CMS Manual System - Louisiana Department of Health and Hospitals

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e. Special Care Fl19____ Receiving hospice care benefit F120____ Receiving radiation therapy F121____ Receiving chemotherapy F122____ Receiving dialysis Form CMS-672 (10/10) ReSIDent CenSuS AnD ConDItIonS of ReSIDentS F123____ Receiving intravenous therapy, parenteral nutrition, and/or blood transfusion F124____ Receiving respiratory treatment F125____ Receiving tracheostomy care F126____ Receiving ostomy care f. Medications F133____ Receiving any psychoactive medication F134____ Receiving antipsychotic medications F135____ Receiving antianxiety medications F136____ Receiving antidepressant medications F137____ Receiving hypnotic medications F138____ Receiving antibiotics F139____ On pain management program I certify that this information is accurate to the best of my knowledge. F127____ Receiving suctioning F128____ Receiving injections (exclude vitamin B12 injections) F129____ Receiving tube feedings Fl30____ Receiving mechanically altered diets including pureed and all chopped food (not only meat) F131____ Receiving specialized rehabilitative services (Physical therapy, speech-language therapy, occupational therapy) F132____ Assistive devices while eating G. other F140____ With unplanned significant weight loss/gain F141____ Who do not communicate in the dominant language of the facility (include those who use sign language) F142____ Who use non-oral communication devices F143____ With advance directives F144____ Received influenza immunization F145____ Received pneumococcal vaccine Signature of Person Completing the Form Title Date to Be CoMPLeteD BY SuRVeY teAM F146 Was ombudsman office notified prior to survey? ___ Yes ___ No F147 Was ombudsman present during any portion of the survey? ___ Yes ___ No F148 Medication error rate _______% 2
GeneRAL InStRuCtIonS: Form CMS-672 (10/10) ReSIDent CenSuS AnD ConDItIonS of ReSIDentS (use with form CMS-672) tHIS foRM IS to Be CoMPLeteD BY tHe fACILItY AnD RePReSentS tHe CuRRent ConDItIon of ReSIDentS At tHe tIMe of CoMPLetIon There is not a federal requirement for automation of the 672 form. The facility may continue to complete the 672 with manual methods. The facility may use the MDS data to start the 672 form, but must verify all information, and in some cases, re-code the item responses to meet the intent of the 672 to represent current resident status according to the definitions of the 672. Since the census is designed to be a representation of the facility during the survey, it does not directly correspond to the MDS in every item. For the purpose of this form “the facility” equals certified beds (i.e., Medicare and/or Medicaid certified beds). For the purpose of this form “residents” means residents in certified beds regardless of payor source. Following the definition of each field, the related MDS codes and instructions will be noted within square brackets ([ ]). Where coding refers to the admission assessment, use the first assessment done after the most recent admission or readmission event. Complete each item by specifying the number of residents characterized by each category. If no residents fall into a category enter a “0”. InStRuCtIonS AnD DefInItIonS: Provider No.: Enter the facility’s assigned provider number. Leave blank for initial certifications. Block F75: Enter the number of facility residents, whose primary payer is Medicare. [Code manually] Block F76: Enter the number of facility residents, whose primary payer is Medicaid. [Code manually] Block F77: Enter the number of facility residents, whose primary payer is neither Medicare nor Medicaid. [Code manually] Block F78: Enter the number of total residents for whom a bed is maintained, on the day the survey begins, including those temporarily away in a hospital or on leave. [Total residents in nursing facility or on bedhold] ADLs (F79 – F93) To determine resident status, unless otherwise noted, consider the resident’s condition for the 7 days prior to the survey. [Horizontal totals must equal the number in F78; Manually re-code all “8” responses.] Bathing (F79 – F81) The process of bathing the body (excluding back and shampooing hair). This includes a full-body bath/shower, sponge bath, and transfer into and out of tub or shower. [F79: G0120A = 0; F80: G0120A = 1, 2, 3; F81: G0120A = 4] Many facilities routinely provide “setup” assistance to all residents such as drawing water for a tub bath or laying out bathing materials. If this is the case and the resident requires no other assistance, count the resident as independent. Dressing (F82 – F84) How the resident puts on, fastens, and takes off all items of street clothing, including donning or removing prostheses (e.g., braces and artificial limbs). [F82: G0110G = 0; F83: G0110G = 1, 2, 3; F84: G0110G = 4] Many facilities routinely set out clothes for all residents. If this is the case and this is the only assistance the resident receives, count the resident as independent. However, if a resident receives assistance with donning a brace, elastic stocking, a prosthesis and so on, securing fasteners, or putting a garment on, count the resident as needing the assistance of 1 or 2 staff. Transferring (F85 – F87) How the resident moves between surfaces, such as to and from the bed, chair, wheelchair or to and from a standing position. (EXCLUDE transfers to and from the bath or toilet). [F85: G0110B = 0; F86: G0110B = 1, 2, 3; F87: G0110B = 4] Many facilities routinely provide “setup” assistance to all residents, such as handing the equipment (e.g., sliding board) to the resident. If this is the case and is the only assistance required, count the resident as independent. Toilet Use (F88 – F90) How the resident uses the toilet room (or bedpan, bedside commode, or urinal). How resident transfers on and off toilet, cleans self after elimination, changes sanitary napkins, ostomy, external catheters, and adjusts clothing prior to and after using toilet. If all that is done for the resident is to open a package (e.g., a clean sanitary pad), count the resident as independent. [F88: G0110I = 0; F89: G0110I = 1, 2, 3; F90: G0110I = 4] 3
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CMS Manual System Pub. 100-07 State
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State Operations Manual Appendix PP
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§483.25(n) Influenza and Pneumococ
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(including eligibility, coverage, c
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___________________________________
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Procedures §483.10(a)(3) and (4) D
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―Advance directive‖ means a wri
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§483.10(b)(5) -- The facility must
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Provide written information concern
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___________________________________
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§483.10(c)(3) Deposit of Funds (i)
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Were limits placed on amounts that
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___________________________________
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(B) Dietary services as required at
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medical service that is recognized
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satisfactorily resolved by discussi
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(i) Transfer to another health care
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Interpretive Guidelines §483.10(g)
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(ii) Any representative of the Stat
