CMS-10630 PACE Audit Process and Data Request Protocol

Programs of All-Inclusive Care for the Elderly (PACE) 2020 Audit Protocol (CMS-10630)

AttachmentIPACEAuditProcessDataRequest

Trial Year and Routine Audits

OMB: 0938-1327

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1327 can be found here:

2022-05-10 - Revision of a currently approved collection

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Programs of All-Inclusive
Care for the Elderly (PACE)
Audit Process and Data Request

Table of Contents
Audit Purpose and General Guidelines ....................................................................................................... 3
Universe Preparation & Submission ........................................................................................................... 6
Audit Elements .......................................................................................................................................... 10
I.

Service Delivery Requests, Appeals and Grievances (SDAG) ...................................................... 10

II. Clinical Appropriateness & Care Planning .................................... Error! Bookmark not defined.
III. Personnel Records.......................................................................................................................... 17
IV. Quality Assessment........................................................................................................................ 18
Appendix ................................................................................................................................................... 19
Appendix A - Programs of All-Inclusive Care for the Elderly (PACE) Record Layouts ..................... 19
Table 1: Service Delivery Requests (SDR) Record Layout .............................................................. 19
Table 2: Appeal Requests (AR) Record Layout................................................................................ 23
Table 3: Grievance Requests (GR) Record Layout ........................................................................... 26
Table 4: List of Personnel (LOP) Record Layout ............................................................................. 28
Table 5: List of Participant Medical Records (LOPMR) Record Layout ......................................... 30
Table 6: On-Call (OC) Record Layout.............................................................................................. 36

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Audit Purpose and General Guidelines
1. Purpose: To evaluate PACE organizations’ (POs’) compliance with regulatory requirements
in the following four areas related to the Programs of All-Inclusive Care for the Elderly
(PACE). The Centers for Medicare and Medicaid Services (CMS) will perform its audit
activities based on these instructions (unless otherwise noted).
•
•
•
•

Service Delivery Requests, Appeals and Grievances (SDAG);
Provision of Services (care planning, participant assessments, interdisciplinary team (IDT)
requirements, medical records, participant observations, etc.);
Personnel Records; and
Quality

2. Audit Review: During the audit, CMS will review data and documentation collected prior to
and during the audit fieldwork, as well as conduct real-time observations of participants and
equipment. CMS reserves the right to access all relevant documentation or information related
to our audit, and may expand our collection of information in order to evaluate participant
impact or outcomes.
3. Universe Data and Documentation Collection Periods: The data/document collection period
for this protocol will be for a period of 6 months prior to, and including, the date of the audit
engagement letter unless otherwise specified. Data collection periods for specific universes have
been defined in Table 1 below. CMS reserves the right to expand the data/document collection
period to ensure sufficient universe size and/or evaluate participant impact.
NOTE: The universe data collection period for the On-call universe begins 3 months prior to the
date of the audit engagement letter and ends on the date of the audit engagement letter.
Data Collection Periods by Universe:
Table 1
Universe
Service Delivery Request
Universe
Appeal Universe
Grievance Universe
List of Personnel Universe
List of Participant Medical
Records Universe
On-Call Universe

Universe Data Collection
Start Date
6 months prior to the date of
the audit engagement letter
6 months prior to the date of
the audit engagement letter
6 months prior to the date of
the audit engagement letter
6 months prior to the date of
the audit engagement letter
6 months prior to the date of
the audit engagement letter
3 months prior to the date of
the audit engagement letter

Universe Data
Collection End Date
Date of the audit
engagement letter
Date of the audit
engagement letter
Date of the audit
engagement letter
Date of the audit
engagement letter
Date of the audit
engagement letter
Date of the audit
engagement letter

4. Responding to Documentation Requests: The PACE organization (PO) is expected to allow
access to any supporting documentation requested during the audit and upload the supporting
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documentation, as requested, to the Health Plan Management System (HPMS) using the
designated file names as indicated in the Document Request Log (DRL). Documentation
requests may include requests for portions of the medical record, or the full medical record when
warranted. Documents must be uploaded within the timeframes specified by the CMS Audit
Team. Additionally, some elements or sample review may be done remotely and organizations
will be expected to provide full case files to CMS upon request.
5. Issues of Non-Compliance Disclosed Prior to Notification of the Audit: POs will be asked to
provide a list of all issues of non-compliance disclosed to CMS prior to the date the audit
engagement letter is issued.
Issues identified by CMS or the SAA through ongoing monitoring or other account management
and oversight activities during the audit year are not considered disclosed. POs should exclude
PACE Quality data already reported to CMS and any data that is not relevant to the audit elements
included in this document.
POs must provide a description of each disclosed issue and the status of correction using the PreAudit Issue Summary template (Attachment III). Attachment III is due 5 business days after the
audit engagement letter is issued. The PO’s Account Manager will review Attachment III to
validate that disclosed issues were reported to CMS prior to receipt of the audit engagement
letter.
When CMS determines that a disclosed issue was promptly identified, corrected, and the risk to
participants has been mitigated, CMS will not apply the Immediate Corrective Action Required
condition classification to that condition. CMS may require organizations to submit a
completed root cause analysis and/or impact analysis for any disclosed issue of non-compliance.
6. Root Cause Analysis/Impact Analysis: Root Cause Analyses and/or Impact Analyses must be
submitted by the PO when they are requested by the CMS audit team. Each Root Cause Analysis
describes the nature of the problem and a description of why the non-compliance occurred.
When necessary, CMS will also request an Impact Analysis. For each Impact Analysis, CMS
will identify the participants that must be reviewed by the organization. The PACE organization
must then identify which of those participants were subject to or impacted by the issues of noncompliance generally from the beginning of the data collection period through the audit exit
conference. However, in some circumstances, CMS may modify the review scope as determined
necessary. 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) and may require
the organization to submit additional case files or provide access to participant medical records.
In the event an Impact Analysis cannot be produced, is incomplete, or is determined by means of
validation to be inaccurate, CMS will report that the scope of non-compliance cannot be
determined and impacted an unknown number of participants within the PO.
7. Calculation of Score: CMS will classify each condition cited during the course of the audit as an
Observation (0 points), Corrective Action Required (CAR) (1 point) or an Immediate Corrective
Action Required (ICAR) (2 points).
After all conditions have been classified, CMS will take the sum of the points and divide that
number by the number of audit elements (i.e., four audit elements) tested to determine the PO’s
overall PACE audit score. Observations will be recorded in the draft and final reports but will
receive a score of zero and, as a result, will not affect the audit score.

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8. Informing PO of Results: CMS will provide daily updates regarding potential conditions
identified during the audit. The CMS Audit Team will be as timely and transparent as possible
when communicating potential conditions. A preliminary summary of conditions identified during
the audit will also be presented during the exit conference. POs will have an opportunity to ask
questions and discuss potential findings during the daily updates and the exit conference.
Following the exit conference the PO will receive a Draft Audit Report. Once the Draft Audit
Report is issued, POs will have 10 business days from the date of issuance to comment on
conditions identified in the report. If the PO submits comments, CMS will review and respond to
each comment before issuing a Final Audit Report.

