NEW SURVEY PROCESS FOR NOVEMBER 2017

NEW SURVEY PROCESS FOR NOVEMBER 2017 for clients of: www.teamtsi.com 800.765.8998 Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240 Tampa, FL 33607 800.275.6252 www.polaris-group.com

NEW SURVEY PROCESS FOR NOVEMBER 2017 Limited Copyright: December 2017, Polaris Group All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution. FH62 - Developed by Polaris Group www.polaris-group.com Page 1 of 118

NEW SURVEY PROCESS FOR NOVEMBER 2017 POST TEST 1. Phase 2 rules go into effect Nov. 28, 2017. a. True b. False 2. The new survey process will be rolled out over time? a. True b. False 3. New Survey process will still include a. Interviews with resident and families b. Resident Counsel Interview c. Investigations using interpretive guidelines and Critical Element pathways d. All of the above 4. Facility tasks include a. Kitchen b. Abuse and Neglect c. Medication Pass d. A and C 5. Which item below is true? a. Infection Control practices are monitored throughout survey. b. Facility Task includes a review of Beneficiary Notices c. Both FH62 - Developed by Polaris Group www.polaris-group.com Page 2 of 118

NEW SURVEY PROCESS FOR NOVEMBER 2017 POST TEST ANSWERS 1. Phase 2 rules go into effect Nov. 28, 2017. a. True b. False A 2. The new survey process will be rolled out over time? a. True b. False B 3. New Survey process will still include a. Interviews with resident and families D b. Resident Counsel Interview c. Investigations using interpretive guidelines and Critical Element pathways d. All of the above 4. Facility tasks include a. Kitchen b. Abuse and Neglect c. Medication Pass d. A and C D 5. Which item below is true? a. Infection Control practices are monitored throughout survey. b. Facility Task includes a review of Beneficiary Notices c. Both C FH62 - Developed by Polaris Group www.polaris-group.com Page 3 of 118

New Long Term Care Survey Process Overview Overview of Regulation Reform F-tag Renumbering New Interpretive Guidance (IG) Current Survey Processes vs. New Survey Process New LTC Survey Process 2 FH62 - Developed by Polaris Group www.polaris-group.com Page 4 of 118

Overview of Regulation Reform 3 Overview of Regulation Reform The regulation reform implements a number of pieces of legislation from the Affordable Care Act (ACA) and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, including the following: Quality Assurance and Performance Improvement (QAPI) Reporting suspicion of a crime Increased discharge planning requirements Staff training section 4 FH62 - Developed by Polaris Group www.polaris-group.com Page 5 of 118

New Interpretive Guidance (IG) Appendix PP is Final in transmittal https://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/2017-Transmittals- Items/R173SOMA.html?DLPage=1&DLEntries=10&DLSor t=1&dlsortdir=descending Appendix P will not be replaced. Instead the Long Term Care Survey Process (LTCSP) guide will be used. https://www.cms.gov/medicare/provider-enrollment-and- Certification/GuidanceforLawsAndRegulations/Downloads/ LTCSP-Procedure-Guide.pdf 5 Implementation Grid Implementation Date Type of Change Details of Change Phase 1: November 28, 2016 (Implemented) Nursing Home Requirements for Participation New Regulatory Language was uploaded to the Automated Survey Processing Environment (ASPEN) under current F Tags Phase 2: November 28, 2017 F Tag numbering Interpretive Guidance (IG) Implement new survey process New F Tags Updated IG Begin surveying with the new survey process No CMP Sanctions imposed for Phase 2 Rules for one year. Phase 3: November 28, 2019 Requirements that need more time to implement Requirements that need more time to implement 6 FH62 - Developed by Polaris Group www.polaris-group.com Page 6 of 118

Phase 2 of LTC Regulations Delay imposition of certain sanctions for 18 months CMP, Discretionary Denial of payments, and Discretionary Termination. Does not apply to statutorily-required Denials of Payments, or Terminations. F-tags include: F655 Baseline F740 Behavioral Health F741 Sufficient/Competent Staff Beh. Health F754 PRN limitations F881 Antibiotic Stewardship ** No delay for F608 Reporting crimes F838 Facility Assess. F865 QAPI Plan F926 Smoking Continue with Dementia Focused Surveys Stopping MDS Focused Surveys 7 Phase 2 of LTC Regulations CMS will freeze Health Inspection Domain on Nov. 29 th for one year. Any surveys that are completed prior to Nov. 29 th under old system will be entered into ASPEN system and could change your rating after that date. ADRs submitted prior to Nov. 29 th, if S/S changes, update may impact 5 Star CMS stated they may remove third survey in the Spring of 2018; meaning your Health Domain score could be re-calculated using last 2 Surveys only. 8 FH62 - Developed by Polaris Group www.polaris-group.com Page 7 of 118

F-tag Renumbering 9 F-tag Renumbering The image above is the F-tag Crosswalk showing: The original regulatory grouping and the new associated grouping The original regulation number and the new associated regulation number The original F-tag and the associated new F-tag See attached List of revised F-tag 10 FH62 - Developed by Polaris Group www.polaris-group.com Page 8 of 118

New Interpretive Guidance (IG) 11 New Interpretive Guidance (IG) CMS is in the process of updating information for Appendices P and PP. Once the guidance is approved it will be available in the SOM. States should ensure surveyors use the most recent version of the regulation. Advanced copy Appendix PP is available https://www.cms.gov/medicare/provider-enrollment-and- Certification/GuidanceforLawsAndRegulations/Download s/advance-appendix-pp-including-phase-2-.pdf 12 FH62 - Developed by Polaris Group www.polaris-group.com Page 9 of 118

Current Survey Processes vs. New Survey Process Information about the survey process and implementation can be found at: https://www.cms.gov/medicare/provider-enrollment- and-certification/guidanceforlawsandregulations/nursing- Homes.html Video on new survey process at: https://surveyortraining.cms.hhs.gov/pubs/classinformation.aspx?cid=0cmsltcsurproc_ltcproviders 13 Why is CMS Changing the LTC Survey Process? Two different survey processes existed to review for the Requirements of Participation (Traditional and QIS). Surveyors identified opportunities to improve the efficiency and effectiveness of both survey processes. The two processes appeared to identify slightly different quality of care/quality of life issues. CMS set out to build on the best of both the Traditional and QIS processes to establish a single nationwide survey process. 14 FH62 - Developed by Polaris Group www.polaris-group.com Page 10 of 118

Goals of New Process Same survey for entire country Strengths from Traditional & QIS New innovative approaches Effective and efficient Resident-centered Process is computer software-based Survey process and software are in testing and development and validation Balance between structure and surveyor autonomy 15 16 FH62 - Developed by Polaris Group www.polaris-group.com Page 11 of 118

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New LTC Survey Process Overview Survey Process 1. Off-site preparation 2. Initial pool process Screen, prioritize, interview/observe/limited record review 3. Sample Selection and concerns identified 4. Facility Tasks and Closed Record Reviews 5. Investigation into identified concerns 6. Facility Tasks and other tasks 7. Decision-making 8. Exit 19 Section I. Offsite Prep 20 FH62 - Developed by Polaris Group www.polaris-group.com Page 13 of 118