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___________________________________
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efore the resident may exercise tha
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§483.12(a) Transfer, and Discharge
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§483.10(o), Tag F177, addresses th
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Look for changes in source of payme
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How to notify the ombudsman (name,
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___________________________________
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Interpretive Guidelines §483.12(d)
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Interpretive Guidelines §483.12(d)
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―Convenience‖ is defined as any
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order reflecting the presence of a
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consistently implemented. Determine
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monitored separation from other Res
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to prevent occurrences, monitoring
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injurious behaviors, residents with
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A certified nurse aide found guilty
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o Day-to-day use of plastic cutlery
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for the resident‘s safety. For ex
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If a facility changes its policy to
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___________________________________
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Staff should strive to reasonably a
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egarding medical information. The f
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The report stated that, ―Resident
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If not contraindicated, modifying t
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o Visual interaction and to compens
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For residents from diverse ethnic o
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Encouraging volunteer-type work tha
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12 Christenson, M.A. (1996). Enviro
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selected this activity. The Nationa
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Interview the social services staff
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Identifies how the facility will pr
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o Determine if the facility has acc
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(ii) Has 2 years of experience in a
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Once the team has completed its inv
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___________________________________
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transportation services that are no
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F252 (Rev. 66, Issued: 10-01-10, Ef
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Although this Tag can be used for i
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___________________________________
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___________________________________
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Intent §483.20 To provide the faci
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(vii) Psychosocial well-being ―Ps
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___________________________________
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Resident‘s decision making change
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___________________________________
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(i) Admission assessment. (ii) Annu
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Completing an assessment that is no
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Interpretive Guidelines §483.20(h)
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Submitting correction(s) to informa
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If the resident has refused treatme
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. Do the dietitian and speech thera
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Are physicians‘ orders carried ou
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What types of pre-discharge prepara
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If the resident‘s PAS report indi
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Briefly review the assessment, care
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and knowledge of the resident, shou
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Determine whether the facility had
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NOTE: Guidance regarding pressure u
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The resident has the right to refus
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others being hypersensitivity, idio
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Examples of clinical resources avai
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indicators which may represent pain
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• Impact of pain on quality of li
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National Center for Complementary a
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3 National Center for Complementary
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The objective of this protocol is t
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How effective the interventions hav
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Nurse Interview. Interview a nurse
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Communicated with the health care p
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qualified persons with input from t
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of pain. First, the team must rule
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The resident experienced daily or l
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Extensive Assistance - While reside
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Procedures: §483.25(a)(1)(ii) Dete
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Identify if resident triggers CAAs
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USE OF SPEECH, LANGUAGE, OR OTHER F
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___________________________________
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Probes: §483.25(b) Identify if res
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―Debridement‖- Debridement is t
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OVERVIEW A pressure ulcer can occur
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procedures, during prolonged ambula
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Assessment of a resident‘s skin c
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Both urine and feces contain substa
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use of lifting devices for repositi
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in accord with resident‘s overall
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Whether pain, if present, is being
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Some clinicians utilize validated i
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generally impairs wound healing, se
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15 Fuhrer M., Garber S., Rintola D.
