CMS-10630 Special Recommendations

The PACE Organization (PO) Monitoring and Audit Process in Part 460 of 42 CFR (CMS-10630)

SpecialistRecommendations1P94.xlsx

OMB: 0938-1327

Document [xlsx]
Download: xlsx | pdf

Overview

Instructions
Root Cause Detail
Root Cause Summary
Participant Impact


Sheet 1: Instructions

Audit Review Period:


Issue of non-compliance: Remaining alert to information from specialists/contracted providers


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 any specialists, ER providers, or hospital providers recommended services for the participant.

• 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:

Sheet 2: Root Cause Detail

Brief Description Of Issue
(Completed By The CMS Audit Lead)
Detailed Description of the Issue
(Explain what happened)

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)

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, did the participant have specialist consultations, emergency room visits, or hospitalizations?

(Yes/No)

If NO, the PO may enter NA in columns H through X.
Enter the type of specialist consultation.

If the participant had an emergency room visit, enter "ER." If the participant had a hospitalization, enter "hospitalization"

Enter NA if the participant did not have any specialist consultations, emergency room visits, or hospitalizations.
Enter the date of each specialist consultation, emergency room visit, and hospitalization. For emergency room visits and hospitalizations, enter the discharge date.

MM/DD/YYYY

Enter NA if the participant did not have any specialist consultations, emergency room visits, or hospitalizations.
Identify all services (including items and/or drugs) recommended or ordered by the specialist, emergency room provider, or hospital provider.

Enter each item and service in a separate row.

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider.
Date the specialist consultation report, ER records, or hospital records were received by the PO.

MM/DD/YYYY

If records were not received, enter "not received."

Enter NA if the participant did not have any specialist consultations, emergency room visits, or hospitalizations.
Did the IDT remain alert to all pertinent information from the specialists/ER/Hospital, including recommendations made by these providers?

Yes/No

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider.
Did the PACE PCP order the recommended service/item?

(Yes/No)

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No service/item was ordered or recommended by the specialist, emergency room provider, or hospital provider.
Date the service/item was ordered by the PCP.

MM/DD/YYYY

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No service/item was ordered or recommended by the specialist, emergency room provider, or hospital provider; or
3) The PCP did not order the service/item.
Date the service/item ordered by the PCP was provided to the participant.

If service/item was ordered but not provided, enter "not provided."
If more than one item or service was ordered, please identify the date each item was ordered.

MM/DD/YYYY

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No service/item was ordered or recommended by the specialist, emergency room provider, or hospital provider; or
3) The PCP did not order the service/item.
If service/item was ordered by the PCP but was not provided, please explain why it was not provided.

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No service/item was ordered or recommended by the specialist, emergency room provider, or hospital provider; or
3) The PCP did not order the service/item.
If the PCP did not order the service/item, did the IDT document their rationale for not ordering the service/item in the participant's medical record?

(Yes/No)

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or
3) The PACE PCP ordered the service/item.
What was the PCP's rationale for not ordering the service/item?

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or
3) The PACE PCP ordered the service/item; or
4) The PACE PCP did not document their rationale for not ordering the service/item.
Date the PCP documented their rationale for not ordering the service/item.

MM/DD/YYYY

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or
3) The PACE PCP ordered the service/item; or
4) The PACE PCP did not document their rationale for not ordering the service/item.
If the PCP did not order the service/item, did the participant receive the service/item by some other means?

For example, was the service/item provided at a specialist office?

(Yes/No)

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or
3) The PACE PCP ordered the service/item.
Date the participant received the service/item (by other means)

MM/DD/YYYY

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or
3) The PACE PCP ordered the service/item; or
4) The participant did not receive the service/item by some other means.
If the participant experienced negative outcomes, did they occur, in some part, as a result of the failure to provide or a delay in the provision of care and/or services?

(Yes/No)

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or
3) The PACE PCP ordered the services/items and they were provided as expeditiously as the participant's health required.
If yes, describe the negative outcomes.

Enter NA if:
1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or
2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or
3) The PACE PCP ordered the services/items and they were provided as expeditiously as the participant's health required.
4) The participant did not experience any 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.
(Example) Jane Smith
1234 1/1/2021 NA Yes ophthalmology 2/1/2021 glasses 2/4/2021
Yes 2/5/2021 2/28/2021 NA NA NA NA NA NA No NA
(Example) Jane Smith
1234 1/1/2021 NA Yes ophthalmology 2/1/2021 follow-up in one month 2/4/2021
No NA NA NA Yes The PCP wanted to have the participant evaluated by a retinal specialist before ordered f/u with ophthalmology. 2/5/2021 NA NA No NA
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