New MDS Items for October 2017

New MDS Items for October 2017 for clients of: www.teamtsi.com 800.765.8998 Content developed and presented by: Polaris Group 3030 N. Rocky Point Drive, Suite 240 Tampa, FL 33607 800.275.6252 www.polaris-group.com

New MDS Items for Oct. 2017 Limited Copyright: October 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 FH6 - Developed by Polaris Group www.polaris-group.com Page 1 of 61

New MDS Items for Oct. 2017 POST-TEST 1. Opioid use over last 7 days is now tracked in Section N. a. True b. False 2. Which of the following was added to SCSA criteria? a. Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment. b. Not only the emergence of a new pressure ulcer at Stage 2 or higher, but also a new unstageable pressure ulcer/injury, a new deep tissue injury. c. No criteria was added d. Both a and b 3. Whenever there is a Medicare End Date on a Discharge Assessment; Code A0310H as 01 yes this is a SNF Part A Discharge Assessments. a. True b. False 4. Coding an alarm in new section P0200, indicates this alarm device is restrictive. a. True b. False FH6 - Developed by Polaris Group www.polaris-group.com Page 2 of 61

New MDS Items for Oct. 2017 POST TEST ANSWERS 1. Opioid use over last 7 days is now tracked in Section N. a. True b. False A 2. Which of the following was added to SCSA criteria? a. Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment. b. Not only the emergence of a new pressure ulcer at Stage 2 or higher, but also a new unstageable pressure ulcer/injury, a new deep tissue injury. c. No criteria was added D d. Both a and b 3. Whenever there is a Medicare End Date on a Discharge Assessment; Code A0310H as 01 yes this is a SNF Part A Discharge Assessments. a. True b. False A 4. Coding an alarm in new section P0200, indicates this alarm device is restrictive. a. True b. False B FH6 - Developed by Polaris Group www.polaris-group.com Page 3 of 61

New MDS Items Oct. 2017 1 Clarifications of Current Items on MDS 2 FH6 - Developed by Polaris Group www.polaris-group.com Page 4 of 61

Chapter 2 New criteria listed for a Significant Change in Status MDS Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment (p. 2-25) Not only the emergence of a new pressure ulcer at Stage 2 or higher, but also a new unstageable pressure ulcer/injury, a new deep tissue injury (p. 2-26) Also added language on Baseline Care Plan preferences and goals 3 Section A Section A The incorrect examples for A2400 (#3 and #5) were corrected to indicate that A0310H should be coded 1 (Yes a SNF Part A PPS Discharge assessment) on the OBRA Discharge assessment. Further explanation was added to both examples: Even though only an OBRA Discharge was required, when the Date of the End of the Medicare Stay is on the day of or one day before the Date of Discharge, MDS specifications require that A0310H be coded as 1. Confirm with your software this is set up with alert. 4 FH6 - Developed by Polaris Group www.polaris-group.com Page 5 of 61

Section A Section A The incorrect examples for A2400 (#3 and #5) were corrected to indicate that A0310H should be coded 1 (Yes a SNF Part A PPS Discharge assessment) on the OBRA Discharge assessment. We had been coding no when NOT a planned discharged (such as to hospital or AMA) as PPS Discharge (NPE) was not required for QM. Check with your software provider. 5 Section A Code A0310H - Part A End of Stay Assessment Code 1 Yes, even though PPS End of Stay (NPE) item set is not required, and will not be included in QM. 6 FH6 - Developed by Polaris Group www.polaris-group.com Page 6 of 61

Section A Code A0310H - Part A End of Stay Assessment Code 1 Yes, even though PPS End of Stay (NPE) item set is not required, and will not be included in QM. 7 Section G Updated ADL Algorithm no changes No change in three or more rules 8 FH6 - Developed by Polaris Group www.polaris-group.com Page 7 of 61

Section G Pages G-9 G-10 contain helpful clarifications: If the resident transferred out of bed or chair for incontinence care or to use the bedpan or urinal, the transfer is coded in G0110B. How the resident uses the bedpan or urinal is coded in G0110I Toilet use. Item G0600 Mobility Devices: Instructions for G0600C, Wheelchair (manual or electric), have added: Do not include geri-chairs, reclining chairs with wheels, positioning chairs, scooters, and other types of specialty chairs. 9 Section G CMS has added four new bullet points to the Coding Tips and Special Populations section for G0110 (Activities of Daily Living (ADL) Assistance): 1. Some residents are transferred between surfaces, including to and from the bed, chair, and wheelchair, by staff, using a full-body mechanical lift. Whether or not the resident holds onto a bar, strap, or other device during the full-body mechanical lift transfer is not part of the transfer activity and should not be considered as resident participation in a transfer. 10 FH6 - Developed by Polaris Group www.polaris-group.com Page 8 of 61