Offsite Preparation Team Coordinator (TC) completes offsite preparation Repeat deficiencies Results of last Standard survey Complaints Variances/waivers Review CASPER 3 Prior survey history Assigned Units to Surveyors based on facility floor plan 21 Offsite Preparation Team Coordinator (TC) completes offsite preparation Upload MDS data to software for initial sample selection focus on MDS data/qm At least one MDS in last 180 days Excludes stays with only Entry and Discharge Assessments 70% of sample pre-selected Closed record pre-selected 22 FH62 - Developed by Polaris Group www.polaris-group.com Page 14 of 118

Section II. Facility Entrance 23 Facility Entrance Team Coordinator (TC) conducts an Entrance Conference Updated Entrance Conference Worksheet Updated facility matrix needed first day Brief visit to the kitchen Surveyors go to assigned areas unit will be assigned for Initial Pool Reviews will start process immediately. 24 FH62 - Developed by Polaris Group www.polaris-group.com Page 15 of 118

Entrance Worksheets Review and prepare your Survey information accordingly. Will ask for Facility Assessment Will ask for QAPI Plan 25 26 FH62 - Developed by Polaris Group www.polaris-group.com Page 16 of 118

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Roster Matrix New Admissions within 30 days - complete Matrix upon entrance All other residents within 4 hours 31 Updated Facility Matrix 32 FH62 - Developed by Polaris Group www.polaris-group.com Page 19 of 118

Begin practicing filling it out and work with software company. 33 34 FH62 - Developed by Polaris Group www.polaris-group.com Page 20 of 118

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Section III. Initial Pool Process CMS says on average 8 to 10 hours 37 Initial Pool Process Full Alpha Census and list of all residents admitted within last 30 days is requested immediately upon arrival at Entrance Surveyors go immediately to assigned unit, and may ask for list of residents on unit with admit date. Surveyors will screen all residents in their assigned area will round - observe resident, room, care observations, may introduce themselves maybe up to 10 minutes per resident on unit. 38 FH62 - Developed by Polaris Group www.polaris-group.com Page 22 of 118

Initial Pool Process Screening used to identify initial pool - eight residents per surveyor 70% selected offsite- 30% by surveyor based on screen Will see MDS indicators on software Review Roster Matrix for new admissions Offsite selected randomly by computer Vulnerable based on observations New admissions Complaints (up to 5 across all surveyors) Identified concern during screening 39 Initial Pool Process Screening used to identify initial pool eight residents per surveyor If available include (may be spread out across all surveyors) Smokers Receiving dialysis Receiving Hospice Care On ventilator On Transmission-based Precautions Only can remove offsite selected resident from Pool if discharged; may review as a discharged chart. 40 FH62 - Developed by Polaris Group www.polaris-group.com Page 23 of 118

Resident Interviews Initial Pool Process Initial Pool 8 per surveyor Formal observations performed around 20 minutes each To perform full interview, if interviewable Interview will have suggested questions not a specific surveyor script Must cover all care areas via observation, interview, or limited chart review if needed Includes Rights, QoL, QoC Target for further investigation or no issue for each resident in initial pool sample 41 Resident Representative/Family Interviews Initial Pool Process Non-interviewable residents Interview someone familiar with the resident s care. Complete at least three during initial pool process or early enough to follow-up on concerns across all Surveyors Sampled residents, if possible, but can chose other residents to find family member to interview. Target to investigate further or no issue for each resident in pool. 42 FH62 - Developed by Polaris Group www.polaris-group.com Page 24 of 118

Resident Representative/Family Interviews Initial Pool Process MDS Discrepancies identified for further investigation based on interviews or observations. Using software MDS data; MDS coded as having pain, resident states no pain Resident has contracture; no contracture on MDS 43 Limited Record Review Initial Pool Process Conduct limited record review, based on interviews and observations, are completed including MDS indicators All initial pool residents: Check for advanced directives and confirm specific information from interview or observations New Admissions broad list of high risk medications and hospice May interview staff, if needed but limited Limit Record Review, spend most of time on interviews/observations 44 FH62 - Developed by Polaris Group www.polaris-group.com Page 25 of 118

Limited Record Review Initial Pool Process If interview not conducted, or refused, or not available; review certain care areas in record Pressure Ulcers, Dialysis, Infection, Nutrition (including weight loss), Falls last 120 days, Decline in ADLs, Low Risk Bowel/Bladder incontinence, Unplanned hospitalization, Elopement, and/or Change in Condition in last 120 days. Confirm insulin, anticoagulant, and antipsychotic with a diagnosis of Alzheimer s or dementia, and if any PASARR Level 2 (Pre-Admission Screening and Resident Review) 45 Initial Pool Tools Resident Interview Care Areas and Probes Tool Resident Observation Care Areas and Probes Tool Resident Representative Questions Resident Record Review Care Areas See attachments 46 FH62 - Developed by Polaris Group www.polaris-group.com Page 26 of 118

Dining First Full Meal Dining observe first full meal Will use CE Pathway CMS-20053 Dining Cover all dining rooms and room trays Observe enough to adequately identify concerns If feasible, observe initial pool residents with weight loss If concerns identified, observe another meal 47 Team Meetings Brief meeting at the end of each day Workload Coverage Concern Synchronize/share data (if needed) 48 FH62 - Developed by Polaris Group www.polaris-group.com Page 27 of 118

Section IV. Sample Selection for Investigations Around 20% of census Active Residents 49 Sample Size 50 FH62 - Developed by Polaris Group www.polaris-group.com Page 28 of 118

Sample Selection Select final sample for further investigation Prioritize using sampling considerations: Replace discharged residents selected offsite with those selected onsite Can replace residents selected offsite with rationale Harm, Substandard Quality of Care if suspected, IJ if identified Abuse Concern and/or Complaint All MDS QM indicator areas if not already included 51 Sample Selection Unnecessary Medication Review System selects five residents for full medication review Use Unnecessary Medication Review Broad range of high-risk medications and adverse consequences Residents may or may not be in investigative sample 52 FH62 - Developed by Polaris Group www.polaris-group.com Page 29 of 118

Sample Selection If investigating Abuse Will ask for all allegations of abuse since last survey Will select one for review Will use Abuse CE Pathway 53 Sample Selection Complaint Investigation Only investigate single resident if only one complaint If more than one, then complete on 3 residents 54 FH62 - Developed by Polaris Group www.polaris-group.com Page 30 of 118

Sample Selection Even if not identified for investigation include: Hospice Dialysis Vent Transmission-based precautions If need more for sample Residents with most concerns Prior survey issues Areas of facility not represented in sample From Unnecessary Drug Review sample QoL or QoC. 55 Section V. Investigation 56 FH62 - Developed by Polaris Group www.polaris-group.com Page 31 of 118

Resident Investigation General Guidelines Conduct investigations for all concerns that warrant further investigation for sampled residents Continuous observations, if required Interview representative, if appropriate, when concerns are identified 57 Investigations Majority of time spent observing and interviewing with relevant review of record to complete investigation Use Appendix PP and critical elements (CE) pathways or guidelines, or Facility Task tools 58 FH62 - Developed by Polaris Group www.polaris-group.com Page 32 of 118

