Crosswalk

Current CMS-10630 (2020)
AttachmentIPACEAuditProtocol, Title
Page: Programs of All-Inclusive Care for
the Elderly (PACE) Audit Process and Data
Request
AttachmentIPACEAuditProtocol, Audit
Purpose and General Guidelines

Summary of Changes in Proposed CMS-10630
(starting in 2023)

Explanation of
Changes

Burden
Impact

•

Retitled to “Programs of All-Inclusive Care
for the Elderly (PACE) Audit Protocol”

Modify

Minor wording change
for clarity

None

•

Retitled this section to “Audit Purpose and
Scope”
Updated terminology to reflect regulatory
changes
Removed audit process instructions
unrelated to the purpose and scope of the
audit
Moved data collection periods by universe
information to Appendix A
Retitled this section to “Initial
Documentation and Data Submissions”
Removed audit process instructions
unrelated to the collection of initial
documentation and data submissions
Moved all instructions related to initial
documentation and data submissions to
this section
Added 3 new initial documentation
requests

Modify

Technical changes,
Changes due to
regulatory updates
(effective March 2021),
Streamlined
information

None

Modify

Technical changes,
Changes due to
regulatory updates
(effective March 2021),
Streamlined
information, Changes
for clarity based on
audit experience

Moderate

•
•
•

AttachmentIPACEAuditProtocol, Universe
Preparation & Submission

Type of Change

•
•
•
•

Current CMS-10630 (2020)
AttachmentIPACEAuditProtocol, Audit
Elements, Service Delivery Requests,
Appeals, and Grievances (SDAG)

Summary of Changes in Proposed CMS-10630
(starting in 2023)
•
•

•
•
•
•
AttachmentIPACEAuditProtocol, Audit
Elements, Provision of Services

•

•
•
•
AttachmentIPACEAuditProtocol, Audit
Elements, Personnel Records

•

•
•

Renamed this element to “Service
Determination Requests, Appeals, and
Grievances (SDAG)”
Removed audit process instructions
unrelated to the collection of
documentation and data for the Personnel
element
Added new documentation requests and
compliance standards
Modified current compliance standards
Added instructions on how to submit case
files to CMS
Provided additional detail regarding CMS’
approach to reviewing compliance
standards
Removed audit process instructions
unrelated to the collection of
documentation and data for the Personnel
element
Added new documentation requests and
compliance standards
Modified current compliance standards
Provided additional detail regarding CMS’
approach to reviewing compliance
standards
Removed audit process instructions
unrelated to the collection of
documentation and data for the Personnel
element
Made minor technical updates to
compliance standards and compliance
standard instructions
Provided additional detail regarding CMS’
approach to reviewing compliance
standards

Type of Change

Explanation of
Changes

Burden
Impact

Modify

Technical changes,
Changes due to
regulatory updates
(effective March 2021),
Streamlined
information, Clarified
instructions, Changes
for clarity based on
audit experience

Moderate

Modify

Technical changes,
Changes due to
regulatory updates
(effective March 2021),
Streamlined
information, Clarified
instructions, Changes
for clarity based on
audit experience

Moderate

Modify

Technical changes,
Streamlined
information, Clarified
instructions

None

Current CMS-10630 (2020)
AttachmentIPACEAuditProtocol, Quality
Assessment

Summary of Changes in Proposed CMS-10630
(starting in 2023)
•
•

•
•

Type of Change

Explanation of
Changes

Burden
Impact

Renamed this element to “Compliance
and Quality Improvement”
Removed audit process instructions
unrelated to the collection of
documentation and data for the Personnel
element
Added new documentation requests and
compliance standards related to
compliance oversight
Provided additional detail regarding CMS’
approach to reviewing compliance
standards
Created a new section, “Analysis of
Potential Non-Compliance”, which
streamlines instructions and further
describes Root Cause Analysis, Impact
Analysis, additional records review
collection, and CMS’ validation of the
accuracy of documentation submitted by
the PO during the audit
Consolidated universe related information
to Appendix A

Modify

Technical changes,
Streamlined
information, Clarified
instructions, Changes
for clarity based on
audit experience

Moderate

Modify

Clarified instructions

None

Modify

Technical changes,
Clarified instructions

None

Technical changes,
Changes due to
regulatory updates
(effective March 2021),
Changes for clarity
based on audit
experience
Technical changes,
Changes due to
regulatory updates
(effective March 2021),
Changes for clarity
based on audit
experience

Moderate

CMS proposes a new
AttachmentIPACEAuditProtocol section:
“Analysis of Potential Non-Compliance”
(No equivalent in the current protocol)

•

AttachmentIPACEAuditProtocol, Appendix
A

•

AttachmentIPACEAuditProtocol, Appendix
A, Table 1: Service Determination
Requests (SDR) Record Layout
16 columns in the Record Layout

•
•
•

Added 10 new data fields
Removed 3 data fields
Modified current data fields

Modify

AttachmentIPACEAuditProtocol, Appendix
A, Table 2: Appeal Requests (AR) Record
Layout
15 columns in the Record Layout

