Survey-and-cert-letter-12-45.pdf

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES RESIDENT CENSUS AND CONDITIONS OF RESIDENTS
Independent
Assist of One or Two Staff
Dependent
A. Bowel/Bladder Status
B. Mobility
F94 ____ With indwelling or external catheter
F100____ Bedfast all or most of time
F95 Of the total number of residents with catheters,
F101____ In a chair all or most of time
how many were present on admission ____? F102____ Independently ambulatory
F96 ____ Occasionally or frequently incontinent of
F103____ Ambulation with assistance or assistive device
F97 ____ Occasionally or frequently incontinent of
F104____ Physically restrained
F105 Of the total number of residents with restraints,
F98 ____ On urinary toileting program
how many were admitted or readmitted with orders for F99 ____ On bowel toileting program
F106____ With contractures
F107 Of the total number of residents with contractures,
how many had a contracture(s) on admission ____?
C. Mental Status
D. Skin Integrity
F108-114 – indicate the number of residents with:
F115-118 – indicate the number of residents with:
F108____ Intellectual and/or developmental disability
F115____ Pressure ulcers (exclude Stage 1)
F109____ Documented signs and symptoms of depression
F116 Of the total number of residents with
pressure ulcers excluding Stage 1, how many F110____ Documented psychiatric diagnosis
residents had pressure ulcers on admission ____?
F117____ Receiving preventive skin care
F111____ Dementia: (e.g., Lewy-Body, vascular or Multi-
infarct, mixed, frontotemporal such as Pick’s disease; F118____ Rashes
and dementia related to Parkinson’s or Creutzfeldt- Jakob diseases), or Alzheimer’s Disease F112____ Behavioral healthcare needs
F113 Of the total number of residents with
behavioral healthcare needs, how many have an
individualized care plan to support them ____?
F114____ Receiving health rehabilitative services
for MI and/or ID/DD
RESIDENT CENSUS AND CONDITIONS OF RESIDENTS
I certify that this information is accurate to the best of my knowledge.
E. Special Care
F119-132 – indicate the number of residents receiving:
F127____ Suctioning
Fl19 ____ Hospice care
F128____ Injections (exclude vitamin B12 injections)
F120____ Radiation therapy
F129____ Tube feedings
F121____ Chemotherapy
Fl30____ Mechanically altered diets including pureed and all
F122____ Dialysis
F123____ Intravenous therapy, IV nutrition, and/or blood transfusion
F131____ Rehabilitative services (Physical therapy, speech-
language therapy, occupational therapy, etc.) F124____ Respiratory treatment
Exclude health rehabilitation for MI and/or ID/DD F125____ Tracheostomy care
F132____ Assistive devices with eating
F126____ Ostomy care
F. Medications
F133-139 – indicate the number of residents receiving:
F140____ With unplanned significant weight loss/gain
F133____ Any psychoactive medication
F141____ Who do not communicate in the dominant
F134____ Antipsychotic medications
language of the facility (include those who use American sign language) F135____ Antianxiety medications
F142____ Who use non-oral communication devices
F136____ Antidepressant medications
F143____ With advance directives
F137____ Hypnotic medications
F144____ Received influenza immunization
F138____ Antibiotics
F145____ Received pneumococcal vaccine
F139____ On pain management program
TO BE COMPLETED BY SURVEY TEAM
F146 Was ombudsman office notified prior to survey?
F147 Was ombudsman present during any portion of the survey?
F148 Medication error rate _______%
RESIDENT CENSUS AND CONDITIONS OF RESIDENTS
(use with Form CMS-672)
GENERAL INSTRUCTIONS:
THIS FORM IS TO BE COMPLETED BY THE FACILITY AND REPRESENTS THE CURRENT CONDITION OF RESIDENTS AT
THE TIME OF COMPLETION
There is no federal requirement to automate the 672 form. A facility may use its MDS data to assist in completing the entry fields for the
672 form, however, facilities should ensure that the MDS information is not simply counted and copied over into the form. All conditions
noted on this form that are not identified on the MDS must be counted manually. This information is designed to be a representation
of the facility during survey; it does not directly correspond to the MDS data in every field. The information entered on this form must
be reflective of all residents as of the day of survey; therefore all information entered must be independently verified.
Following certain entry fields, the related MDS 3.0 item(s) is noted. Remember, that although MDS items are noted for some fields, the field itself may need to be completed differently to reflect the current status of all residents as of the day of survey. The MDS items are provided only as a reference point, the form is to be completed using the time frames and other specific instructions as noted below.
