CMS Pub. 100-11, ch. 10, § 30.2

Level One Reporting Requirements refers to those data elements for monitoring that are

regularly reported by PACE organizations via the Health Plan Management System

(HPMS) PACE monitoring module. These monitoring elements are detailed in the HPMS

PACE User’s Guide, Fall 2005

(https://www.cms.gov/PACE/Downloads/hpmsmanual.pdf) and include:

• Routine Immunizations;

• Grievances and Appeals;

• Enrollments;

• Disenrollments;

• Prospective Enrollees;

• Readmissions;

• Emergency (Unscheduled) Care;

• Unusual Incidents; and,

• Deaths.

The HPMS database is regularly monitored by staff in the CMS Regional Office (RO)

and State Administering Agency (SAA).

Data reported in response to the Level One Reporting Requirement are used by PACE

organizations to identify opportunities for quality improvement. For example, based on

their review of Level One data reported in HPMS, PACE organization’s may:

• Conduct a QAPI activity using a standardized methodology (e.g., Plan, Do,

Check, Act known as PDCA) if a policy or system problem is identified;

• Institute QAPI-driven change in policies, procedures, systems, or training as

appropriate;

• Evaluate the effectiveness of the intervention;

• Track and trend for sustainable improvement;

• Reevaluate until improvement is sustained;

• Document for review during CMS/State Administering Agency audit as

evidence of a performance improvement activity;

• Report findings at least annually to oversight committees including the PACE

organization’s governing board.

[HPMS PACE User’s Guide, Fall 2005; Level Two Guidance, October 2010]