Investigations May Investigate by resident Investigate all care areas identified for that resident Useful approach if interviewed/observed/resident representative or reviewing the record May Investigate by care area Access all residents identified for that care area Useful when interviewing staff 59 Investigation Process Begin with record review of MDS, physician orders, and care plan Use probes in CE Pathways If necessary, return to record to confirm information for interviews and observations Observe and interview staff to determine if implement care plan Note and F/U on deviations Concerns with PU or Incontinence perform continuous observations across shifts 60 FH62 - Developed by Polaris Group www.polaris-group.com Page 33 of 118

Investigation Process While performing observations consider Sufficient Staff and Competencies For safety and maintaining highest practical functioning Review Facility Assessment if have concerns in a specific care area such as: Hospice, Dialysis, vents Activities, nutrition, behavioral/dementia care Resources therapy and pharmacy 61 Other CE Pathways Used for Investigations CMS-20059 Abuse CMS-20078 Pressure Ulcers CMS-20063 Personal Funds CMS-20080 Rehab/Restorative CMS-20065 Activities CMS-20081 Respiratory Care CMS-20066 ADLs CMS-20082 Unnecessary Meds CMS-20067 Behavioral/Emotional CMS-20090 PASARR CMS-20068 Urinary Catheter/UTI CMS-20091 Extended Survey CMS-20069 Communications/sensory CMS-20092 Hydration CMS-20070 Dental CMS-20093 Tube Feeding CMS-20071 Dialysis CMS-20120 Positioning/Mobility CMS-20072 General CMS-20125 Bladder/Bowel Incont CMS-20073 Hospice/End of life CMS-20127 Accidents CMS-20075 Nutrition CMS-20130 Neglect CMS-20076 Pain CMS-20131 Resident Assessment CMS-20077 Physical Restraints CMS-20133 Dementia Care 62 FH62 - Developed by Polaris Group www.polaris-group.com Page 34 of 118

Section VI. Ongoing and Other Survey Activities 63 Closed Record Reviews Complete timely during the investigation portion of survey SAMPLE size is 3 closed records At least one of each - Unexpected death, hospitalization, and community discharge last 90 days System selected or discharged resident Will review Notices on discharged Part A residents Use Appendix PP and CE pathways CMS-20132 Discharge CMS-20123 Hospitalization CMS-20074 Death 64 FH62 - Developed by Polaris Group www.polaris-group.com Page 35 of 118

Facility Task Investigations Complete any time during investigation Use facility task pathways for each Facility Task Critical Element (CE) compliance decision 1. Sufficient/competent Staff - all 2. Infection Control - all 3. Beneficiary Notices 4. Dining Observations all 5. Medication Storage 6. Medication Administration 7. Kitchen Observations 8. QAA/QAPI 9. Resident Council Group Interview 65 Sufficient and Competent Nurse Staffing Review Is a mandatory task, refer to revised Facility Task Pathway CMS-20062 Sufficient and Competent Staff Throughout the survey, consider if staffing concerns can be linked to QoL and QoC concerns Assigned to all surveyors 66 FH62 - Developed by Polaris Group www.polaris-group.com Page 36 of 118

Infection Control Throughout survey, all surveyors should observe for infection control; will use CE Pathway CMS-20054 Infection Prevention Control & Immunizations Assigned surveyor coordinates a review of influenza and pneumococcal vaccinations Assigned surveyor reviews infection prevention and control, and antibiotic stewardship program Observations by all surveyors 67 SNF Beneficiary Protection Notification Review CMS-20052 Beneficiary Notice Will use CE pathway List of residents discharges (home and infacility) provided at Entrance Randomly select three residents Facility completes new worksheet see next slide Review worksheet and notices 68 FH62 - Developed by Polaris Group www.polaris-group.com Page 37 of 118

Select Three residents 69 Notices Worksheet for 3 Selected Residents 70 FH62 - Developed by Polaris Group www.polaris-group.com Page 38 of 118

Dining Subsequent Meal, if Needed Will observe first meal upon arrival. Second meal observed if concerns noted Use Appendix PP and CE Pathway for Dining CMS-20053 Dining Dining task is completed outside any resident specific investigation into nutrition and/or weight loss Assigned to all surveyors 71 Medication Storage & Labeling Medication Storage and labeling Observe half of medication storage rooms and half of medication carts If issues, expand medication room/cart Will use CE Pathway CMS-20089 Medication Storage 72 FH62 - Developed by Polaris Group www.polaris-group.com Page 39 of 118

Medication Administration Medication Administration Recommend nurse or pharmacist Will use CE Pathway CMS-20056 Medication Administration Include sample residents, if opportunity presents itself Reconcile controlled medications, if observed during medication administration Observe different routes, units, and shifts Observe 25 medication opportunities 73 Kitchen Observation In addition to the brief kitchen observation upon entrance, conduct full kitchen investigation Follow Appendix PP and Facility Task Pathway to complete kitchen investigation CMS-20055 Kitchen 74 FH62 - Developed by Polaris Group www.polaris-group.com Page 40 of 118

QAA/QAPI Will use Facility Task Tool CMS-20058 QAA and QAPI Will ask for written QAPI plan upon entrance Will interview staff Done at end of survey 75 Resident Council Meeting Group interview with active members of the council Can invite others try to keep group to no more than 12 Complete early to ensure investigation if concerns identified Will review Council Minutes Refer to updated CE Pathway CMS-20057 Resident Council 76 FH62 - Developed by Polaris Group www.polaris-group.com Page 41 of 118

Triggered Facility Tasks 77 POLARIS GROUP Strategic Solutions For Healthcare www.polaris-group.com Environment Targeted Review Investigate specific concerns Will use CE Pathway CMS-20061 Environment Eliminate redundancy with Life Safety or tags moved to E-tags in Appendix Z Disaster and Emergency Preparedness (Appendix Z) Will not complete review storage of Oxygen, the generator, Disaster planning since part of life safety 78 FH62 - Developed by Polaris Group www.polaris-group.com Page 42 of 118

Personal Funds Targeted Review Investigate specific concerns Will use CE Pathway CMS-20063 Personal Funds Triggered from concerns with access to funds or quarterly statements 79 Resident Assessment Targeted Review Investigate specific concerns Will use CE Pathway CMS-20131 Resident Assessment Triggered if concerns with timeliness of completion or submission or MDS discrepancies 80 FH62 - Developed by Polaris Group www.polaris-group.com Page 43 of 118

Section VII. Potential Citations 81 Potential Citations Software calculates potential tags Team makes compliance determination. Compliance decisions reviewed by team Determines Scope and severity (S/S) Includes Psychosocial Outcomes severity guide Conduct exit conference and relay potential areas of deficient practice 82 FH62 - Developed by Polaris Group www.polaris-group.com Page 44 of 118

Section VIII. Exit Inform Administrator of observations and preliminary findings Will invite Ombudsman and Resident Council Rep May perform exit conference just for residents 83 LTC Survey Training 84 FH62 - Developed by Polaris Group www.polaris-group.com Page 45 of 118

Survey Agency Preparation, continued Implementation of survey process on national level November 28, 2017 Phase 2 of LTC regulations required for implementation November 2017 New CMS approved Basic LTC training material will be released in January 2018 States may need to revise their State Agency training program Information about the survey process and implementation can be found at: https://www.cms.gov/medicare/provider-enrollment-and- Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html 85 Summary Traditional Survey States Much bigger change for these states Going to computer based documentation; facility will need to help provide access and area Still using Roster Matrix for selection QIS States Less of a change overall No structured Interviews anymore Software not driving sample selection 86 FH62 - Developed by Polaris Group www.polaris-group.com Page 46 of 118