Where a field refers to the “admission assessment,” use only the counts from the first assessment since the most recent admission/entry or reentry (OBRA or Scheduled PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E = 1 for each resident).
For the purpose of completing this form the terms: “facility” means certified beds (i.e., Medicare and/or Medicaid certified beds) and “residents” means residents in certified beds regardless of payer source.
INSTRUCTIONS AND DEFINITIONS:
Complete each field by specifying the number of residents in
Dressing (F82 – F84): How the resident puts on, and takes off all
each category. If no residents fall into a category enter a “0”.
items of clothing, including donning/removing prostheses (e.g., braces and artificial limbs) or elastic stockings. G0110G1 = 0 for Provider Number: Facility CMS certification provider number.
F82 OR G0110G1 = 1, 2, OR 3 for F83 OR G0110G1 = 4 for F84.
A0100B; leave blank for initial certifications.
Facilities may set out clothes for residents. If this is the case Block F75: Residents whose primary payer is Medicare.
and this is the only assistance the resident receives, count the resident as independent. However, if a resident receives Block F76: Residents whose primary payer is Medicaid.
assistance, such as with dressing, donning a brace, elastic stocking, a prosthesis , or securing fasteners, etc. count the Block F77: Residents whose primary payer is neither Medicare
resident as needing the assistance of 1 or 2 staff, as appropriate.
Transferring (F85 – F87): How the resident moves between
Block F78: Residents for whom a bed is maintained on the day
surfaces, including, to or from bed, chair, wheelchair, or the survey begins, including those temporarily away in a hospital standing position. (EXCLUDES transfers to/from the bath/ or on leave. This should be representative of residents in the toilet). G0110B1 = 0 for F85 OR G0110B1 = 1, 2, or 3 for F86 nursing facility or those who have a bed-hold.
ADLS (F79 – F93): To determine resident status, unless otherwise
Facilities may provide “setup” assistance to residents, such as noted, consider the resident’s condition for the 7 days prior to the handing equipment (e.g., quad cane) to the resident. If this is the survey. Horizontal totals across the three columns (Independent, case and is the only assistance required, count the resident as Assist of One or Two Staff, and Dependent) must equal the number in Block F78, Total Residents, for each of the ADL categories (Bathing, Dressing, Transferring, Toilet Use and Eating).
Toilet Use (F88 – F90): How the resident uses the toilet, commode,
bedpan, or urinal; transfers on/off toilet; cleanses self after elimination;
Bathing (F79 – F81): This includes a full-body bath/shower,
changes pad(s); manages ostomy or catheter, and adjusts clothing. sponge bath, and transfer into and out of tub or shower. If all that is done for the resident is to open a package (e.g., a clean G0120A = 0 for F79, G0120A = 1, 2, OR 3 for F80. OR incontinence pad), count the resident as independent. G0110I1 = 0 for F88 OR G0110I1 = 1, 2, or 3 for F89 OR G0110I1 = 4 for F90.
Facilities may provide “setup” assistance to residents such as Eating (F91 – F93): How a resident eats and drinks, regardless
drawing water for a tub bath or laying out clothes, bathing of skill. Do not include eating/drinking during medication pass. supplies/toiletries, etc. Also, a resident may only need assistance Includes intake of nourishment by other means (e.g., tube feeding, with washing their back or shampooing their hair. If either of total parenteral nutrition, includes IV fluids administered for these are the case, and the resident requires no other assistance, nutrition or hydration). Facilities may provide “setup” activities, such as opening containers, buttering bread, and organizing the tray; if this is the case and is the only assistance a resident needs, count this resident as independent. G0110H1 = 0 for F91 OR G0110H1 = 1, 2, or 3 for F92 OR G0110H1 = 4 for F93.
RESIDENT CENSUS AND CONDITIONS OF RESIDENTS
(use with Form CMS-672)
A. BOWEL/BLADDER STATUS (F94 – F99) -
F100: Bedfast all or most of time: Who are bedfast all or most
RESIDENTS
of the time (e.g., in bed or geriatric chair/recliner) includes bedfast with bathroom privileges. F94: With an indwelling or an external catheter:
Whose urinary bladder is constantly drained by a catheter (e.g.,
F101: In a chair all or most of time: Who depend on a chair for
an indwelling catheter, a suprapubic catheter or nephrostomy mobility includes those residents who can stand with assistance to tube) or who wears an appliance that is applied over the penis and pivot from bed to wheelchair or to otherwise transfer. The resident connected to a drainage bag to collect urine from the bladder (e.g., cannot take steps without extensive or constant weight-bearing condom catheter or similar appliance). H0100A or B = checked.
support from others and is not bedfast all or most of the time. G0300A or E = 2 OR G0600C = checked.
