Download and print the CMS 802 and the CMS 672 Roster Form will print the 802 records on the CMS Roster/Sample Matrix form. Note that a column that reports a single response will use

Clinical Records System Hi-Tech Software, Inc. CMS Survey Reporting

Page 1 G:\HITECH\Documentation\Clinical Docs\MDS 3.0-CMS-Survey-Reports.doc

CMS Survey Reports for the MDS 3.0: The CMS 802 and the CMS 672 Table of Contents

Download and print the CMS 802 and the CMS 672 ............................................................. 1 CMS 802 Roster ............................................................................................................. 2 CMS 672 Census and Conditions of Residents ............................................................. 3

Edit and Print CMS Survey Forms ......................................................................................... 5 CMS 802 ............................................................................................................................ 6

Edit the 802 Record ........................................................................................................ 7 Print the CMS 802 .......................................................................................................... 9

Detail based on resident’s edited 802 worksheet: ...................................................... 9 CMS 802 Change Register .............................................................................................. 11 CMS 672 .......................................................................................................................... 12

Edit the 672 .................................................................................................................. 14 Print the 672 ................................................................................................................. 17

Detail based on residents’ Face Sheets, MDS, and edited 672 Worksheet:............. 17 CMS 672 Change Register .............................................................................................. 19

Download and print the CMS 802 and the CMS 672 You can also download the CMS forms and instructions from the CMS website at:

http://www.cms.gov/cmsforms/downloads/CMS802.pdf (pub date 10/2010)

http://www.cms.gov/cmsforms/downloads/CMS802P.pdf (pub date 10/2010)

http://www.cms.gov/cmsforms/downloads/CMS672.pdf (pub date 10/2010)

See sample forms on the next 3 pages.



CMS 802 Roster



CMS 672 Census and Conditions of Residents

Page 1



CMS 672 Census and Conditions of Residents Page 2



Edit and Print CMS Survey Forms

Hi-Tech Software Survey Reporting programs do the following:

Read your residents’ MDS 3.0 records to produce the CMS 802 Roster and 672 Census Reports. Run these reports at any time, and for your surveyor.

Allow you to add a record for a new resident

Update a resident’s survey record if MDS information is no longer current. Note that non-Medicare residents can have MDS records up to 90 days old.

Print of list of changes you have made to residents’ survey records.

NOTE: Some survey items cannot be obtained from the MDS, and you must research the answers in the residents’ charts.

To be included on the Roster and Census the resident must meet the following criteria: On the Face Sheet: be coded as either Level 1 or 2 and not have a Discharge Date.

Have an MDS 3.0 that has a "Complete" or "Submitted" status. The most recent MDS must not be a Discharge Return Not Anticipated.



QI / QA / Survey Reports > Surveys

CMS 802

N3A1 N3A2

Use this program to update residents’ 802 records and to print an 802 Survey form.

NOTE: To print the CMS instructions for completing the CMS 802 Roster, under Print Options choose Resident Roster Form Instructions.

Worksheet Date: The date you enter will be used to record observations on the 802 worksheet. The program will locate the most recent complete MDS and record those responses. Any MDS/WS Date prior to your worksheet date will be updated with your date. If the MDS date is more recent, you can edit the worksheet, but the MDS date will be retained as the worksheet date.

Residents to Edit: All to print for the entire facility.

Or select Individual and then enter or select Resident IDs from the Inquiry and add them to the Residents Selected for Editing list on the right side of the screen.

If you select All residents, you can Report by Unit. Select All to print the entire facility sorted by unit. Select Individual Units choose specific units.

Click Edit to display your selections and change information. See the next page.

Click Print to print the 802 for the selected residents’ current 802 records based on the most recent MDS or edited 802 worksheets. See Page 9.



QI / QA / Survey Reports > Surveys > CMS 802

Edit the 802 Record

If a resident’s conditions have changed since the most MDS, you can update the items that will be reported on the roster.

At Residents to Edit select Individual and select the resident to add him/her to the list of residents on the right. You can select multiple residents to be edited, and when your list is complete, click Edit to display the Edit 802 Worksheet so you can edit the selected residents’ roster items.

If you choose to edit the entire facility, a full unit of several residents, you can use the scroll bar on the right side to the screen to scroll down and display additional residents.

On the above screen note the following:

Resident 0068: The Src column includes W (for worksheet) indicating that the resident’s 802 record has been edited. The MDS/WS Date column indicates the date it was last edited.

Resident 1601: The Src column included M (for MDS) indicating that the resident’s 802 record is based on the resident most recent MDS. The MDS/WS Date column indicates that MDS ARD date.

Resident 1564: This is a newly admitted resident without an MDS in the system yet. She has nothing in the Src and Date columns.

Note: The Source Legend at the bottom of the screen defines the codes used in the Src column.



Each roster column is identified by a number and description.

.

You can view additional columns by clicking on the column range buttons at the bottom of the

screen:

Note that some items require multiple columns, for example:

These are items that could have more than one response on the Roster Matrix (below).

NOTE: for column (6) you can choose either Falls or Fx (Fractures) but not both:

To edit a resident’s 802 record, click in front of the ID number. This will open up (un-grey) the check boxes in each column so you can select and de-select the items.

NOTE: When you the Edit column, Src will change from M (for MDS) to W (Worksheet) and the Date will change to the current date.

Make all necessary changes to the resident’s record and then select to edit the other residents.