Section G 2. Transfers via lifts that require the resident to bear weight during the transfer, such as a stand-up lift, should be coded as Extensive Assistance, as the resident participated in the transfer and the lift provided weight-bearing support. 3. How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. 4. When a resident is transferred in or out of bed or a chair for incontinence care or to use the bedpan or urinal, the transfer is coded in G0110B, Transfers. How the resident uses the bedpan/urinal is coded in G0110I, Toilet use. (page G-9-10) 11 Section GG Many wording changes, but no new items. This section deserves a good read by both nursing and therapy to make certain the instructions are being followed as the section is completed. Items of note: Coding on admission should reflect the person s baseline admission functional status, and is based on a clinical assessment that occurs soon after the resident s admission. Only consider helper assistance by direct staff (or contracted) under SNF management not family, private duty, hospice, students. 12 FH6 - Developed by Polaris Group www.polaris-group.com Page 9 of 61

Section GG The admission functional assessment, when possible, should be conducted prior to the person benefitting from treatment interventions in order to determine a true baseline functional status on admission. CMS has made it clear that treatment should not be withheld in order to conduct the functional assessment: If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted (p. GG-3). Coding considers set-up and cleanup, touching assistance, verbal cues. 13 Section GG On page GG-5, there is helpful information for coding usual performance: When coding the resident s usual performance, effort refers to the type and amount of assistance the helper provides in order for the activity to be completed. The 6-point rating scale definitions include the following types of assistance: setup/cleanup, touching assistance, verbal cueing, and lifting assistance. CMS has also clarified on this page that the Discharge functional assessment must be completed within the last three calendar days of the resident s Medicare Part A stay, which includes the day of discharge from Medicare Part A and the two days prior to the day of discharge from Medicare Part A. Medicare End Date is third day. 14 FH6 - Developed by Polaris Group www.polaris-group.com Page 10 of 61

Section GG On page GG-3, in reference to the three-day assessment period, CMS added the statement: A provider may need to use the entire 3-day assessment period to obtain the resident s usual performance. And in regard to discharge goals, additional wording was added to page GG-14 to help with goal planning and to involve the resident and family concerning the goals and anticipated length of stay. Also clarifies that use of dash for Goals does not impact QM as long as there is at least one Goal coded. 15 Section GG In the self-care items, the description of eating on page GG-6 now includes this: Clinicians may code the eating item using the appropriate response codes if the resident eats using his/her hands rather than using utensils (e.g., can feed himself/herself using finger foods). If the resident eats finger foods with his/her hands independently, for example, the resident would be coded as 06, Independent. 16 FH6 - Developed by Polaris Group www.polaris-group.com Page 11 of 61

Section GG 17 Section GG 18 FH6 - Developed by Polaris Group www.polaris-group.com Page 12 of 61

Section GG 19 Section GG Coding Walking or Wheeling with 2 Turns clarification- not new 20 FH6 - Developed by Polaris Group www.polaris-group.com Page 13 of 61

Section H Section H In H0100, Appliances, CMS removed the word sterile from the definition of intermittent catheterization, and added this coding tip: Selfcatheterizations that are performed by the resident in the facility should be coded as intermittent catheterization (H0100D). This includes selfcatheterizations using clean technique. 21 Section I CMS has simplified the coding criteria for I2300 (Urinary Tract Infection (UTI) (Last 30 Days)). Effective Oct. 1, UTI should be coded only if both of the following criteria are met in the last 30 days: 1. It was determined that the resident had a UTI using evidence-based criteria such as McGeer, NHSN, or Loeb in the last 30 days, AND 2. A physician-documented UTI diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days. (pages I-8 I-9) 22 FH6 - Developed by Polaris Group www.polaris-group.com Page 14 of 61

