Form Cms-802s - Roster/sample Matrix Instruction For Surveyors

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
ROSTER/SAMPLE MATRIX INSTRUCTIONS FOR SURVEYORS
(use with Form CMS-802)
The Roster/Sample Matrix form (CMS-802) is used to list all current residents (including residents on bed-hold) and to note pertinent care
categories. The facility completes the resident name, resident room, and columns 6–30, all remaining columns are for Surveyor Use Only.
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.
The Roster/Sample Matrix is a tool for selecting the resident sample and may be used for recording information acquired during the
tour. When using the form to identify the resident sample, indicate by a check whether this CMS-802 is being used for the sample
from Offsite, Phase 1 or Phase 2. The horizontal rows list residents chosen for review (or residents encountered during the tour) and
indicate the characteristics/concerns identified for each resident. Use the resident sample selection table in Appendix P of the State
Operations Manual (SOM) to identify the number of residents required in the sample.
Mark the
Interview:
Individual/Family column with
‘I’
for each resident receiving an interview or with
‘F’
for any non-interviewable
resident receiving a family interview and/or staff observation. Mark the Closed Record/Comprehensive/Focused Review column with
‘CL’
for a closed record review,
‘C’
for a resident chosen for a comprehensive review or
‘FO’
for a resident chosen for a focused
review. Use the vertical columns numbered 1 through 30 for each resident, as appropriate. During each portion of the survey (Offsite,
Phase 1, Phase 2) highlight the vertical columns for each resident potential concern identified.
Resident
Number:
Number each line sequentially down the rows
Surveyor
Assigned:
List initials or surveyor number of surveyor
continuing the numbering sequence for any additional pages needed.
assigned to review each resident.
These numbers may be used as resident identifiers for the sample.
Resident
Room:
Identify room # for the resident.
Resident
Name:
List the name of the resident.
Highlight each column that is an area of concern. For each resident entered on the roster/sample matrix, check all columns that
pertain to the resident according to the Offsite and Sample Selection Tasks of the Survey.
1.
Privacy/Dignity: resident’s right to privacy,
7.
Hi-Risk Pressure Ulcers (Stage 2-4): risk assessment,
(accommodations, written and telephone communication,
clinical assessment, treatment, monitoring, evaluation, and
visitation, personal care, etc.) or concerns that the facility
prevention of pressure ulcers; or other necessary skin care.
does not maintain or enhance resident’s dignity.
Concerns regarding residents identified as having stage 2, 3,
or 4 pressure ulcers or unstageable pressure ulcers.
2.
Social Services: medically related or other social services;
e.g., interpersonal relationships, grief, clothing, etc.
8.
New/Worsened Pressure Ulcers (Stage 2-4): risk
assessment, clinical assessment, treatment, monitoring,
3.
Self-Determination/Accommodation of Needs: resident’s
evaluation, and prevention of pressure ulcers; or other
ability to exercise their rights as citizens; freedom from
necessary skin care. Concerns regarding residents identified
coercion, discrimination or reprisal; self-determination and
as having new or worsened stage 2, 3, or 4 pressure ulcers.
participation; choice of care and schedule, etc.
9.
Physical Restraints: residents identified as physically
4.
Abuse/Neglect: resident abuse, neglect or misappropriation
restrained, including side rails.
of resident property or how the facility responds to
allegations of abuse, neglect or misappropriation of
10. Falls and/or Falls with Major Injury: residents that have
resident property.
fallen within the past 30 days and/or have fallen within the
past 180 days and incurred a major injury.
5.
Clean/Comfortable/Homelike: facility’s environment
11. Psychoactive Medications with Absence of Condition:
including cleanliness, lighting levels, temperature,
comfortable sound levels, or homelike environment and
residents receiving any psychoactive medications in the
the resident’s ability to use their personal belongings and
absence of a psychiatric or mood related diagnoses or
individualize their room to the extent possible.
conditions.
6.
Moderate/Severe Pain (constant or frequent): timely
12. Antianxiety/Hypnotic Medications: residents receiving
assessment and intervention with residents needing pain
anxiolytics and/or hypnotics.
medications or measures to provide comfort, including non-
13. Behavioral Symptoms Affecting Others or Self: residents
medication interventions, or who are on a pain management
with behavioral health care needs; e.g., verbal or physical
program.
outbursts, withdrawing/isolation, etc.
Form CMS-802S (04/12)
1

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