•
•

Added 3 new data fields
Modified current data fields

Modify

Low

Current CMS-10630 (2020)

Summary of Changes in Proposed CMS-10630
(starting in 2023)

Type of Change

Explanation of
Changes

Burden
Impact

Modify

Technical changes,
Changes due to
regulatory updates
(effective March 2021),
Changes for clarity
based on audit
experience
Technical changes,
Changes for clarity
based on audit
experience
Technical changes,
Changes due to
regulatory updates
(effective March 2021),
Changes for clarity
based on audit
experience
Technical changes,
Changes for clarity
based on audit
experience
Technical changes,
Changes due to
regulatory updates
(effective March 2021),
Changes for clarity
based on audit
experience

Low

AttachmentIPACEAuditProtocol, Appendix
A, Table 3: Grievance Requests (GR)
Record Layout
9 columns in the Record Layout

•
•
•

Revised name of the record layout to
“Table 3: Grievance (GR) Record Layout”
Added 1 new data field
Modified current data fields

AttachmentIPACEAuditProtocol, Appendix
A, Table 4: List of Personnel (LOP) Record
Layout
11 columns in the Record Layout
AttachmentIPACEAuditProtocol, Appendix
A, Table 5: List of Participant Medical
Records (LOPMR) Record Layout
40 columns in the Record Layout

•
•
•

Added 3 new data fields
Removed 1 data field
Modified current data fields

Modify

•
•
•

Added 12 new data fields
Removed 10 data fields
Modified current data fields

Modify

AttachmentIPACEAuditProtocol, Appendix
A, Table 6: On-Call (OC) Record Layout
8 columns in the Record Layout

•
•

Added 2 new data fields
Modified current data fields

Modify

CMS proposes a new record layout in
AttachmentIPACEAuditProtocol, Appendix
A, Table 7: Contracted Entities and
Providers (CEP) Record Layout. (No
equivalent in the current protocol)

•

New record layout added,
AttachmentIPACEAuditProtocol, Appendix
A, Table 7: Contracted Entities and
Providers (CEP) Record Layout, which
includes 7 data fields

New

Low

Moderate

Low

Moderate

Current CMS-10630 (2020)
AttachmentIIPACESupplementalQuestions

Summary of Changes in Proposed CMS-10630
(starting in 2023)
•
•
•

Type of Change

Explanation of
Changes

Burden
Impact

Removed 2 questions
Modified questions to clarify the
information requested
Made technical corrections to clarify
questions and fix typographical errors

Modify

Typographical
corrections, Technical
changes, Changes due
to regulatory updates
(effective March 2021),
Changes for clarity
based on audit
experience
Technical changes,
Clarified instructions

Low

Technical changes,
Changes for clarity
based on audit
experience
Technical Changes,
Clarified instructions
and questions, Changes
for clarity based on
audit experience
New attachment
clarifies an existing
audit process

None

AttachmentIIIPreAuditIssueSummary

•

Made minor technical changes

Modify

AttachmentIVObsPartList

•

Renamed the document from
“AttachmentIVOnsiteObsPartList” to
“Attachment_IV_Obs_ParticipantList”
Made minor technical changes
Removed 4 questions
Added 1 question
Modified 6 questions with minor technical
changes

Modify

This new attachment explains how a PACE
organization must submit corrective
action plans to CMS for any issue of noncompliance identified during a PACE audit
The attachment addresses corrective
action plan requirements, implementation
timeframes, Account Management
technical assistance and documentation
submission, and conditions of release
from corrective action plan monitoring

New

AttachmentVAuditSurvey

CMS proposes a new attachment:
AttachmentVICorrectiveActionPlanProcess
(No equivalent in the current protocol)

•
•
•
•

•

•

Modify

None

None

None

Current CMS-10630 (2020)
16 Impact Analyses templates

SDRs1P601P611P85 Impact Analysis
• 22 columns on participant impact
tab

SDRIdentification1P76 Impact Analysis
• 19 columns on participant impact
tab

MedErrors1P02 Impact Analysis
• 20 columns on participant impact
tab
HomeCare1P02 Impact Analysis
• 21 columns on participant impact
tab

Summary of Changes in Proposed CMS-10630
(starting in 2023)
•

18 Impact Analysis templates

SDRs1P601P611P85 Impact Analysis:
• Added 5 columns to Participant Impact
Tab
• Modified 13 columns with minor wording
changes
• Updated instructions for completing
participant impact tab
SDRIdentification1P76 Impact Analysis:
• Added 2 columns to participant impact tab
• Modified 14 columns on participant
impact tab
• Updated instructions for completing
participant impact tab
MedErrors1P02 Impact Analysis:
• Added 1 column to participant impact tab
• Updated instructions for completing
participant impact tab
HomeCare1P02 Impact Analysis:
• Added 1 column to participant impact tab
• 5 columns removed
• Modified 9 columns on participant impact
tab
• Updated instructions for completing
participant impact tab

Type of Change

Explanation of
Changes

Burden
Impact

Add

Added three additional
Impact Analysis
templates:
SpecialistRecommenda
tions1P14,
RequiredServices1P93,
and
CoordinationofCare1P9
5.
Removed one IA from
collection:
AppealExt1P71.
Modified and added
columns to align with
new regulatory
provisions (effective
March 2021).