Section I Many facilities currently use some evidence-based tool to determine whether a resident has a UTI. RAI Manual (page I-9) makes clear that providers must use a tool that is linked to their Infection Prevention and Control Program: In accordance with requirements at 483.80(a) Infection Prevention and Control Program, the facility must establish routine, ongoing and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections. The facility s surveillance system must include a data collection tool and the use of nationally recognized surveillance criteria. Facilities are expected to use the same nationally recognized criteria chosen for use in their Infection Prevention and Control Program to determine the presence of a UTI in a resident. 23 Section I Example: if a facility chooses to use the Surveillance Definitions of Infections (updated McGeer criteria) as part of the facility s Infection Prevention and Control Program, then the facility should also use the same criteria to determine whether or not a resident has a UTI. Removing signs/symptoms for criteria will increase reporting of UTI? Unlikely.. Resident would still need to have whatever signs/symptoms or laboratory findings that are required under the evidence-based criteria chosen for use by the facility. 24 FH6 - Developed by Polaris Group www.polaris-group.com Page 15 of 61

Section I Phase 2 Antibiotic Stewardship also promotes correct use of antibiotics for UTIs. Infection Prevention, Control & Immunizations Facility Task Pathway (form CMS 20054) and the Urinary Catheter or Urinary Tract Infection Critical Element (CE) Pathway (form CMS 20068), as well as the interpretive guidance in F880 (Infection Prevention & Control) and F881 (Antibiotic Stewardship Program) in Appendix PP, tie in the evidence-based criteria requirements for UTI. 25 Section J Section J In J1700, Fall History on Admission/Entry or Reentry, CMS has clarified that an intentional therapeutic intervention challenging a resident s balance and training the resident to recover from loss of balance is not considered an intercepted fall. 26 FH6 - Developed by Polaris Group www.polaris-group.com Page 16 of 61

Section L 27 Section L Section L Coding guidance has been added: Edentulous no teeth at all The dental status for a resident who has some, but not all, of his/her natural teeth that do not appear damaged (e.g., are not broken, loose, with obvious or likely cavity) and who does not have any other conditions in L0200A G, should be coded in L0200Z, none of the above. (p. L-3) Missing teeth, but teeth that are left are good 28 FH6 - Developed by Polaris Group www.polaris-group.com Page 17 of 61

Section M In Section M (Skin Conditions), CMS has clarified that mucosal ulcers shouldn t be coded in M0210 (Unhealed Pressure Ulcers): Mucosal pressure ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made. Therefore, mucosal ulcers (for example, those related to nasogastric tubes, nasal oxygen tubing, endotracheal tubes, urinary catheters, etc.) should not be coded here. (page M-5) This coding change is consistent with the staging guidance / considerations in F686 (Treatment / Services to Prevent / Heal Pressure Ulcers) in Appendix PP. 29 Section M Further clarification of examples of present on admission/entry or reentry are noted on page M-7 and 14. For M1040D, Open lesion(s) other than ulcers, rashes, cuts, the example given has changed from cancer lesion to bullous pemphigoid. 30 FH6 - Developed by Polaris Group www.polaris-group.com Page 18 of 61

Section M Guidance is provided in M0800 for coding worsening of pressure ulcers: If an unstageable pressure ulcer that was present on admission/entry or reentry, is subsequently able to be numerically staged, do not consider it to be worsened because this would be the first time that the pressure ulcer was able to be numerically staged. However, if subsequent to this numerical staging, the pressure ulcer further deteriorates and increases in numerical stage, the ulcer would be considered worsened. (p. M-28) 31 Section O Up to date in item O0300A, Pneumococcal Vaccine, means in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations. This coding tip was added to O0300: If a resident has received one pneumococcal vaccination and it has been less than one year since the resident received the vaccination, he/she is not yet eligible for the second pneumococcal vaccination; therefore, O0300A is coded 1, yes, indicating the resident s pneumococcal vaccination is up to date. (p. O-13) 32 FH6 - Developed by Polaris Group www.polaris-group.com Page 19 of 61

Section O Under O0400, this clarification was added for O0400D, Respiratory therapy: Only minutes that the respiratory therapist or respiratory nurse spends with the resident shall be recorded on the MDS. This time includes resident evaluation/assessment, treatment administration and monitoring, and setup and removal of treatment equipment. Time that a resident self-administers a nebulizer treatment without supervision of the respiratory therapist or respiratory nurse is not included in the minutes recorded on the MDS. Do not include administration of metered-dose and/or dry powder inhalers in respiratory minutes. 33 Section O 34 FH6 - Developed by Polaris Group www.polaris-group.com Page 20 of 61