Click OK to save your changes and move to the next screen of items.

Click any of the 802 range buttons, such as 18 - 22, to save your changes and display that set of 802 items.

Click Exit to save your changes and return to the menu.

Click Clear Worksheet (first screen only) to remove all the worksheets and revert back to the residents’ MDS records as the source of 802 information.



QI / QA / Survey Reports > Surveys > CMS 802

Print the CMS 802

Select the residents to be included (All, Individual or specific Units.)

Select the Print Options. The two below are selected by default and you can change them.

Individual Resident Detail will display a report like the one below:

Detail based on resident’s edited 802 worksheet:

Print this detail by clicking the button in the lower left corner of the display screen.



Resident Roster Form will print the 802 records on the CMS Roster/Sample Matrix form.

Note that a column that reports a single response will use the letter X.

Columns that report multiple responses use multiple letters. For example column 6 uses F for Falls and FX for Fractures.

Print the Resident Roster Form Instructions for explanations of the codes that are used. Resident Roster Form Instructions will print 2 pages of the CMS instructions for completing the 802.



QI / QA / Survey Reports > Surveys >

CMS 802 Change Register N3A3 Use this program to display/print a list of the changes you have made to residents’ 802 roster records. Verify the Worksheet Dates to Print. Click Print.

The report identifies the COLUMN and the CHANGE from an old to a new response:

N-Y: you checked an unchecked item in the roster record. Y-N : you unchecked a checked item.



QI / QA / Survey Reports > Survey

CMS 672

N3A8

Use this program to update residents’ 672 records and to print an 672 Survey form.

NOTE: To print the CMS instructions for completing the CMS 672 Census, under Print Options choose Resident Census Form Instructions.

Worksheet Date: The date you enter will be used to record observations on the 672 worksheet. The program will locate the most recent complete MDS and record those responses. Any MDS/WS Date prior to your worksheet date will be updated with your date. If the MDS date is more recent, you can edit the worksheet, but the MDS date will be retained as the worksheet date.

Residents to Edit: All to print for the entire facility

.. Or select Individual and then enter or select Resident IDs from the Inquiry and add them to the Residents Selected for Editing list on the right side of the screen.

If you select All residents, you can Report by Unit. Select All to print the entire facility sorted by unit. Select Individual Units choose specific units.

Click Edit to display your selections and change information. See the next page.



Click Print to print the 672 for the selected residents’ current 672 records based on the most recent MDS or edited 672 worksheets. See Page 17.



Edit the 672

If a resident’s conditions have changed since the most MDS, you can update the items that will be reported on the roster.

At Residents to Edit select Individual and select the resident to add him/her to the list of residents on the right. You can select multiple residents to be edited, and when your list is complete, click Edit to display the Edit 672 Worksheet so you can edit the selected residents’ roster items.

If you choose to edit the entire facility, a full unit of several residents, you can use the scroll bar on the right side to the screen to scroll down and display additional residents.

On the above screen note the following:

Resident 0068: The Src column includes W (for worksheet) indicating that the resident’s 802 record has been edited. The MDS/WS Date column indicates the date it was last edited.

Resident 1601: The Src column included M (for MDS) indicating that the resident’s 802 record is based on the resident most recent MDS. The MDS/WS Date column indicates that MDS ARD date.

Resident 1564: This is a newly admitted resident without an MDS in the system yet. The Src column includes an F to indicate that 672 information is based on her Face Sheet Record.

The Source Legend at the bottom of the screen defines the codes used in the Src column.

NOTE: Only Payor Information is imported from the Face Sheet.



Column headings compare to items on the 672 form, for example:

HTS screen:

CMS 672 Form:

HTS screen:

CMS Form:



To edit a resident’s 802 record, click in front of the ID number. This will open up (un-grey) the check boxes in each column so you can select and de-select the items.

NOTE: When you the Edit column, Src will change from M (for MDS) to W (Worksheet) and the Date will change to the Worksheet date you entered.

Move through the 672 by clicking on the buttons at the bottom of the screen.

Make all necessary changes to the resident’s record and then select to edit the other residents.

Click OK to save your changes and move to the next screen of items.

Click Exit to save your changes and return to the menu.

Click Clear Worksheet (first screen only) to remove all the worksheets and revert back to the residents’ MDS records as the source of 672 information.



Print the 672

Select the residents to be included (All, Individual or specific Units.)

Select the Print Options. The two below are selected by default and you can change them.

Individual Resident Detail will display a report like the one below that lists the selected residents, the 672 census items, and the source of the census response

Detail based on residents’ Face Sheets, MDS, and edited 672 Worksheet:

Print this detail by clicking the button in the lower left corner of the display screen.

Payer info comes from resident’s Face Sheet

Info comes from resident’s 672 Worksheet or MDS item G-0120-A



Resident Census Form will print the census in the CMS format.



QI / QA / Survey Reports > Surveys >

CMS 672 Change Register N3A9 Use this program to display/print a list of the changes you have made to residents’ 672 roster records. Verify the Worksheet Dates to Print. Click Print.

The report identifies the Census item (F-TAG) and CHANGE from an old to a new response: - I: you provided a new response for a previously unanswered item. Y-N : you unchecked a checked item. N-Y: you checked an unchecked item.

Documents

Download and print the CMS 802 and the CMS 672 Roster Form will print the 802 records on the CMS Roster/Sample Matrix form. Note that a column that reports a single response will use