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 of non-compliance:	Home care services
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 home care services were provided as approved, ordered, and/or care planned during the audit review period. • The review timeframe is the audit review period. Issues noted before or after the audit review period should not be included. • Respond to the questions in the Participant Impact tab for all participants. • After completing the Impact Analysis, if any changes need to be made to the Root Cause Analysis, please update the RCA tab.
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

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.

During the audit review period, was the participant supposed to receive home care (e.g, was home care approved by the IDT, ordered or care planned for the participant)? Enter Yes if the participant was supposed to receive home care during the audit review period. Enter No if home care services were not determined necessary, approved or ordered. If No is entered, enter NA in columns H through P.

Enter the date home care was supposed to start for the participant (this date may fall outside the audit review period). MM/DD/YYYY If the approved/ordered/care planned home care services were modified during the audit review period, enter the date of the modification on a new row. Enter NA, if home care services were not approved, ordered, or care planned at any time during the audit review period.

Enter the participant's home care schedule and identify the services that were to be provided in those dates/times. Enter NA, if home care services were not approved, ordered, or care planned at any time during the audit review period. Example: 5 days a week, 1 hour a day, medication administration.

Were home care services provided as approved, ordered, or care planned? (Yes/No) Enter NA, if home care services were not approved, ordered, or care planned at any time during the audit review period.

Identify dates that home care was not provided as approved, ordered, or care planned, as well as the services not provided. Only include dates if services were not provided because of a PO error, staffing, or process issues such as: a lack of home care agencies/staff, scheduling errors, staff call-outs/no shows, miscommunication, etc. Do not include dates if the participant declined services, was hospitalized, was in a nursing facility, or was otherwise not available to receive the services. Enter NA, if home care services were provided as approved, ordered, or care planned at any time during the audit review period or if home care services were not approved, ordered, or care planned at any time during the audit review period.

For each date (date range) provided in column K, explain why home care was not provided as approved, ordered, or care planned during the audit review period. Enter NA, if home care services were provided as approved, ordered, or care planned at any time during the audit review period or if home care services were not approved, ordered, or care planned at any time during the audit review period.

Did a failure to provide home care services as approved, ordered, or care planned occur due to ineffective communication with or oversight of a contracted provider? (Yes/No)

Were there any negative outcomes that occurred because the participant did not receive home care as approved, ordered, or care planned? (Yes/No) Enter NA, if home care services were provided as approved, ordered, or care planned at any time during the audit review period or if home care services were not approved, ordered, or care planned at any time during the audit review period.

If Yes, please describe the negative outcomes. Enter NA if there were no 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 participant, please enter the information in this column.