PACE Quality Data With RCA

PACE Quality Monitoring
Integrated User Guide

Version: 4/2/2018

Centers for Medicare & Medicaid Services

TABLE OF CONTENTS
Introduction ............................................................................................................................... 3
I.

Getting Started ................................................................................................................... 4
CMS User IDs ...........................................................................................................................................4

II. PACE Quality Monitoring ................................................................................................. 5
PACE Start Page .......................................................................................................................................5

III. Data Entry .......................................................................................................................... 6
Selection Criteria .......................................................................................................................................6
PACE Quality Indicator Selection ............................................................................................................7
PACE Quality Indicator: No Data to Report............................................................................................8
PACE Quality Indicator: Appeals........................................................................................................... 11
PACE Quality Indicator: Emergency room visits .................................................................................. 13
PACE Quality Indicator: Enrollment Data ............................................................................................ 16
PACE Quality Indicator: Denials (of Prospective Enrollees) ................................................................ 18
PACE Quality Indicator: Falls Without Injury...................................................................................... 21
PACE Quality Indicator: Grievances ..................................................................................................... 24
PACE Quality Indicator: Immunizations – Influenza (Oct. thru Mar. 20XX) ..................................... 27
PACE Quality Indicator: Immunizations - Pneumococcal ................................................................... 29
PACE Quality Indicator: Medication Administration Errors................................................................ 31
PACE Quality Indicator: Abuse ............................................................................................................. 34
PACE Quality Indicator: Adverse Drug Reaciton ................................................................................. 38
PACE Quality Indicator: Adverse Outcome ........................................................................................... 42
PACE Quality Indicator: Burns 2nd Degree or Higher .......................................................................... 46
PACE Quality Indicator: Elopement ...................................................................................................... 50
PACE Quality Indicator: Equimpment-Related Occurences................................................................. 54
PACE Quality Indicator: Falls With Injury ........................................................................................... 58
PACE Quality Indicator: Fires/Other Disasters .................................................................................... 62
PACE Quality Indicator: Foodborne Outbreak ..................................................................................... 66
PACE Quality Indicator: Infectious Disease Outbreak ......................................................................... 69
PACE Quality Indicator: Media-Related Event ..................................................................................... 72
PACE Quality Indicator: Medication-Related Occurences ................................................................... 75
PACE Quality Indicator: Motor Vehicle Accidents ............................................................................... 79
Pace Quality Indicator: Pressure Injury ................................................................................................ 82
PACE Quality Indicator: Restraint Use ................................................................................................. 86

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PACE Quality Indicator: Suicide Attempt/Suicide ................................................................................ 90
PACE Quality Indicator: Unexpected Deaths ........................................................................................ 94

IV. Upload Data ..................................................................................................................... 98
Selection Criteria ..................................................................................................................................... 98
Upload Data ............................................................................................................................................. 99
File Uploaded Successfully ..................................................................................................................... 99
Upload File Validation Error................................................................................................................ 100

V. Request Extension.......................................................................................................... 101
Selection Criteria ................................................................................................................................... 101
Request Extension ................................................................................................................................. 101
CMS Approval ....................................................................................................................................... 102

VI. PACE Reports ................................................................................................................ 103
PACE Comparative Data Report – Quality Indicator Section 1 .......................................................... 104
PACE Comparative Data Report – Quality Indicator Section 2 .......................................................... 105
PACE Site Data Report ......................................................................................................................... 107
PACE Status Report .............................................................................................................................. 109

Appendix I: HPMS Contact Information ............................................................................. 111

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INTRODUCTION
In order to comply with the PACE regulation, §460.140, §460.200(b)(1), §460.200 (c), and §460.202,
all PACE Organizations must meet external quality assessment and reporting requirements as specified
by the Centers for Medicare & Medicaid Services (CMS) and the State Administering Agency (SAA).
The PACE quality data elements are reported to CMS using the Health Plan Management System
(HPMS), an information system and data exchange mechanism for Medicare managed care organizations
(MCOs), including PACE Organizations.
HPMS PACE Organization Monitoring Functionality
The HPMS PACE Quality Monitoring module enables PACE organizations to enter certain data required
by CMS and the SAA to monitor the performance of their organization. The PACE Quality Monitoring
module allows one or more PACE organization representatives to enter and edit data for each H Number.
(The H Number is the internal CMS identification number for the managed care contract, and is
identified in the executed PACE program agreement.) An H Number may be associated with one or more
sites, and the PACE Quality Monitoring module requires data to be entered at each site.
PACE data submitted through the PACE Quality Monitoring module must be provided exclusively from
a PACE site, not the parent organization. If the PACE organization has more than one site of
care/treatment, each site must be identified separately. PACE organizations are required to report their
information quarterly.
This manual will provide PACE organization users with guidance on entering data, printing reports, and
navigating the various screens and functions in the module.

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I. GETTING STARTED
CMS USER IDS
Users must have a CMS-issued User ID and password with HPMS access in order to log into the system.
Users must also associate their User ID with the specific Medicare Advantage (MA) contract numbers
they work with in the HPMS.
To obtain a new CMS User ID, users must complete a CMS User ID request form as required. Users
may access the following web site for detailed access instructions, including forms.
https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-andSystems/HPMS/UserIDProcess.html
Direct all further questions related to HPMS user access to HPMS_access@cms.hhs.gov.

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II. PACE QUALITY MONITORING
PACE START PAGE
Below is the HPMS Home Page. This is the first page to display after the user logs into the HPMS.
Select Monitoring from the top navigation bar, then select PACE Quality Monitoring in the fly-out
menu (Table II-1) to advance to the PACE Quality Monitoring Start Page (Table II-2).
Table II-1

The PACE Quality Monitoring Start Page contains the links that enable users to enter and upload data,
view reports, request a reporting-period extension, and either log off the HPMS or return to the HPMS
Home Page.
Table II-2

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III. DATA ENTRY
To enter data (manual option – not upload option) for a PACE site, select the Data Entry link in the
right menu on the PACE Start Page (Table III-1). The user will advance to the Data Entry –
Selection Criteria screen (Table III-2).
Table III-1

SELECTION CRITERIA
Select the organization’s H number from the Data Entry – Selection Criteria screen (Table III-2). After
the H number has been selected, the site names attached to the H number will display. Select the site
name for which to enter data. After the user selects a site, the Collection Period picklist will autopopulate. Select a data-collection quarter.
Generally, only the current data collection quarter will display, but previous periods may display in
some cases.
Table III-2

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PACE QUALITY INDICATOR SELECTION
The Data Entry – Quality Indicator Selection screen (Table III-3) enables the user to specify the
quality indicator for which to enter data. Select the PACE Quality Indicator using the radio buttons to
the left of the quality indicator, and select Edit Quality Indicator.
Note that the status of each quality indicator displays. The valid statuses are: Not Started, No Data
to Report, and Data Submitted. Select Back to return to the Data Entry – Selection Criteria
screen.
Table III-3

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PACE QUALITY INDICATOR: NO DATA TO REPORT
A “No Data to Report” function is available for each quality indicator. Use this function when there is
no data for a quality indicator.
For example, to submit “No Data to Report” for Appeals, select Appeals on the Data Entry – Quality
Indicator Selection screen.
On the Data Entry – Appeals screen (Table III-4), select No Data to Report.
Table III-4

Review the confirmation data on the Data Entry – Appeals – No Data to Report screen (Table III-5).
Select Back to make a correction, or select Submit to return to the Data Entry – Quality Indicator
Selection screen.
Table III-5