Summary Read CE Pathways in preparation for survey INTERVIEW residents and families to anticipate what issues may come up INTERVIEW staff to understanding of a resident s care needs permanent staffing will help Review residents with high risk meds Review advance directives Observe staff care for competencies 87 FH62 - Developed by Polaris Group www.polaris-group.com Page 47 of 118

Long Term Care Rule F Tag: Job Aid Federal Regulatory Groups for Long Term Care Facilities * Substandard quality of care = one or more deficiencies with s/s levels of F, H, I, J, K, or L in Red F540 Definitions 483.10 Resident Rights F550 *Resident Rights/Exercise of Rights F551 Rights Exercised by Representative F552 Right to be Informed/Make Treatment Decisions F553 Right to Participate in Planning Care F554 Resident Self Admin Meds Clinically Appropriate F555 Right to Choose/Be Informed of Attending Physician F557 Respect, Dignity/Right to have Personal Property F558 *Reasonable Accommodations of Needs/Preferences F559 *Choose/Be Notified of Room/Roommate Change F560 Right to Refuse Certain Transfers F561 *Self Determination F562 Immediate Access to Resident F563 Right to Receive/Deny Visitors F564 Inform of Visitation Rights/Equal Visitation Privileges F565 *Resident/Family Group and Response F566 Right to Perform Facility Services or Refuse F567 Protection/Management of Personal Funds F568 Accounting and Records of Personal Funds F569 Notice and Conveyance of Personal Funds F570 Surety Bond Security of Personal Funds F571 Limitations on Charges to Personal Funds F572 Notice of Rights and Rules F573 Right to Access/Purchase Copies of Records F574 Required Notices and Contact Information F575 Required Postings F576 Right to Forms of Communication with Privacy F577 Right to Survey Results/Advocate Agency Info F578 Request/Refuse/Discontinue Treatment;Formulate Adv Di F579 Posting/Notice of Medicare/Medicaid on Admission F580 Notify of Changes (Injury/Decline/Room, Etc.) F582 Medicaid/Medicare Coverage/Liability Notice F583 Personal Privacy/Confidentiality of Records F584 *Safe/Clean/Comfortable/Homelike Environment F585 Grievances F586 Resident Contact with External Entities 483.12 Freedom from Abuse, Neglect, and Exploitation F600 *Free from Abuse and Neglect F602 *Free from Misappropriation/Exploitation F603 *Free from Involuntary Seclusion F604 *Right to be Free from Physical Restraints F605 *Right to be Free from Chemical Restraints F606 *Not Employ/Engage Staff with Adverse Actions F607 *Develop/Implement Abuse/Neglect, etc. Policies F608 *Reporting of Reasonable Suspicion of a Crime F609 *Reporting of Alleged Violations F610 *Investigate/Prevent/Correct Alleged Violation 483.15 Admission, Transfer, and Discharge F620 Admissions Policy F621 Equal Practices Regardless of Payment Source F622 Transfer and Discharge Requirements F623 Notice Requirements Before Transfer/Discharge F624 Preparation for Safe/Orderly Transfer/Discharge F625 Notice of Bed Hold Policy Before/Upon Transfer F626 Perming Residents to Return to Facility 483.20 Resident Assessments F635 Admission Physician Orders for Immediate Care F636 Comprehensive Assessments & Timing F637 Comprehensive Assmt Aer Significant Change F638 Quarterly Assessment At Least Every 3 Months F639 Maintain 15 Months of Resident Assessments F640 Encoding/Transming Resident Assessment F641 Accuracy of Assessments F642 Coordinaon/Cerficaon of Assessment F644 Coordinaon of PASARR and Assessments F645 PASARR Screening for MD & ID F646 MD/ID Significant Change Notification 483.21 Comprehensive Resident Centered Care Plans F655 Baseline Care Plan F656 Develop/Implement Comprehensive Care Plan F657 Care Plan Timing and Revision F658 Services Provided Meet Professional Standards F659 Qualified Persons F660 Discharge Planning Process F661 Discharge Summary 483.24 Quality of Life F675 *Quality of Life F676 *Acvies of Daily Living (ADLs)/ Maintain Abilies F677 *ADL Care Provided for Dependent Residents F678 *Cardio Pulmonary Resuscitaon (CPR) F679 *Acvies Meet Interest/Needs of Each Resident F680 *Qualificaons of Acvity Professional 483.25 Quality of Care F684 *Quality of Care F685 *Treatment/Devices to Maintain Hearing/Vision F686 *Treatment/Svcs to Prevent/Heal Pressure Ulcers F687 *Foot Care F688 *Increase/Prevent Decrease in ROM/Mobility F689 *Free of Accident Hazards/Supervision/Devices F690 *Bowel/Bladder Inconnence, Catheter, UTI F691 *Colostomy, Urostomy, or Ileostomy Care F692 *Nutrion/Hydraon Status Maintenance F693 *Tube Feeding Management/Restore Eang Skills F694 *Parenteral/IV Fluids F695 *Respiratory/Tracheostomy care and Suconing F696 *Prostheses F697 *Pain Management F698 *Dialysis F699 *{PHASE 3} Trauma Informed Care F700 *Bedrails 483.30 Physician Services F710 Resident's Care Supervised by a Physician F711 Physician Visits Review Care/Notes/Order F712 Physician Visits Frequency/Timeliness/Alternate NPPs F713 Physician for Emergency Care, Available 24 Hours F714 Physician Delegaon of Tasks to NPP F715 Physician Delegaon to Diean/Therapist 483.35 Nursing Services F725 Sufficient Nursing Staff F726 Competent Nursing Staff F727 RN 8 Hrs/7 days/wk, Full Time DON F728 Facility Hiring and Use of Nurse F729 Nurse Aide Registry Verificaon, Retraining Report 30: LTC Rule Job Aid Page 1 of 2 Friday, July 14, 2017 FH62 - Developed by Polaris Group www.polaris-group.com Page 48 of 118

