30 Day Crosswalk

Section in Current CMS-10630
(11/27/2019)
Appeals1P651P661P681P73

Original Language

Clarification or Change

Revised Language

If the answer to this question is No the PO may
enter NA in fields I-O.

Technical Clarification

If the answer to this question is No the PO may
enter NA in fields H-O.

Annual/Semiannual Assessments:

Technical Clarification

Semiannual Assessments:

Did the participant experience a change in their
health or psychosocial status during the audit
review period that?

Technical Clarification

Did the participant experience a change in their
health or psychosocial status during the audit
review period that required a change is status
assessment?

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

Technical Clarification

General Information: This information is to be
completed for all Impact Analyses

Participant Impact Tab
Column G
Assessment1P491P501P82
Instructions Tab
Instructions Section
Assessment1P491P501P82
Participant Impact Tab
Column F
Assessment1P491P501P82
Participant Impact Tab
Column AD

AttachmentIPACEAudit
ProcessDataRequest
Universe Preparation &
Submission
Purpose
AttachmentIPACEAudit
ProcessDataRequest
Universe Preparation &
Submission
2.2.1 Documentation

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.

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

To evaluate PACE organizations (PO’s)’
compliance with regulatory requirements in the
following four areas related to the Programs of AllInclusive Care for the Elderly (PACE).

Typographical Error

The PO’s Quality Assessment and Performance
Improvement (QAPI) plan(s) that were in use
during the data collection period;

Technical Clarification

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.
To evaluate PACE organizations’ (POs’)
compliance with regulatory requirements in the
following four areas related to the Programs of AllInclusive Care for the Elderly (PACE).

The PO’s Quality Improvement (QI) plan(s) that
were in use during the data collection period;

Section in Current CMS-10630
(11/27/2019)
AttachmentIPACEAudit
ProcessDataRequest
Universe Preparation &
Submission

Original Language

Clarification or Change

Revised Language

NOTE: Organizations must submit the information
identified in Attachment IV in writing but do not
need to submit the information using the excel
template Attachment IV and may submit the
information in another format so long as all
requested information is included.

Added additional language to
clarify data entry requirements
based on comments.

Quality Assessment Review: CMS will conduct an
interview and review data/documentation with the
PO’s staff responsible for the development and
implementation of the quality assessment and
performance improvement program.

Technical Clarification

NOTE: Organizations must submit the information
identified in Attachment IV in writing but do not
need to submit the information using the excel
template Attachment IV and may submit the
information in another format so long as all
requested information is included. Requests for
observation data will typically be limited to
participants assigned to an IDT at the center are
CMS auditors are conducting the onsite portion of
the audit. However, CMS reserves the right to
request data for participants from other PACE
centers, as needed, to ensure all of the observations
can be completed. For example, if medication
administration or wound care is not being provided
at the center where the onsite audit is conducted,
CMS auditors may request data from other PACE
centers in order to determine whether observations
may be completed at an alternative site. The audit
team will identify the subset of participants for
whom information must be provided.
Quality Assessment Review: CMS will conduct an
interview and review data/documentation with the
PO’s staff responsible for the development and
implementation of the quality improvement
program.

2. Review Quality Assessment and Performance
Improvement Documentation:

Technical Clarification

2.3 Documentation

AttachmentIPACEAudit
ProcessDataRequest
Audit Elements
IV Quality Assessment
1. Quality Assessment Review
AttachmentIPACEAudit
ProcessDataRequest
Audit Elements
IV Quality Assessment
2. Review Quality Assessment
and Performance Improvement
Documentation

CMS will review relevant documentation and
information related to the PO’s quality assessment
and performance improvement program.

2. Review Quality Improvement Documentation:
CMS will review relevant documentation and
information related to the PO’s quality
improvement program.

Section in Current CMS-10630
(11/27/2019)
AttachmentIPACEAudit
ProcessDataRequest

Original Language

Clarification or Change

Revised Language

Documentation that staff members and contractors
are involved in the development and
implementation of the QAPI program

Technical Clarification

Documentation that staff members and contractors
are involved in the development and
implementation of the QI program

3.1. Did the PO develop and/or implement an
effective, data driven quality assessment and
performance improvement program?

Technical Clarification

3.1. Did the PO develop and/or implement an
effective, data driven quality improvement
program?

3.2. Did the PO ensure that the appropriate staff
were involved in the development and
implementation of QAPI activities and did the PO
appropriately disseminate information related to
the QAPI activities?

