CMS-10630 Personnel Impact Analysis Template

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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
		Initial personnel competencies
		Personnel licensure
		OIG exclusion checks
		Background checks
		Communicable disease clearance
		Driver Specific Training
Scope:	Initial personnel competencies: • The scope of the Impact Analysis is no more than 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel sample selection and meet the following criteria: 1. Were newly hired during the audit review period; and 2. Provided participant care in the PACE centers or participant homes. Personnel licensure: • The scope of the Impact Analysis is no more than 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel sample selection and had direct participant contact in the PACE centers or participant homes. OIG exclusion checks: • The scope of the Impact Analysis is no more than 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel sample selection and were newly hired during the audit review period.
	Background checks: • The scope of the Impact Analysis is no more than 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel sample selection and were newly hired during the audit review period. Communicable disease clearance: • The scope of the Impact Analysis is no more than 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel sample selection and meet the following criteria: 1. Were newly hired during the audit review period; and 2. Had direct participant contact in the PACE centers or participant homes. Driver specific training: • The scope of the Impact Analysis is no more than 50% of staff (including employees and contractors) during the audit review period who were not included in the personnel sample selection and transported participants.
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. • Respond to the questions in the Participant Impact 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

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: Initial personnel competencies

This information is to be completed if the Impact Analysis is being requested for: Personnel licensure

This information is to be completed if the Impact Analysis is being requested for: OIG exclusion checks

This information is to be completed if the Impact Analysis is being requested for: Background checks

This information is to be completed if the Impact Analysis is being requested for: Communicable disease clearance

This information is to be completed if the Impact Analysis is being requested for: Driver Specific Training

General Information: This information may be completed for all Impact Analyses

Employee First Name

Employee Last Name

Job Title

Date of Hire MM/DD/YYYY

Date of Initial Participant Contact MM/DD/YYYY

Date Individual Began Providing Care Independently MM/DD/YYYY

Date of Termination MM/DD/YYYY Enter NA if employee was not terminated during audit review period.

Type of Employment Enter contract, Full-time, Part-time, Volunteer, or Other.

License (Yes/No)

Is there documentation that the staff member's competency was evaluated prior to them providing participant care independently? (Yes/No) *This requirement only applies to personnel newly hired during the audit review period. If the auditor did not select Initial personnel competencies on the instructions tab the PO may enter NA in columns J through K. Enter NA in columns J through K if the employee did not provide participant care independently during the audit review period.

Date of competency evaluation completed. MM/DD/YYYY Enter Not Completed if the competency evaluation was never done.

Is the individual (employee or contractor) required to have a license in order to perform care and/or services in the PO's state? (Yes/No) *This requirement applies to all personnel. If the auditor did not select Personnel licensure on the instructions tab the PO may enter NA in columns L through N.

Type of license(s) required? *This requirement applies to all personnel. Enter NA if the staff member is not required to have a license.

Is there documentation that the staff member had a valid license during the audit review period? (Yes/No) *This requirement applies to all personnel. Enter NA if the staff member is not required to have a license or did not have direct participant contact during the audit review period.

Is there documentation that an OIG exclusion check was completed before the date of hire? (Yes/No) *This requirement only applies to personnel newly hired during the audit review period. If the auditor did not select OIG exclusion checks on the instructions tab the PO may enter NA in columns O through P.

Date the OIG check was completed. MM/DD/YYYY Enter Not Completed if the OIG check was never completed.

Is there documentation that a background check was completed before the date of hire? (Yes/No) *This requirement only applies to personnel newly hired during the audit review period. If the auditor did not select Background checks on the instructions tab the PO may enter NA in columns Q through R.

Date the background check was completed. MM/DD/YYYY Enter Not Completed if the background check was never completed.

Is there documentation that the individual (employee or contractor) was evaluated and determined to be free of communicable diseases prior to engaging in direct participant contact? (Yes/No) *This requirement only applies to personnel newly hired during the audit review period. If the auditor did not select Communicable disease clearance on the instructions tab the PO may enter NA in columns S through T. Enter NA in columns S through T if the staff member did not have direct participant contact during the audit review period.

Date the individual was screened/medically cleared of communicable diseases. MM/DD/YYYY Enter Not Completed if the individual was never medically cleared. Enter NA if the staff member did not have direct participant contact during the audit review period.

Date the driver was provided training on handling the special needs of the participants. MM/DD/YYYY Enter Not Completed if the individual was never provided training. If the auditor did not select Driver Specific Training on the instructions tab or if the individual was not a driver the PO may enter NA in columns U through W.

Date the driver was provided training on handling emergency situations. MM/DD/YYYY Enter Not Completed if the individual was never provided training.

Date the driver began driving participants for the PACE organization. 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 staff member please enter the information in this column.