Federal Regulatory Groups for Long Term Care Facilities * Substandard quality of care = one or more deficiencies with s/s levels of F, H, I, J, K, or L in Red F730 Nurse Aide Perform Review 12Hr/Year In service F731 Waiver Licensed Nurses 24Hr/Day and RN Coverage F732 Posted Nurse Staffing Informaon 483.40 Behavioral Health Services F740 Behavioral Health Services F741 Sufficient/Competent Staff Behav Health Needs F742 *Treatment/Svc for Mental/Psychosocial Concerns F743 *No Pattern of Behavioral Difficulties Unless Unavoidable F744 *Treatment /Service for Dementia F745 *Provision of Medically Related Social Services 483.45 Pharmacy Services F755 Pharmacy Svcs/Procedures/Pharmacist/Records F756 Drug Regimen Review, Report Irregular, Act On F757 *Drug Regimen is Free From Unnecessary Drugs F758 *Free from Unnec Psychotropic Meds/PRN Use F759 *Free of Medicaon Error Rate sof 5% or More F760 *Residents Are Free of Significant Med Errors F761 Label/Store Drugs & Biologicals 483.50 Laboratory, Radiology, and Other Diagnostic Se F770 Laboratory Services F771 Blood Blank and Transfusion Services F772 Lab Services Not Provided On Site F773 Lab Svs Physician Order/Nofy of Results F774 Assist with Transport Arrangements to Lab Svcs F775 Lab Reports in Record LabName/Address F776 Radiology/Other Diagnostic Services F777 Radiology/Diag. Svcs Ordered/Nofy Results F778 Assist with Transport Arrangements to Radiology F779 X Ray/Diagnosc Report in Record Sign/Dated 483.55 Dental Services F790 Roune/Emergency Dental Services in SNFs F791 Roune/Emergency Dental Services in NFs 483.60 Food and Nutrition Services F800 Provided Diet Meets Needs of Each Resident F801 Qualified Dietary Staff F802 Sufficient Dietary Support Personnel F803 Menus Meet Res Needs/Prep in Advance/Followed F804 Nutrive Value/Appear,Palatable/Prefer Temp F805 Food in Form to Meet Individual Needs F806 Resident Allergies, Preferences and Substutes F807 Drinks Avail to Meet Needs/Preferences/ Hydraon F808 Therapeuc Diet Prescribed by Physician F809 Frequency of Meals/Snacks at Bedme F810 Assistive Devices Eang Equipment/Utensils F811 Feeding Asst Training/Supervision/Resident F812 Food Procurement, Store/Prepare/Serve Sanitary F813 Personal Food Policy F814 Dispose Garbage & Refuse Properly 483.65 Specialized Rehabilitative Services F825 Provide/Obtain Specialized Rehab Services F826 Rehab Services Physician Order/Qualified Person 483.70 Administration F835 Administration F836 License/Comply w/fed/state/local Law/Prof Std F837 Governing Body F838 Facility Assessment F839 Staff Qualifications F840 Use of Outside Resources F841 Responsibilies of Medical Director F842 Resident Records Identifiable Information F843 Transfer Agreement F844 Disclosure of Ownership Requirements F845 Facility closure Administrator F846 Facility closure F849 Hospice Services F850 *Qualifications of Social Worker >120 Beds F851 Payroll Based Journal 483.75 Quality Assurance and Performance Improvem F865 QAPI Program/Plan, Disclosure/Good Faith Attempt F866 {PHASE 3} QAPI/QAA Data Collecon and Monitoring F867 QAPI/QAA Improvement Acvies F868 QAA Committee 483.80 Infection Control F880 Infection Prevention & Control F881 Antibiotic Stewardship Program F882 {PHASE 3} Infecon Prevenonist Qualificaons/Role F883 *Influenza and Pneumococcal Immunizaons 483.85 {PHASE 3} Compliance and Ethics Program F895 {PHASE-3} Compliance and Ethics Program 483.90 Physical Environment F906 F907 F908 F909 F910 F911 F912 F913 F914 F915 F916 F917 F918 F919 F920 F921 F922 F923 F924 F925 F926 Emergency Electrical Power System Space and Equipment Essenal Equipment, Safe Operang Condion Resident Bed Resident Room Bedroom Number of Residents Bedrooms Measure at Least 80 Square Ft/Resident Bedrooms Have Direct Access to Exit Corridor Bedrooms Assure Full Visual Privacy Resident Room Window Resident Room Floor Above Grade Resident Room Bed/Furniture/Closet Bedrooms Equipped/Near Lavatory/Toilet Resident Call System Requirements for Dining and Activity Rooms Safe/Funconal/Sanitary/ Comfortable Environment Procedures to Ensure Water Availability Ventilation Corridors Have Firmly Secured Handrails Maintains Effecve Pest Control Program Smoking Policies 483.95 Training Requirements F940 F941 F942 F943 F944 F945 F946 F947 F948 F949 {PHASE 3} Training Requirements General {PHASE 3} Communication Training {PHASE-3} Resident s Rights Training Abuse, Neglect, and Exploitation Training {PHASE 3} QAPI Training {PHASE 3} Infection Control Training {PHASE-3} Compliance and Ethics Training Required In Service Training for Nurse Aides Training for Feeding Assistants {PHASE-3} Behavioral Health Training Report 30: LTC Rule Job Aid Page 2 of 2 Friday, July 14, 2017 FH62 - Developed by Polaris Group www.polaris-group.com Page 49 of 118

As of: 06/28/2017 Phase 2 Tag Crosswalk Effective November 28, 2017 Tag # (As of Nov. 28, 2017) SQC Tag? X = Yes Tag Title CFR Regulatory Groupings Tags / Subparts Implemented in Phase 3 Old Tag (Taken from App PP 03 08 2017) RegulationText that was Moved to New Tag F540 Definitions 483.5 F150 483.5 F550 X Resident Rights/Exercise of Rights 483.10(a)(1)(2)(b)(1)(2) 483.10 Resident Rights F151 F240 F241 483.10(b)(1)(2) 483.10(a)(1)(2) 483.10(a)(1) F551 Rights Exercised by Representative 483.10(b)(3) (7)(i) (iii) 483.10 Resident Rights F152 483.10(b)(3) (7) F552 Right to be Informed/Make Treatment Decisions F553 Right to Participate in Planning Care 483.10(c)(2)(3) 483.10 Resident Rights F554 F555 F557 F558 F559 X X Resident Self Admin Meds Clinically Appropriate Right to Choose/Be Informed of Attending Physician Respect, Dignity/Right to have Personal Property Reasonable Accommodations of Needs/Preferences Choose/Be Notified of Room/Roommate Change 483.10(c)(1)(4)(5) 483.10 Resident Rights F154 483.10(c)(1)(4)(5) F154 F280 483.10(c)(7) 483.10 Resident Rights F176 483.10(c)(7) 483.10(c)(2)(iii) 483.10(c)(2)(i)(ii)(iv)(v)(3)(i) (iii) 483.10(d)(1) (5) 483.10 Resident Rights F163 483.10(d)(1)(2)(4)(5) 483.10(e)(2) 483.10 Resident Rights F252 483.10(e)(2) 483.10(e)(3) 483.10 Resident Rights F246 483.10(e)(3) 483.10(e)(4) (6) 483.10 Resident Rights F175 F247 483.10(e)(4)(5) 483.10(e)(6) F560 Right to Refuse Certain Transfers 483.10(e)(7)(i) (iii)(8) 483.10 Resident Rights F177 483.10(e)(7) (8) F561 X Self Determination 483.10(f)(1) (3)(8) 483.10 Resident Rights F242 F245 483.10(f)(1) (3) 483.10(f)(8) F562 Immediate Access to Resident 483.10(f)(4)(i)(A) (G) 483.10 Resident Rights F172 483.10(f)(4)(i) F563 Right to Receive/Deny Visitors 483.10(f)(4)(ii) (v) 483.10 Resident Rights F172 483.10(f)(4)(ii) (v) F564 Inform of Visitation Rights/Equal Visitation Priviledges F565 X Resident/Family Group and Response 483.10(f)(5)(i) (iv)(6)(7) 483.10 Resident Rights F566 F567 F568 F569 F570 Right to Perform Facility Services or Refuse Protection/Management of Personal Funds Accounting and Records of Personal Funds Notice and Conveyance of Personal Funds Surety Bond Security of Personal Funds 483.10(f)(4)(vi)(A) (D) 483.10 Resident Rights F172 483.10(f)(4)(vi)(A) (D) F243 F244 483.10(f)(5)(i) (iii)(6)(7) 483.10(f)(5)(iv) 483.10(f)(9)(i) (iv) 483.10 Resident Rights F169 483.10(f)(9) 483.10(f)(10)(i)(ii) 483.10 Resident Rights F158 F159 483.10(f)(10)(i) 483.10(f)(ii) 483.10(f)(10)(iii) 483.10 Resident Rights F159 483.10(f)(10(iii) 483.10(f)(10)(iv)(v) 483.10 Resident Rights F159 483.10(f)(iv) 483.10(f)(10)(vi) 483.10 Resident Rights F161 483.10(f)(10(vi) 1 FH62 - Developed by Polaris Group www.polaris-group.com Page 50 of 118