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Universe Preparation & Submission
1. Responding to Universes and Documentation Requests: The PO is expected to submit accurate
and timely universe and documentation submissions within the timeframes identified below. CMS
may request revised universes if data issues are identified. The resubmission request may occur
before and/or after the entrance conference depending on when the issue was 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. If the PO fails to provide accurate and timely universe submissions, CMS will
document this in the PO’s audit report and this may impact condition classifications.
2. Documentation and Data Submission Timeframes: Universes and documentation collected
prior to and during the audit are used to determine PO compliance with the PACE requirements
within the four identified audit elements. Documentation and universes must be submitted in the
timeframes indicated below.
2.1. Documentation due within 5 business days of the audit engagement letter: POs
must submit the following documentation in Microsoft Word (.docs), Microsoft Excel
(.xlsx) or Portable Document File (PDF):
•
•

Completed PACE Supplemental Questions (Audit Engagement Letter, Attachment II);
Completed Pre-Audit Issue Summary (Audit Engagement Letter, Attachment III);

2.2. Documentation and Data Universes due within 20 business days of the audit engagement
letter: POs will provide universes of all service delivery requests, appeals, grievances,
personnel employed during the data collection period, and participants enrolled during the
data collection period. POs will also submit a universe of all after-hours calls that occurred
during the last three months of the data collection period. In addition to data universes, the
PO will provide the documents identified in 2.2.1.
2.2.1 Documentation:
• The PO’s Quality Improvement (QI) plan(s) that were in use during the data
collection period;
• Participant Advisory Committee (PAC) minutes for the data collection period;
and
2.2.2 Data Universes:
• Table 1: Service Delivery Requests (SDR)
• Table 2: Appeal Requests (AR)
• Table 3: Grievance Requests (GR)
• Table 4: List of Personnel (LOP)
• Table 5: List of Participant Medical Records (LOPMR)
• Table 6: On-call (OC)
2.3. Documentation due the first day of the onsite portion of audit fieldwork: The PO will
submit the following documentation when auditors arrive onsite for the audit fieldwork.
• Completed Onsite Observation Participant List (Attachment IV).
NOTE: Organizations must submit the information identified in Attachment IV in writing but
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do not need to submit the information using the excel template Attachment IV and may submit
the information in another format so long as all requested information is included. Requests for
observation data will typically be limited to participants assigned to an IDT at the center where
CMS auditors are conducting the onsite portion of the audit. However, CMS reserves the right
to request data for participants from other PACE centers, as needed, to ensure all of the
observations can be completed. For example, if medication administration or wound care is not
being provided at the center where the onsite audit is conducted, CMS auditors may request
data from other PACE centers in order to determine whether observations may be completed at
an alternative site. The audit team will identify the subset of participants for whom information
must be provided.
3. Pulling and Submitting Universes: POs must submit each universe in the Microsoft Excel
(.xlsx) file format with a header row that corresponds to the record layouts shown in Appendix A,
Tables 1-6.
For the service delivery request, appeal and grievance universes, cases that fall in the data
collection period must be submitted based on the date the request/grievance was
processed/resolved (or should have been processed/resolved). The date the request or grievance
was received may fall outside of the data collection period. Service delivery request and appeal
universes should be all inclusive, regardless of whether the request was determined to be
approved, denied, or partially denied/partially approved.
For the personnel universe, POs must include all personnel who were employed at any time
during the data collection period. This includes part-time employees, full-time employees,
contracted employees, volunteers, and temporary employees. For contracted employees, the PO
should only include those employees that provided services to participants in the participant’s
home, a PACE center, an Alternative Care Setting (ACS) or transporting a participant (i.e., PACE
driver). This includes employees of contracted agencies who provide services to PACE
participants, if that employee provides care at one of the settings identified above. POs do not
need to include employees of institutional contracted providers such as nursing facilities and
hospitals. POs do not need to submit actual personnel records for each employee, only the
information identified in Appendix A, Table 4.
For the participant medical record universe, POs must include all participants who were enrolled at
any point during the data collection period. This includes participants who were enrolled prior to or
during the data collection period, regardless of whether or not they are still enrolled (e.g.,
disenrolled or expired). POs do not need to submit medical records with the universes for each
participant, only the information identified in Appendix A, Table 5.
For the on-call universe, POs must submit all information relating to all calls received after-hours.
Unlike the other universes, the on-call universe only needs to include calls that occurred in the last
three months of the data collection period.
4. CMS Analysis of Universes: CMS will complete data entry tests on all of the universes
to ensure there are no blank entries and data is properly formatted. In addition to
analyzing universes throughout the audit for varying compliance standards, CMS will
also perform the timeliness tests on the universes identified in Table 2 below.

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Table 2
Record
Table
Layout Universe
#
1

SDR

Service
Delivery
Requests

Appeal
Requests

Applicable
Audit
Compliance Standard To Apply CFR Ref.
Test
Element
SDAG
• Notification is provided to the 460.104(d)(2) Notification
(ii) and
participant/representative no
460.104(d)(2)
later than 72 hours following
(iii)
the date the request was
received by the IDT.
• Notification is provided to the
participant/representative no
later than 8 days following the
date the request was received by
the IDT, if an extension was
taken.
SDAG
• Notification is provided to the 460.122(c)(5) Notification
,
participant/representative no
later than 30 days from the date 460.122(f)(2),
of receipt for a standard appeal. and
• Notification is provided to the 460.122(f)(3)
participant/representative no
later than 72 hours from receipt
of a request for an expedited
appeal.
• Notification is provided to the
participant/representative no later
than 17 days from receipt of a
request for an expedited appeal
for which an extension is taken.

5. Selecting Samples: Auditors will review the universes collected from the PO and select
samples in accordance with the instructions noted below. For elements done via desk
review (e.g., the Service Delivery Request, Appeals, and Grievance (SDAG) element
and/or Personnel), samples will be provided to the PO two business days before the
review of each element. Onsite observations conducted as part of the Provision of
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Services element will be selected from the Onsite Observation Participant List
(Attachment IV) on the first day of the onsite audit. Medical record samples for the
Provision of Services Element will be provided for informational purposes to the PO one
hour prior to the start of the review of medical records. The PO is not expected to upload
any medical record documentation within the one hour timeframe following receipt of the
samples. PACE organizations are required to allow CMS immediate access to the
medical records for each sample within that time, in whatever manner was agreed upon
by the audit team and organization.