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of Localized Chronic Wound Infectio
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Previously unidentified open areas;
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complications including reassessmen
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If not, the development of the pres
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o Determine if the care plan was pe
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Examples of possible avoidable nega
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(Rev. 66, Issued: 10-01-10, Effecti
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later stages of dementia, diabetes,
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the resident‘s concerns and offer
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Functional and cognitive capabiliti
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toileting and response to specific
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cognitive deficit—provided that t
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the epidermis (comparable to a deep
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adequate. Based on the resident‘s
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Follow-Up of UTIs rectal temperatur
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9 Maki, D.G. & Tambyah, P.A. (2001)
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Whether the resident is on a schedu
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catheter/continence services. Reque
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Defines the catheter, tubing and ba
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If the attending physician is unava
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Assess, prevent (to the extent poss
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perform relevant activities of dail
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Requires immediate correction, as t
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The failures of the facility to pro
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Identify if resident triggers CAAs
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Probes: §483.25(f)(1) For sampled
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___________________________________
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Using universal precautions and cle
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Monitor the effectiveness of the
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Directs resources to address safety
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Monitoring is the process of evalua
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those (e.g., disease, environment)
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Addressing the factors for the fall
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155°F 148°F 140°F 133°F 127°F
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NOTE: The Safe Medical Devices Act
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ENDNOTES 1 Centers for Medicare & M
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Use To evaluate whether the facilit
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2. Interview The adequacy of the su
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Changes in condition such as the ab
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Noncompliance for F323 After comple
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Once the survey team has completed
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Unsafe wandering and/or elopement t
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Severity Level 1 Considerations: No
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―Qualified dietitian‖ refers to
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Current standards of practice recom
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dry mouth, and diseases of the orop
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Based on analysis of relevant infor
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For many residents (including overw
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In deciding whether and how to inte
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End-of-Life Resident choices and cl
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11 Chouinard, J. (2000). Dysphagia
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Objectives Use INVESTIGATIVE PROTOC
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Nutrition interventions, such as sn
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Whether the facility identified res
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Review of Facility Practices Relate
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42 CFR §483.20(b)(1), Tag F272, Co
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DEFICIENCY CATEGORIZATION (Part IV,
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If immediate jeopardy has been rule
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Intent §483.25(j) The intent of th
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Is proper administration technique
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§483.25(k)(5) Standard: Tracheal S
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(v) In the presence of adverse cons
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physical actions such as: pacing, c
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o Support decisions about modifying
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individual with dementia, to improv
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Medication management is based in t
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Whether the signs, symptoms, or rel
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o Pain; o Chronic psychiatric illne
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Common Conditions/ Symptoms Example
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Identifying the essential informati
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necessarily indicate a need for dos
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Sometimes, the decision about wheth
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The continued use is in accordance
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J., & Bates, D.W. (2005). Incidence
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(NSAIDs) Medication Issues and Conc
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Antibiotics Medication Issues and C
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Medication Issues and Concerns prim
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Medication Issues and Concerns Mono
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chlorpropamide glyburide Antifungal
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Medication Issues and Concerns MAO
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Medication Issues and Concerns days
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Medication Issues and Concerns Medi
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uspirone Medication Issues and Conc
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Medication Issues and Concerns amio
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Medication Issues and Concerns Angi
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Nitrates, e.g., Medication Issues a
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Medication Issues and Concerns Anti
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Medication Issues and Concerns esom
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Medication Issues and Concerns laxa
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Medication Issues and Concerns Resp
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Medication Issues and Concerns hygi
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Medication Issues and Concerns All
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iperiden trihexyphenidyl olanzapine
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NOTE: This review is not intended t
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If during the review, you identify
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How he/she approaches the MRR proce
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o Failure to monitor a medication c
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42 CFR 483.20(b), F272, Comprehensi
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Complications (such as diarrhea wit
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NOTE: If Severity Level 3 (actual h
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―Resident Condition‖ -- The res
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Medication Errors Due to Failure to
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Medications Administered with Enter
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if the facility uses the ―recap
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technique requires a comparison of
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eaction to the vaccine than would h
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o Persons who are 50 years of age o
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Sampling: To determine if education
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Processes to address issues that ar
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The facility failed to document tha
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Requires immediate correction as th
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(ii) other nursing personnel. §483
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(3) The State finds that, for any p
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(A) Has only patients whose physici
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For SNFs and SNF/NFs which may be w
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Assessing special nutritional needs
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Probes: §483.35(c)(1) Are resident
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___________________________________
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Interpretive Guidelines: §483.35(f
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―Food Preparation‖ refers to th
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for growth of harmful pathogens. Ba
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Source of Primary Agents of Primary
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Food Receiving and Storage When foo
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specified below will either kill da
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may consist of a combination of foo
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at the manifold, which is the area
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INVESTIGATIVE PROTOCOL SANITARY CON
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2. Interview Observe that foods are
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cooling, and ensure that PHF/TCS fo
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2. Degree of harm (actual or potent
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Severity Level 1 Considerations: No
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Intent: §483.35(h) The intent of t
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Whether they are assisting assigned
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and drink. If concerns are identifi
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Compliance with 42 CFR 483.35(h), F
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eligibility to eat and drink with a
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Examples of the facility‘s non-co
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delegating and supervising follow-u
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Probes: §483.40(b) Do services ord
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For what reasons are residents sent
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(2) Obtain the required services fr
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Probes: §483.45(a)(1)(2) 1. For ph
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a care plan must be developed, foll
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Are residents missing teeth and may
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Definitions are provided to clarify
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The National Coordinating Council f
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Establish procedures that address m
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How the receipt of medications from
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Documentation of actual disposition
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the pharmaceutical services. Fourth
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The facility‘s failure to involve
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The facility in collaboration with
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(2) The pharmacist must report any
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errors, or other irregularities, an
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NOTE: The surveyor‘s review of me
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o Seizure activity; o Spontaneous o
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Common Medication-Medication Intera
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The identification of any irregular
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aspects of pharmaceutical services.
