DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES RESIDENT CENSUS AND CONDITIONS OF RESIDENTS Provider No. Medicare Medicaid F75 ADL Other Total Residents F76 Independent F77 Assist of One or Two Staff F78 Dependent Bathing F79 F80 F81 Dressing F82 F83 F84 Transferring F85 F86 F87 Toilet Use F88 F89 F90 Eating F91 F92 F93 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, how many were present on admission ____? F101____ In a chair all or most of time F102____ Independently ambulatory F96 ____ Occasionally or frequently incontinent of bladder F103____ Ambulation with assistance or assistive device F97 ____ Occasionally or frequently incontinent of bowel F104____ Physically restrained F98 ____ On urinary toileting program F105 Of the total number of residents with restraints, how many were admitted or readmitted with orders for restraints ____? 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 F110____ Documented psychiatric diagnosis (exclude dementias and depression) 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 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 F118____ Rashes 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 Form CMS-672 (05/12) 1 American LegalNet, Inc. www.FormsWorkFlow.com 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 chopped food (not only meat) F122____ Dialysis F124____ Respiratory treatment F131____ Rehabilitative services (Physical therapy, speechlanguage therapy, occupational therapy, etc.) Exclude health rehabilitation for MI and/or ID/DD F125____ Tracheostomy care F132____ Assistive devices with eating F123____ Intravenous therapy, IV nutrition, and/or blood transfusion F126____ Ostomy care F. Medications G. Other 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 language of the facility (include those who use American sign language) F134____ Antipsychotic medications 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 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 _______% Form CMS-672 (05/12) 2 American LegalNet, Inc. www.FormsWorkFlow.com 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 otherwise noted, consider the resident’s condition for the 7 days prior to the survey. Horizontal totals across the three columns (Independent, 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). Bathing (F79 – F81): This includes a full-body bath/shower, sponge bath, and transfer into and out of tub or shower. G0120A = 0 for F79, G0120A = 1, 2, OR 3 for F80. OR G0120A = 4 for F81. Facilities may provide “setup” assistance to residents such as drawing water for a tub bath or laying out clothes, bathing supplies/toiletries, etc. Also, a resident may only need assistance with washing their back or shampooing their hair. If either of these are the case, and the resident requires no other assistance, count the resident as independent. Dressing (F82 – F84): How the resident puts on, and takes off all items of clothing, including donning/removing prostheses (e.g., braces and artificial limbs) or elastic stockings. G0110G1 = 0 for F82 OR G0110G1 = 1, 2, OR 3 for F83 OR G0110G1 = 4 for F84. Facilities may set out clothes for 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, such as with dressing, donning a brace, elastic stocking, a prosthesis , or securing fasteners, etc. count the resident as needing the assistance of 1 or 2 staff, as appropriate. Transferring (F85 – F87): How the resident moves between surfaces, including, to or from bed, chair, wheelchair, or standing position. (EXCLUDES transfers to/from the bath/ toilet). G0110B1 = 0 for F85 OR G0110B1 = 1, 2, or 3 for F86 OR G0110B1 = 4 for F87. Facilities may provide “setup” assistance to residents, such as handing equipment (e.g., quad cane) 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, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad(s); manages ostomy or catheter, and adjusts clothing. If all that is done for the resident is to open a package (e.g., a clean incontinence pad), count the resident as independent. G0110I1 = 0 for F88 OR G0110I1 = 1, 2, or 3 for F89 OR G0110I1 = 4 for F90. Eating (F91 – F93): How a resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, includes IV fluids administered for 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. Form CMS-672 (05/12) 3 American LegalNet, Inc. www.FormsWorkFlow.com RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (use with Form CMS-672) A. BOWEL/BLADDER STATUS (F94 – F99) RESIDENTS F94: With an indwelling or an external catheter: Whose urinary bladder is constantly drained by a catheter (e.g., an indwelling catheter, a suprapubic catheter or nephrostomy tube) or who wears an appliance that is applied over the penis and connected to a drainage bag to collect urine from the bladder (e.g., condom catheter or similar appliance). H0100A or B = checked. F95: Of the total number of residents with catheters: Who had a catheter present on admission/entry or reentry. H0100A or B = checked. To complete this field 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). F96: Occasionally or frequently incontinent of bladder: Who have an incontinent episode two or more times per week. Do not include residents with an indwelling or external catheter. H0100A and B = not checked AND H0300 =1, 2, or 3. F97: Occasionally or frequently incontinent of bowel: Who have a loss of bowel control two or more times per week. H0400 = 2 or 3. F98: On urinary toileting program: With a systematically implemented, individualized urinary