CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

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Overview

Instructions
Root Cause Detail
Root Cause Summary
Participant Impact

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Sheet 1: Instructions

Audit Review Period:
Issue(s) of non-compliance:	Auditors: Select All that Apply	Issue
		Unscheduled Assessments
		Semiannual Assessments
		Initial Assessments
Scope:	Unscheduled Assessments: • 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. Semiannual Assessments: • 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. Initial Assessments: • The scope of this Impact Analysis is limited to 50% of the participants newly 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:	General: • After completing the Impact Analysis, if any changes need to be made to the Root Cause Analysis, please update the RCA tab. • The review timeframe is the audit review period. Errors noted prior to the audit review period should not be included. Unscheduled Assessments: • 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: 1. If the participant had a change in status; and 2. If all required IDT members completed assessments as required. Semiannual Assessments: • 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 all required IDT members completed assessments as required. Initial Assessments: • 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 all required IDT members completed assessments as required.
Impact Analysis Due Date:

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Sheet 2: Root Cause Detail

Brief Description Of Issue (Completed By The CMS Audit Lead)

Detailed Description of the Issue (Explain what happened)

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Sheet 3: Root Cause Summary

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)

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

# of Individuals Impacted

Action Taken to Resolve System/ Operational Issues

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

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

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)

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Sheet 4: Participant Impact

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

This information is to be completed if the Impact Analysis is being requested for: Unscheduled Assessments

This information is to be completed if the Impact Analysis is being requested for: Semiannual Assessments

This information is to be completed if the Impact Analysis is being requested for: Initial Assessments

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

Participant First Name

Participant Last Name

Medicare Beneficiary Identifier

Participant ID

Date of Enrollment MM/DD/YYYY

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

Did the participant experience a change in their health or psychosocial status during the audit review period that required a change is status assessment? (Yes/No) If the auditor did not select Unscheduled Assessments on the instructions tab the PO may enter NA in columns G-N. If the answer to this question is No the PO may enter NA in columns H-N.

When did the change in status occur? If there was more than one change in status, use a new row for each date. MM/DD/YYYY

Is there documentation that assessments were completed by all required IDT members (at a minimum this includes: PCP, RN and MSW, and any other discipline determined to be actively involved in the care plan) in response to the change in condition? (Yes/No)

Enter the IDT members who did not complete assessments. Enter NA if the participant received all required assessments.

Date the first change in status assessment was completed. MM/DD/YYYY

Date the last change in status assessment was completed. MM/DD/YYYY

Were all required assessments completed in-person? (Yes/No)

Identify the assessments that were not completed in-person. (PCP, RN, etc.) Enter NA if participant had all assessments completed in person.

Should the participant have had a Semi-annual Assessment during the audit review period? (Yes/No) If the auditor did not select Semiannual Assessments on the instructions tab the PO may enter NA in columns O-X. If the answer to this question is No enter NA in columns P-X.

Did the participant have a Semi-annual Assessment completed during the audit review period? (Yes/No)

Did the PCP, RN, and MSW determine that any other IDT were actively involved in the development or implementation of the participant's plan of care? If yes, list the disciplines as determined by the PCP, RN, and MSW. If no, enter NA.

List the IDT members who DID NOT complete assessments (at a minimum the required disciplines include PCP, RN, MSW and any disciplines identified in the previous column). Enter NA if all required semi-annual assessments were completed.

Were all assessments completed in-person? (Yes/No)

Identify the assessments that were not completed in-person. (PCP, RN, etc.) Enter NA if all assessments were completed in person.

When should the assessments have been completed? MM/DD/YYYY

When was the first assessment completed? MM/DD/YYYY

When was the last assessment completed? MM/DD/YYYY

Where did the participant reside at the time of the assessments (e.g. home, SNF, ALF, hospital, etc.)?

Did the required IDT members complete all initial assessments (at a minimum this includes PCP, RN, MSW, RD, HCC, RT/AC, PT and OT)? (Yes/No) If the auditor did not select Initial Assessments on the instructions tab the PO may enter NA in columns Y-AD. If the answer to this question is Yes enter NA in columns Z-AD.

List the IDT members who DID NOT complete assessments.

Were all assessments completed in-person? (Yes/No)

Identify any assessments not completed in-person. (RN, MSW, etc.) Enter NA if all assessments were completed in person.

Were all assessments completed within 30 days of the participant's enrollment? (Yes/No)

Date last initial assessment was completed. MM/DD/YYYY

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.