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Audit Elements
I. Service Delivery Requests, Appeals and Grievances (SDAG)
1. Select Sample Cases: CMS will select 40 targeted sample cases. When selecting sample cases,
CMS will attempt to ensure that the sample set is representative of various types of service
requests, appeals and grievances. CMS will use all universes, documentation, and available
information in order to target samples for review. The SDAG sample set will include:
•
•
•
•
•

10 denied service delivery requests
10 approved service delivery requests
5 denied appeals
5 approved appeals
10 grievances

CMS reserves the right to adjust the number of service delivery requests, appeals or grievance
samples if the number of entries in a given universe is less than the number of required samples. For
example, if a PO does not have 5 approved appeals, CMS may add additional denied appeals or
additional approved service delivery requests to make up the total number of samples. Additionally,
CMS may add samples or case review in order to further investigate potential non-compliance or
participant impact.
2. Review Sample Case Documentation: CMS will review all sample case file documentation to
determine compliance with regulatory requirements including: identifying the request, processing
the request, notifying participants timely and appropriately, and providing any approved services.
The PO will need to provide the following documents via HPMS during the audit:
2.1. For service delivery requests:
• Documentation of the initial request (received in writing, orally, etc.) including any system
notes, progress notes, logs, or other data related to the receipt of the service delivery request
• All assessments conducted in response to the service delivery request and any IDT notes or
discussions regarding the assessment
• Documentation of the IDT’s decision to approve or deny the request based on assessment(s)
conducted in response to the request by the IDT
• Documentation of the involvement of the IDT in reviewing the service delivery request
including disciplines involved in the review
• For service delivery request denials:
 A copy of the written notification of the denial including the specific reason for the
denial and the participant’s appeal rights
 Documentation of oral notification of the denial including the reason for the denial and
documentation that appeal rights were provided orally
• For service delivery request approvals:
 If oral notification was provided, medical record notes and/or documentation of
notification to the participant/designated representative
 If written notification was provided, a copy of the written notification provided to the
participant/designated representative
 Documentation showing the service and/or item was provided (e.g., an annotation in the
participant’s medical record, assessments, progress notes)
• Any other reports, system notes, or logs that document denial or approval of the request
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•

and participant notification
If applicable, documentation regarding any extension that was taken including the
rationale for the extension and who requested the extension

2.2. For appeals:
• Documentation of the initial appeal request (received in writing, orally, etc.) including any
system notes, progress notes, logs, or other data related to the appeal request
• All case notes, progress notes and assessments related to the appeal including the
underlying service delivery request denial
• Documentation identifying the third-party reviewers and their credentials
• Documentation that the participant was given an opportunity to present evidence in-person
as well as in writing
• Documentation indicating why an appeal was expedited (if applicable)
• Documentation indicating why an expedited appeal was extended, including the
participant’s request for an extension and State administering agency’s approval of the
extension (if applicable)
• Documentation of the third-party decision, including:
 For denials: a copy of the written notification letter provided to the participant
including their external appeal rights available through Medicare and/or
Medicaid
 For denials: documentation that CMS was notified of an appeal decision that was wholly
or partially adverse to the participant
 For approvals: documentation of written notification of the decision
• If oral notification was provided, documentation of the oral notification
• Any other reports, system notes, or logs that document denial or approval of the request
and participant notification
• For approvals, documentation that the service and/or item was provided (e.g., an
annotation in the participant’s medical record, progress notes)
2.3. For grievances:
• Documentation of the initial complaint/grievance including system notes, progress notes,
logs, or other data related to the grievance
• Documentation detailing each issue in the complaint/grievance
• Documentation of all supplemental information submitted by the participant
and/or their caregiver
• Documentation showing the steps the PO took to resolve each issue identified in the
complaint/grievance, including appropriate correspondence with other departments
within the organization and a description of the final resolution
• Documentation showing resolution notification of each issue identified in the
complaint/grievance to the participant and/or their representative
 If written notification was provided, a copy of the written resolution letter and
documentation of the date/time the letter was mailed
 If oral notification was provided, a copy of progress notes and/or other documentation
of the notification including the date the notification was provided
3. Apply Compliance Standard: At a minimum, CMS will evaluate cases against the criteria in
this section. CMS may review factors not specifically addressed in these questions if it is
determined that there are other requirements not being met.
3.1 Did the PO appropriately process service delivery requests, appeals and grievances?
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3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
3.1.6
3.1.7

Did the PO appropriately identify, classify, and process service delivery requests,
appeals and grievances?
Did the PO use the appropriate personnel to review service delivery requests and
appeals?
Did the PO conduct assessments, as required, in response to a service delivery request?
Did the PO process untimely service delivery requests as appeals?
Did the PO provide participants with a reasonable opportunity to present evidence inperson, as well as in writing, during an appeal?
Did the PO continue providing services to a Medicaid participant, during an appeal, if
the participant requested to continue the services?
Did the PO properly identify and address all issues in a grievance?

3.2 Did the PO appropriately notify participants and/or their designated representatives of
any decision relating to a service delivery request, appeal or grievance?
3.2.1 Did the PO provide oral and written notification of service delivery request
denials that included the specific reason for the denial in understandable
language?
3.2.2 Did the PO provide oral and written notification of service delivery request
denials that included the participant or designated representative’s right to
appeal, including the right to an expedited appeal?
3.2.3 Did the PO provide appropriate written notification for appeal decisions?
3.2.4 Did the PO notify the participant of the grievance resolution(s)?
3.3 Did the PO notify the participant and/or designated representative of the service
delivery request, appeals and grievance decisions within the required timeframes?
3.3.1 Did the PO notify the participant or designated representative of the decision to
approve or deny a service delivery request within 72 hours from the date the request
was received by the IDT?
3.3.2 Did the PO appropriately extend the timeframe for approving or denying a
service delivery request, if applicable?
3.3.3 Did the PO notify the participant of an appeal decision within 30 days or, for
expedited appeals, within 72 hours after the PO receives the appeal?
3.3.4 Did the PO appropriately extend the timeframe for approving or denying an expedited
appeal, if applicable?
3.4 Did the PO effectuate/provide approved service delivery requests and appeals?
4. Sample Case Results: CMS will test each of the 40 cases. If CMS requirements are not met,
conditions (findings) are cited. If CMS requirements are met, no conditions (findings) are cited.
NOTE: Cases and conditions may have a one-to-one or a one-to-many relationship. For example,
one case may have a single condition or multiple conditions of non-compliance.