Technical Clarification

3.2. Did the PO ensure that the appropriate staff
were involved in the development and
implementation of QI activities and did the PO
appropriately disseminate information related to
the QI activities?

Audit Elements
IV Quality Assessment
2. Review Quality Assessment
and Performance Improvement
Documentation
AttachmentIPACEAudit
ProcessDataRequest
Audit Elements
IV Quality Assessment
3.1. Did the PO develop and/or
implement an effective, data
driven quality assessment and
performance improvement
program?
AttachmentIPACEAudit
ProcessDataRequest
Audit Elements
IV Quality Assessment
3.2. Did the PO ensure that the
appropriate staff were involved
in the development and
implementation of QAPI
activities and did the PO
appropriately disseminate
information related to the QAPI
activities?

Section in Current CMS-10630
(11/27/2019)
AttachmentIPACEAudit
ProcessDataRequest

Original Language

Clarification or Change

Revised Language

None

Added additional language to
clarify data entry requirements
based on comments.

• PACE organizations may use any and all
information available to them when populating
these fields, including participant medical records,
claims data, and any other participant-specific
information the PACE organization may maintain.

Were any ER visits or hospitalizations (admission
or observation) a result of hypoglycemia,
hyperglycemia, or decreased oxygen saturation?

Added additional language to
clarify data entry requirements
based on comments.

Appendix A
Table 5: List of Participant
Medical Records (LOPMR)
Record Layout
AttachmentIPACEAudit
ProcessDataRequest
Appendix A
Table 5: List of Participant
Medical Records (LOPMR)
Record Layout

Enter Y if the participant went to the ER or was
admitted to the hospital (or observed at the
hospital) for one of these reasons.

Were any ER visits or hospitalizations
(admission or observation) a result of
hypoglycemia, hyperglycemia, or decreased
oxygen saturation?

Enter N if the participant did not go to the ER or
was not admitted to the hospital (or observed at the
hospital) for one of these reasons.

Enter Y if the participant went to the ER or was
admitted to the hospital (or observed at the
hospital) with a primary or secondary diagnosis
of hypoglycemia, hyperglycemia, or decreased
oxygen saturation.

AttachmentIPACEAudit
ProcessDataRequest

Enter Y if the participant was in a SNF or NF at the
time that the universe is completed.

Enter N if the participant did not go to the ER or
was not admitted to the hospital (or observed at the
hospital with a primary or secondary diagnosis of
hypoglycemia, hyperglycemia, or decreased
oxygen saturation.
Enter Y if the participant was in a SNF or NF at the
time that the universe is completed.

Appendix A

Enter N if the participant was not in a SNF or NF
at the time that the universe is completed.

Row L
Description Column

Table 5: List of Participant
Medical Records (LOPMR)
Record Layout
Row N
Description Column

Added additional language to
clarify data entry requirements
based on comments.

Enter N if the participant was not in a SNF or NF
at the time that the universe is completed. Enter N
if the participant was disenrolled (voluntarily,
involuntarily or deceased) at the time the universe
is completed.

Section in Current CMS-10630
(11/27/2019)

Original Language

Clarification or Change

Revised Language

Enter the frequency that the participant attends the
PACE center at the time the universe is completed.
For example, 5 days per week, 2 times per month,
etc.

Added additional language to
clarify data entry requirements
based on comments.

Enter the frequency that the participant attends the
PACE center at the time the universe is completed.
For example, 5 days per week, 2 times per month,
etc. Enter 0 if the participant was disenrolled
(voluntarily, involuntarily or deceased) at the time
the universe is completed.

PACE organizations may upload also grievance
and service delivery request policies pertaining to
the questions in the PACE Supplemental Questions
tab.

Technical Clarification

PACE organizations may also upload grievance
and service delivery request policies pertaining to
the questions in the PACE Supplemental Questions
tab.

Technical Clarification

Was the non-compliance disclosed to the CMS
account manager prior to the date of the Audit
Engagement Letter?

Pre-Audit Issue Summary Tab

Was the non-compliance disclosed to the CMS
account manager prior to the date of the Audit
Engagement Letter prior to the date of the Audit
Engagement Letter?

Column E

Yes/No

AttachmentIVOnsiteObs
PartList

Enter responses to each question in Onsite
Observation Participant List tab of this document.