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The updated status of the quality indicator “No Data to Report” will display (Table III-6).
Table III-6

A “Data To Report” function is provided to reverse a “No Data to Report” entry.
On the Data Entry – Quality Indicator Selection screen, select the quality indicator for which the
user wishes to reverse the “No Data to Report.”
For example, select Appeals, and select Edit Quality Indicator to advance to the Data Entry –
Appeals (Table III-7) screen. Then select Data To Report.
Table III-7

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On the Data Entry – Appeals – Data to Report confirmation screen (Table III-8), review the
information. Select Back to make a correction, or select Submit to be returned to the Data Entry –
Quality Indicator Selection screen.
Table III-8

On the Data Entry – Quality Indicator Selection screen (Table III-9), the status of the quality
indictor will change from “No Data to Report” to “Not Started.” After the status has changed to “Not
Started,” the user can enter data for this quality indicator.
Table III-9

If records have been reported for a quality indicator, the user must delete ALL before the user can
indicate No Data To Report.
*Note that “No Data to Report” is not an option for the quality indicators Enrollment Data,
Immunizations – Pneumococcal, and Immunization – Influenza. Zeros should be entered for these
quality indicators if there is no data to report.
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PACE QUALITY INDICATOR: APPEALS
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Appeals data.
Please refer to the PACE Quality Monitoring and Reporting Guidance for operational guidance on
reporting Appeals.
Data Reporting Requirements:
1. Source
2. Appeal Type
3. Resolution
On the Data Entry – Quality Indicator Selection screen (Table III-3), select the Appeals Quality
Indicator, and select Edit Quality Indicator.
On the Data Entry – Appeals screen (Table III-10), select Add to advance to the Data Entry –
Appeals – Add screen (Table III-11). Note that the Edit and Delete buttons are disabled on the Data
Entry – Appeals screen if there are no records available to edit or delete. To report no data for the
collection period, see the PACE Quality Indicator: No Data To Report section of the manual.
Table III-10

Select data from all dropdowns (Table III-11).
Table III-11

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Select Next to advance to the Data Entry – Appeals – Verify screen (Table III-12). Review
information. Select Back to make corrections, or Submit.
Table III-12

A Control Number generates for each Appeals record (Table III-13). To edit a record, select the radio
button next to the appropriate control number, and select Edit. To delete a record, select the radio
button next to the appropriate control number, and select Delete. Select Back to return to the Data
Entry – Quality Indicator Selection screen.
Table III-13

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PACE QUALITY INDICATOR: EMERGENCY ROOM
VISITS
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Emergency
Room and Urgent Care Center Visit data. Please refer to PACE Quality Monitoring and Reporting
Guidance for operational guidance on reporting Emergency Room Visits.
Data Reporting Requirements:
1. ER/Urgent Care Center Visit Date
2. Primary Admitting Diagnosis (ICD-10 Codes)
3. Discharge Diagnosis (ICD-10 Codes)
4. Admission to Hospital
5. Participant Living Situation
6. Participant Outcomes (User Ctrl + Right Mouse Select to mark multiple selections)
7. Has the Participant had repeat ER Visits?
On the Data Entry - Quality Indicator Selection screen (III-3), select Emergency Room Visits
Quality Indicator and then select Edit Quality Indicator.
On the Data Entry – Emergency Room Visits screen (Table III-14), select Add to advance to the
Data Entry – Emergency Room Visits – Add screen (Table III-15). Note that the Edit and Delete
buttons are disabled on the Data Entry – Emergency Room Visits screen if there are no records
available to edit or delete. To report no data for the collection period, see the PACE Quality
Indicator: No Data To Report section of the manual.
Table III-14

Enter data in all fields, picklists, and dropdowns. To add a Primary Admitting Diagnosis or
Discharge Diagnosis, enter an ICD-10 code in the Primary Admitting Diagnosis or Discharge
Diagnosis field, then select Add a Diagnosis. To search for an ICD-10 code, select the Code Lookup
link (Table III-16).
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Table III-15

Table III-16

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Select Next to advance to the Data Entry – Emergency Room Visits – Verify screen (11-17).
Review information. Select Back to make corrections, or Submit.
Table III-17

A Control Number generates for each Emergency Room Visits record (Table III-18). To edit a
record, select the radio button next to the appropriate control number, and select Edit. To delete a
record, select the radio button next to the appropriate control number, and select Delete. Select Back
to return to the Data Entry – Quality Indicator Selection screen.
Table III-18

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PACE QUALITY INDICATOR: ENROLLMENT DATA
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Enrollment data.
Please enter participants only once under the correct category. Medicare is for Medicare-Only eligible
participants, Dual Eligible is for both Medicare and Medicaid eligible, etc.
Data Reporting Requirements:
1. Total Census
2. Total New Enrollments
3. Total Disenrollments
4. Total Deaths
On the Data Entry - Quality Indicator Selection screen (Table III-3), select the Enrollment Data
Quality Indicator and select Edit Quality Indicator.
Enter data on the Data Entry – Data Enrollment screen (Table III-19).
Table III-19

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Select Next to advance to the Data Entry – Enrollment Data – Verify screen (Table III-20). Review
information. Select Back to make corrections, or Submit.
Table III-20

The user will enter the number of individuals enrolled in the PACE program at the end of each quarter.

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PACE QUALITY INDICATOR: DENIALS (OF
PROSPECTIVE ENROLLEES)
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Denials (of
Prospective Enrollees) data. Please refer to PACE Quality Monitoring and Reporting Guidance for
operational guidance on reporting Denials (of Prospective Enrollees) data.
Data Reporting Requirements:
1. Is this Person?
2. Date of Denial Occurance
3. Denial Reason
On the Data Entry - Quality Indicator Selection screen (III-3), select Denials (of Prospective
Enrollees) Quality Indicator and then select Edit Quality Indicator.
On the Data Entry – Denials (of Prospective Enrollees) screen (Table III-21), select Add to advance
to the Data Entry – Denials (of Prospective Enrollees) – Add screen (Table III-22). Note that the
Edit and Delete buttons are disabled on the Data Entry – Denials (of Prospective Enrollees) screen
if there are no records available to edit or delete. To report no data for the collection period, see the
PACE Quality Indicator: No Data To Report section of the manual.
Table III-21

Enter data in all fields, picklists, and dropdowns.

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Table III-22

Select Next to advance to the Data Entry – Denials (of Prospective Enrollees) – Verify screen (Table
III-23). Review information. Select Back to make corrections, or Submit.
Table III-23

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A Control Number generates for each Denials (of Prospective Enrollees) record (Table III-24). To
edit a record, select the radio button next to the appropriate control number, and select Edit. To delete
a record, select the radio button next to the record to be deleted, and select Delete. Select Back to
return to the Data Entry – Quality Indicator Selection screen.
Table III-24

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PACE QUALITY INDICATOR: FALLS WITHOUT INJURY
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Falls Without
Injury data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational
guidance on reporting Falls Without Injury data.
Data Reporting Requirements:
1. Location of Fall
2. Time of Fall
3. Contributing Factors (Can have multiple selections by Ctrl + select the below selections)
4. Actions Taken (User Ctrl + Right Mouse Select for multiple selections)
On the Data Entry - Quality Indicator Selection screen (III-3), select Falls Without Injury Quality
Indicator and then select Edit Quality Indicator.
On the Data Entry – Falls Without Injury screen (Table III-25), select Add to advance to the Data
Entry – Falls Without Injury – Add screen (Table III-26). Note that the Edit and Delete buttons are
disabled on the Data Entry – Falls Without Injury screen if there are no records available to edit or
delete. To report no data for the collection period, see the PACE Quality Indicator: No Data To
Report section of the manual.
Table III-25

Enter data in all fields, picklists, and dropdowns.

