Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

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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 of non-compliance:	IDT remaining alert to pertinent input
Scope:	• The scope of this Impact Analysis is limited to 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 documentation during the audit review period identified in this tab (Instructions). • Determine if the IDT remained alert to pertinent information from any individual with direct knowledge of or contact with the participant, including: other team members, participants, caregivers, employees, contractors, and designated representatives. • Respond to the questions in the Participant Impact tab. • 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

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 IDT (or any member of the IDT) fail to remain alert to pertinent information from any individual with direct knowledge of or contact with the participant? (Yes/No) If NO, enter NA in columns H through V.

Who initially reported the information? Examples include, but are not limited to: PCP, RN, MSW, RT, OT, PT, HCC, dietitian, center manager, PCA, driver, participant, caregiver, other employees, contractors, and designated representative. Enter NA if the IDT remained alert to all pertinent information during the audit review period.

When was the information initially reported (the date the information was first documented)? MM/DD/YYYY Enter NA if the IDT remained alert to all pertinent information during the audit review period.

Provide a brief description of the information. Enter NA if the IDT remained alert to all pertinent information during the audit review period.

Which IDT member initially received the information (PCP, RN, MSW, RT, OT, PT, dietitian, HCC, center manager, PCA, driver)? Enter NA if the IDT remained alert to all pertinent information during the audit review period.

Where was the information documented (progress notes, on-call log, etc.)? Enter NA if the IDT remained alert to all pertinent information during the audit review period.

Did the appropriate members of the IDT take action in response to the information at some point (even if the action was delayed)? (Yes/No) Enter NA if the IDT remained alert to all pertinent information during the audit review period.

Date the appropriate members of the IDT took action in response to the information. MM/DD/YYYY Enter NA if the IDT did not take any actions in response to the information or if the IDT remained alert to all pertinent information during the audit review period.

Did the failure to remain alert to pertinent information cause a delay in or failure to: assess the participant, provide necessary care and/or services, provide access to emergency care, etc.? (Yes/No) Enter NA if the IDT remained alert to all pertinent information during the audit review period.

If the failure to remain alert to pertinent information caused a delay in or failure to: assess the participant, provide necessary care and/or services, provide access to emergency care, etc., please describe the care and/or services that were not provided or delayed. Enter NA if all necessary care and services were provided without delay or if the IDT remained alert to all pertinent information during the audit review period.

Were the services delayed or not provided? Enter Delayed or Not Provided Enter NA if all necessary care and services were provided without delay or if the IDT remained alert to all pertinent information during the audit review period.

If delayed, what date did the participant receive the appropriate care and/or services. MM/DD/YYYY Enter Not Provided if the services were never provided. Enter NA if all necessary care and services were provided without delay or if the IDT remained alert to all pertinent information during the audit review period.

What documentation or evidence does the PO have to demonstrate that the necessary care and/or services were provided? (i.e., progress note in the medical record, record from a specialist, etc.). Enter NA if all necessary care and services were provided without delay or if the IDT remained alert to all pertinent information during the audit review period.

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 the IDT remained alert to all pertinent information during the audit review period.

If yes, describe the negative outcomes. Enter NA if there were no negative outcomes or if the IDT remained alert to all pertinent information during the audit review period.

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.