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HEALTH PLAN MANAGEMENT SYSTEM

PACE QUALITY MONITORING USER GUIDE

(02/01/2016)

HPMS PACE Quality Monitoring User Guide Page 1 (02/01/2016)

TABLE OF CONTENTS

Introduction............................................................................................................................................................. 3 I. Getting Started ............................................................................................................................................... 4

CMS User IDs ........................................................................................................................................... 4

II. PACE Quality Monitoring ............................................................................................................................. 5

PACE START PAGE ................................................................................................................................ 5

II. Edit PACE Sites ............................................................................................................................................. 7

Select a Contract ....................................................................................................................................... 7 Select a Site ............................................................................................................................................... 8

Add a PACE site ....................................................................................................................................... 9

Edit a PACE site ..................................................................................................................................... 11

Delete a PACE site .................................................................................................................................. 14

III. Data Entry .................................................................................................................................................... 16

Selection Criteria .................................................................................................................................... 17 PACE Quality Indicator Selection ......................................................................................................... 18

PACE Quality Indicator: No Data to Report ......................................................................................... 19

PACE Quality Indicator: Appeals .......................................................................................................... 25

PACE Quality Indicator: Emergency room visits .................................................................................. 30

PACE Quality Indicator: Enrollment (Census, New Enrollments, Disenrollments) ........................... 35

PACE Quality Indicator: Grievances ..................................................................................................... 38 PACE Quality Indicator: Immunizations - Pneumococcal ................................................................... 47

PACE Quality Indicator: Immunizations – Influenza (Oct. thru Mar. 2016) ...................................... 50

PACE Quality Indicator: Falls Without Injury ..................................................................................... 53

PACE Quality Indicator: Medication Administration Errors ............................................................... 60

PACE Quality Indicator: Kennedy Terminal Ulcer .............................................................................. 66 PACE Quality Indicator: Burns 1st Degree or Less ............................................................................... 74

IV. Upload Data ................................................................................................................................................. 82

Selection Criteria .................................................................................................................................... 82

Upload Data ............................................................................................................................................ 83

File Uploaded successfully ..................................................................................................................... 84

upload file validation error ..................................................................................................................... 85 V. Request Extension ........................................................................................................................................ 86

Selection Criteria .................................................................................................................................... 86

Request Extension .................................................................................................................................. 87


CMS Approval ......................................................................................................................................... 88

VI. PACE Reports .............................................................................................................................................. 89

PACE Comparative Data Report ............................................................................................................ 90 PACE SITE data Report ......................................................................................................................... 94

PACE Status Report ............................................................................................................................... 97

Appendix I: HPMS Contact Information ........................................................................................................... 100


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). These requirements are in your program agreement that will be signed upon permanent-provider application approval. The PACE quality data elements will be 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 function also enables CMS and SAA users to track and monitor data related to 10 key indicators for all PACE organizations. 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 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 time frame is most useful for determining and monitoring trends and patterns of care. CMS and the SAAs will use this monitoring data to identify potential problems, aberrant outcomes, and incidents that may be the first indication of problems in patient care and site operations. These data elements will be used to determine if additional onsite monitoring activities by CMS or the State are necessary. This manual will provide PACE organization users with guidance with entering data, printing reports, and navigating the various screens and functions in the module.


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.

• http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/HPMS/Overview.html

Direct all further questions related to HPMS user access to [email protected].

http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/HPMS/Overview.html




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 click PACE Quality Monitoring in the fly-out menu (Table I-1) to advance to the PACE Quality Monitoring Start Page (Table I-2). Table I-1


The PACE Quality Monitoring Start Page contains the links that enable users to add, edit, and delete a PACE site, 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 I-2


II. EDIT PACE SITES

As mentioned above, data is reported at the PACE Site level. As such, users must ADD (create) Pace Sites to enter data for. Additionally, once added, PACE Sites may be Edited or Deleted. The following will provide some instructions. On the PACE Start Page (Table I-2), click the Edit PACE Sites link in the right-hand menu to advance to the Edit PACE Site – Select a Contract screen (Table II-1).

SELECT A CONTRACT The Edit PACE Site – Select a Contract screen displays the H Numbers assigned to the user based on their PACE Organization affiliation. Select the H Number for which the user would like to enter, edit, or delete a PACE site, and click Next. The user advances to the Edit PACE Site – Select a Site screen (Table II-2). Table II-1


SELECT A SITE The Edit PACE Site – Select a Site screen (Table II-2) displays the H Number selected by the user and the Contract Name, and the PACE sites for that H Number appear in a picklist. Table II-2


ADD A PACE SITE To add a PACE site, click Add on the Edit PACE Site – Select a Site screen. The user will advance to the Edit PACE Site screen (Table II-3). Enter the required data. When complete, click Next. The Edit PACE Site – Verify Site screen will display (Table II-4). Note: The Starting Quarter will be pre-populated with the current reporting quarter. Unless otherwise instructed, it is suggested that you leave this field unchanged. Table II-3


Review the information for accuracy. Click Back to edit data, or click Submit to be returned to the Edit PACE Site – Select a Site screen. Table II-4


EDIT A PACE SITE To edit a PACE site, select the PACE site on the Edit PACE Site – Select a Site (Table II-5) screen, and click Edit. The Edit PACE Site screen will display (Table II-6). Table II-5


Edit the data. Click Next. Table II-6


Review the information on the Edit PACE Site – Verify Site (Table II-7) screen. Click Back to edit data, or click Submit. Note: The Starting Quarter field cannot be edited. Table II-7


DELETE A PACE SITE To delete a PACE site, select the PACE site from the picklist on the Edit PACE Site – Select a Site (Table II-8) screen, and click Delete. Table II-8


On the Edit PACE Site – Verify Site screen (Table II-9), review the information. Click Back to make a correction, or click Submit. Table II-9


III. DATA ENTRY

To enter data (manual option – not upload option) for a PACE site, click 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 auto-populate. 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


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 click 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. Click Back to return to the Data Entry – Selection Criteria screen. Table III-3


PACE QUALITY INDICATOR: NO DATA TO REPORT A “No Data to Report” function is available for each quality indicator (Table III-4). 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), click No Data to Report. Table III-4


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


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 (Table III-7). 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 click Edit Quality Indicator to advance to the Data Entry – Appeals (Table III-7) screen. Then click Data To Report. Table III-7


On the Data Entry – Appeals – Data to Report confirmation screen (Table III-8), review the information. Click Back to make a correction, or click 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, Immunizations – Pneumococcal, and Immunization – Influenza. Zeros should be entered for these quality indicators if there is no data to report.