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Table III-26

Select Next to advance to the Data Entry – Falls Without Injury – Verify screen (Table III-27).
Review information. Select Back to make corrections, or Submit.
Table III-27

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A Control Number generates for each Falls Without Injury record (Table III-28). To edit a record,
select the radio button next to the appropriate control number, and select Edit. To delete a record,
select the radio button next to the appropriate control number, and select Delete. Select Back to return
to the Data Entry – Quality Indicator Selection screen.
Table III-28

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PACE QUALITY INDICATOR: GRIEVANCES
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Grievance data.
Please refer to PACE Quality Monitoring and Reporting Guidance for operational guidance on
reporting Grievances.
Data Reporting Requirements:
1. Source
2. Location
3. Grievance Type and Specific Issue
4. Resolution
5. Actions Taken
On the Data Entry - Quality Indicator Selection screen (III-3), select Grievances Quality Indicator
and then select Edit Quality Indicator.
On the Data Entry – Grievances screen (Table III-29), select Add to advance to the Data Entry –
Grievances – Add screen (Table III-30). Note that the Edit and Delete buttons are disabled on the Data
Entry – Grievances screen if there are no records available to edit or delete. To report no data for the
collection period, see the PACE Quality Indicator: No Data To Report section of the manual.
Table III-29

Enter data in all fields, picklists, and dropdowns.

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Table III-30

Select Next to advance to the Data Entry – Grievances – Verify screen (Table III-31). Review
information. Select Back to make corrections, or Submit.
Table III-31

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A Control Number generates for each Grievance record (Table III-32). To edit a record, select the
radio button next to the appropriate control number, and select Edit. To delete a record, select the
radio button next to the appropriate control number, and select Delete. Select Back to return to the
Data Entry – Quality Indicator Selection screen.
Table III-32

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PACE QUALITY INDICATOR: IMMUNIZATIONS –
INFLUENZA (OCT. THRU MAR. 20XX)
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Influenza
Immunization data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational
guidance on reporting Influenza Immunization data.
Please Note: while the Pneumococcal Immunizations screen will be available for all collection
periods, the Influenza Immunizations screen will only be available during the Flu season, as defined to
begin in October and end in March of the respective year.
Data Reporting Requirements:
Number of participants who received an influenza (i.e., flu) immunization during the reporting year;
(October – March 20XX)
1. Total Number of Participants
• Eligible to Receive Immunization
• Actually Received Immunization(by the PO)
• Had a Reaction to Vaccine
2. Total Participants who DID NOT Receive Immunization
• Medically Contraindicated
• Prior Immunization
• Refused
• Vaccine Unavailable
• Missed Opportunity
Frequency:
Routine immunization data will only be collected during the flu season (e.g., October to March as
defined by CMS).
Flu Immunization data will be entered on the following screen.
On the Data Entry - Quality Indicator Selection screen (III-3), select Immunizations – Influenza
(Oct. – Mar. 20XX) Quality Indicator and then select Edit Quality Indicator.
Enter data on the Data Entry – Immunizations - Influenza (Oct. – Mar. 20XX) screen (Table III33).

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Table III-33

Select Next to advance to the Data Entry – Immunizations - Influenza – Verify screen (Table III34). Review information. Select Back to make corrections, or Submit.
Please Note:
• The following edit is applied to the Data Entry – Immunizations - Influenza (Jan. – Mar.
20XX): the Total Eligible to Receive Immunization must equal Actually Received
Immunization plus the number of Participants Who Did Not Receive Immunization).
• Only one Immunizations Influenza record can be entered for each quarter. This data may be
edited by selecting Immunizations Influenza on the Data Entry – Quality Indicator Selection
screen and then the Edit Quality Indicator button. The previously entered information will
then be displayed.
Table III-34

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PACE QUALITY INDICATOR: IMMUNIZATIONS PNEUMOCOCCAL
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Pneumococcal
Immunization data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational
guidance on reporting Pneumococcal Immunization data.
Data Reporting Requirements:
1. Total Number of Participants
• Total Eligible to Receive Immunization
• Received Immunization (By the PO)
• Had a Reaction to Vaccine
2. Total Participants who DID NOT Receive Immunization
• Medically Contraindicated
• Prior Immunization
• Refused
• Vaccine Unavailable
• Missed Opportunity
Pneumococcal Immunization data will be entered on the following screen.
On the Data Entry - Quality Indicator Selection screen (III-3), select Immunizations Pneumococcal Quality Indicator and then select Edit Quality Indicator.
Enter data on the Data Entry – Immunizations - Pneumococcal screen (Table III-35).
Table III-35

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Select Next to advance to the Data Entry – Immunizations - Pneumococcal – Verify screen (Table
III-36). Review information. Select Back to make corrections, or Submit.
Please Note:
•
•

The following edit is applied to the Data Entry – Immunizations - Pneumococcal: Total
Eligible to Receive Immunization must equal Actually Received Immunization plus the number
of Participants Who Did Not Receive Immunization.
Only one Pneumococcal Immunizations record can be entered for each quarter. This data may
be edited by selecting Pneumococcal Immunizations on the Data Entry – Quality Indicator
Selection screen and then the Edit Quality Indicator button. The previously entered
information will then be displayed.
Table III-36

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PACE QUALITY INDICATOR: MEDICATION
ADMINISTRATION ERRORS
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Medication
Administration Error data. Please refer to PACE Quality Monitoring and Reporting Guidance for
operational guidance on reporting Medication Administration Error data.
Data Reporting Requirements:
1.
2.
3.
4.

Location of Incident
Type of Medication Error
Contributing Factors
Actions Taken

On the Data Entry - Quality Indicator Selection screen (III-3), select Medication Administration
Errors Quality Indicator and then select Edit Quality Indicator.
On the Data Entry – Medication Administration Errors screen (Table III-37), select Add to
advance to the Data Entry – Medication Administration Errors – Add screen (Table III-38). Note
that the Edit and Delete buttons are disabled on the Data Entry – Medication Administration
Errors screen if there are no records available to edit or delete. To report no data for the collection
period, see the PACE Quality Indicator: No Data To Report section of the manual.
Table III-37

Enter data in all fields, picklists, and dropdowns.

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Table III-38

Select Next to advance to the Data Entry – Medication Administration Errors – Verify screen
(Table III-39). Review information. Select Back to make corrections, or Submit.
Table III-39

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A Control Number generates for each Medication Administration Error record (Table III-40). To
edit a record, select the radio button next to the appropriate control number, and select Edit. To delete
a record, select the radio button next to the appropriate control number, and select Delete. Select
Back to return to the Data Entry – Quality Indicator Selection screen.
Table III-40

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PACE QUALITY INDICATOR: ABUSE
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Abuse data.
Please refer to PACE Quality Monitoring and Reporting GuidancePACE Quality Monitoring and
Reporting Guidance for operational guidance on reporting Abuse.
Data Reporting Requirements:
1. Location of Incident
2. Was the Participant Hospitalized?
3. Participant's Current Status
4. Type of Abuse
5. Person Accused of Abuse
6. Was Compliance Maintained with Plan of Care?
7. Was Compliance Maintained with Participant’s Medications?
8. Was the Participant Receiving Mental Health or Substance Abuse Service Prior to the
Incident?
9. Was Adult Protective Services Notified?
ROOT CAUSE ANALYSIS:
10. Contributing Factors*
11. Actions Taken*
12. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Abuse Quality Indicator and
then select Edit Quality Indicator.
On the Data Entry – Abuse screen (Table III-41), select Add to advance to the Data Entry – Abuse –
Add screen (Table III-42). Note that the Edit and Delete buttons are disabled on the Data Entry –
Abuse screen if there are no records available to edit or delete. To report no data for the collection
period, see the PACE Quality Indicator: No Data To Report section of the manual.
Table III-41

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Enter data in all fields, picklists, and dropdowns. To add a Significant Diagnosis, enter an ICD-10
code in the Significant Diagnosis field, then select Add a Diagnosis. To search for an ICD-10 code,
select the Code Lookup link (Table III-43).
Table III-42

Table III-43

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Make Root Cause Analysis selections (Table III-44). To upload an attachment, select “Browse” and
then choose a document.
Table III-44

Select Next to advance to the Data Entry – Abuse – Verify screen (Table III-45). Review
information. Select Back to make corrections, or Submit.

