| Instructions: | • Enter responses to each question in Pre-Audit Issue Summary tab of this document. • Only include issues of non-compliance that occurred during the data collection period. The data collection period begins 6 months prior to the date of the audit engagement letter and, for the purposes of this document, ends on the date of the audit engagement letter. For example, an audit engagement letter is issued on March 3, 2023. The audit review period for this audit is September 3, 2022, through March 3, 2023. • Only include issues of non-compliance that were disclosed to the PACE organization's CMS account manager prior to the date of the audit engagement letter. • Do not include Quality data already reported to CMS. • Do not include data that is not relevant to the audit elements included in the audit protocol. • Do not include issues discovered during routine CMS and SAA monitoring and account management. This includes information discovered during account management calls and information discovered during SAA audits. |
| Due Date: | This document must be completed and submitted to HPMS within 5 business days following the issuance of the audit engagement letter. |
| Issue number | Description of the non-compliance (explain what happened and what the non-compliance was) |
Number of participants impacted Enter unknown if the impact is unknown |
Date non-compliance identified MM/DD/YYYY |
Was the non-compliance disclosed to the CMS account manager prior to the date of the Audit Engagement Letter? Yes/No |
Date non-compliance disclosed to CMS MM/DD/YYYY |
To whom the non-compliance was disclosed at CMS (first and last name) |
Root cause analysis of the non-compliance (explain why it happened) |
How was the non-compliance discovered? | Was the non-compliance fully remediated? (e.g. was the non-compliance fully corrected)? Yes/No |
Describe how the non-compliance was remediated (corrected). | Date system/operational remediation initiated MM/DD/YYYY |
Date system/operational remediation completed MM/DD/YYYY | Description of remediation for negatively impacted participants | Date participant remediation initiated MM/DD/YYYY Enter NA if participant remediation was not initiated. |
Date participant remediation completed MM/DD/YYYY Enter NA if participant remediation was not initiated. |
If remediation or correction was not completed, when is the anticipated completion date? | If remediation or correction was not completed, has the risk to participants been mitigated? | If the risk to participants has been mitigated please explain. |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |