Form CMS-802 Matrix for Providers

Form CMS-802 is a U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services form also known as the "Matrix For Providers". The latest edition of the form was released in January 1, 2018 and is available for digital filing.

Download a PDF version of the Form CMS-802 down below or find it on U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services Forms website.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB Exempt
MATRIX INSTRUCTIONS FOR PROVIDERS
The Matrix is used to identify pertinent care categories for: 1) newly admitted residents in the last 30 days who are
still residing in the facility, and 2) all other residents.
The facility completes the resident name, resident room number and columns 1–20, which are described in detail
below. Blank columns are for Surveyor Use Only.
All information entered into the form should be verifed by a staff member knowledgeable about the resident
population. Information must be refective of all residents as of the day of survey.
Unless stated otherwise, for each resident mark an X for all columns that are pertinent.
1. Residents Admitted within the Past 30 days:
10. Physical Restraints: Resident(s) who have a physical
Resident(s) who were admitted to the facility within
restraint in use. A restraint is defned as the use of
the past 30 days and currently residing in the facility.
any manual method, physical or mechanical device,
material or equipment attached or adjacent to the
2. Alzheimer’s/Dementia: Resident(s) who have a
resident’s body that the individual cannot remove
diagnosis of Alzheimer’s disease or dementia of
easily which restricts freedom of movement or
any type.
normal access to one’s body (e.g., bed rail, trunk
3. MD, ID or RC & No PASARR Level II: Resident(s) who
restraint, limb restraint, chair prevents rising, mitts
have a serious mental disorder, intellectual disability
on hands, confned to room, etc.). Do not code
or a related condition but does not have a PASARR
wander guards as a restraint.
level II evaluation and determination.
11. Fall(s) (F) or Fall(s) with Injury (FI) or Major Injury
4. Medications: Resident(s) receiving any of the
(FMI): Resident(s) who have fallen in the facility
following medications: (I) = Insulin, (AC) =
in the past 90 days or since admission and have
Anticoagulant (e.g. Direct thrombin inhibitors and
incurred an injury or not. A major injury includes
low weight molecular weight heparin [e.g., Pradaxa,
bone fractures, joint dislocation, closed head injury
Xarelto, Coumadin, Fragmin]. Do not include Aspirin
with altered consciousness, subdural hematoma.
or Plavix), (ABX) = Antibiotic, (D) = Diuretic,
Use (F) to identify residents with a fall(s), (FI) to
(O) = Opioid, (H) = Hypnotic, (AA) = Antianxiety,
identify a resident who has sustained an injury
(AP) = Antipsychotic, (AD) Antidepressant,
excluding major injury, and (FMI) to identify a
(RESP) = Respiratory (e.g., inhaler, nebulizer).
resident who has sustained a fall(s) with Major Injury.
NOTE: Record meds according to a drug’s
12. Indwelling Urinary Catheter: Resident(s) with an
pharmacological classifcation, not how it is used.
indwelling catheter (including suprapubic catheter
5. Facility Acquired Pressure Ulcer(s) (any stage):
and nephrostomy tube).
Resident(s) who have a pressure ulcer at any stage,
13. Dialysis: Resident(s) who are receiving (H)
including suspected deep tissue injury (mark I, II, III,
hemodialysis or (P) peritoneal dialysis either within
IV, U for unstageable, S for sDTI).
the facility (F) or offsite (O).
6. Worsened Pressure Ulcer(s) at any stage: Resident(s)
14. Hospice: Resident(s) who have elected or are
with a pressure ulcer at anystage that have
currently receiving hospice services.
worsened.
15. End of Life/Comfort Care/Palliative Care: Resident(s)
7. Excessive Weight Loss without Prescribed Weight
who are receiving end of life or palliative care (not
Loss program: Resident(s) with an unintended (not
including Hospice).
on a prescribed weight loss program) weight loss
> 5% within the past 30 days or >10% within the
16. Tracheostomy: Resident(s) who have a tracheostomy.
past 180 days. Exclude residents receiving hospice
17. Ventilator: Resident(s) who are receiving invasive
services.
mechanical ventilation.
8. Tube Feeding: Resident(s) who receive enteral (E) or
18. Transmission-Based Precautions: Resident(s) who are
parenteral (P) feedings.
currently on Transmission-based Precautions.
9. Dehydration: Resident(s) identifed with actual
19. Intravenous therapy: Resident(s) who are receiving
hydration concerns takes in less than the
intravenous therapy through a central line,
recommended 1,500 ml of fuids daily (water or
peripherally inserted central catheter, or other
liquids in beverages and water in foods with high
intravenous catheter.
fuid content, such as gelatin and soups).
20. Infections: Residents(s) who has a communicable
disease/contagious infection (e.g., MDRO-M,
pneumonia-P, tuberculosis-TB or viral hepatitis-VH,
or c-diff-C) OR has a healthcare-associated infection