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Table III-45

A Control Number generates for each Abuse record (Table III-46). To edit a record, select the radio
button next to the appropriate control number, and select Edit. To delete a record, select the radio
button next to the appropriate control number, and select Delete. Select Back to return to the Data
Entry – Quality Indicator Selection screen.
Table III-46

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PACE QUALITY INDICATOR: ADVERSE DRUG
REACITON
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Adverse Drug
Reaction data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational
guidance on reporting Adverse Drug Reaction.
Data Reporting Requirements:
1. Location of Incident
2. Was the Participant Hospitalized?
3. Participant's Current Status
ROOT CAUSE ANALYSIS:
4. Contributing Factors*
5. Actions Taken*
6. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Adverse Drug Reaction
Quality Indicator and then select Edit Quality Indicator.
On the Data Entry – Adverse Drug Reaction screen (Table III-47), select Add to advance to the
Data Entry – Adverse Drug Reaction – Add screen (Table III-48). Note that the Edit and Delete
buttons are disabled on the Data Entry – Abuse screen if there are no records available to edit or
delete. To report no data for the collection period, see the PACE Quality Indicator: No Data To
Report section of the manual.
Table III-47

Enter data in all fields, picklists, and dropdowns. To add an Adverse Outcome or Significant
Diagnosis, enter an ICD-10 code in the Adverse Outcome or Significant Diagnosis field, then select
Add an Outcome or Add a Diagnosis. To search for an ICD-10 code, select the Code Lookup link
(Table III-49).
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Table III-48

Table III-49

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Make Root Cause Analysis selections (Table III-50). To upload an attachment, select “Browse” and
then choose a document.
Table III-50

Select Next to advance to the Data Entry – Adverse Drug Reaction – Verify screen (Table III-51).
Review information. Select Back to make corrections, or Submit.

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Table III-51

A Control Number generates for each Adverse Drug Reaction record (Table III-52). To edit a
record, select the radio button next to the appropriate control number, and select Edit. To delete a
record, select the radio button next to the appropriate control number, and select Delete. Select Back
to return to the Data Entry – Quality Indicator Selection screen.
Table III-52

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PACE QUALITY INDICATOR: ADVERSE OUTCOME
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Adverse
Outcome data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational
guidance on reporting Adverse Outcome data.
Data Reporting Requirements:
1. Location of Incident
2. Was the Participant Hospitalized?
3. Participant's Current Status
ROOT CAUSE ANALYSIS:
4. Contributing Factors*
5. Actions Taken*
6. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Adverse Outcome Quality
Indicator and then select Edit Quality Indicator.
On the Data Entry – Adverse Outcome screen (Table III-53), select Add to advance to the Data
Entry – Adverse Outcome – Add screen (Table III-54). Note that the Edit and Delete buttons are
disabled on the Data Entry – Adverse Outcome screen if there are no records available to edit or
delete. To report no data for the collection period, see the PACE Quality Indicator: No Data To
Report section of the manual.
Table III-53

Enter data in all fields, picklists, and dropdowns. To add an Adverse Outcome or Significant
Diagnosis, enter an ICD-10 code in the Adverse Outcome or Significant Diagnosis field, then select
Add an Outcome or Add a Diagnosis. To search for an ICD-10 code, select the Code Lookup link
(Table III-55).

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Table III-54

Table III-55

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Make Root Cause Analysis selections (Table III-56). To upload an attachment, select “Browse” and
then choose a document.
Table III-56

Select Next to advance to the Data Entry – Adverse Outcome – Verify screen (Table III-57).
Review information. Select Back to make corrections, or Submit.

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Table III-57

A Control Number generates for each Adverse Outcome record (Table III-58). To edit a record,
select the radio button next to the appropriate control number, and select Edit. To delete a record,
select the radio button next to the appropriate control number, and select Delete. Select Back to return
to the Data Entry – Quality Indicator Selection screen.
Table III-58

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PACE QUALITY INDICATOR: BURNS 2ND DEGREE OR
HIGHER
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Burns 2nd
Degree or Higher data. Please refer to PACE Quality Monitoring and Reporting Guidance for
operational guidance on reporting Burns 2nd Degree or Higher data.
Data Reporting Requirements:
1. Location of Incident
2. Was the Participant Hospitalized?
3. Participant's Current Status
ROOT CAUSE ANALYSIS:
4. Contributing Factors*
5. Actions Taken*
6. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Burns 2nd Degree or Higher
Quality Indicator and then select Edit Quality Indicator.
On the Data Entry – Burns 2nd Degree or Higher screen (Table III-59), select Add to advance to the
Data Entry – Burns 2nd Degree or Higher – Add screen (Table III-60). Note that the Edit and
Delete buttons are disabled on the Data Entry – Burns 2nd Degree or Higher screen if there are no
records available to edit or delete. To report no data for the collection period, see the PACE Quality
Indicator: No Data To Report section of the manual.
Table III-59

Enter data in all fields, picklists, and dropdowns. To add a Type of Burn or Significant Diagnosis,
enter an ICD-10 code in the Type of Burn or Significant Diagnosis field, and then select Add. To
search for an ICD-10 code, select the Code Lookup link (Table III-61).
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Table III-60

Table III-61

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Make Root Cause Analysis selections (Table III-62). To upload an attachment, select “Browse” and
then choose a document.
Table III-62

Select Next to advance to the Data Entry – Burns 2nd Degree of Higher – Verify screen (Table III63). Review information. Select Back to make corrections, or Submit.

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Table III-63

A Control Number generates for each Burns 2nd Degree or Higher record (Table III-64). To edit a
record, select the radio button next to the appropriate control number, and select Edit. To delete a
record, select the radio button next to the appropriate control number, and select Delete. Select Back
to return to the Data Entry – Quality Indicator Selection screen.
Table III-64

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PACE QUALITY INDICATOR: ELOPEMENT
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Elopement data.
Please refer to PACE Quality Monitoring and Reporting Guidance for operational guidance on
reporting Elopement data.
Data Reporting Requirements:
1. Location of Incident
2. Time of Incident
3. Was the Participant Hospitalized?
4. Participant's Current Status
ROOT CAUSE ANALYSIS:
5. Contributing Factors*
6. Actions Taken*
7. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Elopement Quality Indicator
and then select Edit Quality Indicator.
On the Data Entry – Elopement screen (Table III-65), select Add to advance to the Data Entry –
Elopement – Add screen (Table III-66). Note that the Edit and Delete buttons are disabled on the
Data Entry – Elopement screen if there are no records available to edit or delete. To report no data
for the collection period, see the PACE Quality Indicator: No Data To Report section of the
manual.
Table III-65

Enter data in all fields, picklists, and dropdowns. To add a Significant Diagnosis, enter ICD-10 code
in the Significant Diagnosis field, then select Add a Diagnosis. To search for an ICD-10 code, select
the Code Lookup link (Table III-67).