F95: Of the total number of residents with catheters:
Who had a catheter present on admission/entry or reentry.
F102: Independently ambulatory: Who require no help or
H0100A or B = checked. To complete this field use only the oversight; or help or oversight was provided only 1 or 2 times counts from the first assessment since the most recent admission/ during the past 7 days. Do not include residents who use a cane, entry or reentry (OBRA or Scheduled PPS, i.e., A0310A = 01 walker or crutch. G0110C1 or G0110D1 = 0 or 7 and G0110C2 or OR A0310B = 01 or 06 OR A0310E = 1 for each resident).
G0110D2 = 0 or 1 AND G0600A and G0600B = not checked.
F96: Occasionally or frequently incontinent of bladder:
F103: Ambulation with assistance or assistive devices:
Who have an incontinent episode two or more times per week. Who require oversight, cueing, physical assistance or who use a Do not include residents with an indwelling or external catheter. cane, walker, or crutch. Count the use of lower leg splints, orthotics, H0100A and B = not checked AND H0300 =1, 2, or 3.
and braces as assistive devices. G0110C1 or G0110D1 = 1, 2, or 3 AND G0110C2 or G0110D2 = 1, 2 or 3 OR G0600A and/or F97: Occasionally or frequently incontinent of bowel:
Who have a loss of bowel control two or more times per week. H0400 = 2 or 3.
F104: Physically restrained: For whom restraints were used.
Restraints include any manual or physical method or mechanical
F98: On urinary toileting program: With a systematically
device, material or equipment attached or adjacent to the implemented, individualized urinary toileting program resident’s body in such a way that the individual cannot remove (i.e. bladder rehabilitation/retraining, prompted voiding, easily and it restricts freedom of movement or normal access habit training/scheduled voiding) to decrease or prevent to one’s body. Do not include devices such as braces which are urinary incontinence or minimizing or avoiding the negative used for medical/clinical reasons. P0100A through H = 1 or 2.
consequences of incontinence (e.g., pelvic floor exercises). Count all residents on urinary training programs including those F105: Of total number of restrained residents: On admission/
who are incontinent. H0200A = 1 OR H200C = 1 OR H0300 = entry or reentry with an order for restraint(s). P0100A through H = 1 or 2. To complete this field use only the counts from the first assessment since the most recent admission/entry or reentry F99: On bowel toileting program: With a systematically
(OBRA or Scheduled PPS, i.e., A0310A = 01 OR A0310B = 01 implemented, individualized bowel toileting program to decrease or 06 OR A0310E = 1 for each resident).
or prevent bowel incontinence or minimizing or avoiding the negative consequences of incontinence (e.g., use of adequate F106: With contractures: With a restriction of full passive
fluid intake, fiber in the diet, exercise, and scheduled times range of motion of any joint due to deformity, disuse, pain, etc., to attempt bowel movement). Count all residents on toileting includes loss of range of motion in neck, fingers, wrists, elbows, programs including those who are incontinent. H0400 = 2 or 3 shoulders, hips, knees and ankles. G0400A and/or B = 1 or 2. F107: Of the total number with contractures, those who
B. MOBILITY (F100 – F107) - RESIDENTS
had a contracture(s) on admission: To complete this field use
only the counts from the first assessment since the most recent
Total for F100 – F103 should = the number in Block F78, admission/entry or reentry (OBRA or Scheduled PPS, i.e., Total Residents. Algorithm to force mutual exclusivity: Test A0310A = 01 OR A0310B = 01 or 06 OR A0310E = 1 for each for each resident. If F100 = 1 then add 1 to F100, and go to resident). (neck contractures not included in MDS data).
the next resident; If F101 = 1 then add 1 to F101 and go to the next resident; If F103 = 1 then add 1 to F103 and go to the next resident; If F102 = 1 then add 1 and go to the next resident.
