Part 2: Post-Audit ActivitiesBy:

Maria Lane, Florida PACE – FloridaEmmanuel Cheo, Mercy LIFE – Massachusetts

Objectives

★Share post-audit experiences

★Walk through post-audit phase – Case examples of activities Preparing and fulfilling document requests: CAR, ICAR,

CAP Responding to findings: Brief references to RCAs and

IAs

★Forecast based on CMS PACE Audit Updates as of April 2018? Health Plan Management System

Definitions

★CAP: Corrective Action Plan★CAR: Corrective Action Required★HPMS: Health Plan Management System★ICAR: Immediate Corrective Action Required★IA: Impact Analysis★RCA: Root Cause Analysis

Some Activities

Activity Time Frame Focus

Root Cause Analysis

(RCA)

24-48 business

hours

• Systems• What systemic processes led to the outcomes related to

the finding?• Document activity using RCA Templates as instructed• Provide supporting evidence (documentation)

illustrating compliance, or progress toward compliance

Impact Analysis

(IA)

10 business days

• Participants affected or impacted by finding• Actions taken in each case to remedy or mitigate

impact• Supporting evidence (documentation)

Corrective Action Plan

(CAP)

30 calendar days from

draft report date

• Systems and participants impacted. • Actions taken to “cure the non-compliance”• Upload into HPMS using Data Upload tab: “CAP File”

Findings

Type CMS Definition Related Activities Points

CAR

Corrective Action Required:“A systemic deficiency that must be corrected,

but the correction can wait until the [draft] audit report is issued.”

• RCA• IA• QI initiatives

1

ICARImmediate Corrective Action Required:

“A systemic deficiency that is so severe that it requires immediate correction.”

• RCA• IA• QI initiatives

2

ObservationsObservations:

“Conditions of non-compliance that are not systemic, or represent a ‘one-off issue’.”

• Provide supporting evidence to show that issues are/were:

• Not systemic or ongoing

• Did not impact safety or access to care

0

Logistics & Considerations

★Make it easy for the reviewers! Respond timely Simplify: Evidence, evidence, evidence Organize, track and upload documents requested Upload supporting documentation: medical records,

staff/participant education materials, policy and process changes, etc. Use file naming convention(s) and formats as

instructed May cross reference previously uploaded files

Preparation of RCAs

★Florida PACE Centers conducted 5 RCAs post audit for the following:

Florida Appeals in Denial Notice Denial Notice In-person Assessments Service Notifications Competencies Immunizations

Preparation of RCAs

★Florida PACE Centers conducted IAs post audit for the following:

Denial Notice Appeals Process Competencies Immunizations

CAPs

★Key Points Deadline: 30 calendar days after issuance of draft

report of findings Methods used to identify participants

affected/impacted Corrective actions taken, and outcomes, in each

case Supporting documentation: Evidence showing

results/outcomes Upload documents using naming convention Sample

CAR – CAP – Case Example

★Placeholder for Sample

ICAR – CAP – Case Example

★Placeholder for Sample

Response to Draft Report

★Key Points Deadline: 14 business days after issuance of draft

report of findings Upload: HPMS

★Case Example

Response to Draft Audit Report• Draft report was

received 30 days after the survey with preliminary results.

• Draft Report stated cause for each finding that the surveyors identified during the reviewed period.

• After receiving the draft report. All CAPs for CAR conditions needed to be submitted in HPMS within 30 calendar days from the issuance of the finalreport.

QI Initiatives & Outcomes

★SDR In-person assessments Timeliness of IDT decisions Outcomes communicated to AM: Quarterly HPMS

calls

★Appeals Compliance with timeframes

★Grievances Extracting and processing embedded SDR

Tips

★Prepare and Organize Documents

CAR / ICAR

Finding1-2 business days

RCA10 business days

IA

Final Report

Final report was received within 8 days after receiving the draft report. Florida PACE did not object to any of the findings in the draft report.

Corrective Actions

Florida PACE submitted all corrective actions via HPMS website and developed a Monthly Dashboard to show compliance of the findings.

Closing

It is always a great to read words such as:

CMS has accepted and released all CAPs that were submitted by______. The ____ PACE audit is now closed.

Post-Audit QI Implementations

Monthly Dashboard created Formal correspondence createdPolicies were created and updatedEMR updated to track SDRMonthly audits to ensure complianceAdded staff to the Quality Department

Thank you – Questions?

★Updates Fieldwork extended to 2 weeks

• Week 1: Desk review including SDAG element• Week 2: In-person review of onsite element, etc.

State audits may be conducted during CMS audit, or separately

★Resources NPA Audit Prep Guide, and Risk Assessment Package NPA Quality Directors Handbook HPMS Integrated Audit Module User Guide PACE Audit Updates: HPMS Memo dated 04/23/2018