Form Cms-802p - Roster/sample Matrix Provider Instructions printable pdf download

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 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, which are described below. Columns 1–5

and blank columns 31–34 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.

There is no federal requirement to automate the CMS-802 form. A facility may use its MDS data to assist in completing the fields;

however, all conditions noted on this form that are not identified on the MDS must be entered manually. Facilities should ensure

that MDS information is not simply copied over into the form. All information entered by computer should be verified by a staff

member knowledgeable about the resident population. Information must be reflective of all residents as of the day of survey.

Following the definition of certain fields, related MDS item(s) are noted. Although the MDS item(s) are noted for some fields, the field

itself may need to be completed differently or manually 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 noted below.

For each resident mark all columns that are pertinent.

1. – 5. Surveyor Use Only

12. Antianxiety/Hypnotic Medications: Receives anxiolytics

and/or hypnotics. Enter A for anti-anxiety and H for

Moderate/Severe Pain (constant or frequent): Needs pain

hypnotic. Enter the appropriate letter for all possible

medication, comfort measures or is on a pain management

responses. N04010B = ≥ 1, enter A. N0410D = ≥ 1, enter H.

program. J0100A, B, or C = 1 OR J0300 = 1 or 9 OR J0400 =

1, 2, or 3 OR J0500A, B = 1 OR J0600A = 01–10 OR

13. Behavioral Symptoms Affecting Others or Self: Has

J0600B = 1, 2, 3, or 4 OR J0700 =1 OR J0800A, B, C, or D =

behavioral health care needs. E0200A, B, or C = 1, 2 or 3 OR

checked OR J0850 = 1, 2, or 3.

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 and/or B = 1.

Hi-Risk Pressure Ulcers (Stage 2-4): Has stage 2, 3 or

4 pressure ulcer(s) and/or unstageable pressure ulcer(s);

14. Depressive Symptoms: Has symptoms of depression.

M0300B1, M0300C1, M0300D1, M0300E1, M0300F1, or

I5800 or I5900 = checked OR D0300 = 05 – 27 OR D0600 =

M0300G1 > 0.

05 – 30 OR D0350 or D0650 = 1.

New/Worsened Pressure Ulcers (Stage 2-4): Has stage 2, 3

15. Urinary Tract Infection: I2300 = checked.

or 4 pressure ulcer(s) that are new or worsened. M0800A > 0

16. Indwelling Urinary Catheter: H0100A = checked.

and M0800A ≤ M0300B1 OR M0800B > 0 and M0800B ≤

M0300C1 OR M0800C > 0 and M0800C ≤ M0300D1.

17. Lo-risk Residents Who Lose Bowel/Bladder Control–

Incontinence/Toileting Programs: Incontinent of bladder/

Physical Restraints: Has a physical restraint. Enter N

bowel, enter I. If the resident is on a bladder/bowel toileting

for non-side rail devices and S for side rails. Enter the

program, enter T. Enter the appropriate letter for all possible

appropriate letter for all possible responses. P0100A = 1 or

responses. H0200A = 1 or H0200C = 1, enter T. H0300 = 1,

2, enter S; P0100B, C, D, E, F, G, or H = 1 or 2, enter N.

2, or 3, enter I. H0400 = 2 or 3, enter I. H0500 = 1, enter T.

10. Falls and/or Falls with Major Injury: Has fallen within

18. Excessive Weight Loss/Gain: Has had an unintended weight

the past 30 days and/or has fallen within the past 180 days

loss/gain of >5% in one month or >10% in six months, or is

and incurred a major injury. Enter F if fall without injury or

at nutritional risk. K0300 or K0310 = 2.

fracture; Enter Fx if resident has had a fall with major injury

(including fracture). Enter the appropriate letter for all possible

19. Need for Increased ADL Help: Has shown a decline in

responses. I3900 or I4000 = checked, enter Fx. J1700A or B =

ADL areas.

1, enter F. J1700C = 1, enter Fx. J1800 = 1, enter F. J1900A

and/or J1900B = 1 or 2, enter F. J1900C = 1 or 2, enter Fx.

20. Hospice: Has elected or is currently receiving hospice care.

O0100K2 = checked.

11. Psychoactive Medications with Absence of Condition:

Receives any psychoactive medications but has no psychiatric

21. Dialysis: Is receiving hemo- or peritoneal dialysis either

condition. If N0410A through D = ≥ 1 AND I5700 – I6100 =

within the facility or offsite. O0100J1 or O0100J2 = checked.

not checked, and/or I8000 = no psychiatric/mood diagnoses

(i.e., no ICD-9 codes between 295-299 inclusive).

Form CMS-802P (04/12)

Form Cms-802p - Roster/sample Matrix Provider Instructions

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