As of: 06/28/2017 Phase 2 Tag Crosswalk Effective November 28, 2017 Tag # (As of Nov. 28, 2017) F571 SQC Tag? X = Yes Tag Title CFR Regulatory Groupings Limitations on Charges to Personal Funds Tags / Subparts Implemented in Phase 3 Old Tag (Taken from App PP 03 08 2017) 483.10(f)(11)(i) (iii) 483.10 Resident Rights F162 483.10(f)(11)(i) (iii) RegulationText that was Moved to New Tag F572 Notice of Rights and Rules 483.10(g)(1)(16) 483.10 Resident Rights F156 483.10(g)(1)(16) F573 F574 Right to Access/Purchase Copies of Records Required Notices and Contact Information 483.10(g)(2)(i)(ii)(3) 483.10 Resident Rights F153 483.10(g)(2)(3) 483.10(g)(4)(i) (vi) 483.10 Resident Rights F156 483.10(g)(4) F575 Required Postings 483.10(g)(5)(i)(ii) 483.10 Resident Rights F156 483.10(g)(5) F576 Right to Forms of Communication with Privacy 483.10(g)(6) (9) 483.10 Resident Rights F170 F171 F174 483.10(g)(8)(i)(9)(i) (iii) 483.10(g)(7)(ii)(iii) 483.10(g)(6)(7)(i) F577 F578 F579 F580 F582 F583 Right to Survey Results/Advocate Agency Info Request/Refuse/Discontinue Treatment;Formulate Adv Directives Posting/Notice of Medicare/Medicaid on Admission Notify of Changes (Injury/Decline/Room, Etc.) Medicaid/Medicare Coverage/Liability Notice Personal Privacy/Confidentiality of Records 483.10(g)(10)(11) 483.10 Resident Rights F167 F168 483.10(g)(10)(i)(11) 483.10(g)(10)(ii) 483.10(c)(6)(8)(g)(12)(i) (v) 483.10 Resident Rights F155 483.10(c)(6)(8)(g)(12) 483.10(g)(13) 483.10 Resident Rights F156 483.10(g)(13) 483.10(g)(14)(i) (iv) 483.10 Resident Rights F157 483.10(g)(14) 483.10(g)(17)(18)(i) (v) 483.10 Resident Rights F156 483.10(g)(17) (18) 483.10(h)(1) (3)(i)(ii) 483.10 Resident Rights F164 F173 483.10(h)(1)(3)(i) 483.10(h)(3)(ii) F584 X Safe/Clean/Comfortable/ Homelike Environment 483.10(i)(1) (7) 483.10 Resident Rights F252 F253 F254 F256 F257 F258 F461 483.10(i)(1)(i)(ii) 483.10(i)(2) 483.10(i)(3) 483.10(i)(5) 483.10(i)(6) 483.10(i)(7) 483.10(i)(4) F585 Grievances 483.10(j)(1) (4) 483.10 Resident Rights F165 F166 483.10(j)(1) 483.10(j)(2 4) F586 Resident Contact with External Entities 483.10(k) 483.10 Resident Rights F168 483.10(k) F600 X Free from Abuse and Neglect 483.12(a)(1) 483.12 Freedom from Abuse, Neglect, and Exploitation F223 483.12(a)(1) F602 X Free from Misappropriation/Exploitation 483.12 483.12 Freedom from Abuse, Neglect, and Exploitation F223/ F224 483.12 2 FH62 - Developed by Polaris Group www.polaris-group.com Page 51 of 118

As of: 06/28/2017 Phase 2 Tag Crosswalk Effective November 28, 2017 Tag # (As of Nov. 28, 2017) SQC Tag? X = Yes F603 X Free from Involuntary Seclusion 483.12(a)(1) Tag Title CFR Regulatory Groupings 483.12 Freedom from Abuse, Neglect, and Exploitation Tags / Subparts Implemented in Phase 3 Old Tag (Taken from App PP 03 08 2017) F223 RegulationText that was Moved to New Tag 483.12(a)(1) F604 X Right to be Free from Physical Restraints 483.10(e)(1) 483.12(a)(2) 483.10 Resident Rights 483.12 Freedom from Abuse, Neglect, and Exploitation F221 F222 483.10(e )(1), 483.12(a)(2) 483.10(e )(1), 483.12(a)(2) F605 X Right to be Free from Chemical Restraints 483.10(e)(1) 483.12(a)(2) 483.10 Resident Rights 483.12 Freedom from Abuse, Neglect, and Exploitation F222 483.10(e )(1), 483.12(a)(2) F606 X Not Employ/Engage Staff with Adverse Actions 483.12(a)(3)(4) 483.12 Freedom from Abuse, Neglect, and Exploitation F225 483.12(a)(3)(4) F607 X Develop/Implement Abuse/Neglect, etc. Policies 483.12(b)(1) (4) 483.12 Freedom from Abuse, Neglect, and Exploitation (b)(4) Phase 3 Will not be in ASPEN until Phase 3 F226 483.12(b)(1) (4) F608 X Reporting of Reasonable Suspicion of a Crime 483.12(b)(5)(i) (iii) 483.12 Freedom from Abuse, Neglect, and Exploitation No Associated Tag F609 X Reporting of Alleged Violations 483.12(c)(1)(4) 483.12 Freedom from Abuse, Neglect, and Exploitation F225 483.12(c)(1)(4) F610 X Investigate/Prevent/Correct Alleged Violation 483.12(c)(2) (4) 483.12 Freedom from Abuse, Neglect, and Exploitation F225 483.12(c)(2) (4) F620 Admissions Policy 483.15(a)(1) (7) F621 Equal Practices Regardless of Payment Source 483.15(b)(1) (3)(c)(9) F622 Transfer and Discharge Requirements 483.15(c)(1)(i)(ii)(2)(i) (iii) F623 F624 F625 F626 F635 Notice Requirements Before Transfer/Discharge Preparation for Safe/Orderly Transfer/Discharge Notice of Bed Hold Policy Before/Upon Transfer Permitting Residents to Return to Facility Admission Physician Orders for Immediate Care 483.15(c)(3) (6)(8) 483.15(c)(7) 483.15(d)(1)(2) 483.15(e)(1)(2) 483.15 Admission, Transfer, and Discharge 483.15 Admission, Transfer, and Discharge 483.15 Admission, Transfer, and Discharge 483.15 Admission, Transfer, and Discharge 483.15 Admission, Transfer, and Discharge 483.15 Admission, Transfer, and Discharge 483.15 Admission, Transfer, and Discharge F208 F207 F201 F202 F203 F204 F205 F206 483.15(a)(1) (7) 483.15(b)(1) (3)(c)(9) 483.15(c)(1)(i)(ii) 483.15(c)(2)(i) (iii) 483.15(c)(3) (6)(8) 483.15(c)(7) 483.15(d)(1)(i) (iv)(2) 483.15(e)(1)(2) 483.20(a) 483.20 Resident Assessments F271 483.20(a) 3 FH62 - Developed by Polaris Group www.polaris-group.com Page 52 of 118

