The survey team will expect your facility to provide them with a current and up-to-date Resident Census and Conditions of Residents form (CMS-672) within the first 24 hours of the survey.
CMS-672 is to be completed by your facility and it should represent the current conditions of residents at the time of the survey. While there has been no change to the actual form with the new survey process, revisions were made to the form's instructions. Even though there is not a federal requirement for automation of the CMS-672 form, many facilities utilize their MDS 3.0 software program to obtain the report.
CMS-672 may assist surveyors in choosing a sample group of residents to review. Residents must be selected for both the Phase 1 and Phase 2 samples as representatives of concerns to be investigated and to fulfill the case mix stratified sample requirement. If, during sample selection, many more residents are identified than can be selected to represent the concerns of interest, surveyors will consider the factors below in determining which residents to select.
If concerns have been identified in the area of infection control, the survey team will review your policies and procedures, including a focus on what preventative infection control practices your facility has in place. For example, do you administer the influenza vaccine yearly to residents and administer pneumococcal vaccines to new residents as appropriate (do you evaluate whether new residents have received the pneumococcal vaccine within the last five years)?
The survey team will also review the CMS-672 that you completed. They will note any new areas of concern and determine if there appears to be large discrepancies between what is recorded by your facility and what they have observed. If there are large discrepancies, they will ask your facility to verify the totals.
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".
Visit the Everyday Preparation page of the Having A Perfect Survey section for tips on usage and how to keep the form up to date.
The Roster/Sample Matrix (CMS-802) is a tool that surveyors will use for selecting the resident sample and may be used for recording information from the tour. As for the facility staff, you may want to use this form as a tool to maintain the resident status handy at all times. Your MDS software program may produce this form for you but maintaining this form manually may be the better solution.
Begin by initialing completing the form by doing a MDS audit, completing as many of the areas as possible.
Then during morning meetings, the MDS/ Care Plan meeting, Care sub-committee meetings (fall committee, pressure ulcer committee) or resident/family meeting, if any mention is made of the following areas: identify it under the resident name. The 802 form should be your working matrix at all times. Designate one person to keep it up-to-date.
Use this lists to complete your record reviews and your interviews. After completing your initial roster/sample matrix, count across each residents row on how many characteristics each resident has noted on the matrix. Start with those residents that have the most characteristics and do a complete audit and review of that resident, i.e. chart review, MDS audit, Family or resident interview, staff interview.
Get the team together and make sure that all documents are consistent. That the MDS is accurate, the CAA's are complete and accurate, that the care plan identifies all areas of concern. Review the physician orders and make sure that all orders are carried out and documentation is present. Have the team do an environmental review on that resident area. Look at all equipment is it clean and in good working order. Identify all issues of concern and have the team correct them. Identify under column 36 the date of review. Complete 1/3 of your residents monthly so that every 3 months you review each resident.
While CASPER reports and the QM reports can assist surveyors, this information may not represent the current condition of residents or practices in the facility at the time of the survey. Keep in mind that the CASPER information is approximately one year old, and the QM information may be from two to six months old. Resident characteristics that were reported by the facility during the last survey might have changed significantly and may be the source of some discrepancies between CASPER and QM information.
CASPER Report 3 contains the compliance history of the facility. Use it to determine if the facility has patterns of repeat deficiencies in particular tags or related tags. This report also lists the history of any complaint investigations and Federal monitoring surveys.
CASPER Report 4 contains information provided by the facility during the previous survey on the Resident Census.
The CASPER reports will be reviewed along with the QM reports and they will add corroborative information to the QM information, e.g., a pattern of repeat deficiencies in a requirement related to a flagged QM, and/or to point out areas of discrepancies between the QM numerators and the CASPER reports, e.g., the CASPER 4 report lists the facility as having triple the average number of residents in restraints, but the QM for restraints shows the facility has less restraints than most facilities.
Relate information between CASPER Reports 3 and 4, such as a pattern of repeat deficiencies in range of motion and a lower than average percentage of residents receiving rehabilitative services.