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II. Provision of Services
1. Select Sample Cases: This element will be tested using both medical record review and onsite
observations/inspections.
Medical Record Review: CMS will select 30 targeted medical records that appear clinically
significant. When selecting sample cases, CMS will attempt to ensure that the sample set is
representative of various types of medical, functional, and social needs (e.g., hospitalizations,
wound care, dialysis, social needs, home bound, skilled nursing care). CMS will use all universes,
documentation, and available information in order to target participant samples for review. CMS
may expand the scope of review or add medical records as needed in order to appropriately
investigate potential compliance issues discovered during the review of audit elements.
Additionally, CMS may require access to medical records following the audit fieldwork to validate
impact analyses or other submitted information.
Participant Observations: CMS will also conduct 5 participant observations during audit fieldwork
(e.g., week 2) in order to ensure participants are receiving appropriate care and services that were
indicated to be necessary. Observations will also ensure care is being provided following CDC
standard precautions. Observations may include but are not limited to:
• Skilled care provided in participants’ homes, including wound care and medication
administration;
• Skilled care provided at the center, or Alternative Care Setting, including wound care and
medication administration; and
• Dietary/meal services.
CMS may observe more participants if issues are noted that warrant additional observations.
Emergency Equipment: CMS will also conduct an inspection of specific emergency equipment and
emergency medications in order to ensure the PO is properly equipped to handle an emergency
situation.
Vehicle Inspection: CMS will conduct an observation of at least one vehicle that the PO utilizes to
transport participants in order to ensure that the PO is equipped to provide safe and appropriate
transportation services.
2. Review Sample Case Documentation: CMS will review participant medical records and
conduct participant observations to determine compliance with regulatory requirements including:
provision of required services, coordination and management of participant care, completion of
required assessments, and the development and review of participant care plans. CMS may also
conduct interviews with participants, staff and caregivers as determined necessary. The PO must
provide CMS auditors unrestricted access to these records and may be required to upload copies
and/or screenshots of the following documents during and/or after the audit:
Medical Record Review:
• All documentation related to participant assessments:
 Initial comprehensive assessments
 Semi-annual and unscheduled assessments
 Documentation that assessments were completed as required
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 IDT progress notes, evaluations, or other documentation related to initial, semiannual,
and unscheduled assessments
 Documentation related to assessment outcomes, changes in care plans,
participant outcomes, etc.
• All documentation related to participant care plans:
 Documentation showing when and how the care plan was developed/re-evaluated
including documentation of IDT members involved in the development and reevaluation
 Changes made to the care plan at any point
 IDT recommendations and notes related to the care plan
 Assessments that were used in constructing or revising the care plan
 Documentation that the participant and/or caregiver was appropriately involved in
the development and revision of the care plan,
 Documentation showing that services and care indicated in a participant’s care
plan were provided appropriately
• All documentation related to service delivery and emergency care:
 Documentation that the PO is providing all necessary services and care as determined
by the IDT
 Documentation that the PO provides Medicare and Medicaid covered services,
including medications, as appropriate and necessary
 Documentation that the PO provides comprehensive PACE services to
meet participants’ medical, physical, emotional, and social needs
 Documentation that an on-call provider is available to participants 24 hours a day
 Documentation the PO provides immediate access to emergency care
 Documentation of emergency care, including documentation that the
participant was held harmless
 Documentation relating to the use of restraints, if applicable
• Documentation that the PO provided Medicare and Medicaid benefits without any
limitations or conditions related to amount, duration, scope of services, deductibles,
copayments, coinsurance, or other cost-sharing
• Documentation relating to the interdisciplinary team (IDT) including:
 Documentation that the IDT consists of all required members
 Documentation showing appropriate members were involved in assessments and care
planning as required
 Documentation of any communication by the IDT
• All other documentation related to a participants experience and care at the PACE
organization
• Documentation related to visits or consults with specialists
• Documentation from outside provider including hospital records, SNF/NF
records, respite care
• Documentation related to medication administration and orders
• Any documentation relating to the participants dietary needs
• Any documentation relating to a participants attendance at the PACE center
Participant observations:
• A private area (can be the clinic) to view a willing participant receiving care
• Home visit(s) to view a willing participant receiving care
• Visit(s) to an outside facility (such as a SNF), if applicable
Equipment:
• Emergency equipment available at the center
• At least one vehicle used to transport participants
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3. Apply Compliance Standards: At a minimum, CMS will evaluate sample cases against the
following criteria. CMS may review factors not specifically addressed in these questions if it is
determined that there are other requirements not being met.
3.1 Did the PO provide adequate care/services to the participants (including but not
limited to transportation, dietary, medical care, etc.)?
3.1.1 Did the PO furnish mandatory services at the PACE center?
3.1.2 Did the PO provide immediate access to emergency services without prior
authorization?
3.1.3 Did the PO provide access to care and services 24 hours a day as necessary?
3.1.4 Did the PO furnish services and care that meets the needs of each participant in all
care settings, 24 hours a day, every day of the year?
3.2 Did the PO ensure that the IDT was appropriately involved in the participants’
care?
3.2.1 Has the PACE organization established an interdisciplinary team, composed of
the required members at each PACE center?
3.2.2 Is there evidence that the IDT conducted initial and periodic assessments,
developed plans of care, and coordinated 24 hour care delivery?
3.2.3 Is there evidence that members of the IDT remained alert to pertinent input
from other team members, participants, and representatives?
3.2.4 Did the PO continuously monitor the participant's health and psychosocial
status, as well as the effectiveness of the plan of care, through the provision of
services, informal observation, input from participants or representatives, and
communications among members of the interdisciplinary team and other
providers?
3.3 Did the PO perform assessments as required?
3.3.1 Did the PO perform assessments as required (initial, semi-annual, or more
frequently when necessary)?
3.3.2 Did the PO ensure the required IDT members performed assessments?
3.4 Did the PO maintain a complete, accurate, and accessible medical record?
3.5 Did the PO develop and document an appropriate care plan for the participants?
3.5.1 Did the PO evaluate and monitor the participants’ care plans on at least a semiannual
basis?
3.5.2 Did the PO ensure that the appropriate IDT members were involved in
creating and evaluating care plans?
3.5.3 Did the PO document participant and/or representative involvement in the
development, review, and evaluation of care plans?
3.6 Did the PO provide services as approved and/or determined necessary?
3.6.1 Did the PO provide services and care as identified in the care plan and/or primary
care provider orders?
3.6.2 Did the PO provide treatment and medications as identified in the care plan and/or
primary care provider orders?
3.6.3 Did the PO provide all items, care and services determined necessary by the IDT
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(e.g., through approved service requests)?
3.7 Does the PO follow appropriate infection control standards when providing care?
3.7.1 Do personnel wash/sanitize hands as appropriate?
3.7.2 Do personnel don and doff personal protective equipment as appropriate?
3.8 Does the PO have emergency equipment immediately available (suction, oxygen,
medications, etc.)?
3.9 Does the PO have a method of providing safe transportation to participants?
3.9.1 Does the PO have a demonstrated method for securing participants (i.e., seat belts)
and securing DME (e.g., wheelchairs, oxygen, walkers)?
3.9.2 Does the PO have a method for communicating between the vehicle and the PACE
center?
3.9.3 Does the PO provide training to drivers on managing the special needs of the
participants and handling emergency situations?
4. Sample Case Results: CMS will test each of the 30 medical records, 5 participant observations,
and emergency equipment and vehicle inspections. If CMS requirements are not met, conditions
(findings) are cited. If CMS requirements are met, no conditions (findings) are cited. NOTE:
Cases and conditions may have a one-to-one or a one-to-many relationship. For example, one case
may have a single condition or multiple conditions of non-compliance.

