CMS-10630 Coordination of Care

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Overview

Instructions
Detailed Sample Information
Root Cause Analysis
Participant Impact

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Sheet 1: Instructions

Audit Review Period:
Issue of non-compliance:	Coordination of 24-hour Care Delivery
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.
Definitions:	Delayed: Means a service was fully or partially provided at some point but not on the intended date. Facility: Nursing facilities (including long-term, rehabilitation, and respite stays), assisted living facilities, board and care facilities, and other sub-acute residential facilities. IDT authorized services: Any service that is determined necessary by the IDT or an IDT member, approved by the IDT, ordered by a PACE PCP, or care planned. Not provided: Means a service was never provided. Partially provided: Means a service was provided in-part but not as authorized by the IDT. Example: The care plan required home care twice daily (morning and evening), and the participant only received morning home care.
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 (e.g., medical record documentation) to determine if all IDT authorized care and services (and only IDT authorized care and services) were provided to participants who resided in, or received care from, a nursing facility, assisted living facility, board and care facility, or other sub-acute residential facility where coordination of care was required to ensure the delivery of necessary services. This includes temporary placement in a facility (e.g., for respite care or rehabilitation). For the purposes of this impact analysis, do not identify services for participants who ONLY received services in the PACE center and the participant's home. • Consider all relevant documentation and/or evidence, including but not limited to, the medical record, facility records, invoices, outside specialist notes, etc., when determining if services were provided. • A 'service' means all Medicare-covered services, all Medicaid-covered services, and other services determined necessary by the interdisciplinary team to improve and maintain the participant's overall health status, including items and drugs. • Respond to the questions in the participant impact tab. If a participant was not in a nursing facility (including long-term, rehabilitation, and respite stays), assisted living facility, board and care facility, or other sub-acute residential facility during the audit review period, during the audit review period, the PO should enter No in column H and then NA in all additional blue fields. • 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:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1327. This information collection will allow CMS to conduct comprehensive reviews of PACE organizations to ensure compliance with regulatory requirements. The time required to complete this information collection is estimated at 780 per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory per CMS’s authority under Section 1894 and 1934 of the Social Security Act and implementing regulations at 42 CFR § 460.190 and 460.194, which state that CMS, in conjunction with the State Administering Agency (SAA), audit PACE organizations (POs) annually for the first 3 contract years (during the trial period), and then on an ongoing basis following the trial period. Additionally, per § 460.200(a) PACE organizations are required to collect data, maintain records, and submit reports as required by CMS and the State administering agency. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Sheet 2: Detailed Sample Information

Tracking ID Number	Brief Description Of Issue (Completed By The CMS Audit Lead)	Type of Issue Identified (Completed By The CMS Audit Lead) (Applies to condition 1P.02 Only. For all other conditions enter N/A)	Detailed Description of the Issue (Explain what happened)
		x

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Sheet 3: Root Cause Analysis

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.

Definitions: Delayed: Means a service that was fully or partially provided at some point but not on the intended date. Facility: Nursing facilities (including long-term, rehabilitation, and respite stays), assisted living facilities, board and care facilities, and other sub-acute residential facilities. IDT authorized services: Any service that is determined necessary by the IDT or an IDT member, approved by the IDT, ordered by a PACE PCP, or care planned. Not provided: Means a service was never provided. Partially provided: Means a service was provided in-part but not as authorized by the IDT.

During the audit review period, was the participant admitted to a sub-acute facility for any length of time (including respite stays)? Enter Yes if the participant was admitted to a facility. Enter No if the participant was not admitted to a facility. If No, enter NA in all remaining columns.

During the audit review period, were any IDT authorized services not provided, partially provided, or delayed due to a failure to coordinate care with a sub-acute facility? (Examples include, but are not limited to, medications, wound care, therapy, DME, lab tests, diagnostics tests, etc.) If Yes: 1. Enter each IDT authorized service NOT provided, partially provided, or delayed. 2. Enter each service on a new line. 3. Enter the service as ordered, approved, care planned, etc. If No: 1. Enter No. 2. Enter NA in columns J-O. 3. Go to column P Please note: Impact analyses will be returned for correction if each service is not listed in a new row.

Was the service not provided, partially provided, or delayed? (Enter not provided, partially provided, or delayed. Enter partially provided and delayed if both are applicable)

Enter the date the service was ordered or authorized by the IDT or PACE PCP. If the service was a recurring service, enter the date the services were first ordered or authorized. MM/DD/YYYY

Enter the date the order or authorization was communicated to the facility. MM/DD/YYYY

Enter the date the facility began providing the services to the participant. MM/DD/YYYY Enter NA if the service was not provided.

If the service was only partially provided, describe the service provided to the participant.

Describe why the service was not provided, partially provided, or delayed.

During the audit review period, were any services that were NOT authorized by the IDT or ordered PACE PCP (for example, medications, wound care, lab tests, diagnostic tests, etc.) provided by employees or contractors of a sub-acute facility? If Yes: 1. Enter each service provided and NOT authorized by the IDT. 2. Each service provided must be entered on a new line. If No: 1. Enter No. 2. Enter NA in columns Q-U. 3. Go to column V. Please note: Impact analyses will be returned for correction if each service is not listed in a new row.

If the service was ordered by someone other than the PACE PCP, who ordered the service (include their credentials)? If there was no order for the services provided, enter No Order.

Date the service started. MM/DD/YYYY

Date the service ended. MM/DD/YYYY Enter NA if the service is still being provided.

Describe why the service was provided without IDT authorization.

Enter the date the PO became aware of this service being provided to the participant. MM/DD/YYYY

Identify the facility. Enter NA if the participant did not receive services from a facility or received all IDT authorized services and only IDT authorized services from a facility.

Did the participant experience negative outcomes, in some part, as a result of the failure to coordinate care with a contracted facility? (Enter Yes or No)

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

Optional: Please note, you do not have to complete this column. If there are any mitigating factors that you would like CMS to consider related to a specific participant, please enter the information in this column.