RESIDENT CENSUS AND CONDITIONS OF RESIDENTS
(use with Form CMS-672)
C. MENTAL STATUS (F108 – F114) - RESIDENTS
D. SKIN INTEGRITY (F115 – F118) - RESIDENTS
F108: With Intellectual Disability (ID) (Mental retardation
F115: With pressure ulcers: With localized injury to the skin
as defined at 483.45(a)) or Developmental Disability (DD):
and/or underlying tissue, usually over a bony prominence, as a In all of the categories of intellectual or developmental disability result of pressure, or pressure in combination with shear and/ regardless of severity, as determined by the State Mental Health or friction (exclude Stage I). M0300B1, M0300C1, M0300D1, or State Mental Retardation Authorities. A1550A, B through F116: Of the total number of residents with pressure ulcers
F109: With documented signs and symptoms of depression:
(excluding Stage 1), those who had pressure ulcers on
With documented signs and symptoms of depression. D0200A1 admission/entry or reentry: M0300B2, M0300C2, M0300D2,
through D1 = 1 for any indicator present OR D0200I1 = 1OR M0300E2, M0300F2 and/or M0300G2 > 0. To complete this D0200A2 through D2 = 2 or 3 for symptom frequency OR field, use only the counts from the first assessment since the D0300 = 05 - 27 OR D0500A1 through D1 = 1 for any indicator most recent admission/entry or reentry. (OBRA or Scheduled present OR D0500I1 = 1 OR D0500A2 through D2 = 2 or 3 for PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E = symptom frequency OR D0600 = 05 - 30.
F110: With documented psychiatric diagnosis (exclude
F117: Receiving preventive skin care: Receiving non-
dementias and depression): With primary or secondary
routine skin care ordered by a physician, and/or included in the resident’s comprehensive plan of care (e.g., hydrocortisone ointment to areas of dermatitis three times a day, granulex sprays, etc.). M1200A through I = checked.
Fl18: With rashes: Who have rashes which may or may not
be treated with any medication or special baths, etc. (e.g., Psychotic mood disorders (including mania and depression may include but are not limited to antifungals, corticosteroids, with psychotic features, acute psychotic episodes, brief emollients, diphenhydramines or scabicides).
reactive psychosis and atypical psychosis). I5700, I5900, I5950, I6000 or I6100 = checked. E. SPECIAL CARE (F119 – F132) - RESIDENTS
F111: Dementia: Non-Alzheimer’s Dementia (e.g., Lewy-
F119: Receiving hospice care: Who have elected or are
Body, vascular or Multi-infarct, mixed, frontotemporal such
currently receiving the hospice benefit. O0100K2 = checked.
as Pick’s disease; and dementia related to Parkinson’s or
Creutzfeldt-Jakob diseases), or Alzheimer’s Disease: With a
F120: Receiving radiation therapy: Who are under a treatment
primary or secondary diagnosis of dementia or organic mental plan involving radiation therapy. O0100B1 or O0100B2 = syndrome including, Non-Alzheimer’s Dementia (e.g., Lewy- Body, vascular or Multi-infarct, mixed, frontotemporal such as Pick’s disease; and dementia related to Parkinson’s or Creutzfeldt- F121: Receiving chemotherapy: Who are under a treatment
Jakob diseases). I4200 or I4800 = checked plan involving chemotherapy. O0100A1 or O0100A2 = checked.
F112: With behavioral health care needs: With one or more
F122: Receiving dialysis: Receiving hemodialysis or
of the following indicator(s): wandering, verbally abusive, peritoneal dialysis either within the facility or offsite. O0100J1 physically abusive, socially inappropriate/disruptive, and resistive to care. E0200A, B, or C = 1, 2, or 3 OR E0300 = 1 OR E0500A, B, or C = 1 OR E0600A, B, or C = 1 OR E0800 = 1, 2, F123: Receiving intravenous therapy, IV nutrition and/
or 3 OR E0900 = 1, 2, or 3 OR E1000A or B = 1.
or blood transfusion: Receiving fluids, medications, all or
most of their nutritional requirements and/or blood and blood
F113: Of the total number with behavioral healthcare needs,
products administered intravenously. K0510A2, O0100H2, or those having an individualized care plan to support them:
With behavior symptoms who are receiving an individualized care plan/program designed to support and manage behavioral F124: Receiving respiratory treatment: Resceiving treatment
by the use of respirators/ventilators, oxygen, IPPB or other inhalation therapy, pulmonary toilet, humidifiers, and other F114: Receiving health rehabilitative services for Mental
methods to treat conditions of the respiratory tract. This does Illness (MI) and/or ID/DD: Receiving health rehabilitative
not include residents receiving tracheostomy care or respiratory suctioning. O0100C2, O0100F2, or O0100G2 = checked.