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III. Personnel Records
1. Select Sample Cases: CMS will select 10 targeted 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. Additionally, CMS may add additional samples or case
review in order to further investigate potential non-compliance or participant impact.
2. Review Sample Case Documentation: CMS will review all sample case file documentation to
determine compliance with regulatory requirements. The PO must provide CMS auditors
unrestricted access to these records and may be required to upload copies and/or screenshots of
the following documents during and/or after the audit:
•
•
•
•
•

Documentation of any and all background checks conducted
Documentation of any and all OIG excluded provider checks conducted
Documentation that personnel have current and active licensure, if licensure is required for
their position
Documentation that personnel were determined to be free of communicable disease
Documentation of completed competencies

3. Apply Compliance Standards: At a minimum, CMS will evaluate cases against the following
criteria. CMS may review factors not specifically addressed in these questions if it is determined
that there are other related PACE requirements not being met.
3.1 Did the PO conduct a background check on personnel prior to their date of hire?
3.2 Did the PO conduct an OIG exclusion check for personnel prior to their date of hire?
3.3 Did the PO ensure that personnel were appropriately licensed, if applicable?
3.4 Did the PO ensure that all staff with direct participant contact were medically cleared
of communicable diseases before engaging in direct participant contact?
3.5 Did the PO ensure that personnel completed competencies before working independently?
4. Sample Case Results: CMS will test each of the 10 files. If CMS requirements are not met,
conditions (findings) are cited. If CMS requirements are met, no conditions (findings) are cited.
NOTE: Cases and conditions may have a one-to-one or a one-to-many relationship. For example,
one case may have a single condition or multiple conditions of non-compliance.

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IV. Quality Assessment
1. Quality Assessment Review: CMS will conduct an interview and review data/documentation
with the PO’s staff responsible for the development and implementation of the quality
improvement program.
2. Review Quality Improvement Documentation: CMS will review relevant documentation and
information related to the PO’s quality improvement program. The PO will need to produce the
following documents during the audit and may be requested to produce screenshots or copies of
any of the following:
•

•
•
•

Documentation that the PO collects, analyzes, and uses data to improve
performance in the following areas:
 Utilization of PACE services
 Participant and caregiver satisfaction
 Participant assessment data including: physiological well-being, functional
status, cognitive ability, social and behavioral functioning, and quality of life
 The effectiveness and safety of staff and contracted services including:
competency of clinical staff, promptness of service delivery, and achievement
of treatment goals
 Nonclinical areas such as: grievances, appeals, transportation services, meals,
and environmental issues
Specific actions taken in response to the detected issue(s), if applicable
Documentation that staff members and contractors are involved in the development and
implementation of the QI program
Documentation that the results of quality initiatives are communicated to staff and
contractors

3. Apply Compliance Standards: At a minimum, CMS will evaluate all available documentation
against the following criteria. CMS may review factors not specifically addressed in these
questions if it is determined that there are other requirements not being met.
3.1. Did the PO develop and/or implement an effective, data driven quality improvement
program?
3.1.1. Does the PO collect and analyze the minimum required data including: utilization of
PACE services, participant and caregiver satisfaction, participant assessment data, the
effectiveness and safety of staff and contracted services, and nonclinical areas, such as
grievances, appeals, transportation services, meals, and environmental issues?
3.1.2. Does the PO use the minimum required data (utilization, participant and caregiver
satisfaction, participant assessments, effectiveness and safety of staff and contracted
services, and nonclinical data) to improve the delivery of PACE services?
3.2. Did the PO ensure that the appropriate staff were involved in the development and
implementation of QI activities and did the PO appropriately disseminate
information related to the QI activities?
4. Review Results: CMS will use all available documentation to assess whether CMS requirements
are met. If CMS requirements are not met, conditions (findings) are cited. If CMS requirements
are met, no conditions (findings) are cited. NOTE: Conditions may have a one-to-one or a oneto-many relationship. For example, one issue may result in a single condition or multiple
conditions of non-compliance.
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Appendix
Appendix A - Programs of All-Inclusive Care for the Elderly (PACE) Record Layouts
The universes for the PACE audits must be submitted as a Microsoft Excel (.xlsx) file with a header
row. Do not include additional information outside of what is dictated in the record layout.
Please use a comma (,) with no spaces to separate multiple values within one field if there is more
than one piece of information for a specific field (e.g., PCP, RN, MSW). Do not include any
leading or trailing spaces and do not leave any fields blank.
Table 1: Service Delivery Requests (SDR) Record Layout
• Include all requests processed by the PO as service delivery requests.
• 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 data collection period).
Column
ID
A
B
C

Field Name

Description

Example

Participant First
Name
Participant Last
Name
Participant ID

First name of the participant.

Jane

Last name of the participant.

Doe

The identification number the PO uses to
identify the participant.
Indicate if the request was submitted by the
participant or designated representative (which
may include a caregiver, family member, POA,
legal guardian, etc.).
Date the service delivery request was received
by the interdisciplinary team (IDT). Submit in
MM/DD/YYYY format (e.g., 01/01/2020).

1234

Provide the category or type of service delivery
request. Examples include: Center Days, Eye
Wear, Dental, Home Care, Medications, etc.
Provide a description of the service delivery
request.

Home Care

Person who
Submitted the
Service Request

Date Service
Delivery
Request
Received
Category of the
Request

Description
of the
Request

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Participant

02/01/2020

The participant requested
an increase in home care
from 1x per day, 5 days
per week to 2x per day, 5
days per week.

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Column
ID
H

Field Name

Description

Example

Date(s)
Assessment(s)
Performed

Enter the date(s) the IDT member(s) completed
required assessments in response to the service
delivery request.

02/01/2020, 02/02/2020,
02/03/2020

If more than one assessment was completed, enter
all dates separated by a comma.
Submit in MM/DD/YYYY format (e.g.,
01/01/2020).

Discipline(s)
Performing
Assessment(s)

Assessment(s)
In-person

Enter NA if an assessment was not completed or if
the assessment(s) was not completed in response
to the service delivery request (e.g., do not include
semi-annual assessments if they were not done in
response to the requested service).
Indicate which IDT members completed
PCP,RN,PT
assessments. If more than one discipline
completed an assessment, include all applicable
disciplines separated by commas.
Enter NA if an assessment was not completed or
was not completed in response to the service
delivery request.
Enter Y if any assessment or assessments were
completed and were conducted in-person.

Enter N if assessments were completed but none
of the assessments were conducted in-person.
Enter NA if no assessment was completed or was
not completed in response to the service delivery
request.

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Column
ID
K

Field Name

Description

Example

Request
Disposition

Valid fields include: Approved, Denied, Partially
Approved/Denied, or Withdrawn.

