6720FDG CMS802

User Manual: 6720FDG

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

ROSTER/SAMPLE MATRIX

Offsite _____ Phase I _____ Phase 2 _____ Provider # __________________

Resident Number

Resident Room

Surveyor Assigned

Total Sample:_______________

Phase 1 ____________________

Phase 2 ____________________

Individual Interview (I) ______

Family Interview (F) ________

Closed Record (CL) _________

Comprehensive (C) __________

Focused Review (FO) ________

Interview: Individual/Family

Closed Record/Comprehensive/Focused

Privacy/Dignity Issues

Social Services

Self-Determination/Accommodation of Needs

Abuse/Neglect

Clean/Comfort/Homelike

Moderate/Severe Pain (Constant or Frequent)

Hi-Risk Pressure Ulcer (Stage 2-4)

New/Worsened Pressure Ulcers (Stage 2-4)

Physical Restraints

Falls including Falls with Major Injury

Psychoactive Meds with Absence of Condition

Antianxiety/Hypnotic Medication Use

Behavior Symptoms Affecting Others/Self

Depressive Symptoms

Urinary Tract Infection

Indwelling Urinary Catheter

Lo-Risk Resident Lose Bowel/Bladder Control

Excessive Weight Loss/Gain

Need for Increased ADL Help

Hospice

Dialysis

Admittance/Transfer/Discharge

MI (Non-Dementia) or ID/DD

Language/Communication

Vision/Hearing/Other Assistive Devices

ROM/Contractures/Positioning

Specialty Care (

Tube Feeding, Central Lines, Ventilators, O

2

)

Hydration/Swallowing/Oral Health

Infections

Specialized Rehab Services (OT, PT, Speech, etc.)

Resident Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

Form CMS-802 (04/12)