CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

Audit Review Period:
Issue of non-compliance:

Home care services

Scope:

• 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.

Instructions:

• 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 home care services were not provided, delayed, or reduced at any point during the audit review period.
• The review timeframe is the audit review period. Issues noted before or after the audit review period should not be included.
• Respond to the questions in the participant impact tab for all participants. If a participant was not impacted by the condition (i.e., they received all home
care services in a timely manner), the PO should enter No in Column F and NA in all additional blue fields.
Please do not leave any blank spaces.
• 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.

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)

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)

During the Audit Review Period
a. Did the IDT determine home care was necessary;
b. Did a provider order home care; or
c. Was home care included in the care plan?
Enter Yes if any of the above are true.

If the answer to column F is Yes, please indicate whether the home care If the answer to column F is Yes, was home
was:
care included in the care plan?
a. Determined necessary by the IDT;
b. Approved as part of a service delivery request;
c. Approved as part of an appeal;
d. Ordered by a provider?

Enter No if home care services were not determined necessary,
approved or ordered.
If No is entered, the organization may enter NA in all remaining fields.

Pending OMB Approval (0938-New)

(Yes/No)

Enter the type of home care that was determined necessary, approved
or ordered (e.g., chore services, medication administration, etc.).
If the participant was approved for multiple types of home care
services, please identify each on a separate line in the IA.

Enter the date when home care was first determined
necessary, approved, ordered, or care planned (start
date).

Please enter the participant's home care schedule (how many days a week, etc.).

Pending OMB Approval (0938-New)

Enter the total number of hours per
week home care services were
determined necessary, approved,
ordered, or care planned.

If there was a delay in providing
home care, enter Delayed.

If there was a delay, when did the participant
begin receiving the number of home care
hours/schedule determined necessary,
If home care services were never approved, ordered, or care planned?
provided enter Not Provided.
If home care services were never provided
enter Not Provided.
If home care services were
reduced, enter Reduced.
Enter NA if home care services were promptly
provided as approved/ordered.
Enter NA if home care services
were promptly provided as
approved/ordered.

Pending OMB Approval (0938-New)

At any point during the audit review period was there any reduction in
If the answer to column O is yes, when did the
home care hours that resulted from staffing, financial, or resource issues? participant begin receiving reduced home care hours?

If the answer to column O is yes, how many hours of
homecare was the participant actually receiving?

(Yes/No/NA)
Do not include decreases requested by the participant or caregiver.

Pending OMB Approval (0938-New)

If the participant's necessary, approved, ordered, or
care planned home care services were delayed or
reduced or not provided, please explain the cause.

Were there any negative outcomes resulting from:
a. a delay in the start of home care;
b. Not providing home care; or
c. a reduction in the number of hours of home care?

If Yes, please describe the Negative Outcomes?
Enter NA if there were no negative outcomes.

(Yes/No/NA)

Pending OMB Approval (0938-New)

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 participant, please enter
the information in this column.