Approved

Enter approved if all of the requested services
and/or items were approved as requested.
Enter denied if all of the requested services
and/or items were denied.
Enter partially approved/denied if the request was
not fully approved as requested and/or the PO
provided a modified or alternative service to the
participant.

Reason for
Denial

Extension

Date of Oral
Notification

Enter Withdrawn if the participant and/or the
designated representative requested to withdraw
the service delivery request prior to the
organization rendering a decision.
If the request was denied or partially
denied, please enter a brief explanation of
why the request was denied.
Enter NA if the request was approved or
withdrawn.
Enter Y if the PO took an extension when
processing the service delivery request in
order to allow more time to render a
decision.
Enter N if the PO did not take an extension.
Enter the date the PO provided oral
notification, to the participant and/or the
designated representative, of the decision (e.g.,
approve or deny the request).

Glasses were denied
because the participant was
assessed to have 20/20
vision.

02/03/2020

Submit in MM/DD/YYYY format (e.g.,
01/01/2020).
Enter NA if oral notification was not provided or
not documented.

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Column
ID
O

Field Name

Description

Example

Date of Written
Notification

Enter the date the PO provided written
notification, to the participant and/or
designated representative, of the decision (e.g.,
approve or deny the request).

02/03/2020

Submit in MM/DD/YYYY format (e.g.,
01/01/2020).
Enter NA if written notification was not provided
or not documented.

Date Service
Provided

Enter the date that the approved service or item
was provided to the participant. Please enter a
date for any request that was partially or fully
approved.

02/04/2020

Submit in MM/DD/YYYY format (e.g.,
01/01/2020).
Enter NA if the request was denied, withdrawn or
if there was no documentation of the effectuation
(provision) of the service.

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Table 2: Appeal Requests (AR) Record Layout
• Include all requests processed as standard or expedited appeals received by the PO.
• Exclude appeals from external reviewers (i.e., Medicaid appeals).
• 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 data collection
period).
Column
ID
A
B
C
D

Field Name

Description

Example

Participant First
Name
Participant Last
Name
Participant ID

First name of the participant.

John

Last name of the participant.

Smith

The identification number the PO uses to identify
the participant.
Indicate if the request was submitted by the
participant, caregiver or family.

12345

Date the appeal was received by the PO.

03/01/2020

Submit in MM/DD/YYYY format (e.g., 01/01/2020).
This column only applies to expedited appeals.
Enter the time the appeal was received by the PO.

Person who
Submitted the
Appeal
Date Appeal
Received
Time Appeal
Received

Caregiver

Submit in HH:MM format (e.g., 23:54).

Expedited

Enter NA for standard appeals (i.e., if the appeal
was not expedited).
Enter Y if the appeal was processed as expedited.

Extension

Enter N if the appeal was not expedited (i.e., was
processed as a standard appeal).
This column only applies to expedited appeals.

Enter Y if the PO took an extension when processing
an expedited appeal.
Enter N if the PO did not take an extension on an
expedited appeal.
Enter NA if the appeal was not expedited (i.e., was
processed as a standard appeal).

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Column
ID
I

Field Name

Description
of the
Appeal/
Specific
Issue
Request
Disposition

Category of the
Appeal/ Appeal
Type

Description

Example

Provide the category or type of appeal request. Valid
Dentures
fields include: Decreased Center Attendance, Denial of
Enrollment, Dentures, Durable Medical Equipment,
Glasses, Hearing Aid, Home Modification(s), Increased
Center Attendance, Increased Home Care, Involuntary
Disenrollment, Medical Procedure, Medical Supplies,
Nursing Facility Placement - Long Term, Nursing
Facility Placement – Respite, Nursing Facility
Placement - Short Term, Specialist Consultation or
Visit, Surgical Procedure, Transportation, or Other
Provide a description of the appeal.

The participant
requested full upper
and lower dentures.

Valid fields include: Approved, Denied, Partially
Approved/Denied or Withdrawn.

Approved

Enter approved if all of the requested services and/or
items were approved as requested.
Enter denied if all of the requested services and/or
items were denied.
Enter partially approved/denied if the request was not
fully approved as requested and/or the PO provided a
modified or alternative service to the participant.

Reason for Denial

Date of Written
Notification

Enter Withdrawn if the participant and/or designated
representative requested to withdraw the appeal prior
to a decision being rendered.
If the appeal was denied or partially denied, please
enter a brief explanation of why the request was
denied.
Enter NA if the appeal was approved or withdrawn.
Enter the date the PO provided written notification
to the participant or other representative (e.g.
family or caregiver), of the third-party’s decision to
approve or deny the appeal.

Glasses were denied
because the participant
was assessed to have
20/20 vision.
03/10/2020

Submit in MM/DD/YYYY format (e.g.,
01/01/2020).
Enter NA if written notification was not provided or
not documented.

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Column
ID
N

Field Name

Description

Example

Time of Written
Notification

This column only applies to expedited appeals.
Enter the time the PO provided written notification
to the participant or other representative (e.g. family
or caregiver), of the third-party’s decision to
approve or deny the appeal.

Submit in HH:MM format (e.g., 23:59).

Date Service
Provided

Enter NA if the appeal was not expedited (i.e., was
processed as a standard appeal) or if written
notification was not provided.
Enter the date that the approved service or item was
05/01/2020
provided to the participant. Please enter a date for any
appeal that was partially or fully approved.
Submit in MM/DD/YYYY format (e.g.,
01/01/2020).
Enter NA if the appeal was not approved (i.e., denied)
or if the service was not provided or if there was no
documentation of the effectuation (provision) of the
service.

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Table 3: Grievance Requests (GR) Record Layout
• Include all complaints processed as grievances.
• Submit grievances based on the date the PO’s decision was rendered or should have been
rendered (the date the complaint was initiated may fall outside of the data collection
period).
Column
ID
A
B
C
D

Field Name

Description

Example

Participant First
Name
Participant Last
Name
Participant ID

First name of the participant.

Jane

Last name of the participant.

Doe

The identification number the PO uses to identify
the participant.
Indicate if the grievance was submitted by the
participant, caregiver or family.

123456

Date the grievance was received by the PO.
Submit in MM/DD/YYYY format (e.g.,
01/01/2020).
Provide the category or type of grievance.
Valid fields include: Activities,
Communication, Contracted Specialist,
Contracted Facility (Hospital, SNF, etc.),
Dietary, Disenrollment, Enrollment, Home
Care, Marketing, Medical Care, Medication,
PACE Services, Supplies, Transportation, or
Other

04/01/2020

Person who
submitted the
Grievance
Date
Grievance
Received
Category of the
Grievance/
Grievance Type

Description
of the
Grievance/
Specific
Issue
Grievance
Resolution

Participant

Home Care

Provide a description of the grievance. If multiple
The participant was
issues were included in the complaint, please provide dissatisfied with the time
it took to arrange a
a brief description of each issue in the grievance.
cardiology appointment.
Enter Y if the grievance was fully resolved (i.e., all
issues within the grievance were resolved).