PACE QUALITY INDICATOR: APPEALS The HPMS Pace Quality Reporting Module provides functionality for the reporting of Appeals data. Please refer to PACE Level I Guidance for operational guidance on reporting Appeals. Data Reporting Requirements:

1. Source • Caregiver • Family • Participant

2. Appeal Type • Decreased Center Attendance • Denial of Enrollment • Dentures • Durable Medical Equipment • Glasses • Hearing Aid • Home Modification(s) • Increased Center • Attendance • Increased Home Care • Involuntary Disenrollment • Medical Procedure • Medical Supplies • Nursing Facility Placement – Long Term • Nursing Facility Placement – Respite • Nursing Facility Placement – Short Term • Specialist Consultation or Visit • Surgical Procedure • Transportation • Other - Provide description in the text box

3. Resolution • Approved • Denied

Frequency: PACE Organizations are asked to submit appeals data on a quarterly basis.


. On the Data Entry – Quality Indicator Selection screen (Table III-6), select the Appeals quality indicator(s), and click Edit Quality Indicator. On the Data Entry – Appeals screen (Table III-10); click 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


After entering the data, click Next to advance to the Data Entry – Appeals – Verify screen (Table III-12). Table III-11


Review the information. Click Back to make a correction, or click Submit. Table III-12


A Control Number is generated and assigned to each Appeals record. The Data Entry - Appeals screen (Table III-13) displays all the appeals that have been recorded for the quarter. To edit an appeal, click the radio button next to the appropriate control number and click the Edit button. To delete an appeal, click the radio button next to the appeal to be deleted and click the Delete button. Click Back on the Data Entry – Appeals Screen to return to the Data Entry - Quality Indicator Selection screen. Table III-13


PACE QUALITY INDICATOR: EMERGENCY ROOM VISITS The HPMS Pace Quality Reporting Module provides functionality for the reporting of Emergency Room Visit data. Please refer to PACE Level I Guidance for operational guidance on reporting Emergency Room Visits. Data Reporting Requirements:

1. ER Visit Date 2. Primary Admitting Diagnosis (ICD-10 Codes) 3. Discharge Diagnosis (ICD-10 Codes) 4. Admission to Hospital (Yes or No) 5. Participant Living Situation

• Assisted Living With Staff on Duty • Nursing Facility - Long Term • Nursing Facility - Short Term • Private Home/Apartment - Alone • Private Home/Apartment - With Family/Caregiver • Private Home/Apartment - With Roommate • Supportive Housing - Alone with Staff on Duty • Supportive Housing - With Caregiver • Supportive Housing - With Roommate

6. Participant Outcomes (User Ctrl + Right Mouse Click to mark multiple selections) • Change in Plan of Care • Discharged to a higher level of care • Discharged to Home • DME(medical equipment) provided • Hospital Admission • Medication changes • New Diagnosis • No new diagnoses or interventions • Reassessment by Member(s) of IDT • Referral for PCP follow-up • Referral for Specialist follow-up • Enter Readmission Date • Enter Initial Admission Date • Enter Discharge Date • Enter Diagnoses • Enter Areas of Improvement Identified

7. Has the Participant had repeat ER Visits within the current Reporting Period? (Yes or No)


How to use the measure: . On the Data Entry - Quality Indicator Selection screen, click the radio button to the left of the Emergency Room Visits quality indicator and then click Edit Quality Indicator. Click Add on the Data Entry – Emergency Room Visits screen (Table III-14). Table III-14


The Data Entry - Emergency Room Visits - Add screen will appear (Table III-15). Note that the Edit and Delete buttons are disabled if there are no records available to edit or delete. See the PACE Quality Indicator: No Data To Report section of this manual if the user wishes to report no data for the collection period. Upon completion of the data entry, click Next to advance to the Data Entry - Emergency Room Visits – Verify screen (Table – III-16). Table III-15


Review the information on the Data Entry – Emergency Room Visits – Verify screen (Table III-16). Click Back to make a correction, or click Submit. Table III-16


A Control number is assigned to each emergency room visit record. The Data Entry - Emergency Room Visits screen (Table III-17) displays all the emergency room visits that have been entered for the quarter. To edit an Emergency Room Visits record, click the radio button next to the appropriate control number then click Edit. Delete records by clicking the radio button next to the control number to be deleted on the Data Entry - Emergency Room Visits screen and then the Delete button. Click Back to return to the Data Entry - Quality Indicator Selection screen. Table III-17


PACE QUALITY INDICATOR: ENROLLMENT (CENSUS, NEW ENROLLMENTS, DISENROLLMENTS)

The HPMS Pace Quality Reporting Module provides functionality for the reporting of Enrollment data. Follow below links for definitions of relevant Census/Enrollment/Disenrollment requirements. Resources:

• http://www.cdc.gov/flu/protect/whoshouldvax.htm#flu-shot • http://www.cdc.gov/flu/professionals/vaccination/ • http://www.cdc.gov/flu/professionals/vaccination/ • http://www.cdc.gov/vaccines/vpd-vac/should-not-vacc.htm#pcv7

Data Reporting Requirements:

1. Total Census 2. Total New Enrollments

• Medicare • Dual Eligible • Medicaid • Private Pay

3. Total Disenrollments • Medicare • Dual Eligible • Medicaid • Private Pay

How to use the measure: It is expected that CMS and their State Agency partners will use this data to monitor trends and patterns. The data will also be used to determine if there are accessibility issues and if the PACE Organization has sufficient financial resources to conduct appropriate marketing activities. This information can also be used to evaluate the PACE Organization’s ability to maintain an appropriate census. It is also expected that CMS and their State Agency partners will utilize this information to determine if there are any problems with site operations, such as accessibility or provision of services, etc., which are causing voluntary disenrollments. In addition, this information can be used to review the organization’s policies on involuntary disenrollments.


