CMS Manual System - Louisiana Department of Health and Hospitals

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Resident Number Resident Room Surveyor Assigned total sample: Phase 1 Phase 2 Form CMS-802 (10/10) Individual Interview (i) Family Interview (F) Closed Record (Cl) Comprehensive (C) Focused Review (F) RosteR/sample matRix ReVieW FoR sURVeYoR Use ResiDeNt CHaRaCteRistiCs Interview: individual/Family Closed Record/Comprehensive/Focused Privacy/Dignity Issues Social Services Choices Abuse/Neglect Clean/Comfort/Homelike Falls/Fractures abrasions/Bruises Behavior symptoms Depression 9 or more medications Cognitive impairment incontinence/toilet programs Catheter Fecal impaction Uti/Infection Control/Antibiocs Weight/Nutrition/Swallow/Dentures tube Feeding Dehydration elimiNatioN NUtRitioN Bedfast Residents Offsite _____ Phase I _____ Phase 2 _____ Prov. # ___________________ aDl Decline/Concern Rom/Contractures/Positioning pHYsiCal FUNCtioN Resident Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 psychoactive medications physical Restraints activities QUalitY oF liFe pressure sores/Ulcers Pain/Comfort Language/Communication Vision/Hearing/Devices Specialized Rehab Assistive Devices Hospice Dialysis Oxygen/ Respiratory Care Admittance/Transfer/Discharge MR/MI (Non-Dementia)
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES ROSTER/SAMPLE MATRIX INSTRUCTIONS FOR PROVIDERS (use with Form CMS-802) The Roster/Sample Matrix form (CMS-802 ) is used by the facility to list all current residents (including residents on bedhold) and to note pertinent care categories. The facility completes the following: resident name, resident room, and columns 6–35, which are described below. All remaining columns are for Surveyor Use Only. There is not a federal requirement for automation of Form CMS-802. The facility may continue manual coding of Form CMS-802. The facility may use MDS data to provide a “worksheet” of the form, but must amend item responses as necessary to represent current resident status on the first day of the survey. The MDS items below are provided as a reference point, but the form is to be completed using the time frames and other specific instructions below. The information required on the Provider Instructions is not based on the Quality Measures/Indicators. For each resident mark all columns that are pertinent 6. Falls/Fractures: If the resident has fallen within the past 30 15. UTI/Infection Control/Antibiotics: If the resident has an days; or has had a fracture within the last 180 days. Code infection or is on antibiotics, check this column. ‘Fx’ if the resident has fractures and code ‘F’ for falls. [M1040A = checked or I1700, I2000, I2100, I2200, I2300, [I3900 or I4000 = checked, or J1900C = 1, code Fx; 2. I2400, or I2500 = checked] J1700A = 1, then code F] 16. Weight Change/Nutrition/Swallowing/Dentures: If the 7. Abrasions/Bruises: If the resident currently has abrasions, resident has had an unintended weight loss/gain of 5% in bruises, or skin tears, check this column. one month or 10% in six months, has had chronic insidious [J1900B = checked] weight loss or is at nutritional risk, mark this column. If the 8. Behavioral Symptoms: If the resident has behavioral symptoms, as listed in the MDS, mark this column. [E0300 = 1 or E0800 = 1, 2, or 3 or E0900 = 1, 2, or 3] 9. 10. Depression: If the resident has symptoms of depression, as listed in the MDS, check this column. [I5800 = checked or D0200B1, F1, or I1 = 1 or D0500B1, F1, or I1 = 1] 9 or More Medications: If the resident is using 9 or more medications, check this column. [Code manually] 11. Cognitive Impairment: If the resident is cognitively Form CMS-802P (10/10) resident is in a restorative dining program, has chewing or swallowing problems that may affect dietary intake, or has dentures, mark this column. Code ‘W’ for weight change, ‘S’ for chewing or swallowing problems, ‘D’ for dentures, and ‘R’ for restorative dining program. [K0300 = 2, code W; K0100A, B, C, or D = checked, code S; L0200A = checked, code D; O0500H > 0, code R; Code manually for anything not represented by MDS data] No crosswalk is available for chronic insidious weight loss or nutritional risk. Insidious weight loss is a slow, steady, and persistent weight loss over time that when reviewed in the aggregate is clinically significant. Code manually with a W for either. impaired, check this column. 17. Tube Feedings: If the resident has a feeding tube, check Crosswalk: this column. If B5a, b, c, d, e or f are greater than 0, then 802 - 9 = [K0500B = checked] checked. [C0500 < 13 or C0700 = 1 or C0800 = 1 or C1000 = 2 or 3 or C1300A, B, C, or D = 1 or 2] 18. Dehydration: If the resident has problems with dehydration, check this column. [J1550C = checked] 12. Incontinence/Toileting Programs: If the resident is incontinent of bladder, code ‘I’. If the resident is on a bladder training program, code ‘T’. [H0300 = 1, 2, or 3 and H0100A or B = not checked, code I; H0200A = 1 or coded manually, code T 13. Catheter: If the resident has an indwelling urinary catheter, check this column. [H0100A = checked] 14. Fecal Impaction: If the resident has had fecal impaction within the last 90 days, check this column. [Code manually] 19. Bedfast Residents: If the resident is bedfast, check this column. [Code manually] 20. ADL Decline/Concern: If the resident has shown a decline in ADL areas, check this column. [Code manually] 21. ROM/Contractures/Positioning: If the resident has functional limitations in range of motion, check this column. [G0400A or B = 1 or 2; Code manually for neck or anything not represented by MDS data] 1
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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
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(ii) Responsible for the management
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Probes: §483.75(e)(2 - 4) During a
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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 648 and 649: e. Special Care Fl19____ Receiving
Page 650 and 651: Form CMS-672 (10/10) ReSIDent CenSu
Page 652 and 653: Form CMS-672 (10/10) ReSIDent CenSu
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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