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Table III-66

Table III-67

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Make Root Cause Analysis selections (Table III-68). To upload an attachment, select “Browse” and
then choose a document.
Table III-68

Select Next to advance to the Data Entry – Elopement – Verify screen (Table III-69). Review
information. Select Back to make corrections, or Submit.

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Table III-69

A Control Number generates for each Elopement record (Table III-70). To edit a record, select the
radio button next to the appropriate control number, and select Edit. To delete a record, select the
radio button next to the appropriate control number, and select Delete. Select Back to return to the
Data Entry – Quality Indicator Selection screen.
Table III-70

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PACE QUALITY INDICATOR: EQUIMPMENT-RELATED
OCCURENCES
The HPMS Pace Quality Reporting Module provides functionality for the reporting of EquipmentRelated Occurrences data. Please refer to PACE Quality Monitoring and Reporting Guidance for
operational guidance on reporting Equipment-Related Occurrences data.
Data Reporting Requirements:
1. Location of Incident
2. Was the Participant Hospitalized?
3. Participant's Current Status
ROOT CAUSE ANALYSIS:
4. Contributing Factors*
5. Actions Taken*
6. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Equipment-Related
Occurrences Quality Indicator and then select Edit Quality Indicator.
On the Data Entry – Equipment-Related Occurrences screen (Table III-71), select Add to advance
to the Data Entry – Equipment-Related Occurrences – Add screen (Table III-72). Note that the
Edit and Delete buttons are disabled on the Data Entry – Equipment-Related Occurrences screen if
there are no records available to edit or delete. To report no data for the collection period, see the
PACE Quality Indicator: No Data To Report section of the manual.
Table III-71

Enter data in all fields, picklists, and dropdowns. To add an Adverse Outcome or Significant
Diagnosis, enter ICD-10 code in the Adverse Outcome or Significant Diagnosis field, then select Add
an Outcome or Add a Diagnosis. To search for an ICD-10 code, select the Code Lookup link (Table
III-73).
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Table III-72

Table III-73

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Make Root Cause Analysis selections (Table III-74). To upload an attachment, select “Browse” and
then choose a document.
Table III-74

Select Next to advance to the Data Entry – Abuse – Verify screen (Table III-75). Review
information. Select Back to make corrections, or Submit.

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Table III-75

A Control Number generates for each Equipment-Related Occurrences record (Table III-76). To
edit a record, select the radio button next to the appropriate control number, and select Edit. To delete
a record, select the radio button next to the appropriate control number, and select Delete. Select Back
to return to the Data Entry – Quality Indicator Selection screen.
Table III-76

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PACE QUALITY INDICATOR: FALLS WITH INJURY
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Falls With
Injury data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational
guidance on reporting Falls With Injury data.
Data Reporting Requirements:
1. Location of Incident
2. Was the Participant Hospitalized?
3. Participant's Current Status
ROOT CAUSE ANALYSIS:
4. Contributing Factors *
5. Actions Taken*
6. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Falls With Injury Quality
Indicator and then select Edit Quality Indicator.
On the Data Entry – Falls With Injury screen (Table III-77), select Add to advance to the Data
Entry – Falls With Injury – Add screen (Table III-78). Note that the Edit and Delete buttons are
disabled on the Data Entry – Falls With Injury screen if there are no records available to edit or
delete. To report no data for the collection period, see the PACE Quality Indicator: No Data To
Report section of the manual.
Table III-77

Enter data in all fields, picklists, and dropdowns. To add an Adverse Outcome or Significant
Diagnosis, enter ICD-10 code in the Adverse Outcome or Significant Diagnosis field, then select Add
an Outcome or Add a Diagnosis. To search for an ICD-10 code, select the Code Lookup link (Table
III-79).

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Table III-78

Table III-79

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Make Root Cause Analysis selections (Table III-80). To upload an attachment, select “Browse” and
then choose a document.
Table III-80

Select Next to advance to the Data Entry – Abuse – Verify screen (Table III-81). Review
information. Select Back to make corrections, or Submit.

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Table III-81

A Control Number generates for each Falls With Injury record (Table III-82). To edit a record,
select the radio button next to the appropriate control number, and select Edit. To delete a record,
select the radio button next to the appropriate control number, and select Delete. Select Back to return
to the Data Entry – Quality Indicator Selection screen.
Table III-82

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PACE QUALITY INDICATOR: FIRES/OTHER DISASTERS
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Fires/Other
Disasters data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational
guidance on reporting Fires/Other Disasters data.
Data Reporting Requirements:
1. Type of Disaster
2. Location of Incident
3. Was the Participant Hospitalized?
4. Participant’s Current Status
ROOT CAUSE ANALYSIS:
5. Contributing Factors*
6. Actions Taken*
7. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Fires/Other Disasters Quality
Indicator and then select Edit Quality Indicator.
On the Data Entry – Fires/Other Disasters screen (Table III-83), select Add to advance to the Data
Entry – Fires/Other Disasters – Add screen (Table III-84). Note that the Edit and Delete buttons are
disabled on the Data Entry – Fires/Other Disasters screen if there are no records available to edit or
delete. To report no data for the collection period, see the PACE Quality Indicator: No Data To
Report section of the manual.
Table III-83

Enter data in all fields, picklists, and dropdowns. To add an Adverse Outcome or Significant
Diagnosis, enter ICD-10 code in the Adverse Outcome or Significant Diagnosis field, then select Add
an Outcome or Add a Diagnosis. To search for an ICD-10 code, select the Code Lookup link (Table
III-85).
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Table III-84

Table III-85

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Make Root Cause Analysis selections (Table III-86). To upload an attachment, select “Browse” and
then choose a document.
Table III-86

Select Next to advance to the Data Entry – Fires/Other Disasters – Verify screen (Table III-87).
Review information. Select Back to make corrections, or Submit.

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Table III-87

A Control Number generates for each Fires/Other Disasters record (Table III-88). To edit a record,
select the radio button next to the appropriate control number, and select Edit. To delete a record,
select the radio button next to the appropriate control number, and select Delete. Select Back to return
to the Data Entry – Quality Indicator Selection screen.
Table III-88

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PACE QUALITY INDICATOR: FOODBORNE OUTBREAK
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Foodborne
Outbreak data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational
guidance on reporting Foodborne Outbreak data.
Data Reporting Requirements:
1. Were the Participants Hospitalized?
2. Location of Incident
3. Participants' Current Status*
4. Incident Reported To
ROOT CAUSE ANALYSIS:
5. Contributing Factors*
6. Type of Pathogen
7. Actions Taken*
8. Ongoing Improvements
On the Data Entry - Quality Indicator Selection screen (III-3), select Foodborne Outbreak Quality
Indicator and then select Edit Quality Indicator.
On the Data Entry – Foodborne Outbreak screen (Table III-89), select Add to advance to the Data
Entry – Foodborne Outbreak – Add screen (Table III-90). Note that the Edit and Delete buttons are
disabled on the Data Entry – Foodborne Outbreak screen if there are no records available to edit or
delete. To report no data for the collection period, see the PACE Quality Indicator: No Data To
Report section of the manual.
Table III-89

Enter data in all fields, picklists, and dropdowns.