On the Data Entry - Quality Indicator Selection screen, click the radio button to the left of the Enrollment quality indicator and then click Edit Quality Indicator to enter enrollment data (Table III-18); upon completion of the data entry click Next. Table III-18


Review the information on the Data Entry – Enrollment – Verify screen (Table III-19). Click Back to make a correction, or click Submit to be returned to the Data Entry – Quality Indicator Selection screen. Note that only one Enrollment record can be entered for each quarter. Enrollment data may be edited by selecting Enrollment on the Data Entry – Quality Indicator Selection screen, and then clicking Edit Quality Indicator. The previously entered data will display. Table III-19

The user will enter the number of individuals enrolled in the PACE program at the end of each month, identified by payee. The months listed are based on the quarter and year. The PACE Organization user can continue to enter Enrollment information up to the last calendar day of the 4th consecutive month from the beginning of the current quarter.


PACE QUALITY INDICATOR: GRIEVANCES The HPMS Pace Quality Reporting Module provides functionality for the reporting of Grievance data. Please refer to PACE Level I Guidance for operational guidance on reporting Grievances. Data Reporting Requirements:

1. Source • Caregiver • Contracted Provider • Family • Participant

2. Location • Alternative Care Setting • Assisted Living Facility • Contracted Physician's Office • Hospital • Inpatient Hospice • Nursing Facility • PACE Center

3. Grievance Type and Specific Issue

Grievances Type Specific Issue Activities •

• • • • •

Activities are Not Age or Ability Appropriate Dissatisfied with Frequency of Activities Dissatisfied with the Quantity of Activities Dissatisfied with the Variety or Type of Activities Requesting Activities Outside of the Center (Trips) Requesting more Activities for Men

Communication • •

Call(s) Not Returned Communication is Unclear

• • • • • • • • • •

Difficulty Contacting On-call Difficulty Contacting the PACE Center during center hours Not Informed of Appointment(s) in a timely manner Not Informed of Appointment (s) outside of PACE center Not Informed of Changes in the Participant’s Condition Not Informed of Changes to Home Care Schedule Not Informed of Changes to Medication Not Informed of Changes to Scheduled Appointment(s) Rude Behavior/Communication Staff is Inattentive

• Other* Contracted Specialist •

• Dissatisfied with the Care Provided Dissatisfied with how Toenails were Cut

• • • •

Length of Time to Receive Dentures Length of Time to Receive glasses Length of Time to Schedule an Appointment Physician Behavior (rude behavior)


Grievances Type Specific Issue • • • •

Records were not Sent to Specialist Prior to Appointment Specialist Appointment was not Made Time in Waiting Room Other*

Contracted Facility (Hospital, SNF, etc.)

• • • • • • • • • •

Availability of Staff to Provide Assistance Cleanliness of the Facility Did not Provide for Participant ADLs Missing Clothes or Personal Items Participant Left in Bed Too Long Quality of Care at the Facility Report of Abuse Staff Behavior (rude behavior) Staffing Other*

Dietary • •

All Participants at Table are not Served at the Same Time Dissatisfied with Alternate Selections

• •

• • • • • • • • • • •

Dissatisfied with Physician Prescribed Diet Dissatisfied with Selection or Variety of Foods (include snacks, ethnic foods, etc.) Dissatisfied with Sugar-free Food Items Food Temperature is Too Cold Food Temperature is Too Hot Foreign Object Not Allowed to Bring Food from Home Not Allowed to Use Salt or Pepper Not Enough Assistance from Staff During Meals Quality of Food Staff Hand Washing/Infection Control Wait Time for Food Service is Too Long Other*

Disenrollment • •

•

Dissatisfied with how Care was Coordinated with New Provider(s) New Provider did not Receive Medical Records from the PACE Organization Other*

Enrollment • Dissatisfied with Cost • Not Aware of the Need to Utilize the PACE Organization’s

Network Provider

• •

Unaware of Participant liability Other*

Home Care • • • • • • • • • • • • • •

Dissatisfied with Staff Behavior (rude behavior) Dissatisfied with Staff Member Assigned to Perform Home Care Missed Appointment Report of Abuse Report of Missing Items Requesting a Decrease in Home Care Requesting Additional Home Care Staff does not have Enough Time to Complete Tasks Staff Early for Appointment Staff Late for Appointment Staff not Aware of Tasks to be Completed Staff Unable to Enter the Home/Access Lock Box Tasks were not Completed Unable to Hear or Understand Staff Member


Grievances Type Specific Issue • Other*

Marketing • • •

PACE Organization Misrepresented Available Services PACE Organizations Marketing is Misleading Other*

Medical Care • • • • •

Activity Interrupted to Complete Clinic Visit Activity Interrupted to Complete therapy Disagreement with Diagnosis or Treatment Dissatisfied with Frequency of Clinic Visits – Too Few Dissatisfied with Wait Time in the Clinic

• • •

Insufficient Privacy in the Clinic Insufficient Privacy when Receiving Personal Care Insufficient Staff in Clinic

• • • •

Insufficient Staff in PT/OT Area OT/PT Area is Too Small Pain is not Addressed by the Clinical Staff Personal Care is Rushed

• •

Physician does not Listen to Participant Concerns Other*

Medication • •

Disagreement with Medication Regime Medication Error

• • •

Medication is Missing Medication is not Administered in a Private Setting Medication is not Available