Low

Modify

Modified and added
columns to align with
new regulatory
provisions (effective
March 2021).

Low

Modify

Minor wording changes
for clarity

Low

Modify

Minor wording changes
for clarity

Low

Modify

Low

Current CMS-10630 (2020)

Summary of Changes in Proposed CMS-10630
(starting in 2023)

Type of Change

Explanation of
Changes

Burden
Impact

AlertIDT1P14 Impact Analysis
• 22 columns on participant impact
tab

AlertIDT1P14 Impact Analysis:
• Modified 15 columns on the participant
impact tab
• Removed 1 column on the participant
impact tab
• Added 1 column on the participant impact
tab
• Updated instructions tab
Appeals1P651P661P681P73 Impact Analysis:
• Updated instructions tab, including adding
instructions for a new condition
• Added 5 columns on the participant
impact tab
• Removed 2 columns on the participant
impact tab
• Modified 13 columns on the participant
impact tab
Assessments1P491P50 Impact Analysis:
• Added 1 column on the participant impact
tab
• Modified 4 columns on the participant
impact tab
• Updated instructions tab
Effectuation1P021P111P30 Impact Analysis:
• Added 2 columns on the participant
impact tab
• Removed 1 column on the participant
impact tab
• Modified 8 columns on the participant
impact tab
• Updated instructions tab

Modify

Wording changes for
clarity and based on
regulation changes
(effective March 2021)

Low

Modify

Wording changes for
clarity and based on
regulation changes
(effective March 2021)

Low

Modify

Wording changes for
clarity

Low

Modify

Minor wording changes
for clarity

Low

Appeals1P651P661P681P73 Impact
Analysis
• 37 columns on the participant
impact tab

Assessments1P491P50 Impact Analysis
• 30 columns on the participant
impact tab

Effectuation1P021P111P30 Impact
Analysis
• 34 columns on the participant
impact tab

Current CMS-10630 (2020)

Summary of Changes in Proposed CMS-10630
(starting in 2023)

Type of Change

Explanation of
Changes

Burden
Impact

EmergencyCare1P07 Impact Analysis:
• 25 columns on the participant
impact tab

EmergencyCare1P07 Impact Analysis:
• Added 1 column to the participant impact
tab
• Modified 2 columns on the participant
impact tab
• Updated instructions tab
Grievances1P311P751P77 Impact Analysis:
• Added 1 column to the participant impact
tab
• Modified 3 columns on the participant
impact tab
• Updated instructions tab
Personnel Impact Analysis:
• Added 2 columns on the participant
impact tab
• Removed 1 column on the participant
impact tab
• Updated instructions tab
ProvisionofServices1P02 Impact Analysis:
• Added 1 column on the participant impact
tab
• Removed 2 columns on the participant
impact tab
• Modified 9 columns on the participant
impact tab
• Updated instructions tab
Restraints1P09 Impact Analysis:
• Added 3 columns on the participant
impact tab
• Removed 2 columns on the participant
impact tab
• Modified 6 columns on the participant
impact tab
• Updated instructions tab

Modify

Minor wording changes
for clarity

Low

Modify

Minor wording changes
for clarity

Low

Modify

Minor wording changes
for clarity

Low

Modify

Minor wording changes
for clarity

Low

Modify

Minor wording changes
for clarity

Low

Grievances1P311P751P77 Impact Analysis
• 27 columns on the participant
impact tab

Personnel Impact Analysis
• 25 columns on the participant
impact tab

ProvisionofServices1P02 Impact Analysis
• 17 columns on the participant
impact tab

Restraints1P09 Impact Analysis
• 25 columns on the participant
impact tab

Current CMS-10630 (2020)

Summary of Changes in Proposed CMS-10630
(starting in 2023)

Type of Change

Explanation of
Changes

Burden
Impact

SrvcRestrict1P90 Impact Analysis
• 19 columns on the participant
impact tab

SrvcRestrict1P90 Impact Analysis:
• Added 1 column on the participant impact
tab
• Deleted 1 column on the participant
impact tab
• Modified 5 columns on the participant
impact tab
• Updated instructions tab
WoundCare1P02 Impact Analysis:
• Added 1 column to the participant impact
tab
• Deleted 1 column on the participant
impact tab
• Modified 14 columns on the participant
impact tab
• Updated instructions tab
RootCauseTemplate
• Added 1 tab for detailed description of the
individual non-compliance

Modify

Minor wording changes
for clarity

Low

Modify

Minor wording changes
for clarity

Low

Modify

Detailed noncompliance and the
general request for a
cause was combined
on a single tab. This
revision splits that
information/request on
to two tabs for clarity.

Low

WoundCare1P02 Impact Analysis:
• 23 columns on the participant
impact tab

RootCauseTemplate
• 2 tabs (instructions and Root
Cause)