CMS-10630 Grievances Impact Analysis Template

---

Overview

Instructions
Root Cause Detail
Root Cause Summary
Participant Impact

---

Sheet 1: Instructions

Audit Review Period:
Issue(s) of non-compliance:	Auditors: Select All that Apply	Issue
		Resolution of participant grievances
		Recognizing complaints as grievances
		Discussing grievances with participants
Scope:	Resolution of participant grievances: • All grievances during the audit review period. Recognizing complaints as grievances: • The scope of this Impact Analysis is no more than 50% of the participants enrolled during the audit review period who were not included in the grievance sample selection. • The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab. Discussing grievances with participants: • The scope of this Impact Analysis is no more than 50% of the participants enrolled during the audit review period who were not included in the grievance sample selection. • The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab.
Instructions:	General: • The review timeframe is the audit review period. Errors noted prior to 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 RCA tab. Resolution of participant grievances: • Review each grievance and respond to the questions in the Participant Impact tab. Recognizing complaints as grievances: • 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 participant, participant's family members, or participant representative submitted a complaint verbally or in writing. • Respond to the questions in the Participant Impact tab. Discussing grievances with participants: • 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 participant was informed of the grievance process at the time of enrollment and on at least an annual basis. • Respond to the questions in the Participant Impact tab.
Impact Analysis Due Date:

---

Sheet 2: Root Cause Detail

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

Detailed Description of the Issue (Explain what happened)

---

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)

---

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: Resolution of participant grievances

This information is to be completed if the Impact Analysis is being requested for: Recognizing complaints as grievances

This information is to be completed if the Impact Analysis is being requested for: Discussing grievances with participants

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.

Date the participant, caregiver or family member submitted the grievance. MM/DD/YYYY If the auditor did not select Resolution of participant grievances on the instructions tab the PO may enter NA in columns G-M. (Note for internal DAPS Purposes Only - This question was previously included in the "General information Section." I've shifted it to the "Resolution of participant grievances section."

Enter the number of unique issues contained within the grievance.

Enter a brief description of each issue identified in the grievance.

Enter the number of issues contained within the grievance that have supporting documentation verifying the issues were resolved.

Which issues were unresolved? Enter a brief description. Enter NA if all issues within the grievance were resolved.

Why were the issues not resolved? Enter NA if all issues within the grievance were resolved.

Did the participant experience any negative outcomes as a result of the failure to resolve all issues within a grievance? (Yes/No) Enter NA if all issues within the grievance were resolved.

Did the participant, their caregivers, or their family members express a complaint, either written or oral, expressing dissatisfaction with service delivery or the quality of care furnished during the audit review period? (Yes/No) If the auditor did not select Recognizing complaints as grievances on the instructions tab the PO may enter NA in columns N-W. If the answer to this question is No enter NA in columns O-W.

Enter the date of the complaint. MM/DD/YYYY

Describe the complaint.

Where is the complaint documented (progress notes, assessments, PAC minutes, on-call, etc.)?

Is there documentation that the complaint was processed as a grievance in accordance the PO's grievance policies? (Yes/No)

When was the participant, family member, or participant representative notified of the resolution of the grievance. MM/DD/YYYY If the participant/family member was not notified enter Not Notified.

Was the complaint reviewed and resolved outside of the grievance process? (Yes/No)

If yes, what was the resolution? Enter NA if the complaint was not resolved outside of the grievance process.

If yes, when was it resolved? MM/DD/YYYY Enter NA if the complaint was not resolved outside of the grievance process.

Were there any negative participant outcomes as a result of the failure to recognize complaints as grievances? (Yes/No)

Is there documentation that the participant was informed of the grievance process, in writing, upon enrollment? (Yes/No) Enter NA if the participant was not newly enrolled during the audit review period. If the auditor did not select Discussing grievances with participants on the instructions tab the PO may enter NA in columns X-AA.

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.

Did the participant or participant representative file a grievance during the audit review period? (Yes/No)

Were there any negative participant outcomes as a result of the participant not being informed of the grievance process? (Yes/No)

If the participant experienced any negative outcomes, please describe the negative outcomes.

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 grievance, please enter the information in this column.