AttachmentIPACEAudit
ProcessDataRequest
Appendix A
Table 5: List of Participant
Medical Records (LOPMR)
Record Layout
Row AB
Description Column
AttachmentIIPACESupplemental
Questions
Instructions Tab
Instructions Section

AttachmentIIIPreAuditIssueSummary

Yes/No

Instructions Tab
Instructions Section

Modified location of preexisting instructions

Enter responses to each question in Onsite
Observation Participant List tab of this document.
Organizations have the option of submitting the
information using this excel template or may
submit the information in another format the
organization can provide. If certain information is
not available on the first day of audit, please
discuss this with the audit lead prior to submitting.

Section in Current CMS-10630
(11/27/2019)
AttachmentIVOnsiteObs
PartList
Instructions Tab
Due Date Section

AttachmentIVOnsiteObs
PartList
Instructions Tab

Original Language

Clarification or Change

Revised Language

Organizations must submit all of the information
identified on tab 2 (OnsiteObsParticipantList) of
this template via HPMS on the first day of the
onsite audit. Organizations have the option of
submitting the information using this excel
template or may submit the information in another
format the organization can provide. If certain
information is not available on the first day of
audit, please discuss this with the audit lead prior
to submitting.
- Participants who are scheduled to have
medications administer by an employee or
contracted employee in the PACE center or
participant's home on the week of the onsite audit;

Modified location of preexisting instructions

Organizations must submit all of the information
identified on tab 2 (OnsiteObsParticipantList) of
this template via HPMS on the first day of the
onsite audit.

Technical Clarification

- Participants who are scheduled to have
medications administered by an employee or
contracted employee in the PACE center or
participant's home on the week of the onsite audit;

Which days will wound care performed?

Technical Clarification

Which days will wound care be performed?

Instructions Section

AttachmentIVOnsiteObs
PartList

M/T/W/Th/F

M/T/W/Th/F

Enter NA if the participant does not receive wound
care from PO staff.

Enter NA if the participant does not receive wound
care from PO staff.

List all days that wound care will be performed.
Which days will home care be provided?

List all days that wound care will be performed.
Which days will home care be provided?

OnsiteObsParticipantList Tab
Column K

AttachmentIVOnsiteObs
PartList

Technical Clarification

M/T/W/Th/F

M/T/W/Th/F

Column N

Enter NA if the participant does not receive wound
care from PO staff.

Enter NA if the participant does not receive home
care.

AttachmentVAuditSurvey

List all days that apply.
Clinical Appropriateness and Care Planning

OnsiteObsParticipantList Tab

Audit Activities Section
Questions 2-5

Technical Clarification

List all days that apply.
Provision of Services

Section in Current CMS-10630
(11/27/2019)
AttachmentVAuditSurvey

Original Language

Clarification or Change

Revised Language

Onsite

Technical Clarification

Removed

Clinical Appropriateness and Care Planning Impact
Analysis Template

Technical Clarification

Provision of Services Impact Analysis Template

Additionally, since publishing this package for the
60-day comment period, a new regulation has gone
into effect which allows CMS to conduct ongoing
audits using a risk assessment.

Added regulation in response
to comments.

Emergency Notification Information: This is to be
completed for all participants during the Impact
Analysis review period.

Instruction Clarification

Additionally, since publishing this package for the
60-day comment period, a new regulation has gone
into effect which allows CMS to conduct ongoing
audits using a risk assessment (see the Medicare
and Medicaid Programs; Programs of All-Inclusive
Care for the Elderly (PACE) Final Rule published
in the Federal Register on June 3, 2019 (84 FR
25610)).
Emergency Notification Information: This is to be
completed for all selected participants.

Billing Information: If requested, these questions
must be completed for all participants during the
Impact Analysis review period.

Instruction Clarification

Billing Information: If requested, these questions
must be completed for all selected participants.

Additional Information: This is to be completed for
all participants during the Impact Analysis review
period.

Instruction Clarification

Additional Information: This is to be completed for
all selected participants.

Audit Activities Section
Questions 2-5

CMS10630Supporting
StatementAPACE
Justification
Section 12.4: Information
Collection Instruments and
Instruction/Guidance Documents
CMS10630Supporting
StatementAPACE
Justification
Section 15: Program Burden
Changes
EmergencyCare1P07
Participant Impact Tab
Row 1 Instructions
Columns G-P
EmergencyCare1P07
Participant Impact Tab
Row 1 Instructions
Columns V-W
EmergencyCare1P07
Participant Impact Tab
Row 1 Instructions

Section in Current CMS-10630
(11/27/2019)

Original Language

Columns X-Z
Effectuation1P021P111P30

Date of Disenrollment

Participant Impact Tab

Enter NA if the participant is still enrolled.

Column E
Effectuation1P021P111P30

What evidence/documentation does the PO have
that demonstrates the service was approved?

Clarification or Change

Technical Clarification

Revised Language

Date of Disenrollment
MM/DD/YYYY

Technical Clarification

Enter NA if the participant is still enrolled.
What evidence/documentation does the PO have
that demonstrates the service was provided?

Participant Impact Tab
Column M
EmergencyCare1P07
Participant Impact Tab

Enter NA if the service was not provided to the
participant.
Time of assessment.

Technical Clarification

Enter NA if the participant did not contact the PO
before utilizing emergency services.

HH:MM AM/PM

Column N
EmergencyCare1P07
Participant Impact Tab
Column P

Grievances1P311P751P77
Instructions Tab

Did staff or contractors from the PO:
• Instruct the participant and/or caregiver that prior
authorization was needed before to going to the ER
or calling 911; or
• Instruct the participant and/or caregiver that
approval was needed before to going to the ER or
calling 911; or
• Instruct the participant and/or caregiver not to go
to the ER or call 911?

Technical Clarification

Enter NA if the participant did not contact the PO
before utilizing emergency services.
Did staff or contractors from the PO:
• Instruct the participant and/or caregiver that prior
authorization was needed before going to the ER or
calling 911; or
• Instruct the participant and/or caregiver that
approval was needed before going to the ER or
calling 911; or
• Instruct the participant and/or caregiver not to go
to the ER or call 911?

(Yes/No)

(Yes/No)

Enter NA if the participant did not contact the PO
before utilizing emergency services.
• Review the selected medical records to determine
if the participant was informed of the grievance
process at the time of enrollment and on at least
annually basis.

Enter NA if the participant did not contact the PO
before utilizing emergency services.
• Review the selected medical records to determine
if the participant was informed of the grievance
process at the time of enrollment and on at least an
annual basis.

Instructions Section
Grievances1P311P751P77

Date of Disenrollment

Participant Impact Tab

Enter NA if the participant is still enrolled.

Column E

Enter NA if the service was not provided to the
participant.
Time of assessment.

Technical Clarification

Technical Clarification

Date of Disenrollment
MM/DD/YYYY
Enter NA if the participant is still enrolled.

Section in Current CMS-10630
(11/27/2019)
Grievances1P311P751P77
Participant Impact Tab
Column Q
Grievances1P311P751P77
Participant Impact Tab
Column W
Grievances1P311P751P77
Participant Impact Tab
Column X
Grievances1P311P751P77

Original Language

Is their documentation that the complaint was
processed as a grievance in accordance the PO's
grievance policies?
(Yes/No)
Is their documentation that the participant was
informed of the grievance process, in writing, upon
enrollment?
(Yes/No)
Is their documentation that the participant was
informed of the grievance process, in writing, on
an annual basis?

Participant Impact Tab

(Yes/No)
Enter NA if the participant was not disenrolled
before the grievance process was reviewed or if
the participant was newly enrolled.

Column X
HomeCare1P02

During the Audit Review Period

Participant Impact Tab
Column F

Clarification or Change

Technical Clarification

Technical Clarification

Technical Clarification

Technical Clarification

Technical Clarification

Is there documentation that the complaint was
processed as a grievance in accordance the PO's
grievance policies?
(Yes/No)
Is there documentation that the participant was
informed of the grievance process, in writing, upon
enrollment?
(Yes/No)
Is there documentation that the participant was
informed of the grievance process, in writing, on
an annual basis?
(Yes/No)
Enter NA if the participant was disenrolled before
the grievance process was reviewed or if the
participant was newly enrolled.

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?

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?

If the PO enters Yes to any of the above enter yes
in this column.

Enter Yes if any of the above are true.
Enter No if home care services were not
determined necessary, approved or ordered.

Enter No if home care services were not
determined necessary, approved or ordered.
(Yes/No)

HomeCare1P02

Revised Language

If No is entered, the organization may enter NA in
all remaining fields.
If the answer to column F is Yes, please indicate
whether the home care was:

If No is entered, the organization may enter NA in
all remaining fields.