• Medication was Discontinued • Medication was not Delivered to Home • •

Requested Medication was not Provided Other*

PACE Services • • • • • • •

Dissatisfied with Ability to Obtain Routine Dental Care Dissatisfied with Ability to Obtain Routine Hearing Services Dissatisfied with Ability to Obtain Routine Vision Care Dissatisfied with Availability of Specialist Services Dissatisfied with Center Attendance – Too Few Days Dissatisfied with Center Attendance – Too Many Days Dissatisfied with Provider Network – Homecare Providers

• • • •

Dissatisfied with Provider Network – Hospitals Dissatisfied with Provider Network – Nursing Facilities Dissatisfied with Provider Network – Specialists Other*

Supplies • • • • •

Dissatisfied with Quality of Supplies Insufficient Quantity of Supplies Participant Privacy Issue Supplies were not Delivered to Home Other*

Transportation • •

Arrives Too Early Cannot Take Wheelchair on Van

• •

Complaint of Discomfort Condition of the Vehicle

• • • • •

Dissatisfied with Drivers Speed or Driving Late Pickup Length of Ride Too Long Missed Pick-up Not Aware of Change in Pick-up Time


Grievances Type Specific Issue • Not Enough Room on Van when Supplies are Being Delivered • Other participants Behavior on the Van • Participant arrived at Home in Soiled Clothing • Temperature on Van is Too Hot/Cold • Van Crowded • Other*

Other* • Other*

*Note: If the user selects "Other" as the source of the grievance, the associated text field will be enabled. This text field is now required.

4. Resolution • Resolved to Participants Satisfaction. • Alternative Solution – If selected, please enter a short description under

Alternative Resolution text box.

5. Actions Taken (Use Ctrl + Right Mouse Click for multiple selections) • Added Additional Activities • Added Additional Contracted Facilities • Added Additional Contracted Specialists • Added Additional Equipment • Added Additional Menu Items • Added Additional Staff • Added Additional Transportation • Changed Staff that Provides Care • Conducted Contractor Oversight • Conducted Quality Oversight at PACE Center • Counseled Staff • Dietary Assessment • Equipment was Serviced or Replaced • Home Care Assessment • Implemented a New Policy • Increased Home Care Hours • Instituted Quality Improvement Measures • Met with Contracted Provider to Review Grievance • Modified the PACE Center Environment • Obtained Opinion from a Specialist • OT Assessment • Participant or Caregivers Reeducated on Policies/Procedures • PCP Assessment • Provided Participant Education • Provided Staff Education/Training • PT Assessment • Revised Activity Schedule • Revised Existing Policy • Revised Marketing Material


• Revised Process for Communicating with Contracted Facility • Revised Process for Communicating with Contracted Specialist • Revised Process for Medication Delivery • Revised Process for Scheduling Clinic Visits • Revised Process for Scheduling Transportation • Revised Provider Contract • Revised the Participant’s Plan of Care • RN Assessment • Staff Placed on Performance Improvement Plan • Staff Reeducated on Policies/Procedures • SW Assessment • Transportation Assessment

Frequency: PACE Organizations will be asked to submit grievances data on a quarterly basis.


On the Data Entry – Quality Indicator Selection screen, click the radio button to the left of the Grievances quality indicator, and click Edit Quality Indicator. The user will advance to the Data Entry – Grievances screen (Table III-20). Click Add to advance to the Data Entry – Grievances – Add screen (Table III-21). Table III-20


On the Data Entry – Grievances – Add screen, the Edit and Delete buttons are disabled if there are no records to edit or delete. See the PACE Quality Indicator: No Data To Report section of this manual if the user wishes to report no data for the collection period. When data entry is complete, click Next to advance to the Data Entry – Grievances – Verify screen (Table III-22). Table III-21


A Control Number generates for each grievance record (Table III-23). The Data Entry – Grievances screen displays all grievances that have been recorded for this quarter. To edit a grievance record, click the radio button next to the appropriate control number, and click Edit. To delete a grievance record, click the radio button next to the grievance record to be deleted, and click Delete. Click Back to make a correction. Table III-23


PACE QUALITY INDICATOR: IMMUNIZATIONS - PNEUMOCOCCAL The HPMS Pace Quality Reporting Module provides functionality for the reporting of Pneumococcal Immunization data. Please refer to PACE Level I 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

Frequency: Routine immunization data will only be collected during the flu season. Pneumococcal Immunization data will be entered on the following screen. These data will be entered quarterly. The PACE Organization user has up to twenty business days after the end of the quarter to enter the Pneumococcal Immunization information. At that time, information for the next quarter’s data entry will be displayed.


On the Data Entry - Quality Indicator Selection screen, click the radio button to the left of the Immunizations – Pneumococcal quality indicator and then click Edit Quality Indicator to enter Immunizations Pneumococcal data (Table III-24). After entering data, click Next. Table III-24


Review the information on the Data Entry – Pneumococcal Immunizations – Verify screen (Table III-25). Click Back to make a correction, or click Submit to be returned to the Data Entry – Quality Indicator Selection screen. Please Note:

• The following edit is applied to the Data Entry – Pneumococcal Immunizations: 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-25


PACE QUALITY INDICATOR: IMMUNIZATIONS – INFLUENZA (OCT. THRU MAR. 2016) The HPMS Pace Quality Reporting Module provides functionality for the reporting of Influenza Immunization data. Please refer to PACE Level I 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 2016)

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. These data will be entered at the end of the January. The PACE Organization user has up to twenty business days after the end of the month of March to enter the Flu Immunization information. At that time, information for the next quarter’s data entry will be displayed.