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The pharmacist‘s MRR failed to id
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(3) Determines that drug records ar
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During a medication pass, medicatio
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This requirement has several aspect
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Determine whether the noncompliance
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§483.65 Infection Control The faci
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―Contact precautions‖ are measu
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Critical aspects of the infection p
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Conducting data analysis to help de
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observations of staff practices and
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Complications from invasive diagnos
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Airborne transmission can occur by
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After removing gloves or aprons; an
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Depending on the situation, options
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tears or holes be replaced. It is r
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ENDNOTES 68 Siegel, J.D., Rhinehart
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Guidelines for environmental infect
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INVESTIGATIVE PROTOCOL FOR INFECTIO
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Multiple use items (e.g., shower ch
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Interview the Designated Infection
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Utilize infection precautions to mi
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Properly implement transmission bas
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influenza in residents on another,
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§483.70(a)(6)(ii) The dispensers a
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Additional guidance is available in
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§483.70(d)(1)(i) Accommodate no mo
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Procedures: §483.70(d)(1)(iv) Ther
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Interpretive Guidelines: §483.70(d
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centralized nursing station, this c
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Are spaces adaptable for all intend
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defined as substandard quality of c
Page 598 and 599: (ii) Responsible for the management
Page 600 and 601: Probes: §483.75(e)(2 - 4) During a
Page 602 and 603: 1919(e)(2)(A) of the Act the facili
Page 604 and 605: Interpretive Guidelines: §483.75(f
Page 606 and 607: The medical director helps the faci
Page 608 and 609: MEDICAL DIRECTION The facility is r
Page 610 and 611: The medical director is responsible
Page 612 and 613: REFERENCES 1 Pattee JJ, Otteson OJ.
Page 614 and 615: support with ventilators, intraveno
Page 616 and 617: The medical director provides input
Page 618 and 619: V. DEFICIENCY CATEGORIZATION (Part
Page 620 and 621: NOTE: If immediate jeopardy has bee
Page 622 and 623: Intent: §483.75(j)(1) The intent o
Page 624 and 625: Probes: §483.75(j)(1)(i) - (iv) Ar
Page 626 and 627: An inability to order radiological
Page 628 and 629: There is a written policy, at the h
Page 630 and 631: If there is a problem with confiden
Page 632 and 633: (i) Residents will be transferred f
Page 634 and 635: Preventing deviation from care proc
Page 636 and 637: Meetings of the QAA committee must
Page 638 and 639: INVESTIGATIVE PROTOCOL QUALITY ASSE
Page 640 and 641: The assigned surveyor should interv
Page 642 and 643: 2. Degree of harm (actual or potent
Page 644 and 645: The facility‘s QAA committee meet
Page 646 and 647: R04SOM 11/12/2004 Guidance to Surve
Page 650 and 651: Form CMS-672 (10/10) ReSIDent CenSu
Page 652 and 653: Form CMS-672 (10/10) ReSIDent CenSu
Page 654 and 655: DEPARTMENT OF HEALTH AND HUMAN SERV
Page 656 and 657: 22. Psychoactive Medications: If th
Page 658 and 659: 16. Weight Change/Nutrition/Swallow
Page 660 and 661: RESIDENT REVIEW WORKSHEET (continue
Page 662: RESIDENT REVIEW WORKSHEET (continue
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