CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

Audit Review Period:
Issue of non-compliance:

Provision of 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 (e.g., medical record documentation) to determine if any necessary services or items were not provided. POs should consider any
documentation and/or evidence that shows provision of services including the medical record, invoices, outside specialist notes, etc.
• Respond to the questions in the participant impact tab. If a participant was not impacted by the condition (i.e., they received all services in a timely manner), the PO should
enter No in column F and then NA in all additional blue fields.
• Following the completion of the Participant Impact tab, POs should review and revised the Root Cause Analysis tab to reflect the final impact and make any additional changes
necessary.

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, were any services or items:

Was the delayed service/item:

Describe the service/item that was delayed or not provided.

• determined necessary by the IDT or an IDT member;
• Approved by IDT; or
• ordered by a PCP or physician extender;

• determined necessary by the IDT or an IDT member;
• Approved by IDT; or
• ordered by a PCP or physician extender?

(Each service or item that was delayed or not provided must be entered on a new line.)

NOT provided or delayed?

If another scenario applies, please enter a brief description.

Enter Yes if the participant did not receive services, or if services were
delayed.
Enter No if the participant received all services (in a timely manner).
If No, the organization may enter NA in all remaining fields.

Pending OMB Approval (0938-New)

Was the service/item included in the
participant's care plan?

Was the service/item delayed or was the service/item
not provided?

When should the service have started or when should
the item have been provided to the participant?

If the service/item was delayed, when was it provided to the
participant?

(Yes/No)

(Enter Delayed or Not provided)

MM/DD/YYYY

MM/DD/YYYY
Enter Not Provided if the service/item was never provided.
Enter NA if the service/item was not delayed.

Pending OMB Approval (0938-New)

In what setting was or should the service/item have
been provided? (PACE Center, SNF, ALF, Home)

Describe why the service/item was delayed or not provided.

Did the participant experience negative
outcomes, in some part, as a result of the
failure to provide the service or item in a
timely manner?
(Enter Y or N)

Pending OMB Approval (0938-New)

If yes, describe the negative outcomes.

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

Enter NA if the participant did not experience negative outcomes.

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.

Pending OMB Approval (0938-New)