On the Data Entry - Quality Indicator Selection screen, click the radio button to the left of the Immunizations – Influenza (Oct. – Mar. 2016) quality indicator and then click Edit Quality Indicator. On the Data Entry – Influenza Immunizations (Oct. – Mar. 2016) screen (Table III-26) the user can enter data; when the data entry is complete, click Next. Table III-26


Review the information on the Data Entry – Influenza Immunizations (Oct. – Mar. 2016) – Verify screen (Table III-27). Click Back to make a correction, or click Submit to be returned to the Data Entry – Quality Indicator Selection screen. Please Note:

• The following edit is applied to the Data Entry – Immunizations Influenza (Jan. – Mar. 2016): 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-27


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 Level I Guidance for operational guidance on reporting Falls Without Injury data. Data Reporting Requirements:

1. Location of Fall • Alternative Care Setting - Activity Area • Alternative Care Setting - Bathroom • Alternative Care Setting - Dining Room • Alternative Care Setting - Hallway • Alternative Care Setting - Outside • Assisted Living - Outside • Assisted Living Facility - Bathroom • Assisted Living Facility - Bedroom • Assisted Living Facility - Day Room/Activity Area • Assisted Living Facility - Dining Room • Assisted Living Facility - Hallway • Assisted Living Facility - Therapy • Caregiver/Family/Friend - Home • Community - Indoors • Community - Outdoors • Participant Home - Basement • Participant Home - Bathroom • Participant Home - Bedroom • Participant Home - Dining Room • Participant Home - Hallway • Participant Home - Kitchen • Participant Home - Living Room • Participant Home - Outside • Participant Home - Stairs • Hospital - Bathroom • Hospital - Bedroom • Hospital - ER • Hospital - Exam Room • Hospital - Hallway • Hospital - Imaging (CT, MRI, X-ray) • Hospital - Therapy • Inpatient Hospice • Nursing Facility - Activity Area • Nursing Facility - Bathroom • Nursing Facility - Bedroom • Nursing Facility - Dining Room


• Nursing Facility - Hallway • Nursing Facility - Outside • Nursing Facility - Therapy • Other - Provide Additional Details • PACE Center - Activity Area • PACE Center - Bathroom • PACE Center - Clinic • PACE Center - Dining Room • PACE Center - Hallway • PACE Center - Outside • PACE Center - Therapy • PACE Transportation - Fell while Entering or Exiting a Vehicle • PACE Transportation - Fell while on the Vehicle

2. Time of Fall • Morning • Afternoon • Evening • Night

3. Contributing Factors (Can have multiple selections by Ctrl + click the below selections) • Dizziness • Environment in Disrepair • Fainted • Found on Floor • Hypoglycemia • Hypotension • Improper Footwear • Improper Transfer - Caregiver • Improper Transfer - Family Member • Improper Transfer - PACE Contractor • Improper Transfer - PACE Staff • Loss of Balance • Lost Balance because Items were not Properly Stored • Lost Balance because Legs Gave Out/Buckled • Lost Balance Because Location was in Disrepair • Muscle Weakness • Needed to Use the Restroom • Not using DME (Cane, walker) • Participant Attempted to Transfer without Assistance • Participant Unbuckled Seatbelt • Seatbelt not Buckled • Syncope • Tripped on Rug • Tripped Over Object • Uneven Pavement


• Unknown 4. Actions Taken (User Ctrl + Right Mouse Click for multiple selections)

• Family/Caregiver Education • Home Care Assessment • Implemented a New Policy • Implemented Falls Prevention Programs in Center • Increased PT or OT • Initiated Contractor Oversight • Initiated Quality Improvement Activities • Medication Evaluation/Change • Modified Assisted Living Facility Environment • Modified Hospital Environment • Modified Nursing Facility Environment • Modified PACE Center environment • Modified the Participant's Home Environment • OT Assessment • Participant Education • PCP Assessment • PT Assessment • Revised Existing Policy • RN Assessment • Staff Education • Supplied the Participant with New DME • Other – If selected, please enter a short description under Other Action text box.


On the Data Entry – Quality Indicator Selection screen, click the radio button to the left of the Falls Without Injury quality indicator and click Edit Quality Indicator to advance to the Data Entry – Falls Without Injury screen (Table III-28). Click Add to add an incident and proceed to the Falls Without Injury – Add screen (Table III-29). Table III-28


The Edit and Delete buttons are disabled if there are no records to edit or delete. To report no data for the collection period, see the PACE Quality Indicator: No Data To Report section of this manual. Table III-29


When data entry is complete, click Next to advance to the Data Entry – Falls Without Injury – Verify screen (Table III-30). Review the information. Click Back to make a correction, or click Submit. Table III-30


A Control Number generates for each Falls Without Injury record (Table III-31). To edit a record, click the radio button next to the appropriate control number, and click Edit. To delete an incident record, click the radio button next to the incident record to be deleted, and click Delete. Click Back to return to the Data Entry – Quality Indicator Selection screen. Table III-31


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 Level I Guidance for operational guidance on reporting Medication Administration Error data. Data Reporting Requirements:

1. Location of Incident • Alternative Care Setting • Assisted Living Facility • Hospital • Inpatient Hospice • Nursing Facility • PACE Center • Participant Home

2. Type of Medication Error • Medication Administered - Incorrect Route • Medication Administered - Incorrect Dose • Medication Administered - Incorrect Medication • Medication Administered - Incorrect Time • Medication not Administered - Dispensed to wrong Participant • Medication not Administered - Dose Omitted • Medication not Administered - Incorrect Dose Dispensed to Participant • Medication not Administered - Incorrect Medication Dispensed to Participant • Medication not Administered - Medication Incorrectly Labeled

3. Contributing Factors (Can have multiple selections by Ctrl + click the below selections) • Change in Method of Delivery • Change in Pharmacy Provider • Communication between PACE Inpatient Hospice • Communication between PACE Organization and ACS • Communication between PACE Organization and Assisted Living Facility • Communication between PACE Organization and Hospital • Communication between PACE Organization and Nursing Facility • Communication between PACE Organization and Pharmacy • Medication Administered by staff not Permitted to Administer Medication • New Staff Member • Order Transcription Error • Participant ID Error • Pharmacy Error • Physician Prescription Error • Similar Name • Staff Error


• Other – If selected, please enter a short description under Other Contributing Factor text box.

