CMS-10630 Required Services

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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
		Services provided by caregivers
		Services provided by individuals or entities not employed or contracted by the PACE organization (other than caregivers)
Scope:	• 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 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 caregivers were utilized by the PACE organization to provide services determined necessary by the IDT. • Respond to the questions in the participant impact tab. • The review timeframe is the audit review period. Errors noted before or after 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.
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: Services provided by caregivers

This information is to be completed if the Impact Analysis is being requested for: Services provided by individuals or entities not employed or contracted by the PACE organization (other than caregivers)

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.

At any point during the audit review period, did the IDT determine that the participant required assistance with ADLS or IADLS? (Yes/No) ADLs include: eating, bathing/showering, dressing, toileting, mobility, and transfers. IADLs include: meal preparation, shopping for groceries or personal items, laundry, housekeeping, medication management, communication (use of telephone or computer), and transportation.

At any point during the audit review period, did the IDT determine that the participant required supervision (the participant was unsafe if left alone without supervision)? (Yes/No) If the responses to column G and column H are NO, enter NA in columns I through T

During the audit review period, did the participant's caregivers (family, friends, etc.) provide assistance with any ADLs or IADLs? If Yes, enter the type(s) and frequency of ADL/IADL assistance provided by caregivers. For example: • medication administration 2x/day, 7 days/week • meal preparation 3x/day, 4 days/week • laundry once a week • bathing 3x/week If No, enter No.

During the audit review period, did the participant's caregivers (family, friends, etc.) provide supervision? If Yes, enter the type(s) and frequency of supervision provided. For example: • supervision during the day, 5 days per week • supervision during the evening, 2 days per week • supervision at night, 7 days per week If No, enter No. If the responses to columns I and J are both "No", enter NA in columns K-T.

During the audit review period, did the participant's caregivers (family, friends, etc.) express any unwillingness or inability to provide assistance with ADLs, IADLs, or supervision? (Yes/No) Enter NA if the PO provided all necessary services during the audit review period (the answers to columns I and J are No).

If the participant's caregivers expressed any unwillingness or inability to provide assistance with ADLs, IADLs, or supervision: 1. identify if the caregiver was unwilling or unable; and 2. briefly describe the type(s) of assistance/supervision the caregivers were unwilling or unable to provide. For example: • Unwilling to provide supervision between 7 PM and 7 AM, 7 days/week. • Unable to provide assistance with bathing, 2 days/week. • Unwilling to provide assistance with meal preparation, 2x/day, 5 days/week. Enter NA if: • The PO provided all necessary services during the audit review period (the answers to columns I and J are No); or • The participant's caregivers did not express any unwillingness or inability to provide assistance with ADLs, IADLs, or supervision.

Enter the first (earliest) date the participant's caregivers first expressed an unwillingness/inability to provide assistance with ALDs, IADLs, or supervision. MM/DD/YYYY Enter NA if: • The PO provided all necessary services during the audit review period (the answers to columns I and J are No); or • The participant's caregivers did not express any unwillingness or inability to provide assistance with ADLs, IADLs, or supervision.

During the audit review period, did the IDT determine that the participant's caregivers (family, friends, etc.) were unsafe to provide assistance with ADLs, IADLs, or supervision? (Yes/No) Enter NA if the PO provided all necessary services during the audit review period (the answers to columns I and J are No).

If the IDT determined the participant's caregivers were unsafe to provide assistance with ADLs, IADLs, or supervision, briefly describe the type(s) of assistance/supervision the caregivers were unsafe to provide. For example: • Unsafe to provide supervision between 7 PM and 7 AM, 7 days/week. • Unsafe to provide assistance with bathing, 2 days/week. • Unsafe to provide assistance with meal preparation, 2x/day, 5 days/week. Enter NA if: • The PO provided all necessary services during the audit review period (the answers to columns I and J are No); or • The IDT did not determine that the participant's caregivers were unsafe to provide assistance with ADLs, IADLs, or supervision.

If the IDT determined the participant's caregivers (family, friends, etc.) were unsafe to provide assistance with ADLs, IADLs, or supervision, briefly explain why the caregiver was unsafe to provide assistance. Enter NA if: • The PO provided all necessary services during the audit review period (the answers to columns I and J are No); or • The IDT did not determine that the participant's caregivers were unsafe to provide assistance with ADLs, IADLs, or supervision.

Enter the first (earliest) date the IDT determined the participant's caregivers were unsafe to provide assistance with ADLs, IADLs, or supervision. MM/DD/YYYY Enter NA if: • The PO provided all necessary services during the audit review period (the answers to columns I and J are No); or • The IDT did not determine that the participant's caregivers were unsafe to provide assistance with ADLs, IADLs, or supervision.

If caregivers reported they were unwilling or unable to provide assistance/supervision (noted in columns L) or the IDT determined caregivers were unsafe to provide assistance/supervision (noted in column O), did the PO provide the services in full? (Yes/No) Enter NA if: • The PO provided all necessary services during the audit review period (the answers to columns I and J are No); or • The participant's caregivers did not express unwillingness/inability to provide assistance with ADLs, IADLs, or supervision; or • The IDT did not determine that the participant's caregivers were unsafe to provide assistance with ADLs, IADLs, or supervision.

If the PO provided some services, but did not provide the services (noted in columns L and O) in full, describe the services provided by the PO. Enter NA if: • The PO provided all necessary services during the audit review period (the answers to columns I and J are No); or • The participant's caregivers did not express unwillingness/inability to provide assistance with ADLs, IADLs, or supervision; or • The IDT did not determine that the participant's caregivers were unsafe to provide assistance with ADLs, IADLs, or supervision.

Enter the date when services were initiated. MM/DD/YYYY Enter NA if: • The PO provided all necessary services during the audit review period (the answers to columns I and J are No); or • The participant's caregivers did not express unwillingness/inability to provide assistance with ADLs, IADLs, or supervision; or • The IDT did not determine that the participant's caregivers were unsafe to provide assistance with ADLs, IADLs, or supervision.

During the audit review period, did the participant receive IDT approved, ordered or care planned services from an individual or entity that was NOT contracted or employed by the PACE organization (other than a caregiver)? (Yes/No) If No, answer NA in columns V through Z.

What service(s), that were determined necessary by the IDT, were provided by individuals or entities not contracted or employed by the PACE organization (other than a caregiver)? Identify the service(s) Enter NA if the participant received all services through employees or contractors of the PACE organization.

When did the IDT determine that a service (including IADLs, ADLs, supervision and other services) provided through individuals or entities not employed or contracted with the PACE organization (other than a caregiver) was necessary (IDT approved, ordered or care planned)? If multiple services are being provided through individuals or entities not employed or contracted with the PACE organization, enter each service and the date the service was approved. Enter NA if the participant only receives care and services through employees or contractors of the PACE organization and/or from caregivers.

If a service(s) was provided by an individual or entity not employed or contracted with the PACE organization (other than a caregiver), identify the individual or entity providing services to the participant. Enter NA if the participant only receives care and services through employees or contractors of the PACE organization and/or from caregivers.

When were the services provided to the participant? Enter the date. Enter NA if the participant only receives care and services through employees or contractors of the PACE organization and/or from caregivers.

Why did the participant receive services through individuals or entities not employed or contracted by the PACE organization? Enter NA if the participant only receives care and services through employees or contractors of the PACE organization and/or from caregivers.

Were there any negative participant outcomes related to a participant receiving care or services through individuals or entities other than an employee or contractor (including family members or caregivers)? (Yes/No)

If yes, describe the negative outcomes. Enter NA if the participant did not experience 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.