RESIDENT CENSUS AND CONDITIONS OF RESIDENTS
(use with Form CMS-672)
F125: Receiving tracheostomy care: Receiving care involved
F134: Antipsychotic medications: Days entered for N0410A > 0
in maintenance of the airway, the stoma and surrounding skin, and dressings/coverings for the stoma. O0100E2 = checked.
F126: Receiving ostomy care: Receiving care for a colostomy,
ileostomy, uretrostomy, or other ostomy of the intestinal and/or urinary tract. DO NOT include tracheostomy. H0100C = checked.
F127: Receiving suctioning: That require use of a mechanical
device which provides suction to remove secretions from the respiratory tract via the oral cavity, nasal passage, or tracheostomy. O0100D2 = checked. (Note: O0100D2 does not include oral suctioning, so residents who receive oral suctioning F128: Receiving injections: That have received one or more
injections within the past 7 days. (Exclude injections of Vitamin B 12.) Review residents where N0300 > 0. Omit from the count any resident whose only injection currently is B12. F129: Receiving tube feeding: Who receive all or most of
their nutritional requirements via a feeding tube that delivers food/nutritional substances directly into the GI system (e.g., nasogastric tube, gastrostomy tube). K0510B2 = checked.
F135: Antianxiety medications (anxiolytics): Days entered for
N0410B > 0
F130: Receiving mechanically altered diets: Receiving a
mechanically altered diet including pureed and/or chopped foods F131: Receiving rehabilitative services: Receiving care
designed to improve functional ability provided by, or under the direction of a rehabilitation professional (physical therapist, occupational therapist, speech-language pathologist). Exclude health rehabilitation for MI and/or ID/DD. Any minutes > 0 F136: Antidepressant medications: Days entered for N0410C > 0
F132: Assistive devices with eating: Who are using devices to
maintain independence and to provide comfort when eating (i.e., plates with guards, large handled flatware, large handle mugs, extend hand flatware, etc.). O0500C or H > 0.
F. MEDICATIONS (F133 – F139) - RESIDENTS
F133: Receiving psychoactive medications: That receive
medications classified as antipsychotics, anxiolytics, antidepressants, and/or hypnotics. Days entered > 0 for N0410A, Use the following lists to assist you in determining the number of residents receiving psychoactive medications. These lists are not meant to be all inclusive; therefore, a resident receiving
a psychoactive medication not on this list, should be counted under F133 and any other medication category that applies: RESIDENT CENSUS AND CONDITIONS OF RESIDENTS
(use with Form CMS-672)
F137: Hypnotic medications: Days entered for N0410D > 0
F142: Who use non-oral communication: Who communicate
via non-oral methods, including, picture boards, computers, etc. A1100B, Preferred Language (e.g. American Sign Language).
F143: Who have advance directives: Who have advance
directives, such as Physician’s Orders for Life-Sustaining Treatment (POLST), a living will or durable power of attorney for health care, recognized under state law and relating to the F138: Receiving antibiotics: Receiving antibacterial
provisions of care when the individual is incapacitated.
sulfonamides, antibiotics, etc., either for prophylaxis or treatment. Days entered for N0410F > 0.
F144: Received influenza immunization: Who received the
influenza immunization within the last 12 months. O0250A = 1.
F139: On a pain management program: With a specific plan
for control of difficult to manage or intractable pain, which
F145: Received pneumococcal vaccine: Who received the
may include self medication pumps or regularly scheduled administration of medication alone or in combination with non-medication interventions (e.g., massages heat/cold, biofeedback, LEAVE BLANK (F146-F148) – To Be Completed By
Survey Team
G. OTHER RESIDENT CHARACTERISTICS
F146: Ombudsman notice: Indicate whether or not the State
Ombudsman was notified prior to the survey.
(F140 – F145)
F140: With unplanned significant weight loss/gain: Who have
F147: Ombudsman presence: Indicate whether or not the State
experienced unplanned weight loss/gain of > 5% in one month Ombudsman was present at any time during the survey.
or > 10% over six months. K0300 or K0310 = 2.
F148: Medication error rate: Calculate and enter the
F141: Who do not communicate in the dominant language
medication error percentage of the facility.
at the facility: Who do not speak or understand the dominant
language spoken in the facility and need or want an interpreter to
communicate. A1100A = 1.

Source: http://www.creativesolutionsunlimited.com/web_watch_docs/CMS_672_05_12.pdf