4. Actions Taken (Use the Ctrl + Right Mouse Click button for multiple selections) • Family/Caregiver Education • Home Care Assessment • Implemented a New Policy • Implemented Falls Prevention Programs in Center • Increased PT or OT • Initiated Contractor Oversight • Initiated Quality Improvement Activities • Medication Evaluation/Change • Modified Assisted Living Facility Environment • Modified Hospital Environment • Modified Nursing Facility Environment • Modified PACE Center environment • Modified the Participant's Home Environment • OT Assessment • Participant Education • PCP Assessment • PT Assessment • Revised Existing Policy • RN Assessment • Staff Education • Supplied the Participant with New DME • Other – If selected, please enter a short description under Other Action text box.


On the Data Entry – Quality Indicator Selection screen, click the radio button to the left of the Medication Administration Errors quality indicator, and click Edit Quality Indicator. The user will advance to the Data Entry – Medication Administration Errors screen (Table III-32). Click Add to add an incident and advance to the Data Entry – Medication Administration Errors – Add screen (Table III-33). Table III-32


The Edit and Delete buttons are disabled on this screen if there are no records to edit or delete. To report no data for the collection period, see the PACE Quality Indicator: No Data To Report section of this manual. When data entry is complete, click Next to advance to the Medication Administration Errors – Verify screen (Table III-34). Table III-33


A Control Number generates for each medication administration error record. The Data Entry – Medication Administration Errors (Table III-35) screen displays all incidents that have been entered for the quarter. To edit a medication administration errors record, click the radio button next to the appropriate control number, and click Edit. To delete a record, click the radio button next to the Medication Administration Errors record to be deleted and click Delete. On the Data Entry – Medication Administration Errors screen, click Back to return to the Data Entry – Quality Indicator Selection screen. Table III-35


PACE QUALITY INDICATOR: KENNEDY TERMINAL ULCER The HPMS Pace Quality Reporting Module provides functionality for the reporting of Kennedy Terminal Ulcer data. Please refer to PACE Level I Guidance for operational guidance on reporting Kennedy Terminal Ulcer data. Data Reporting Requirements:

1. Location of Incident • Alternative Care Setting • Assisted Living Facility • Caregiver/Family/Friend Home • Community • Contracted Facility or Provider - Not Listed Above • Hospital • Inpatient Hospice • Nursing Facility • PACE Center • Participant Home • Supported Living Environment - Not Listed Above

2. Location of Ulcer • Ankle - Left • Ankle - Right • Buttocks - Left • Buttocks - Medial • Buttocks - Right • Calf - Left • Calf - Right • Ear - Left • Ear - Right • Elbow - Left • Elbow - Right • Head - Posterior • Heel - Left • Heel - Right • Hip - Left • Hip - Right • Knee - Left • Knee - Right • Nose • Sacrum • Scrotum • Shoulder - Left • Shoulder - Right • Thigh - Left


• Thigh - Right • Toe - Left 2nd Toe • Toe - Left 3rd Toe • Toe - Left 4th Toe • Toe - Left 5th Toe • Toe - Left Great Toe • Toe - Right 2nd Toe • Toe - Right 3rd Toe • Toe - Right 4th Toe • Toe - Right 5th Toe • Toe - Right Great Toe

3. Contributing Factors (For multiple selections, use Ctrl + click the below selections) • Adaptive Equipment Not Used • Changes in Skin Condition Not Reported - Caregiver • Changes in Skin Condition Not Reported - Contractor • Changes in Skin Condition Not Reported - Participant • Changes in Skin Condition Not Reported - Staff • Decrease in Center Attendance • Decrease in Home Care • Delay or Cancelation of Scheduled Home Care • Diagnosis of Dementia • Dietary Assessment Not Completed • Difficulty Swallowing • Documentation Not Completed Properly - Contractor • Documentation Not Completed Properly - Staff • Dressing Change - Delayed • Dressing Change - Not Completed • Dressing Change - Not Completed as Ordered • Equipment Malfunction • Incontinent of Bladder • Incontinent of Bowel • Lack of Education - Caregiver • Lack of Education - Contractor • Lack of Education - Participant • Lack of Education - Staff • Non-Compliance with Medication(s) • Non-compliance with Plan of Care - Caregiver • Non-compliance with Plan of Care - Contractor • Non-compliance with Plan of Care - Participant • Non-compliance with Plan of Care - Staff • Non-Compliance with PO Policies • Nutritional Intake - Decreased • Nutritional Supplements Not Provided • Participant - Bedbound • Participant - Cognitive Impairment


• Participant - End of Life • Participant - Failure to Thrive • Participant - Multiple Comorbidities • Participant - Non-Ambulatory • Participant - Non-Compliance with Prescribed Diet • Participant - Non-Compliance with Skin Care Regimen • Participant - Refused Treatment • Participant Left Unsupervised • PO Does Not Have Applicable Policies • Poor Dentition • Pressure Relieving Device Not Used Properly - Caregiver • Pressure Relieving Device Not Used Properly - Contractor • Pressure Relieving Device Not Used Properly - Participant • Pressure Relieving Device Not Used Properly - Staff • Risk for Skin Breakdown Not on Care Plan • Skin Assessment - Delayed • Skin Assessment - Not Completed • Skin Condition Not Properly Documented • Unknown • Other – If selected please enter a short description in Other Contributing Factor

text box. 4. Actions Taken (For multiple selections, use the Ctrl + Right Mouse-click)