As of: 06/28/2017 Phase 2 Tag Crosswalk Effective November 28, 2017 Tag # (As of Nov. 28, 2017) SQC Tag? X = Yes Tag Title CFR Regulatory Groupings Tags / Subparts Implemented in Phase 3 Old Tag (Taken from App PP 03 08 2017) RegulationText that was Moved to New Tag F636 Comprehensive Assessments & Timing 483.20(b)(1)(2)(i)(iii) 483.20 Resident Assessments F272 F273 F275 483.20(b)(1) 483.20(b)(2)(i) 483.20(b)(2)(iii) F637 F638 F639 F640 Comprehensive Assmt After Significant Change Quarterly Assessment At Least Every 3 Months Maintain 15 Months of Resident Assessments Encoding/Transmitting Resident Assessment 483.20(b)(2)(ii) 483.20 Resident Assessments F274 483.20(b)(2)(ii) 483.20(c) 483.20 Resident Assessments F276 483.20(c ) 483.20(d) 483.20 Resident Assessments F279 F286 483.20(d) 483.20(d) 483.20(f)(1) (4) 483.20 Resident Assessments F287 483.20(f)(1) (4) F641 Accuracy of Assessments 483.20(g) 483.20 Resident Assessments F278 483.20(g) F642 F644 Coordination/Certification of Assessment Coordination of PASARR and Assessments 483.20(h) (j) 483.20 Resident Assessments F278 483.20(h) (j) 483.20(e)(1)(2) 483.20 Resident Assessments F285 483.20(e) F645 PASARR Screening for MD & ID 483.20(k)(1) (3) 483.20 Resident Assessments F285 483.20(k)(1) (3) F646 MD/ID Significant Change Notification 483.20(k)(4) 483.20 Resident Assessments F285 483.20(k)(4) F655 Baseline Care Plan 483.21(a)(1) (3) 483.21 Comprehensive Resident Centered Care Plans No Associated Tag F656 Develop/Implement Comprehensive Care Plan 483.21(b)(1) 483.21 Comprehensive Resident Centered Care Plans F279 483.21(b)(1) F657 Care Plan Timing and Revision 483.21(b)(2)(i) (iii) 483.21 Comprehensive Resident Centered Care Plans F280 483.21(b)(2)(i) (iii) F658 Services Provided Meet Professional Standards 483.21(b)(3)(i) 483.21 Comprehensive Resident Centered Care Plans F281 483.21(b)(3)(i) F659 Qualified Persons 483.21(b)(3)(ii)(iii) 483.21 Comprehensive Resident Centered Care Plans (b)(iii) Phase 3 Will not be in ASPEN until Phase 3 F282 483.21(b)(3)(ii) F660 Discharge Planning Process 483.21(c)(1)(i) (ix) 483.21 Comprehensive Resident Centered Care Plans F284 483.21(c)(1)(i) (ix) F661 Discharge Summary 483.21(c)(2)(i) (iv) 483.21 Comprehensive Resident Centered Care Plans F283 F284 483.21(c)(2)(i) (iii) 483.21(c)(2)(iv) 4 FH62 - Developed by Polaris Group www.polaris-group.com Page 53 of 118

As of: 06/28/2017 Phase 2 Tag Crosswalk Effective November 28, 2017 Tag # (As of Nov. 28, 2017) SQC Tag? X = Yes Tag Title CFR Regulatory Groupings Tags / Subparts Implemented in Phase 3 Old Tag (Taken from App PP 03 08 2017) RegulationText that was Moved to New Tag F675 X Quality of Life 483.24 483.24 Quality of Life F309 483.24 F676 F677 F678 F679 F680 X X X X X Activities of Daily Living (ADLs)/ Maintain Abilities ADL Care Provided for Dependent Residents Cardio Pulmonary Resuscitation (CPR) Activities Meet Interest/Needs of Each Resident Qualifications of Activity Professional 483.24(a)(1)(b)(1) (5)(i) (iii) 483.24 Quality of Life F310 F311 483.24(a)(b)(1) (5)(i) (iii) 483.24(a)(1) 483.24(a)(2) 483.24 Quality of Life F312 483.24(a)(2) 483.24(a)(3) 483.24 Quality of Life F155 483.24(a)(3) 483.24(c)(1) 483.24 Quality of Life F248 483.24(c)(1) 483.24(c)(2)(i)(ii)(A) (D) 483.24 Quality of Life F249 483.24(c)(2)(i)(ii)(A) (D) F684 X Quality of Care 483.25 483.25 Quality of Care F309 483.25 F685 X Treatment/Devices to Maintain Hearing/Vision 483.25(a)(1)(2) 483.25 Quality of Care F313 483.25(a)(1) (2) F686 X Treatment/Svcs to Prevent/Heal Pressure Ulcers 483.25(b)(1)(i)(ii) 483.25 Quality of Care F314 483.25(b)(1)(i)(ii) F687 X Foot Care 483.25(b)(2)(i)(ii) 483.25 Quality of Care F328 483.25(b)(2)(i)(ii) F688 F689 F690 F691 F692 X X X X X Increase/Prevent Decrease in ROM/Mobility Free of Accident Hazards/Supervision/Devices Bowel/Bladder Incontinence, Catheter, UTI Colostomy, Urostomy, or Ileostomy Care Nutrition/Hydration Status Maintenance 483.25(c)(1) (3) 483.25 Quality of Care F317 F318 483.25(c)(1) 483.25(c)(2)(3) 483.25(d)(1)(2) 483.25 Quality of Care F323 483.25(d)(1)(2) 483.25(e)(1) (3) 483.25 Quality of Care F315 483.25(e)(1) (3) 483.25(f) 483.25 Quality of Care F328 483.25(f) 483.25(g)(1) (3) 483.25 Quality of Care F325 F327 483.25(g)(1)(3) 483.25(g)(2) F693 X Tube Feeding Management/Restore Eating Skills 483.25(g)(4)(5) 483.25 Quality of Care F322 483.25(g)(4)(5) F694 X Parenteral/IV Fluids 483.25(h) 483.25 Quality of Care F328 483.25(h) F695 X Respiratory/Tracheostomy care and Suctioning 483.25(i) 483.25 Quality of Care F328 483.25(i) F696 X Prostheses 483.25(j) 483.25 Quality of Care F328 483.25(j) F697 X Pain Management 483.25(k) 483.25 Quality of Care F309 483.25(k) F698 X Dialysis 483.25(l) 483.25 Quality of Care F309 483.25(l) 5 FH62 - Developed by Polaris Group www.polaris-group.com Page 54 of 118

