Resident Census And Conditions Of Residents {CMS-672}

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES RESIDENT CENSUS AND CONDITIONS OF RESIDENTS Provider No. Medicare F75 Medicaid F76 Other F77 Total Residents F78 ADL Bathing Dressing Transferring Toilet Use Eating F79 F82 F85 F88 F91 Independent F80 F83 F86 F89 F92 Assist of One or Two Staff F81 F84 F87 F90 F93 Dependent A. Bowel/Bladder Status F94 ____ With indwelling or external catheter F95 Of the total number of residents with catheters, how many were present on admission ____? F96 ____ Occasionally or frequently incontinent of bladder F97 ____ Occasionally or frequently incontinent of bowel F98 ____ On urinary toileting program F99 ____ On bowel toileting program B. Mobility F100____ Bedfast all or most of time F101____ In a chair all or most of time F102____ Independently ambulatory F103____ Ambulation with assistance or assistive device F104____ Physically restrained F105 Of the total number of residents with restraints, how many were admitted or readmitted with orders for restraints ____? F106____ With contractures F107 Of the total number of residents with contractures, how many had a contracture(s) on admission ____? C. Mental Status F108-114 ­ indicate the number of residents with: F108____ Intellectual and/or developmental disability F109____ Documented signs and symptoms of depression F110____ Documented psychiatric diagnosis (exclude dementias and depression) F111____ Dementia: (e.g., Lewy-Body, vascular or Multiinfarct, mixed, frontotemporal such as Pick's disease; and dementia related to Parkinson's or CreutzfeldtJakob 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 D. Skin Integrity F115-118 ­ indicate the number of residents with: F115____ Pressure ulcers (exclude Stage 1) F116 Of the total number of residents with pressure ulcers excluding Stage 1, how many residents had pressure ulcers on admission ____? F117____ Receiving preventive skin care F118____ Rashes Form CMS-672 (05/12) American LegalNet, Inc. www.FormsWorkFlow.com 1 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: Fl19 ____ Hospice care F120____ Radiation therapy F121____ Chemotherapy F122____ Dialysis F123____ Intravenous therapy, IV nutrition, and/or blood transfusion F124____ Respiratory treatment F125____ Tracheostomy care F126____ Ostomy care F127____ Suctioning F128____ Injections (exclude vitamin B12 injections) F129____ Tube feedings Fl30____ Mechanically altered diets including pureed and all chopped food (not only meat) F131____ Rehabilitative services (Physical therapy, speechlanguage therapy, occupational therapy, etc.) Exclude health rehabilitation for MI and/or ID/DD F132____ Assistive devices with eating F. Medications F133-139 ­ indicate the number of residents receiving: F133____ Any psychoactive medication F134____ Antipsychotic medications F135____ Antianxiety medications 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 American sign language) F142____ Who use non-oral communication devices F136____ Antidepressant medications F143____ With advance directives F137____ Hypnotic medications F144____ Received influenza immunization F138____ Antibiotics F139____ On pain management program F145____ Received pneumococcal vaccine Signature of Person Completing the Form Title Date TO BE COMPLETED BY SURVEY TEAM F146 F147 F148 Was ombudsman office notified prior to survey? Was ombudsman present during any portion of the survey? Medication error rate _______% ___ Yes ___ Yes ___ No ___ No Form CMS-672 (05/12) American LegalNet, Inc. www.FormsWorkFlow.com 2 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 each category. If no residents fall into a category enter a "0". Provider Number: Facility CMS certification provider number. A0100B; leave blank for initial certifications. Block F75: Residents whose primary payer is Medicare. Block F76: Residents whose primary payer is Medicaid. Block F77: Residents whose primary payer is neither Medicare nor Medicaid. Block F78: Residents for whom a bed is maintained on the day the survey begins, including those temporarily away in a hospital or on leave. This should be representative of residents in the nursing facility or those who have a bed-hold. ADLS (F79 ­ F93): To determine resident status, unless