toileting program (i.e. bladder rehabilitation/retraining, prompted voiding, habit training/scheduled voiding) to decrease or prevent urinary incontinence or minimizing or avoiding the negative consequences of incontinence (e.g., pelvic floor exercises). Count all residents on urinary training programs including those who are incontinent. H0200A = 1 OR H200C = 1 OR H0300 = 1, 2 or 3. F99: On bowel toileting program: With a systematically implemented, individualized bowel toileting program to decrease or prevent bowel incontinence or minimizing or avoiding the negative consequences of incontinence (e.g., use of adequate fluid intake, fiber in the diet, exercise, and scheduled times to attempt bowel movement). Count all residents on toileting programs including those who are incontinent. H0400 = 2 or 3 OR H0500 OR H0600 = 1. B. MOBILITY (F100 – F107) - RESIDENTS Total for F100 – F103 should = the number in Block F78, Total Residents. Algorithm to force mutual exclusivity: Test for each resident. If F100 = 1 then add 1 to F100, and go to 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. F100: Bedfast all or most of time: Who are bedfast all or most of the time (e.g., in bed or geriatric chair/recliner) includes bedfast with bathroom privileges. F101: In a chair all or most of time: Who depend on a chair for mobility includes those residents who can stand with assistance to pivot from bed to wheelchair or to otherwise transfer. The resident cannot take steps without extensive or constant weight-bearing support from others and is not bedfast all or most of the time. G0300A or E = 2 OR G0600C = checked. F102: Independently ambulatory: Who require no help or oversight; or help or oversight was provided only 1 or 2 times during the past 7 days. Do not include residents who use a cane, walker or crutch. G0110C1 or G0110D1 = 0 or 7 and G0110C2 or G0110D2 = 0 or 1 AND G0600A and G0600B = not checked. F103: Ambulation with assistance or assistive devices: Who require oversight, cueing, physical assistance or who use a cane, walker, or crutch. Count the use of lower leg splints, orthotics, and braces as assistive devices. G0110C1 or G0110D1 = 1, 2, or 3 AND G0110C2 or G0110D2 = 1, 2 or 3 OR G0600A and/or G0600B = checked. F104: Physically restrained: For whom restraints were used. Restraints include any manual or physical method or mechanical device, material or equipment attached or adjacent to the resident’s body in such a way that the individual cannot remove easily and it restricts freedom of movement or normal access to one’s body. Do not include devices such as braces which are used for medical/clinical reasons. P0100A through H = 1 or 2. F105: Of total number of restrained residents: On admission/ 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 (OBRA or Scheduled PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E = 1 for each resident). F106: With contractures: With a restriction of full passive range of motion of any joint due to deformity, disuse, pain, etc., includes loss of range of motion in neck, fingers, wrists, elbows, shoulders, hips, knees and ankles. G0400A and/or B = 1 or 2. F107: Of the total number with contractures, those who had a contracture(s) on admission: To complete this field 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). (neck contractures not included in MDS data). Form CMS-672 (05/12) 4 American LegalNet, Inc. www.FormsWorkFlow.com 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 as defined at 483.45(a)) or Developmental Disability (DD): In all of the categories of intellectual or developmental disability regardless of severity, as determined by the State Mental Health or State Mental Retardation Authorities. A1550A, B through E = checked. F115: With pressure ulcers: With localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/ or friction (exclude Stage I). M0300B1, M0300C1, M0300D1, M0300E1, M0300F1and/or M0300G1 > 0. F109: With documented signs and symptoms of depression: With documented signs and symptoms of depression. D0200A1 through D1 = 1 for any indicator present OR D0200I1 = 1OR D0200A2 through D2 = 2 or 3 for symptom frequency OR D0300 = 05 - 27 OR D0500A1 through D1 = 1 for any indicator present OR D0500I1 = 1 OR D0500A2 through D2 = 2 or 3 for symptom frequency OR D0600 = 05 - 30. F116: Of the total number of residents with pressure ulcers (excluding Stage 1), those who had pressure ulcers on admission/entry or reentry: M0300B2, M0300C2, M0300D2, M0300E2, M0300F2 and/or M0300G2 > 0. To complete this field, 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.) F110: With documented psychiatric diagnosis (exclude dementias and depression): With primary or secondary psychiatric diagnosis including: ‡ Schizophrenia ‡ Schizo-affective disorder ‡ Schizophreniform disorder ‡ Delusional disorder ‡ Anxiety disorder ‡ Psychotic mood disorders (including mania and depression with psychotic features, acute psychotic episodes, brief reactive psychosis and atypical psychosis). I5700, I5900, I5950, I6000 or I6100 = checked. F117: Receiving preventive skin care: Receiving nonroutine 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. F111: Dementia: Non-Alzheimer’s Dementia (e.g., LewyBody, vascular or Multi-infarct, mixed, frontotemporal such as Pick’s disease; and dementia related to Parkinson’s or Creutzfeldt-Jakob diseases), or Alzheimer’s Disease: With a primary or secondary diagnosis of dementia or organic mental syndrome including, Non-Alzheimer’s Dementia (e.g., LewyBody, vascular or Multi-infarct, mixed, frontotemporal such as Pick’s disease; and dementia related to Parkinson’s or CreutzfeldtJakob diseases). I4200 or I4800 = checked F119: Receiving hospice care: Who have elected or are currently receiving the hospice benefit. O0100K2 = checked. F112: With behavioral health care needs: With one or more of the following indicator(s): wandering, verbally abusive, 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, or 3 OR E0900 = 1, 2, or 3 OR E1000A or B = 1. F122: Receiving dialysis: Receiving hemodialysis or peritoneal dialysis either within the facility or offsite. O0100J1 or O0100J2 = checked. F113: Of the total number with behavioral healthcare needs, 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 needs (as noted in F112). F114: Receiving health rehabilitative services for Mental Illness (MI) and/or ID/DD: Receiving health rehabilitative services for MI and/or ID/DD. Fl18: With rashes: Who have rashes which may or may not be treated with any medication or special baths, etc. (e.g., may include but are not limited to antifungals, corticosteroids, emollients, diphenhydramines or scabicides). E. SPECIAL CARE (F119 – F132) - RESIDENTS F120: Receiving radiation therapy: Who are under a treatment plan involving radiation therapy. O0100B1 or O0100B2 = checked. F121: Receiving chemotherapy: Who are under a treatment plan involving chemotherapy. O0100A1 or O0100A2 = checked. F123: Receiving intravenous therapy, IV nutrition and/ or blood transfusion: Receiving fluids, medications, all or most of their nutritional requirements and/or blood and blood products administered intravenously. K0510A2, O0100H2, or O0100I2 = checked. F124: Receiving respiratory treatment: Resceiving treatment by the use of respirators/ventilators, oxygen, IPPB or other inhalation therapy, pulmonary toilet, humidifiers, and other methods to treat conditions of the respiratory tract. This does not include residents receiving tracheostomy care or respiratory suctioning. O0100C2, O0100F2, or O0100G2 = checked. Form CMS-672 (05/12) 5 American LegalNet, Inc. www.FormsWorkFlow.com RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (use with Form CMS-672) F125: Receiving tracheostomy care: Receiving care involved 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 will have to be counted separately.) 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. F130: Receiving mechanically altered diets: Receiving a mechanically altered diet including pureed and/or chopped foods (not only meat). K0510C2 = checked. 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 entered in O0400. 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, B, C or D. 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: F134, F135, F136, and/or F137. F134: Antipsychotic medications: Days entered for N0410A > 0 ‡ Clozapine ‡ Haloperidol ‡ Haloperiodal Deconate ‡ Droperidol ‡ Loxapine ‡ Thioridazine ‡ Molindone ‡ Theothixene ‡ Zyprexa ‡ Pimozide ‡ Fluphenazine Deconate ‡ Fluphenazine ‡ Quetiapine ‡ Risperidone ‡ Mesoridazine ‡ Promazine ‡ Trifluoperazine ‡ Chlorprothixene ‡ Chlorpromazine ‡ Acetophenazine ‡ Perphenazine F135: Antianxiety medications (anxiolytics): Days entered for N0410B > 0 ‡ Lorazepam ‡ Oxazepam ‡ Prazepam ‡ Diazepam ‡ Clonazepam ‡ Hydroxyzine ‡ Chlordiazepoxide ‡ Halazepam ‡ Alprazolam F136: Antidepressant medications: Days entered for N0410C > 0 ‡ Aripiprazole ‡ Amoxapine ‡ Nortriptyline ‡ Wellbutrin ‡ Trazodone ‡ Venlafaxine ‡ Amtriptyline ‡ Lithium ‡ Maprotiline ‡ Isocarboxazid ‡ Phenelzine ‡ Serzone ‡ Desipramine ‡ Tranylcypromine Paroxetine ‡ Fluoxetine ‡ Sertraline ‡ Doxepin ‡ Imipramine ‡ Protriptyline Form CMS-672 (05/12) 6 American LegalNet, Inc. www.FormsWorkFlow.com RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (use with Form CMS-672) F137: Hypnotic medications: Days entered for N0410D > 0 ‡ Flurazepam ‡ Quazepam ‡ Estazolam ‡ Temazepam ‡ Triazolam ‡ Zolpidem F138: Receiving antibiotics: Receiving antibacterial sulfonamides, antibiotics, etc., either for prophylaxis or treatment. Days entered for N0410F > 0. F139: On a pain management program: With a specific plan for control of difficult to manage or intractable pain, which may include self medication pumps or regularly scheduled administration of medication alone or in combination with nonmedication interventions (e.g., massages heat/cold, biofeedback, etc.). J0100A, B, or C = 1. 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 provisions of care when the individual is incapacitated. F144: Received influenza immunization: Who received the influenza immunization within the last 12 months. O0250A = 1. F145: Received pneumococcal vaccine: Who received the pneumococcal vaccine. O0300A = 1. LEAVE BLANK (F146-F148) – To Be Completed By Survey Team G. OTHER RESIDENT CHARACTERISTICS (F140 – F145) F146: Ombudsman notice: Indicate whether or not the State Ombudsman was notified prior to the survey. F140: With unplanned significant weight loss/gain: Who have experienced unplanned weight loss/gain of > 5% in one month or > 10% over six months. K0300 or K0310 = 2. F147: Ombudsman presence: Indicate whether or not the State Ombudsman was present at any time during the survey. F141: Who do not communicate in the dominant language 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. F148: Medication error rate: Calculate and enter the medication error percentage of the facility. Form CMS-672 (05/12) 7 American LegalNet, Inc. www.FormsWorkFlow.com