Enter N if all issues in the grievance were not
resolved or none of the issues were resolved.

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Column
ID
I

Field Name

Description

Example

Date of Resolution
Notification, Oral
and/or Written

Date notification of the grievance resolution was
provided by the PO to the participant and/or
caregiver. If both oral and written notification was
provided, enter the first notification date. Submit
in MM/DD/YYYY format (e.g., 01/01/2020).

04/05/2020

Enter NA if the grievance was not resolved or if no
notification of the grievance resolution was made.
Enter NNR if the participant, family or caregiver
specifically requested not to receive notification
about the grievance resolution.

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Table 4: List of Personnel (LOP) Record Layout
• Include all personnel employed during the data collection period (i.e., volunteer, parttime, full time, and contract).
• Include any personnel hired during the data collection period.
• Include only those contracted employees that provide care/services to participants in the
participant’s home, at the PACE center (or ACS) or when transporting participants (i.e.,
drivers).
• Exclude all personnel terminated prior to the data collection period.
Column Field Name
ID
A
Employee First
Name
B
Employee Last
Name
C
Job Title
D

Job Description

Date of Hire

Type of
Employment

Direct
Participant
Contact

Example

First name of the employee.

John

Last name of the employee.

Smith

Provide the job title of the employee. Examples: Home
Health Aide, Physical Therapist, etc.
Provide a brief description of the job duties.

Physical Therapist

Date the employee was hired by the PO. Submit in
MM/DD/YYYY format (e.g., 01/01/2020).
Date of Termination Date the employee was terminated or resigned from the
PO. Submit in MM/DD/YYYY format (e.g.,
01/01/2020).

Description

License

IDT Member

Enter NA if the employee is still working for the PO.
Provide the type of employment for the employee.
Valid entries are: contract, Full-time, Part-time,
Volunteer, or Other.
Enter Y if the employee had direct participant contact
during the data collection period.
Enter N if the employee did not have direct participant
contact during the data collection period.
Enter Y if the employee requires a license in order to
perform their duties with the PO.
Enter N if the employee does not require a license in
order to perform their duties with the PO.
Enter Y if the employee is a part of the PO’s IDT. If a
PO has multiple IDTs, the PO should enter Y if this
individual is a member of any IDT.

Provides
physical therapy
12/01/2018
NA

Full-time

Enter N if the employee is not a member of the PO’s
IDT.

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Column Field Name
ID

Description

Example

Enter the discipline(s) the individual represents on the
IDT. Valid entries are:

IDT Role

PCP, RN, MSW, Home Care Coordinator, OT, PT,
Dietitian, Recreational Therapist/Activities
Coordinator, Personal Care Attendant, Transportation,
Center Manager, Other.
Enter NA if the individual is not a part of an IDT.

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Table 5: List of Participant Medical Records (LOPMR) Record Layout
• Include all participants enrolled in the PO at some point during the data collection period.
• Exclude all participants disenrolled prior to the data collection period.
• PACE organizations may use any and all information available to them when populating these
fields, including participant medical records, claims data, and any other participant-specific
information the PACE organization may maintain.
Column Field Name
ID
A
Participant First
Name
B
Participant Last
Name
C
Participant ID
D

Medicare
Beneficiary
Identifier

PACE Center

Date of Enrollment

Date of
Disenrollment

Reason for
disenrollment
Number of
Hospital
Admissions/
Observations

30-Day Hospital
Readmissions

Description

Example

First name of the participant.

Jane

Last name of the participant.

Doe

The identification number the PO uses to identify the
participant.
If the participant has Medicare, enter the Medicare
Beneficiary Identifier.

1234

Enter NA if the participant is not a Medicare participant.
If the PO has more than one center, enter the name of the
participant’s assigned center.
If there is only one center, enter NA.
Date the participant was enrolled in the PO. Submit in
MM/DD/YYYY format (e.g., 01/01/2020).
Date the participant disenrolled from the PO. Submit in
MM/DD/YYYY format (e.g., 01/01/2020).
Enter NA if the participant is still enrolled.
Provide the reason for the disenrollment.
Enter NA if the participant is still enrolled.
Enter the number of hospital admissions and/or observations
that occurred during the data collection period.
This includes:
• Admissions/observations from an emergency room,
• Direct admissions,
• Unplanned admissions, and
• Planned admissions.
Enter Y if the participant had an unplanned hospital
readmission, for any cause, within 30 days of discharge from
the previous admission, during the data collection period.

6M52L458T10

Center 1

05/01/2018
NA

Enter N if the participant did not have an unplanned
hospital readmission, for any cause, within 30 days of
discharge from the previous admission during the data
collection period.

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Column Field Name
ID
K
Number of
Emergency Room
Visits
L
Hospitalization/
Emergency
Room Reason

Description

Example

Enter the number of emergency room visits that occurred
during the data collection period. Include ER visits that
resulted in a hospital admission or observation.
Were any ER visits or hospitalizations (admission or
observation) a result of hypoglycemia, hyperglycemia, or
decreased oxygen saturation?

Enter Y if the participant went to the ER or was admitted to
the hospital (or observed at the hospital) with a primary or
secondary diagnosis of hypoglycemia, hyperglycemia, or
decreased oxygen saturation.

Number of
SNF/NF
Admissions

Currently in
SNF/NF

Direct SNF
Admission

Enter N if the participant did not go to the ER or was not
admitted to the hospital (or observed at the hospital with a
primary or secondary diagnosis of hypoglycemia,
hyperglycemia, or decreased oxygen saturation.
Enter the number of skilled nursing facility/nursing facility
admissions that occurred during the data collection period.
This should include all SNF/NF admissions for any cause,
including admission as a result of a request for services.
Enter Y if the participant was in a SNF or NF at the time that
the universe is completed.
Enter N if the participant was not in a SNF or NF at the time
that the universe is completed. Enter N if the participant was
disenrolled (voluntarily, involuntarily or deceased) at the
time the universe is completed.
At any point during the data collection period, was the
participant admitted directly to the SNF from the PACE
center or participant’s home for a service other than respite
care?

Enter Y if the participant had a direct SNF admission during
the data collection period.
Enter N if the participant did not have a direct SNF
admission during the data collection period or if the direct
SNF admission was for respite care.

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Column Field Name
ID
P
Specialist
Consultations/
Visits

Description

Example

Did the participant have a consultation/visit with or was the
participant examined or treated by any of the following types
of specialties during the data collection period?

Cardiology,
Oncology,
Rheumatology

Cardiology
Gastroenterology
Hematology
Oncology
Pulmonary Medicine
Rheumatology
If Yes, enter each type of specialty.