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Table III-90

Make Root Cause Analysis selections (Table III-91). To upload an attachment, select “Browse” and
then choose a document.
Table III-91

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Select Next to advance to the Data Entry – Foodborne Outbreak – Verify screen (Table III-92).
Review information. Select Back to make corrections, or Submit.
Table III-92

A Control Number generates for each Foodborne Outbreak record (Table III-93). To edit a record,
select the radio button next to the appropriate control number, and select Edit. To delete a record,
select the radio button next to the appropriate control number, and select Delete. Select Back to return
to the Data Entry – Quality Indicator Selection screen.
Table III-93

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PACE QUALITY INDICATOR: INFECTIOUS DISEASE
OUTBREAK
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Infectious
Disease Outbreak data. Please refer to PACE Quality Monitoring and Reporting Guidance for
operational guidance on reporting Infectious Disease Outbreak data.
Data Reporting Requirements:
1. Were the Participants Hospitalized?
2. Location of Incident*
3. Participants' Current Status*
4. Incident Reported To
ROOT CAUSE ANALYSIS:
5. Contributing Factors*
6. Type of Pathogen
7. Actions Taken*
8. Ongoing Improvements
On the Data Entry - Quality Indicator Selection screen (III-3), select Infectious Disease Outbreak
Quality Indicator and then select Edit Quality Indicator.
On the Data Entry – Infectious Disease Outbreak screen (Table III-94), select Add to advance to the
Data Entry – Infectious Disease Outbreak – Add screen (Table III-95). Note that the Edit and
Delete buttons are disabled on the Data Entry – Infectious Disease Outbreak screen if there are no
records available to edit or delete. To report no data for the collection period, see the PACE Quality
Indicator: No Data To Report section of the manual.
Table III-94

Enter data in all fields, picklists, and dropdowns.

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Table III-95

Make Root Cause Analysis selections (Table III-96). To upload an attachment, select “Browse” and
then choose a document.
Table III-96

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Select Next to advance to the Data Entry – Infectious Disease Outbreak – Verify screen (Table III97). Review information. Select Back to make corrections, or Submit.
Table III-97

A Control Number generates for each Infectious Disease Outbreak record (Table III-98). To edit a
record, select the radio button next to the appropriate control number, and select Edit. To delete a
record, select the radio button next to the appropriate control number, and select Delete. Select Back
to return to the Data Entry – Quality Indicator Selection screen.
Table III-98

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PACE QUALITY INDICATOR: MEDIA-RELATED EVENT
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Media-Related
Event data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational guidance
on reporting Media-Related Event data.
Data Reporting Requirements:
1. Were the Participants Hospitalized?
2. Participants' Current Status*
3. Media Reporting the Event*
ROOT CAUSE ANALYSIS:
4. Contributing Factors*
5. Actions Taken*
6. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Media-Related Event Quality
Indicator and then select Edit Quality Indicator.
On the Data Entry – Media-Related Event screen (Table III-99), select Add to advance to the Data
Entry – Media-Related Event – Add screen (Table III-100). Note that the Edit and Delete buttons
are disabled on the Data Entry – Media-Related Event screen if there are no records available to edit
or delete. To report no data for the collection period, see the PACE Quality Indicator: No Data To
Report section of the manual.
Table III-99

Enter data in all fields, picklists, and dropdowns.

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Table III-100

Make Root Cause Analysis selections (Table III-101). To upload an attachment, select “Browse” and
then choose a document.
Table III-101

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Select Next to advance to the Data Entry – Media-Related Event – Verify screen (Table III-102).
Review information. Select Back to make corrections, or Submit.
Table III-102

A Control Number generates for each Media-Related Event record (Table III-103). To edit a
record, select the radio button next to the appropriate control number, and select Edit. To delete a
record, select the radio button next to the appropriate control number, and select Delete. Select Back
to return to the Data Entry – Quality Indicator Selection screen.
Table III-103

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PACE QUALITY INDICATOR: MEDICATION-RELATED
OCCURENCES
The HPMS Pace Quality Reporting Module provides functionality for the reporting of MedicationRelated Occurrences data. Please refer to PACE Quality Monitoring and Reporting Guidance for
operational guidance on reporting Medication-Related Occurrences data.
Data Reporting Requirements:
1. Location of Incident
2. Type of Medication Error
3. Was the Participant Hospitalized?
4. Participant's Current Status
ROOT CAUSE ANALYSIS:
5. Contributing Factors*
6. Actions Taken*
7. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Medication-Related
Occurrences Quality Indicator and then select Edit Quality Indicator.
On the Data Entry – Medication-Related Occurrences screen (Table III-104), select Add to advance
to the Data Entry – Medication-Related Occurrences – Add screen (Table III-105). Note that the
Edit and Delete buttons are disabled on the Data Entry – Medication-Related Occurrences screen if
there are no records available to edit or delete. To report no data for the collection period, see the
PACE Quality Indicator: No Data To Report section of the manual.
Table III-104

Enter data in all fields, picklists, and dropdowns. To add an Adverse Outcome or Significant
Diagnosis, enter ICD-10 code in the Adverse Outcome or Significant Diagnosis field, then select Add
an Outcome or Add a Diagnosis. To search for an ICD-10 code, select the Code Lookup link (Table
III-106).
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Table III-105

Table III-106

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Make Root Cause Analysis selections (Table III-107). To upload an attachment, select “Browse” and
choose a document.
Table III-107

Select Next to advance to the Data Entry – Medication-Related Occurrences – Verify screen (Table
III-108). Review information. Select Back to make corrections, or Submit.

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Table III-108

A Control Number generates for each Medication-Related Occurrences record (Table III-109). To
edit a record, select the radio button next to the appropriate control number, and select Edit. To delete
a record, select the radio button next to the appropriate control number, and select Delete. Select Back
to return to the Data Entry – Quality Indicator Selection screen.
Table III-109

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PACE QUALITY INDICATOR: MOTOR VEHICLE
ACCIDENTS
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Motor Vehicle
Accidents data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational
guidance on reporting Motor Vehicle Accidents data.
Data Reporting Requirements:
1. Were the Participants Hospitalized?
2. Participant’s Current Status*
3. Other Vehicles/Parties Involved*
4. Were any non-PACE participants injured?
5. Was the PACE driver issued a citation ?
ROOT CAUSE ANALYSIS:
6. Contributing Factors*
7. Actions Taken*
8. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Motor Vehicle Accidents
Quality Indicator and then select Edit Quality Indicator.
On the Data Entry – Motor Vehicle Accidents screen (Table III-110), select Add to advance to the
Data Entry – Motor Vehicle Accidents – Add screen (Table III-111). Note that the Edit and Delete
buttons are disabled on the Data Entry – Motor Vehicle Accidents screen if there are no records
available to edit or delete. To report no data for the collection period, see the PACE Quality
Indicator: No Data To Report section of the manual.
Table III-110

Enter data in all fields, picklists, and dropdowns.