• Assessment - Activities • Assessment - Dietary • Assessment - Home Care Coordinator • Assessment - OT • Assessment - PCP • Assessment - PT • Assessment - RN • Assessment - SW • Change in Participant Diet • Education - Contracted Provider/Facility • Education - Family/Caregiver • Education - Participant • Education - Staff • Increased Center Attendance • Increased Frequency of Repositioning • Increased Frequency of Skin Assessments • Increased Frequency of Toileting • Increased Home Care • Increased PT or OT • Increased Staff at Contracted Provider/Facility • Increased Staff at PACE Center • Initiated Contractor Oversight • Initiated Quality Improvement Activities


• Medication Change • Medication Evaluation • Modified Environment - Participant's Home • Modified Environment - Assisted Living Facility • Modified Environment - Hospital • Modified Environment - Nursing Facility • Modified Environment - PACE Center • Policy - Implemented a New Policy • Policy - Revised an Existing Policy • Provided Dietary Supplements • Provided Participant with Medical Alert System • Provided Participant with New DME • Provided Pressure Reducing DME • Revised Participant Plan of Care • Specialist Consultation • Surgical Interventions • Other – If selected please enter a short description in the Other Action text box.


On the Data Entry - Quality Indicator Selection screen, click the radio button to the left of the Kennedy Terminal Ulcer quality indicator and then click Edit Quality Indicator. Click Add on the Data Entry - Kennedy Terminal Ulcer screen (Table III-36) to advance to the Data Entry – Kennedy Terminal Ulcer – Add screen (Table III-37) to add a record. Table III-36


The Edit and Delete buttons are disabled on this screen if there are no records to edit or delete. See the PACE Quality Indicator: No Data To Report section of this manual if the user wishes to report no data for the collection period. When data entry is complete, click Next to advance to the Data Entry - Kennedy Terminal Ulcer – Verify screen (Table III-38). Table III-37


A Control Number is generated for each record. The Data Entry - Kennedy Terminal Ulcer screen (Table III-39) displays all the incidents that have been entered for the quarter. To edit a Kennedy Terminal Ulcer record, click the radio button next to the appropriate control number then click Edit. To delete Kennedy Terminal Ulcer records, click the radio button next to the Kennedy Terminal Ulcer record to be deleted and click Delete. Click Back to return to the Data Entry - Quality Indicator Selection screen. Table III-39


PACE QUALITY INDICATOR: BURNS 1ST DEGREE OR LESS The HPMS Pace Quality Reporting Module provides functionality for the reporting of Burns 1st Degree or Less data. Please refer to PACE Level I Guidance for operational guidance on reporting Burns 1st Degree or Less data. Data Reporting Requirements:

1. Location of Incident • Alternative Care Setting • Assisted Living Facility • Caregiver/Family/Friend Home • Community • Contracted Facility or Provider - Not Listed Above • Hospital • Inpatient Hospice • Nursing Facility • PACE Center • Participant Home • Supported Living Environment - Not Listed Above

2. Time of Burn • Morning • Afternoon • Evening • Night

3. Location of Burn • Abdomen - Anterior • Abdomen - Posterior • Ankle - Left • Ankle - Right • Arm - Left Anterior Forearm • Arm - Left Anterior Upper Arm • Arm - Left Posterior Forearm • Arm - Left Posterior Upper Arm • Arm - Right Anterior Forearm • Arm - Right Anterior Upper Arm • Arm - Right Posterior Forearm • Arm - Right Posterior Upper Arm • Buttocks - Left • Buttocks - Right • Calf - Left Anterior • Calf - Left Posterior • Calf - Right Anterior • Calf - Right Posterior • Chest - Anterior • Chest - Posterior


• Ear - Left • Ear - Right • Elbow - Left • Elbow - Right • Eye - Left • Eye - Right • Eyelid - Left • Eyelid - Right • Face - Cheeks • Face - Forehead • Face - Lips • Finger - Left Fifth (Baby) • Finger - Left Fourth (Ring) • Finger - Left Second (Index) • Finger - Left Third (Middle) • Finger - Right Fifth (Baby) • Finger - Right Fourth (Ring) • Finger - Right Second (Index) • Finger - Right Third (Middle) • Foot - Left Dorsal • Foot - Left Plantar • Foot - Right Dorsal • Foot - Right Plantar • Genitals • Hand - Left Dorsal • Hand - Left Palm • Hand - Right Dorsal • Hand - Right Palm • Head - Posterior • Head - Scalp • Heel - Left • Heel - Right • Hip - Left • Hip - Right • Knee - Left • Knee - Right • Mouth (Internal) • Neck - Anterior • Neck - Posterior • Nose • Sacrum • Shoulder - Left • Shoulder - Right • Thigh - Left Anterior • Thigh - Right Anterior


• Thigh - Right Posterior • Thigh - Left Posterior • Throat (Internal) • Thumb - Left • Thumb - Right • Toe - Left 2nd Toe • Toe - Left 3rd Toe • Toe - Left 4th Toe • Toe - Left 5th Toe • Toe - Left Great Toe • Toe - Right 2nd Toe • Toe - Right 3rd Toe • Toe - Right 4th Toe • Toe - Right 5th Toe • Toe - Right Great Toe

4. Contributing Factors (Use the Ctrl + Right Mouse Click button for multiple selections) • Adaptive Equipment Not Used • Decrease in Center Attendance • Decrease in Home Care • Delay or Cancelation of Scheduled Home Care • Diagnosis of Dementia • Equipment Malfunction • Hot Food • Hot Water • Improper Food Handling • Improper Use of Chemicals • Improperly Stored Chemicals • Lack of Education - Caregiver • Lack of Education - Contractor • Lack of Education - Participant • Lack of Education - Staff • Location in Disrepair • Non-Compliance with Medication(s) • Non-Compliance with Plan of Care - Caregiver • Non-Compliance with Plan of Care - Contractor • Non-Compliance with Plan of Care - Participant • Non-Compliance with Plan of Care - Staff • Non-Compliance with PO Policies • Participant - Cognitive Impairment • Participant - Cooking • Participant - Cooking (instructed not to cook) • Participant - Did Not Wait for Assistance • Participant - Smoking • Participant - Using Curling Iron