Diagnosis of
Diabetes Mellitus
(DM)

Diagnosis of
Congestive Heart
Failure (CHF)

CHF Exacerbation

If No, enter N.
Enter Y if the participant had a diagnosis of diabetes mellitus
during the data collection period.
Enter N if the participant did not have a diagnosis of
diabetes mellitus during the data collection period.
Enter Y if the participant had a diagnosis of congestive heart
failure during the data collection period.
Enter N if the participant did not have a diagnosis of
congestive heart failure during the data collection period.
Enter Y if the participant was diagnosed with a CHF
exacerbation during the data collection period.

Enter N if the participant was not diagnosed with a CHF
exacerbation or the participant did not have a diagnosis of
CHF during the data collection period.
T

Diagnosis of
Enter Y if the participant had a diagnosis of chronic
Chronic Obstructing obstructive pulmonary disease during the data collection
Pulmonary Disease period.
(COPD)
Enter N if the participant did not have a diagnosis of chronic
obstructive pulmonary disease during the data collection
period.
Diagnosis of
Enter Y if the participant had a diagnosis of dementia
Dementia
during the data collection period.

Enter N if the participant did not have a diagnosis of
dementia during the data collection period.

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Column Field Name
ID
V
Other Diagnoses

Description

Example

Did the participant have any of the following
diagnoses/conditions during the data collection period?

AIDS,
Hepatitis C,
Cancer - lung

AIDS
Hepatitis C
Cancer (any type – specify the type in the response)
Auto-immune disorder (any type – specify the type in the
response)
Anemia
Multiple Sclerosis
Myasthenia Gravis
Hunter's Syndrome
Paroxysmal Nocturnal Hemoglobinuria
Hemolytic Uremic Syndrome
Hereditary Angioedema
If Yes, enter each diagnosis and where applicable specify the
type.

Transplant

If No, enter N.
Has the participant ever undergone a transplant surgery?

Enter Y if the participant has ever undergone a transplant
(this is not limited to the time the participant was enrolled in
the PO and applies to any type of transplant).

Received Home
Care

Enter N if the participant has never undergone a transplant.
Enter skilled if the participant ever received either skilled
home care or a combination of skilled and unskilled home
care during the data collection period.

Skilled

Enter unskilled if the participant only received unskilled
home care during the data collection period.

Assistance with
Administering
Medications

Enter NA if the participant did not receive home care during
the data collection period.
Enter Y if an employee/contracted employee administered
medication to the participant in the participant’s home
and/or the PACE center at any time during the data
collection period.

Enter N if an employee/contracted employee did not
administer medication to the participant in the participant’s
home and/or the PACE center at any time during the data
collection period. Prompting/medication reminders are not
considered medication administration assistance.

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Column Field Name
ID
Z
Pain
Management

Opioid
Utilization

Description

Example

Enter Y if the participant received any treatment or
modality used to treat, reduce, control, or eliminate pain
during the data collection period.

Enter N if the participant did not receive any treatment or
modality used to treat, reduce, control, or eliminate pain
during the data collection period.
Was the participant prescribed one or more opioid
medications during the data collection period?

Enter Y if the participant was prescribed one or more opioid
medications.

Current Center
Attendance

Skilled
Therapy

Number of Falls
Reported in
PACE Quality
data
Functional
Decline

Number of
Infections

Pressure Ulcers

Enter N if the participant was not prescribed any opioid
medications.
Enter the frequency that the participant attends the PACE
center at the time the universe is completed. For example,
5 days per week, 2 times per month, etc. Enter 0 if the
participant was disenrolled (voluntarily, involuntarily or
deceased) at the time the universe is completed.
Enter Y if the participant received any physical or
occupational therapy services that were provided by
licensed personnel during the data collection period.
Enter N if the participant did not receive any physical or
occupational therapy services that were provided by
licensed personnel during the data collection period.
Enter the number of falls the participant had that were
reported in the PACE Quality Data during the data
collection period.
Enter Y if the participant experienced a functional decline,
as defined by the PO, during the data collection period.
Enter N if the participant did not experience a functional
decline during the data collection period.
Enter the number of infections the participant had during the
data collection period. This includes all types of infections
as defined by the PO’s infection control plan.
Enter Y if the participant had a stage II, III, IV, or
unstageable pressure ulcer at any time during the data
collection period.

3 days per
week

Enter N if the participant did not have a stage II, III, IV, or
unstageable pressure ulcer during the data collection period.

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Column Field Name
ID
AH
Incontinent

Indwelling Catheter

Significant
Weight Loss

Restraints

Oxygen Use

Dialysis

Impaired Vision

Description

Example

Enter Y if the participant was routinely incontinent during
the data collection period.

Enter N if the participant was not routinely incontinent or
had acute/transient incontinence during the data collection
period.
Enter Y if the participant had an indwelling catheter during
the data collection period.
Enter N if the participant did not have an indwelling
catheter during the data collection period.
Enter Y if the participant had a weight loss of more than 5%
within a 30 day period or 10% within a 180-day period.
Enter N if the participant did not have a weight loss of more
than 5% within a 30 day period or 10% within a 180-day
period.
If physical or chemical restraints were used on the
participant at any point during the data collection period,
please describe the type of restraint used.
Enter N if physical or chemical restraints were not used on
the participant at any point during the data collection
period.
Enter Y if the participant required oxygen on a regular basis
at any point during the data collection period.
Enter N if the participant did not require oxygen on a regular
basis at any point during the data collection period.
Enter Y if the participant received dialysis during the data
collection period.
Enter N if the participant did not receive dialysis during
the data collection period.
Enter Y if the participant had impaired vision (i.e.,
blindness or severely impaired vision without corrective
lenses) during the data collection period.

Enter N if the participant did not have impaired vision
during the data collection period.

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Table 6: On-Call (OC) Record Layout
• Include all after hour calls received by the PO.
• Exclude all calls received during normal business hours.
Column
ID
A
B
C

Field Name

Description

Example

Participant First Name
Participant Last Name
Participant ID

Jane
Doe
1234

Caller Information

Date of Call

Time of Call

Call Description/
Reason For Call

First name of the participant.
Last name of the participant.
The identification number the PO
uses to identify the participant.
Identify who made the call (e.g.,
participant, daughter, spouse,
caregiver).
Date the call was received. Submit
in MM/DD/YYYY format (e.g.,
01/01/2020).
Time the call was received.
Submit in HH:MM format (e.g.,
23:54).
Provide a description of the
reason for the call.

Response to Call

Provide a description of the
response to the call as it relates to
the participant (e.g., did the PO
send someone to the participant’s
home, did the participant go to the
hospital).

Daughter

02/01/2019

20:15

The participant called to report
chest pain. Described the pain as
persistent and radiating down
left arm.
Called EMS for transport to
hospital.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1327. The time required to complete this information
collection is estimated to average 240 hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions
for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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File Type	application/pdf
File Title	Programs of All-Inclusive Care for the Elderly (PACE)
Subject	AUDIT PROCESS AND DATA REQUEST
Author	CMS
File Modified	2020-01-28
File Created	2020-01-27