engagement letter and, for the purposes of this document, ends on the date of the audit engagement letter. For example, an audit
engagement letter is issued on March 3, 2019. The audit review period for this audit is September 3, 2018, through March 3, 2019.
• Only include issues of non-compliance that were disclosed to the PACE organization's CMS account manager prior to the date of the Audit
Engagement Letter.
• Do not include Quality data already reported to CMS.
• Do not include data that is not relevant to the audit elements included in the Audit Process and Data Request document.
• Do not include issues discovered during routine CMS and SAA monitoring and account management. This includes information discovered
during account management calls and information discovered during SAA audits.

Due Date:

This document must be completed and submitted to HPMS within 5 business days following the issuance of the audit engagement letter.

OMB No: 0938-1327 (Expires: 03/31/2020)

Issue
number

Description of the non-compliance
(explain what happened and what the non-compliance was)

Number of
participants impacted

Date non-compliance
identified

Enter unknown if the
impact is unknown

MM/DD/YYYY

Was the non-compliance disclosed to
the CMS account manager prior to the
date of the Audit Engagement Letter?

Date non-compliance disclosed to
CMS
MM/DD/YYYY

To whom the noncompliance was
disclosed at CMS
(first and last name)

Root cause analysis of the non-compliance
(explain why it happened)

How was the non-compliance discovered?

Was the non-compliance fully Describe how the non-compliance
remediated?
was remediated (corrected).
(e.g. was the non-compliance fully
corrected)?

Yes/No
Yes/No

Date system/operational
remediation initiated
MM/DD/YYYY

OMB No: 0938-1327 (Expires: 03/31/2020)

Date system/operational
remediation completed
MM/DD/YYYY

Description of remediation for negatively
impacted participants

Date participant remediation
initiated MM/DD/YYYY

Date participant remediation
completed MM/DD/YYYY

Enter NA if participant
remediation was not initiated.

Enter NA if participant
remediation was not initiated.

If remediation or correction was not If remediation or correction was not
completed, when is the anticipated
completed, has the risk to
completion date?
participants been mitigated?

If the risk to participants has been
mitigated please explain.