(e.g., wound infection-WI or UTI).
CMS-802 (01/2018)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB Exempt
MATRIX INSTRUCTIONS FOR PROVIDERS
The Matrix is used to identify pertinent care categories for: 1) newly admitted residents in the last 30 days who are
still residing in the facility, and 2) all other residents.
The facility completes the resident name, resident room number and columns 1–20, which are described in detail
below. Blank columns are for Surveyor Use Only.
All information entered into the form should be verifed by a staff member knowledgeable about the resident
population. Information must be refective of all residents as of the day of survey.
Unless stated otherwise, for each resident mark an X for all columns that are pertinent.
1. Residents Admitted within the Past 30 days:
10. Physical Restraints: Resident(s) who have a physical
Resident(s) who were admitted to the facility within
restraint in use. A restraint is defned as the use of
the past 30 days and currently residing in the facility.
any manual method, physical or mechanical device,
material or equipment attached or adjacent to the
2. Alzheimer’s/Dementia: Resident(s) who have a
resident’s body that the individual cannot remove
diagnosis of Alzheimer’s disease or dementia of
easily which restricts freedom of movement or
any type.
normal access to one’s body (e.g., bed rail, trunk
3. MD, ID or RC & No PASARR Level II: Resident(s) who
restraint, limb restraint, chair prevents rising, mitts
have a serious mental disorder, intellectual disability
on hands, confned to room, etc.). Do not code
or a related condition but does not have a PASARR
wander guards as a restraint.
level II evaluation and determination.
11. Fall(s) (F) or Fall(s) with Injury (FI) or Major Injury
4. Medications: Resident(s) receiving any of the
(FMI): Resident(s) who have fallen in the facility
following medications: (I) = Insulin, (AC) =
in the past 90 days or since admission and have
Anticoagulant (e.g. Direct thrombin inhibitors and
incurred an injury or not. A major injury includes
low weight molecular weight heparin [e.g., Pradaxa,
bone fractures, joint dislocation, closed head injury
Xarelto, Coumadin, Fragmin]. Do not include Aspirin
with altered consciousness, subdural hematoma.
or Plavix), (ABX) = Antibiotic, (D) = Diuretic,
Use (F) to identify residents with a fall(s), (FI) to
(O) = Opioid, (H) = Hypnotic, (AA) = Antianxiety,
identify a resident who has sustained an injury
(AP) = Antipsychotic, (AD) Antidepressant,
excluding major injury, and (FMI) to identify a
(RESP) = Respiratory (e.g., inhaler, nebulizer).
resident who has sustained a fall(s) with Major Injury.
NOTE: Record meds according to a drug’s
12. Indwelling Urinary Catheter: Resident(s) with an
pharmacological classifcation, not how it is used.
indwelling catheter (including suprapubic catheter
5. Facility Acquired Pressure Ulcer(s) (any stage):
and nephrostomy tube).
Resident(s) who have a pressure ulcer at any stage,
13. Dialysis: Resident(s) who are receiving (H)
including suspected deep tissue injury (mark I, II, III,
hemodialysis or (P) peritoneal dialysis either within
IV, U for unstageable, S for sDTI).
the facility (F) or offsite (O).
6. Worsened Pressure Ulcer(s) at any stage: Resident(s)
14. Hospice: Resident(s) who have elected or are
with a pressure ulcer at anystage that have
currently receiving hospice services.
worsened.
15. End of Life/Comfort Care/Palliative Care: Resident(s)
7. Excessive Weight Loss without Prescribed Weight
who are receiving end of life or palliative care (not
Loss program: Resident(s) with an unintended (not
including Hospice).
on a prescribed weight loss program) weight loss
> 5% within the past 30 days or >10% within the
16. Tracheostomy: Resident(s) who have a tracheostomy.
past 180 days. Exclude residents receiving hospice
17. Ventilator: Resident(s) who are receiving invasive
services.
mechanical ventilation.
8. Tube Feeding: Resident(s) who receive enteral (E) or
18. Transmission-Based Precautions: Resident(s) who are
parenteral (P) feedings.
currently on Transmission-based Precautions.
9. Dehydration: Resident(s) identifed with actual
19. Intravenous therapy: Resident(s) who are receiving
hydration concerns takes in less than the
intravenous therapy through a central line,
recommended 1,500 ml of fuids daily (water or
peripherally inserted central catheter, or other
liquids in beverages and water in foods with high
intravenous catheter.
fuid content, such as gelatin and soups).
20. Infections: Residents(s) who has a communicable
disease/contagious infection (e.g., MDRO-M,
pneumonia-P, tuberculosis-TB or viral hepatitis-VH,
or c-diff-C) OR has a healthcare-associated infection
(e.g., wound infection-WI or UTI).
CMS-802 (01/2018)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MATRIX FOR PROVIDERS
Resident Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
CMS-802 (01/2018)

Download Form CMS-802 Matrix for Providers

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