As of: 06/28/2017 Phase 2 Tag Crosswalk Effective November 28, 2017 Tag # (As of Nov. 28, 2017) SQC Tag? X = Yes Tag Title CFR Regulatory Groupings F699 X Trauma Informed Care 483.25(m) 483.25 Quality of Care F700 X Bedrails 483.25(n)(1) (4) 483.25 Quality of Care F710 F711 F712 F713 F714 F715 Resident's Care Supervised by a Physician Physician Visits Review Care/Notes/Order Physician Visits Frequency/Timeliness/Alternate NPPs Physician for Emergency Care, Available 24 Hours Physician Delegation of Tasks to NPP Physician Delegation to Dietitian/Therapist Tags / Subparts Implemented in Phase 3 Entire tag Phase 3 Will not be in ASPEN until Phase 3 Old Tag (Taken from App PP 03 08 2017) F323 F461 RegulationText that was Moved to New Tag No Associated Tag 483.25(n)(1) (3) 483.25(n)(4) 483.30(a)(1)(2) 483.30 Physician Services F385 483.30(a)(1)(2) 483.30(b)(1) (3) 483.30 Physician Services F386 483.30(b)(1) (3) 483.30(c)(1) (4) 483.30 Physician Services F387 F388 483.30(c)(1)(2) 483.30(c)(3)(4) 483.30(d) 483.30 Physician Services F389 483.30(d) 483.30(e)(1)(4)(f) 483.30 Physician Services F390 483.30(e)(1)(4)(f) 483.30(e)(2)(3) 483.30 Physician Services F390 483.30(e)(2(3) F725 Sufficient Nursing Staff 483.35(a)(1)(2) 483.35 Nursing Services F353 483.35(a)(1)(2) F726 Competent Nursing Staff 483.35(a)(3)(4)(c) 483.35 Nursing Services F353 F498 483.35(a)(3)(4) 483.35(c) F727 RN 8 Hrs/7 days/wk, Full Time DON 483.35(b)(1) (3) 483.35 Nursing Services F354 483.35(b)(1) (3) F728 F729 F730 F731 F732 Facility Hiring and Use of Nurse Aide Nurse Aide Registry Verification, Retraining Nurse Aide Perform Review 12 Hr/Year In service Waiver Licensed Nurses 24 Hr/Day and RN Coverage Posted Nurse Staffing Information F740 Behavioral Health Services 483.40 F741 F742 F743 X X Sufficient/Competent Staff Behav Health Needs Treatment/Svc for Mental/Psychosocial Concerns No Pattern of Behavioral Difficulties UnlessUnavoidable 483.35(d)(1) (3) 483.35 Nursing Services F494 F495 483.35(d)(1)(2) 483.35(d)(3) 483.35(d)(4) (6) 483.35 Nursing Services F496 483.35(d)(4) (6) 483.35(d)(7) 483.35 Nursing Services F497 483.35(d)(7) 483.35(e)(1) (7)(f)(1)(2) 483.35 Nursing Services F355 483.35(e)(1) (7)(f)(1)(2) 483.35(g)(1) (4) 483.35 Nursing Services F356 483.35(g)(1) (4) 483.40(a)(1)(2) 483.40(b)(1) 483.40(b)(2) F744 X Treatment /Service for Dementia 483.40(b)(3) 483.40 Behavioral Health Services 483.40 Behavioral Health Services 483.40 Behavioral Health Services 483.40 Behavioral Health Services 483.40 Behavioral Health Services F319 F320 F309 No Associated Tag No Associated Tag 483.40(b)(1) 483.40(b)(2) 483.40(b)(3) 6 FH62 - Developed by Polaris Group www.polaris-group.com Page 55 of 118

As of: 06/28/2017 Phase 2 Tag Crosswalk Effective November 28, 2017 Tag # (As of Nov. 28, 2017) F745 F755 F756 F757 F758 F759 F760 F761 SQC Tag? X = Yes X X X X X Tag Title CFR Regulatory Groupings Provision of Medically Related Social Services Pharmacy Svcs/Procedures/Pharmacist /Records Drug Regimen Review, Report Irregular, Act On Drug Regimen is Free From Unnecessary Drugs Free from Unnec Psychotropic Meds/PRN Use Free of Medication Error Rates of 5% or More Residents Are Free of Significant Med Errors Label/Store Drugs & Biologicals 483.40(d) 483.45(a)(b)(1) (3) 483.40 Behavioral Health Services 483.45 Pharmacy Services Tags / Subparts Implemented in Phase 3 Old Tag (Taken from App PP 03 08 2017) F250 F425 F431 RegulationText that was Moved to New Tag 483.40(d) 483.45(a)(b)(1) 483.45(b)(2)(3) 483.45(c)(1)(2)(4)(5) 483.45 Pharmacy Services F428 483.45(c)(1)(2)(4)(5) 483.45(d)(1) (6) 483.45 Pharmacy Services F329 483.45(d) 483.45(c)(3)(e)(1) (5) 483.45 Pharmacy Services F329 F428 483.45(e)(1) (5) 483.45(c)(3) 483.45(f)(1) 483.45 Pharmacy Services F332 483.45(f)(1) 483.45(f)(2) 483.45 Pharmacy Services F333 483.45(f)(2) 483.45(g)(h)(1)(2) 483.45 Pharmacy Services F431 483.45(g) (h) F770 Laboratory Services 483.50(a)(1)(i) 483.50 Laboratory, Radiology, and Other Diagnostic Services F502 F503 483.50(a)(1) 483.50(a)(i) F771 Blood Blank and Transfusion Services 483.50(a)(1)(ii) 483.50 Laboratory, Radiology, and Other Diagnostic Services F502 F503 483.50(a)(1) 483.50(a)(ii) F772 Lab Services Not Provided On Site 483.50(a)(1)(iv) 483.50 Laboratory, Radiology, and Other Diagnostic Services F503 483.50(a)(iv) F773 Lab Svs Physician Order/Notify of Results 483.50(a)(2)(i)(ii) 483.50 Laboratory, Radiology, and Other Diagnostic Services F504 F505 483.50(a)(2)(i) 483.50(a)(2)(ii) F774 Assist with Transport Arrangements to Lab Svcs 483.50(a)(2)(iii) 483.50 Laboratory, Radiology, and Other Diagnostic Services F506 483.50(a)(2)(iii) F775 Lab Reports in Record Lab Name/Address 483.50(a)(2)(iv) 483.50 Laboratory, Radiology, and Other Diagnostic Services F507 483.50(a)(2)(iv) F776 Radiology/Other Diagnostic Services 483.50(b)(1)(i)(ii) 483.50 Laboratory, Radiology, and Other Diagnostic Services F508 F509 483.50(b)(1) 483.50(b)(i)(ii) F777 Radiology/Diag. Svcs Ordered/Notify Results 483.50(b)(2)(i)(ii) 483.50 Laboratory, Radiology, and Other Diagnostic Services F510 F511 483.50(b(2)(i) 483.50(b)(2)(ii) F778 Assist with Transport Arrangements to Radiology 483.50(b)(2)(iii) 483.50 Laboratory, Radiology, and Other Diagnostic Services F512 483.50(b)(2)(iii) 7 FH62 - Developed by Polaris Group www.polaris-group.com Page 56 of 118