CMS-10630 Personnel Impact Analysis Template

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

Scope:

Auditors:
Select All that Apply

Issue
Initial personnel competencies
Personnel licensure
OIG exclusion checks
Background checks
Communicable disease clearance
Driver Specific Training

Initial personnel competencies:
• The scope of the Impact Analysis is limited to 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel
sample selection and meet the following criteria:
1. Were newly hired during the audit review period; and
2. Had direct participant contact in the PACE centers or participant homes.
Personnel licensure:
• The scope of the Impact Analysis is limited to 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel
sample selection and had direct participant contact in the PACE centers or participant homes.
OIG exclusion checks:
• The scope of the Impact Analysis is limited to 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel
sample selection and meet the following criteria:
1. Were newly hired during the audit review period; and
2. Had direct participant contact in the PACE centers or participant homes.
Background checks:
• The scope of the Impact Analysis is limited to 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel
sample selection and meet the following criteria:
1. Were newly hired during the audit review period; and
2. Had direct participant contact in the PACE centers or participant homes.
Communicable disease clearance:
• The scope of the Impact Analysis is limited to 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel
sample selection and meet the following criteria:
1. Were newly hired during the audit review period; and
2. Had direct participant contact in the PACE centers or participant homes.
Driver specific training:
• The scope of the Impact Analysis is limited to 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel
sample selection and transported participants.

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.
• 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
Employee First Name

Employee Last Name

Job Title

Job Description

Date of Hire

Date of Termination

Type of Employment

Direct Participant Contact

License

MM/DD/YYYY

MM/DD/YYYY

Enter contract, Full-time, Parttime, Volunteer, or Other.

(Yes/No)

(Yes/No)

Enter NA if employee was not
terminated during audit review
period.

Pending OMB Approval (0938-New)

This information is to be completed if the Impact Analysis is being requested for: Initial personnel competencies
Is there documentation that the staff member's competency was evaluated prior to Date of competency evaluation completed.
them working independently?
MM/DD/YYYY
(Yes/No)
Enter Not Completed if the competency
evaluation was never done.
*This requirement only applies to personnel newly hired during the audit review
period.

Date of individual providing participant care independently.
MM/DD/YYYY

If the auditor did not select Initial personnel competencies on the instructions tab
the PO may enter NA in fields J-L.
Enter NA if the employee did not have direct participant contact during the audit
review period.

Pending OMB Approval (0938-New)

This information is to be completed if the Impact Analysis is being requested for: Personnel licensure
Is the staff member required to have a license in order Type of license(s) required?
to perform care in the PO's state?

This information is to be completed if the Impact Analysis is being requested for: OIG exclusion checks
Is there documentation that the staff member had a valid
license during the audit review period?

Is there documentation that an OIG exclusion check was
completed before the date of hire?

(Yes/No)

*This requirement applies to all personnel.

(Yes/No)

(Yes/No)

*This requirement applies to all personnel.

Enter NA if the staff member is not required to have a
license.

*This requirement applies to all personnel.

*This requirement only applies to personnel newly hired during
the audit review period.

If the auditor did not select Personnel licensure on the
instructions tab the PO may enter NA in fields M-O.

Enter NA if the staff member is not required to have a license or
did not have direct participant contact during the audit review If the auditor did not select OIG exclusion checks on the
period.
instructions tab the PO may enter NA in fields P-Q.

Pending OMB Approval (0938-New)

Date the OIG check was completed.
MM/DD/YYYY
Enter Not Completed if the OIG check was never completed.

This information is to be completed if the Impact Analysis is being requested for: Background checks

This information is to be completed if the Impact Analysis is being requested for: Communicable disease clearance

Is there documentation that a background check was completed Date the background check was completed.
before the date of hire?
MM/DD/YYYY
(Yes/No)
Enter Not Completed if the background check was never
completed.
*This requirement only applies to personnel newly hired during
the audit review period.

Is there documentation that the staff member was evaluated by a PCP, NP, or PA, and determined to Date the individual was screened/medically cleared of communicable
be free of communicable diseases prior to engaging in direct participant contact?
diseases.

If the auditor did not select Background checks on the
instructions tab the PO may enter NA in fields R-S.

(Yes/No)

MM/DD/YYYY

*This requirement only applies to personnel newly hired during the audit review period.

Enter Not Completed if the individual was never medically cleared.

If the auditor did not select Communicable disease clearance on the instructions tab the PO may
enter NA in fields T-U.

Enter NA if the staff member did not have direct participant contact during
the audit review period.

Enter NA if the staff member did not have direct participant contact during the audit review period.

Pending OMB Approval (0938-New)

This information is to be completed if the Impact Analysis is being requested for: Driver Specific Training
Date the driver was provided training on handling the special needs of the
participants.
MM/DD/YYYY
Enter Not Completed if the individual was never provided training.

General Information: This information may be completed for all Impact Analyses

Date the driver was provided training on handling emergency situations.

Date the driver began driving participants for the PACE organization.

Optional: Please note, you do not have to complete this column.

MM/DD/YYYY

MM/DD/YYYY

If there are any mitigating factors that you would like CMS to consider related to a
specific staff member please enter the information in this column.

Enter Not Completed if the individual was never provided training.

If the auditor did not select Driver Specific Training on the instructions tab
the PO may enter NA in fields V-X.

Pending OMB Approval (0938-New)