CMS-10630 Onsite Audit

Instructions:

• Enter responses to each question in Onsite Observation Participant List tab of this document. Organizations have the option of submitting the information
using this Excel template or may submit the information in another format the organization can provide. If certain information is not available on the first day of
audit, please discuss this with the audit lead prior to submitting.
• Only include participants who meet the following criteria:
- Participants who are scheduled to have medications administered by an employee or contracted employee in the PACE center or participant's
home on the week of the onsite audit;
- Participants who are scheduled to have wound care performed by an employee or contracted employee in the PACE center or participant's
home on the week of the onsite audit;
- Participants who are scheduled to receive in-home care on the week of the onsite audit;
- Participants who are scheduled to attend the center, have specialized diets, and receive meals at the PACE center on the week of the onsite
audit.
• Do not include participants who are disenrolled at the time of the onsite audit.

Due Date:

Organizations must submit all of the information identified on tab 2 (OnsiteObsParticipantList) of this template via HPMS on the first day of the onsite audit.

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

Will the participant be
administered medication
the week of the onsite
audit?

Will the participant be administered medication
in the PACE center, the participant's home, or
both?

How will the medication be administered?
PO/SQ/IM/Inhalation/Ocular/Otic/Transdermal/
Sublingual/IV/PEG

Which days are the medications
administered?

Will the participant receive wound care
the week of the onsite audit?

M/T/W/Th/F

Yes/No

PACE center/home/both

PACE center/home/both

Yes/No
Enter NA if the participant does not receive
medication administered by PO staff.
Participant First Name

Participant Last Name

Participant ID

Will the participant receive wound care in
the PACE center, the participant's home,
or both?

Enter NA if the participant does not receive
medication administered by PO staff.
If multiple medications are administered list all
methods.

Enter NA if the participant does not receive
medication administered by PO staff.
If multiple medications are administered,
identify all days the participant will receive
medications and which administration will
be done each day.

Enter NA if the participant does not
receive wound care from PO staff.

What type of wound care will be
completed?
Pressure Ulcer/Stasis
Ulcer/Surgical/Skin Tear/Other
Enter NA if the participant does
not receive wound care from PO
staff.
If more than one type of wound
care will be completed, list all
applicable types.

Which days will wound care be
performed?
M/T/W/Th/F
Enter NA if the participant does
not receive wound care from PO
staff.
List all days that wound care will
be performed.

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

Will the participant receive
home care the week of the
onsite audit?

What type of tasks will be completed?

Which days will home care be provided?

Skilled Care - Wound care, medication administration, Foley
catheter insertion, IV change, etc.

M/T/W/Th/F

Yes/No
Unskilled Care - Assistance with ADLs such as bathing,
dressing, etc.

Enter NA if the participant does not receive
home care.

Does the participant require a
What type of diet does the
specialized diet such as pureed,
participant require?
mechanical soft, tube feeding,
If multiple diet orders, identify
diabetic, cardiac etc.?
all that currently apply.
Yes/No

Which days will the participant receive meals at
the PACE center?
M/T/W/Th/F
Enter NA if the participant does not have a
specialized diet.

List all days that apply.
Chore Services - housekeeping services with no hands-on
participant care.
Enter NA if the participant does not receive home care.
If multiple services are received list all that apply.

List all days that apply.