• Participant - Using Iron • Participant - Using Lighter or Matches • Participant Left Unsupervised • PO Does Not Have Applicable Policies • Sun Exposure • Unknown • Other – If selected please enter a short description under Other Contributing

Factor text box. 5. Actions Taken (Use the Ctrl + Right Mouse Click button for multiple selections)

• Assessment - Activities • Assessment - Dietary • Assessment - Home Care Coordinator • Assessment - OT • Assessment - PCP • Assessment - PT • Assessment - RN • Assessment - SW • Education - Contracted Provider/Facility • Education - Family/Caregiver • Education - Participant • Education - Staff • Implemented Fire/Burn Prevention Programs in Center • Increased Center Attendance • Increased Home Care • Increased PT or OT • Increased Staff at Contracted Provider/Facility • Increased Staff at PACE Center • Initiated Contractor Oversight • Initiated Quality Improvement Activities • Installed Fire Extinguisher in Participant Home • Installed Smoke Detectors in Participant Home • Medication Change • Medication Evaluation • Modified Environment - Participant's Home • Modified Environment - Assisted Living Facility • Modified Environment - Hospital.


On the Data Entry - Quality Indicator Selection screen, click the radio button to the left of the Burns 1st Degree or Less quality indicator and then click Edit Quality Indicator to advance to the Data Entry – Burns 1st Degree or Less screen (Table III-40). Click Add to add an incident and advance to the Data – Entry - Burns 1st Degree or Less – Add screen (Table III-41). Table III-40


The Edit and Delete buttons are disabled on this screen if there are no records to edit or delete. See the PACE Quality Indicator: No Data To Report section of this manual if the user wishes to report no data for the collection period. When data entry is complete, click Next to advance to the Data Entry - Burns 1st Degree or Less –- Verify screen (Table III-42). Table III-41


A Control Number is generated for each Burns 1st Degree or Less record. The Data Entry - Burns 1st Degree or Less screen (Table III-43) displays all the incidents that have been entered for the quarter. To edit a record, click the radio button next to the appropriate control number then click Edit. To delete a record, click the radio button next to each record to be deleted and click Delete. Click Back to return to the Data Entry - Quality Indicator Selection screen. Table III-43


IV. UPLOAD DATA

On the PACE Start Page (Table I-2), click 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


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


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


V. REQUEST EXTENSION

The HPMS PACE Quality Reporting Module allows for the reporting of data for a quarter 30 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 I-2), click on 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 click 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 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; click Next. The user will advance to the Request Extension – Extension Request – Confirmation screen (Table V-3). Click Back to return to the Request Extension screen. Table V-2


On the Request Extension – Extension Request – Confirmation screen (Table V-3) review the information. Click Back to make a correction, or click 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 date they requested to submit all data.


VI. PACE REPORTS

The PACE Reports allow users to access and view the Comparative Data 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 I-2), click on the PACE Reports link on the right-hand menu to advance to the HPMS PACE Start Page 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 click Next. Please Note: The reports contain, except for the comparative report, only data submitted by the user’s PACE Organization. No data, other than contact information, is viewable by other PACE Organizations. Table VI-1


PACE COMPARATIVE DATA REPORT The Comparative Data Report displays comparative data of like organizations without revealing identifiable information. The PACE Comparative Data Report screen (Table VI-2) is used to launch the Comparative Data Report. Select the Reporting Period(s) and Region(s) for which you wish to run the report. Indicate the section of the report you wish to view and click Next. Table VI-2


Table VI-3 is a sample PACE Comparative Report for Enrollments & Total Counts. Click Download to Excel to export the report contents to Excel. Click Back to return to the previous screen (Table VI-2). Table VI-3


Table VI-4 is a sample PACE Comparative Report for Pneumococcal Immunizations. Click Download to Excel to export the report contents to Excel. Click Back to return to the previous screen (Table VI-2). Table VI-4


Table VI-5 is a sample PACE Comparative Report for Influenza Immunizations. Click Download to Excel to export the report contents to Excel. Click Back to return to the previous screen (Table VI-2). Table VI-5


PACE SITE DATA REPORT The PACE Site Data Report displays the monitoring data for the ten PACE quality indicators by Site. The PACE Site Data Report – Select a Reporting Period (Table VI-6) is the screen used to launch the PACE Site Data Report. Select the Reporting Period and click Next. Table VI-6


This will advance the user to the PACE Site Data Report – Reporting Period screen (Table VI-7). Select the Contract Number and the Site for which you wish to run the report, click Next. Table VI-7


The PACE Site Data Report (Table VI-8) will be displayed. Click Download to Excel to export the report contents to Excel. Click Back to return to the previous screen. Table VI-8


PACE STATUS REPORT The PACE Status Report (Table VI-9) displays the PACE site quality indicators for which data has not been submitted. The PACE Status Report – Select a Reporting Period (Table VI-9) is the screen used to launch the PACE Site Data Report. Select the Reporting Period and click Next. Table VI-9


This will advance the user to the PACE Status Report – Reporting Period screen (Table VI-10). Select the Contract Number and Site for which you wish to run the report, click Next. Table VI-10


The PACE Status Report (Table VI-11) will be displayed. Click Download to Excel to export the report contents to Excel. Click Back to return to the previous screen. Table VI-11


APPENDIX I: HPMS CONTACT

INFORMATION

Subject Matter Name Phone Email Address

HPMS Technical Help

HPMS Help Desk 800-220-2028

[email protected]

HPMS Password Reset Requests

CMS Action Desk 410-786-2580 N/A

HPMS User Access Questions

HPMS User Access Mailbox

N/A [email protected]

HPMS PACE Monitoring Related Questions

CMS DMAO Mailbox N/A DMAO.lmi.org

General HPMS PACE Monitoring Module Inquiries

Timothy Hoogerwerf 410-786-9962 [email protected]

mailto:[email protected]

mailto:[email protected]

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