CMS-10630 Root Cause Analysis Template

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Overview

Instructions
Detailed Sample Information
Root Cause Analysis

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Sheet 1: Instructions

Audit Review Period:
Scope:	Participants enrolled during the audit review period.
Instructions:	• Respond to the relevant questions in the Detailed Sample Information and Root Cause Analysis tabs. • Detailed Sample Information tab: * Columns A and B - Will be completed by the audit lead. * Column C - The PO will enter details relating to the investigation of each issue identified in Column A. • Root Cause tab: * Columns A through C - Will be completed by the audit lead. * Columns D and E - The PO must enter the root cause or causes for the issue(s) which is summarized in Column B (Details for the individual issues are located in the Detailed Sample Information tab). * Only complete columns E and if it is easily known (i.e., the root cause is based off of a disclosed issue (full investigation was already done) or the scope is easily determined based on the cause/ type of issue identified). If the scope is not easily known, enter NA in these columns. * Only complete columns G through L if the condition relates to a disclosed issue for which correction was already initiated/completed. If the condition was first discovered on audit, the organization may enter NA in those columns.
Root Cause Analysis Due Date:

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Sheet 2: Detailed Sample Information

Brief Description Of Issue (Completed By The CMS Audit Lead)	Type of Issue Identified (Completed By The CMS Audit Lead) (Applies to condition 1P.02 Only. For all other conditions enter N/A)	Detailed Description of the Issue (Explain what happened)
	x

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Sheet 3: Root Cause Analysis

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)