Form Cms-672 - Resident Census And Conditions Of Residents Page 3
Download a blank fillable Form Cms-672 - Resident Census And Conditions Of Residents in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cms-672 - Resident Census And Conditions Of Residents with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7RESIDENT 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
Dressing (F82 – F84): How the resident puts on, and takes off all
each category. If no residents fall into a category enter a “0”.
items of clothing, including donning/removing prostheses (e.g.,
braces and artificial limbs) or elastic stockings. G0110G1 = 0 for
Provider Number: Facility CMS certification provider number.
F82 OR G0110G1 = 1, 2, OR 3 for F83 OR G0110G1 = 4 for F84.
A0100B; leave blank for initial certifications.
Facilities may set out clothes for residents. If this is the case
Block F75: Residents whose primary payer is Medicare.
and this is the only assistance the resident receives, count
the resident as independent. However, if a resident receives
Block F76: Residents whose primary payer is Medicaid.
assistance, such as with dressing, donning a brace, elastic
stocking, a prosthesis , or securing fasteners, etc. count the
Block F77: Residents whose primary payer is neither Medicare
resident as needing the assistance of 1 or 2 staff, as appropriate.
nor Medicaid.
Transferring (F85 – F87): How the resident moves between
Block F78: Residents for whom a bed is maintained on the day
surfaces, including, to or from bed, chair, wheelchair, or
the survey begins, including those temporarily away in a hospital
standing position. (EXCLUDES transfers to/from the bath/
or on leave. This should be representative of residents in the
toilet). G0110B1 = 0 for F85 OR G0110B1 = 1, 2, or 3 for F86
nursing facility or those who have a bed-hold.
OR G0110B1 = 4 for F87.
ADLS (F79 – F93): To determine resident status, unless otherwise
Facilities may provide “setup” assistance to residents, such as
noted, consider the resident’s condition for the 7 days prior to the
handing equipment (e.g., quad cane) to the resident. If this is the
survey. Horizontal totals across the three columns (Independent,
case and is the only assistance required, count the resident as
Assist of One or Two Staff, and Dependent) must equal the number
independent.
in Block F78, Total Residents, for each of the ADL categories
(Bathing, Dressing, Transferring, Toilet Use and Eating).
Toilet Use (F88 – F90): How the resident uses the toilet, commode,
bedpan, or urinal; transfers on/off toilet; cleanses self after elimination;
Bathing (F79 – F81): This includes a full-body bath/shower,
changes pad(s); manages ostomy or catheter, and adjusts clothing.
sponge bath, and transfer into and out of tub or shower.
If all that is done for the resident is to open a package (e.g., a clean
G0120A = 0 for F79, G0120A = 1, 2, OR 3 for F80. OR
incontinence pad), count the resident as independent. G0110I1 = 0 for
G0120A = 4 for F81.
F88 OR G0110I1 = 1, 2, or 3 for F89 OR G0110I1 = 4 for F90.
Facilities may provide “setup” assistance to residents such as
Eating (F91 – F93): How a resident eats and drinks, regardless
drawing water for a tub bath or laying out clothes, bathing
of skill. Do not include eating/drinking during medication pass.
supplies/toiletries, etc. Also, a resident may only need assistance
Includes intake of nourishment by other means (e.g., tube feeding,
with washing their back or shampooing their hair. If either of
total parenteral nutrition, includes IV fluids administered for
these are the case, and the resident requires no other assistance,
nutrition or hydration). Facilities may provide “setup” activities,
count the resident as independent.
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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical