CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

Audit Review Period:
Issue of non-compliance:

Wound care

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 the participants had wounds that required wound care.
• Respond to the questions in the participant impact tab.
• The review timeframe is the audit review period. Errors noted before or after 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.

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, did the participant have a wound
(pressure, arterial, surgical, etc.) requiring wound care?
(Yes/No)

Enter the type of wound.
If the participant had multiple wounds, list
each wound in a new row.

Enter the date the wound was first
noticed/documented.

If the wound was a pressure ulcer, enter the initial
stage.

MM/DD/YYYY

Enter NA if the wound was not a pressure ulcer.

If No, the PO may enter NA in all remaining fields.

Pending OMB Approval (0938-New)

Was a wound care order required?

Was wound care ordered by a PCP?

When was wound care ordered?

Enter the wound care order, if applicable.

(Yes/No)

(Yes/No)

MM/DD/YYYY

Enter NA if wound care was not ordered.

Enter NA if wound care was not ordered.

Pending OMB Approval (0938-New)

Was wound care provided without an order?

How frequently was wound care to be completed?

(Yes/No)

Enter NA if wound care was not completed.

Is there documentation that wound care was
provided as frequently as required?
(Yes/No)

Pending OMB Approval (0938-New)

When should have wound care begun/been initiated?
MM/DD/YYYY

When did wound care begin (when was wound care initiated)? Is there documentation that wound care was
provided as ordered?
MM/DD/YYYY
(Yes/No)

If wound care was not provided as ordered, please describe how the wound
care provided differed from the wound care ordered.
Enter NA if wound care was provided as ordered.

Pending OMB Approval (0938-New)

If the participant experienced negative outcomes, did they If yes, describe the negative outcomes.
occur, in some part, as a result of the failure to provide the
item or service?
Enter NA if participant did not experience negative outcomes.
(Yes/No)

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.