CMS-10630 Grievances Impact Analysis Template

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

Scope:

Auditors:
Select All that Apply

Issue
Resolution of participant grievances
Recognizing complaints as grievances
Discussing grievances with participants

Resolution of participant grievances:
• All grievances during the audit review period.
Recognizing complaints as grievances:
• 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 grievance sample selection.
• The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab.
Discussing grievances with participants:
• 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 grievance sample selection.
• The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab.

Instructions:

General:
• The review timeframe is the audit review period. Errors noted prior to the audit review period should not be included.
• 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.
Resolution of participant grievances:
• Review each grievance and respond to the questions in the Participant Impact tab.
Recognizing complaints as grievances:
• 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 the participant, participant's family members, or participant representative submitted a compliant verbally or in writing.
• Respond to the questions in the Participant Impact tab.
Discussing grievances with participants:
• 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 the participant was informed of the grievance process at the time of enrollment and on at least an annual basis.
• Respond to the questions in the Participant Impact 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)

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

Date the participant/participant
representative submitted the
grievance.

Enter NA if the participant is still MM/DD/YYYY
enrolled.

Pending OMB Approval (0938-New)

This information is to be completed if the Impact Analysis is being requested for: Resolution of participant grievances
Enter the number of unique issues contained within
the grievance.
If the auditor did not select Resolution of participant
grievances on the instructions tab the PO may enter
NA in fields G-L.

Enter a brief description of each issue identified in the grievance.

Enter the number of issues contained
within the grievance that have supporting
documentation verifying the issues were
resolved?

Which issues were unresolved? Enter a
brief description.
Enter NA if all issues within the grievance
were resolved.

Why were the issues not resolved?
Enter NA if all issues within the grievance
were resolved.

Did the participant experience any negative
outcomes as a result of the failure to
resolve all issues within a grievance?
(Yes/No)
Enter NA if all issues within the grievance
were resolved.

Pending OMB Approval (0938-New)

This information is to be completed if the Impact Analysis is being requested for: Recognizing complaints as grievances
Did the participant, their family members, or representative express a complaint, either
written or oral, expressing dissatisfaction with service delivery or the quality of care
furnished during the audit review period?

Enter the date of the complaint.

(Yes/No)

MM/DD/YYYY

Describe the complaint.

Where is the complaint documented (progress notes, assessments,
PAC minutes, on-call, etc.)?

Is there documentation that the complaint When was the participant, family member, Was the complaint reviewed and resolved
was processed as a grievance in accordance or participant representative notified of the outside of the grievance process?
the PO's grievance policies?
resolution of the grievance.
(Yes/No)

If the auditor did not select Recognizing complaints as grievances on the instructions tab the
PO may enter NA in fields M-V.

If the participant/family member was not
notified enter Not Notified.
MM/DD/YYYY

If the answer to this question is No enter NA in columns N-V

Pending OMB Approval (0938-New)

(Yes/No)

If yes, what was the resolution?

If yes, when was it resolved?

Enter NA if the complaint was not resolved
outside of the grievance process.

Enter NA if the complaint was not resolved
outside of the grievance process.

Were there any negative participant
outcomes as a result of the failure to
recognize complaints as grievances?
(Yes/No)

This information is to be completed if the Impact Analysis is being requested for: Discussing grievances with participants
Is there documentation that the participant was Is there documentation that the participant was Did the participant or participant
informed of the grievance process, in writing,
informed of the grievance process, in writing, on representative file a grievance during the
an annual basis?
upon enrollment?
audit review period?
(Yes/No)

(Yes/No)

If the auditor did not select Discussing
grievances with participants on the instructions
tab the PO may enter NA in fields W-Z.

Enter NA if the participant was disenrolled
before the grievance process was reviewed or if
the participant was newly enrolled.

(Yes/No)

Were there any negative participant
outcomes as a result of the participant not
being informed of the grievance process?
(Yes/No)

Enter NA if the participant was not newly
enrolled during the audit review period.

Pending OMB Approval (0938-New)

General Information: This information is to be completed for all Impact Analyses
If the participant experienced any negative outcomes, please describe the negative
outcomes.

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 grievance, please enter the information in this column.

Pending OMB Approval (0938-New)