CMS-10630 Root Cause Analysis Template

Audit Review Period:
Scope:

Participants enrolled during the audit review period.

Instructions:

• Respond to the relevant questions in the Root Cause Analysis:
* Columns A through C will be filled out by the Audit Lead.
* Columns D and E must be filled out for all Root Cause Analyses and include details relating to the
investigation.
* Columns F and G should be filled out if they are easily known (i.e., the root cause is based off of a
disclosed issue (full investigation was already done) or the scope is easily determined based off of
the cause/ type of issue identified). If the scope is not easily known, enter NA in these columns.
* Only complete columns H through M if the condition relates to a disclosed issue for which
correction was already initiated/completed. If the condition was first discovered on audit, the
organization may enter NA in those columns.

Root Cause Analysis Due Date:

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

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)

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

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)

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

Methodology - Describe the process that was undertaken to
determine the # of individuals (e.g. participants) impacted

# of Individuals Impacted

Action Taken to Resolve System/
Operational Issues

Date System/ Operational Remediation
Date System/ Operational Remediation
Initiated
Completed (MM/DD/YY)
(MM/DD/YY)

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

Actions Taken to Resolve Negatively Impacted
Individuals Including Outreach Description and Status

Date Individual Outreach and Remediation
Initiated
(MM/DD/YY)

Date Individual Outreach and
Remediation Completed
(MM/DD/YY)