Technical Clarification

If the answer to column F is Yes, please indicate
whether the home care was:

Participant Impact Tab
Column G

a. Determined necessary by the IDT;
b. Approved as part of a service delivery request;
c. Approved a part of an appeal;
d. Ordered by a provider?

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?

Section in Current CMS-10630
(11/27/2019)

Original Language

Clarification or Change

Technical Clarification

Revised Language

Personnel

Date of Termination

Participant Impact Tab

MM/DD/YYYY

MM/DD/YYYY

Type of Employment

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

Column F
Personnel

Technical Clarification

Participant Impact Tab
Column G
Personnel

Enter contract, Full-time, Part-time, Volunteer, or
Other.
Direct Participant Contact

Technical Clarification

Participant Impact Tab
Column H
Personnel

Participant Impact Tab

Direct Participant Contact
(Yes/No)

License

Technical Clarification

Participant Impact Tab
Column I
Personnel

Date of Termination

License
(Yes/No)

Is there documentation that the staff member was
evaluated by a PCP, NP, or PA, and determined to
be free of communicable prior to engaging in direct
participant contact?

Technical Clarification

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

Column T
Personnel

(Yes/No)
Date the driver was provided training on handling
the special needs of the participants.

Technical Clarification

(Yes/No)
Date the driver was provided training on handling
the special needs of the participants.

Participant Impact Tab
MM/DD/YYYY

MM/DD/YYYY

Enter Not Completed if the individual was never
provided training.

Enter Not Completed if the individual was never
provided training.

Participant Impact Tab

If the auditor did not select Driver Specific
Training on the instructions tab the PO may enter
NA in fields V-W.
Did the participant or their representative request
to initiate, eliminate, or continue a particular item
or service during the audit review period?

If the auditor did not select Driver Specific
Training on the instructions tab the PO may enter
NA in fields V-X.
Did the participant or their representative request
to initiate, eliminate, or continue a particular item
or service during the audit review period?

Column F

(Yes/No)

Column V

SDRIdentification1P76

Technical Clarification

(Yes/No)

Section in Current CMS-10630
(11/27/2019)

SDRIdentification1P76
Participant Impact Tab
Column G
SDRIdentification1P76

Original Language

In No, please enter NA in all remaining columns.
Enter the date he participant or their representative
requested to initiate, eliminate, or continue a
particular item or service.
MM/DD/YYYY
Is their documentation that the request was
processed as a service delivery request?

Clarification or Change

Technical Clarification

Technical Clarification

Revised Language

If No, please enter NA in all remaining columns.
Enter the date the participant or their representative
requested to initiate, eliminate, or continue a
particular item or service.
MM/DD/YYYY
Is there documentation that the request was
processed as a service delivery request?

Participant Impact Tab
(Yes/No)
Column H
SDRs1P601P611P85

Date of Disenrollment

Participant Impact Tab

Enter NA if the participant is still enrolled.

Column E
SrvcRestrict1P90
Participant Impact Tab
Column J
SrvcRestrict1P90

If the service was requested or determined
necessary by the IDT, what was the request or
recommendation?
(Example: participant requested overnight home
care)
Describe why the limitation that was applied.

(Yes/No)
Technical Clarification

Date of Disenrollment
MM/DD/YYYY

Technical Clarification

Technical Clarification

Enter NA if the participant is still enrolled.
If the service was requested or determined
necessary by the IDT, what was the request or
determination?
(Example: participant requested overnight home
care)
Describe why the limitation was applied.

Participant Impact Tab
Column L
WoundCare1P02

All participants enrolled during the audit review
period.

Technical Clarification

• Review all relevant participant documentation
during the audit review period to determine if each
participant had one or more wounds.

Technical Clarification

Instructions Tab
Scope

WoundCare1P02
Instructions Tab
Scope

• Respond to the questions in the participant impact
tab.

• 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.
• 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.

Section in Current CMS-10630
(11/27/2019)

Original Language

Clarification or Change

Revised Language

• The participant impact tab must include all
participants who were enrolled in the PACE
organization during the audit review period. This
includes new enrollees and participants who were
existing enrollees at the start of the audit review
period.

• 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.

• 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.

• The review timeframe is the audit review period.
Errors noted before or after the audit review period
should not be included.