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Table III-111

Make Root Cause Analysis selections (Table III-112). To upload an attachment, select “Browse” and
then choose a document.
Table III-112

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Select Next to advance to the Data Entry – Motor Vehicle Accidents – Verify screen (Table III113). Review information. Select Back to make corrections, or Submit.
Table III-113

A Control Number generates for each Motor Vehicle Accidents record (Table III-114). To edit a
record, select the radio button next to the appropriate control number, and select Edit. To delete a
record, select the radio button next to the appropriate control number, and select Delete. Select Back
to return to the Data Entry – Quality Indicator Selection screen.
Table III-114

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PACE QUALITY INDICATOR: PRESSURE INJURY
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Pressure Injury
data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational guidance on
reporting Pressure Injury data.
Data Reporting Requirements:
1. Location of Incident
2. Pressure Injury
3. Location of Pressure Injury
4. Was the Participant Hospitalized?
5. Participant's Current Status
ROOT CAUSE ANALYSIS:
6. Contributing Factors*
7. Actions Taken*
8. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Pressure Injury Quality
Indicator and then select Edit Quality Indicator.
On the Data Entry – Pressure Injury screen (Table III-115), select Add to advance to the Data
Entry – Pressure Injury – Add screen (Table III-116). Note that the Edit and Delete buttons are
disabled on the Data Entry – Pressure Injury screen if there are no records available to edit or delete.
To report no data for the collection period, see the PACE Quality Indicator: No Data To Report
section of the manual.
Table III-115

Enter data in all fields, picklists, and dropdowns. To add a Significant Diagnosis, enter ICD-10 code
in the Significant Diagnosis field, then select Add a Diagnosis. To search for an ICD-10 code, select
the Code Lookup link (Table III-117).

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Table III-116

Table III-117

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Make Root Cause Analysis selections (Table III-118). To upload an attachment, select “Browse” and
then choose a document.
Table III-118

Select Next to advance to the Data Entry – Pressure Injury – Verify screen (Table III-119). Review
information. Select Back to make corrections, or Submit.

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Table III-119

A Control Number generates for each Pressure Injury record (Table III-120). To edit a record,
select the radio button next to the appropriate control number, and select Edit. To delete a record,
select the radio button next to the appropriate control number, and select Delete. Select Back to return
to the Data Entry – Quality Indicator Selection screen.
Table III-120

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PACE QUALITY INDICATOR: RESTRAINT USE
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Restraint Use
data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational guidance on
reporting Restraint Use data.
Data Reporting Requirements:
1. Location of Incident
2. Reason for Restraint Use*
3. Type of Restraint
4. Was the Participant Hospitalized?
5. Participant's Current Status
ROOT CAUSE ANALYSIS:
6. Contributing Factors*
7. Actions Taken*
8. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Restraint Use Quality
Indicator and then select Edit Quality Indicator.
On the Data Entry – Restraint Use screen (Table III-121), select Add to advance to the Data Entry –
Restraint Use – Add screen (Table III-122). Note that the Edit and Delete buttons are disabled on the
Data Entry – Restraint Use screen if there are no records available to edit or delete. To report no
data for the collection period, see the PACE Quality Indicator: No Data To Report section of the
manual.
Table III-121

Enter data in all fields, picklists, and dropdowns. To add an Adverse Outcome or Significant
Diagnosis, enter ICD-10 code in the Adverse Outcome or Significant Diagnosis field, then select Add
an Outcome or Add a Diagnosis. To search for an ICD-10 code, select the Code Lookup link (Table
III-123).
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Table III-122

Table III-123

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Make Root Cause Analysis selections (Table III-124). To upload an attachment, select “Browse” and
then choose a document.
Table III-124

Select Next to advance to the Data Entry – Restraint Use – Verify screen (Table III-125). Review
information. Select Back to make corrections, or Submit

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Table III-125

A Control Number generates for each Restraint Use record (Table III-126). To edit a record, select
the radio button next to the appropriate control number, and select Edit. To delete a record, select the
radio button next to the appropriate control number, and select Delete. Select Back to return to the
Data Entry – Quality Indicator Selection screen.
Table III-126

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PACE QUALITY INDICATOR: SUICIDE
ATTEMPT/SUICIDE
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Suicide
Attempt/Suicide data. Please refer to PACE Quality Monitoring and Reporting Guidance for
operational guidance on reporting Suicide Attempt/Suicide data.
Data Reporting Requirements:
1. Location of Incident
2. Type of Incident
3. Immediate Action Taken*
4. Was the Participant Hospitalized?
5. Participant's Current Status
ROOT CAUSE ANALYSIS:
6. Contributing Factors*
7. Actions Taken*
8. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Suicide Attempt/Suicide
Quality Indicator and then select Edit Quality Indicator.
On the Data Entry – Suicide Attempt/Suicide screen (Table III-127), select Add to advance to the
Data Entry – Suicide Attempt/Suicide – Add screen (Table III-128). Note that the Edit and Delete
buttons are disabled on the Data Entry – Suicide Attempt/Suicide screen if there are no records
available to edit or delete. To report no data for the collection period, see the PACE Quality
Indicator: No Data To Report section of the manual.
Table III-127

Enter data in all fields, picklists, and dropdowns. To add a Significant Diagnosis, enter ICD-10 code
in the Significant Diagnosis field, then select Add a Diagnosis. To search for an ICD-10 code, select
the Code Lookup link (Table III-129).
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Table III-128

Table III-129

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Make Root Cause Analysis selections (Table III-130). To upload an attachment, select “Browse” and
then choose a document.
Table III-130

Select Next to advance to the Data Entry – Suicide Attempt/Suicide – Verify screen (Table III-131).
Review information. Select Back to make corrections, or Submit.

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Table III-131

A Control Number generates for each Suicide Attempt/Suicide record (Table III-132). To edit a
record, select the radio button next to the appropriate control number, and select Edit. To delete a
record, select the radio button next to the appropriate control number, and select Delete. Select Back
to return to the Data Entry – Quality Indicator Selection screen.
Table III-132

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PACE QUALITY INDICATOR: UNEXPECTED DEATHS
The HPMS Pace Quality Reporting Module provides functionality for the reporting of Unexpected
Deaths data. Please refer to PACE Quality Monitoring and Reporting Guidance for operational
guidance on reporting Unexpected Deaths data.
Data Reporting Requirements:
1. Location of Incident
2. Was the Participant Hospitalized?
3. Participant's Current Status
ROOT CAUSE ANALYSIS:
4. Contributing Factors*
5. Actions Taken*
6. Ongoing Improvements*
On the Data Entry - Quality Indicator Selection screen (III-3), select Unexpected Deaths Quality
Indicator and then select Edit Quality Indicator.
On the Data Entry – Unexpected Deaths screen (Table III-133), select Add to advance to the Data
Entry – Unexpected Deaths – Add screen (Table III-134). Note that the Edit and Delete buttons are
disabled on the Data Entry – Unexpected Deaths screen if there are no records available to edit or
delete. To report no data for the collection period, see the PACE Quality Indicator: No Data To
Report section of the manual.
Table III-133

Enter data in all fields, picklists, and dropdowns. To add an Adverse Outcome or Significant
Diagnosis, enter ICD-10 code in the Adverse Outcome or Significant Diagnosis field, then select Add
an Outcome or Add a Diagnosis. To search for an ICD-10 code, select the Code Lookup link (Table
III-135).

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Table III-134

Table III-135

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Make Root Cause Analysis selections (Table III-136). To upload an attachment, select “Browse” and
then choose a document.
Table III-136

Select Next to advance to the Data Entry – Unexpected Deaths – Verify page (Table III-137).
Review information. Select Back to make corrections, or Submit.

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Table III-137

A Control Number generates for each Unexpected Deaths record (Table III-138). To edit a record,
select the radio button next to the appropriate control number, and select Edit. To delete a record,
select the radio button next to the appropriate control number, and select Delete. Select Back to return
to the Data Entry – Quality Indicator Selection screen.
Table III-138

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IV. UPLOAD DATA
The HPMS PACE Quality Monitoring module provides PACE Org. users with the ability to upload
certain NON-RCA indicator data in BULK, via the Upload Data functionality.
For detailed instructions on preparing your files for upload, please refer to the “Upload Instructions”
and “Upload Templates and Record Layouts” documentation available under the Documentation
section within the HPMS PACE Quality Monitoring module.
To process the uploads once your file(s) are prepared, on the PACE Start Page (Table II-2), select on
the Upload Data link on the Right-hand menu to advance to the Upload Data – Selection Criteria
screen (Table IV-1).

SELECTION CRITERIA
The Upload Data – Selection Criteria screen (Table IV-1) displays the list of H Numbers assigned to
the user based on the PACE Organization affiliation. The user selects the H Number for which they
would like to upload data; the screen will auto-populate with the site names tied to that H number.
Select the site name for which the data is to be uploaded; the collection period will auto-populate.
Select the data collection quarter.
Generally, only the current data collection quarter will be displayed for selection. However, previous
periods may be displayed under some circumstances.
Table IV-1

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UPLOAD DATA
From the Upload Data screen (Table IV-2) follow the on-screen instruction for uploading data.
Consult the “Upload Instructions” link under Documentation on the PACE Start Page screen for
more detailed instructions.
Table IV-2

FILE UPLOADED SUCCESSFULLY
When an upload is successful the user will receive a screen similar to Table IV-3. The relevant items
on this screen are the Contract Number and the Valid Rows. The number of Valid Rows should match
the number of rows, absent the header row, in the text file which was uploaded.
Table IV-3

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UPLOAD FILE VALIDATION ERROR
A screen similar to Table IV-4 will display when an upload fails. It indicates the line number(s) and
field(s) where the error occurred, the text of the field with the invalid data, and an error message. Note
that a file with a single error will be rejected in its entirety.
Table IV-4

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V. REQUEST EXTENSION
The HPMS PACE Quality Reporting Module allows for the reporting of data for a quarter 45 days
after the close of the quarter. In certain cases, it may be required to request an extension to allow
further time to report.
On the PACE Quality Monitoring Start Page (Table II-2), select the Request Extension link on the
right-hand menu to advance to the Request Extension – Selection Criteria screen (Table V-1).

SELECTION CRITERIA
The Request Extension – Selection Criteria screen (Table V-1) displays the list of H Numbers
assigned to the user based on the PACE Organization affiliation. The user selects the H Number for
which they would like to request an extension. Once the H number has been selected, the Select a Site
field auto-populates with the site names associated with the H number. The user will then select the
site name for which they wish to request an extension and select Next.
Table V-1

REQUEST EXTENSION
At the Request Extension screen (Table V-2) select the checkbox next to each Collection Period that
is to be included in this extension request. Extension Request date is the date to which you wish to
extend the reporting period. The extension date must be a future date from the End Data Collection
date. Enter the reasons for the extension in the Reason for Extension Request text box; select Next.
The user will advance to the Request Extension – Extension Request – Confirmation screen (Table
V-3).
Select Back to return to the Request Extension screen.
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Table V-2

On the Request Extension – Extension Request – Confirmation screen (Table V-3) review the
information. Select Back to make a correction, or select Submit.
Subsequent to the submission, the user will receive an HPMS email informing them that the extension
request has been received by CMS.
Table V-3

CMS APPROVAL
Once the user has submitted the extension request, CMS will review the submission and determine if it
is approved. Each user will be notified of its approval status by CMS via an HPMS email. If CMS
approves the request for extension, the users will have until the CMS approved date to submit all data.
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VI. PACE REPORTS
The PACE Reports allow users to access and view the Comparative Data Report – Quality Indicator
Section 1, Comparative Data Report – Quality Indicator Section 2, Root Cause Analysis Report, Site
Data Report, and Status Report. The reports provide easy and quick reference for data comparison
across PACE Organizations, the review of site data, and the data entry status of each quality indicator
for each PACE site.
On the PACE Quality Monitoring Start Page (Table II-2), select the PACE Reports link on the
right-hand menu to advance to the HPMS PACE Reports – Select a Report screen (Table VI-1).
This screen displays a list of the reports available to PACE Organizations. To view a PACE report,
select the report name and then select Next.
Please Note: The reports contain, except for the comparative reports, only data submitted by the
user’s PACE Organization. No data, other than contact information, is viewable by other PACE
Organizations.
Table VI-1

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PACE COMPARATIVE DATA REPORT – QUALITY
INDICATOR SECTION 1
The Comparative Data Report – Quality Indicator Section 1 displays comparative data of like
organizations without revealing identifiable information.
Select the Reporting Period(s), Region(s), and Reporting Section for which you wish to run the report,
and select Next (Table VI-2). To choose a different PACE report, select Back.
Table VI-2

Select Generate Report to view the report, or select Back to choose a different Reporting Period,
Region, or Report Section (Table VI-3).
Table VI-3

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The PACE Comparative Data Report – Quality Indicator Section 1 will display (Table VI-4).
Select Download to Excel to export the report contents to Excel, or select Back to return to the
previous screen.
Table VI-4

PACE COMPARATIVE DATA REPORT – QUALITY
INDICATOR SECTION 2
The Comparative Data Report – Quality Indicator Section 2 displays comparative data of like
organizations without revealing identifiable information.
Select the Reporting Period(s) and Region(s) for which you wish to run the report, and select Next
(Table VI-5). To choose a different PACE report, select Back.
Table VI-5

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Select Generate Report to view the report, or select Back to choose a different Reporting Period or
Region (Table VI-6).
Table VI-6

The PACE Comparative Data Report – Quality Indicator Section 2 will display (Table VI-7).
Select Download to Excel to export the report contents to Excel, or select Back to return to the
previous screen.
Table VI-7

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PACE SITE DATA REPORT
The PACE Site Data Report displays the monitoring data for the twenty-six PACE quality indicators by
Site.
Select the Reporting Period(s), and select Next (Table VI-8). To choose a different PACE report,
select Back.
Table VI-8

Select the Contract Number and Site for which you wish to run the report, and select Next (Table VI9). To choose a different Reporting Period, select Back.
Table VI-9

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Select Generate Report to view the report, or select Back to choose a different Contract Number or
Site (Table VI-10).
Table VI-10

The PACE Site Data Report will display (Table VI-11). Select Download to Excel to export the
report contents to Excel, or select Back to return to the previous screen.
Table VI-11

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PACE STATUS REPORT
The PACE Status Report displays the PACE site quality indicators for which data has not been
submitted.
Select the Reporting Period(s) for which you wish to run the report, and select Next (Table VI-12). To
choose a different PACE report, select Back.
Table VI-12

Select the Contract Number and Site for which you wish to run the report, and select Next (Table VI13). To choose a different Reporting Period, select Back.
Table VI-13

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The PACE Status Report will display (Table VI-14). Select Download to Excel to export the report
contents to Excel, or select Back to return to the previous screen.
Table VI-14

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APPENDIX I: HPMS CONTACT
INFORMATION
Subject Matter

Name

Phone

Email Address

HPMS Technical
Help

HPMS Help Desk

800-220-2028

hpms@cms.hhs.gov

HPMS Password
Reset Requests

CMS IT Help Desk

410-786-2580

N/A

HPMS User
Access Questions

HPMS User Access
Mailbox

N/A

hpms_access@cms.hhs.gov

HPMS PACE
Monitoring
Related Questions

CMS DMAO Mailbox

N/A

General HPMS
PACE Monitoring
Module Inquiries

Timothy Hoogerwerf

HPMS

410-786-9962

DMAO.lmi.org

Timothy.hoogerwerf@cms.hhs.gov

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