Section O Items O0600, Physician Examinations, and O0700, Physician Orders, are not required to be completed by CMS, but some individual states continue to require their completion, so assessors must know their state s requirements (O-43, 45) If the state does not require completion of the items, use the standard no information code (a dash, - ). This clarification for physician orders was added: Includes orders written by medical doctors, doctors of osteopathy, podiatrists, dentists, and physician assistants, nurse practitioners, clinical nurse specialists, qualified dietitians, clinically qualified nutrition professionals or qualified therapists, working in collaboration with the physician as allowable by state law. (p. O-45) 35 Section Q CMS revised the Intent statement (page Q-1) for Section Q (Participation in Assessment and Goal Planning) to clarify that having the opportunity to learn about home and community-based services and to receive long term care in the least restrictive setting possible is a civil right for all residents. The agency then updated the coding instructions for individual items in Section Q to further address resident rights, including the following revised instructions: 36 FH6 - Developed by Polaris Group www.polaris-group.com Page 21 of 61

Section Q Q0300 (Resident s Overall Expectation): This item is individualized and resident-driven rather than what the nursing home staff judge to be in the best interest of the resident. This item focuses on exploring the resident s expectations, not whether or not the staff considers them to be realistic. Coding other than the resident s stated expectation is a violation of the resident s civil rights. (page Q-5) 37 Section Q Q0400 (Discharge Plan): Should a planned relocation not occur, it might create stress and disappointment for the resident and family that will require support and nursing home care planning interventions. However, a referral should not be avoided based upon facility staff judgment of potential discharge success or failure. It is the resident s right to be provided information if requested and to receive care in the most integrated setting. (pages Q-9 and Q-10) 38 FH6 - Developed by Polaris Group www.polaris-group.com Page 22 of 61

Section Q Q0490 (Resident s Preference to Avoid Being Asked Question Q0500B): Note: Let the resident know that they can change their mind about requesting information regarding possible return to the community at any time and should be referred if they voice this request, regardless of schedule of MDS assessment(s). (page Q-12) 39 Section Q 40 FH6 - Developed by Polaris Group www.polaris-group.com Page 23 of 61

Section Q Q0500 (Return to Community): Steps for Assessment: 5. Ask the resident if he or she wants information about different kinds of supports that may be available for community living. Responding yes will be a way for the individual and his or her family, significant other, or guardian or legally authorized representative to obtain additional information about services and supports that would be available to support community living. It is simply a request for information, not a request for discharge. (page Q-14 and Q-15) On the survey side, this ties into the Discharge Critical Element Pathway (form CMS- 20132), as well as the interpretive guidance in F660 (Discharge Planning Process) in Appendix PP. 41 Chapter 4 On pages 4-10 and 4-11 there is a revised list of how the overall care plan should be oriented. The first three items are new: 1. Assisting the resident in achieving his/her goals. 2. Individualized interventions that honor the resident s preferences. 3. Addressing ways to try to preserve and build upon resident strengths. There are also numerous mentions of resident goals and preferences. 42 FH6 - Developed by Polaris Group www.polaris-group.com Page 24 of 61

SECTIONS with NEW CODING ITEMS 43 Section N Section N (Medications) includes several new items that correlate to issues that surveyors will review as appropriate for the final survey sample via two CE Pathways during the new survey process: Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Critical Element Pathway (form CMS- 20082) and/or Pain Recognition and Management Critical Element Pathway (form CMS 20076). 44 FH6 - Developed by Polaris Group www.polaris-group.com Page 25 of 61

Section N - Opioids New code by classification 45 Section N Opioids 46 FH6 - Developed by Polaris Group www.polaris-group.com Page 26 of 61

Section N Opioids For N0410H, the Pain Recognition and Management CE Pathway includes the following questions under Nurse, DON, Hospice Nurse, Attending Practitioner, Pharmacist, Medical Director Interviews and Record Review, respectively: How do you monitor for the emergence or presence of adverse events related to opioid medications or the consequences of interventions? What indicators and characteristics of the resident s pain, including causes and contributing factors related to pain, have been identified, and addressed in the care plan? 47 Section N Other Coding clarifications: 48 FH6 - Developed by Polaris Group www.polaris-group.com Page 27 of 61

Section N New Section Only on NC and NQ MDS 49 Section N New Section 50 FH6 - Developed by Polaris Group www.polaris-group.com Page 28 of 61

51 Note, the question is not whether on antipsychotic during the last 7 day look-back period; but whether they received any antipsychotic, even if discontinued at this time, since admission/entry/reentry or prior OBRA assessment. Some of these may have been discontinued without a GDR. New questions only on NC and NQ 52 FH6 - Developed by Polaris Group www.polaris-group.com Page 29 of 61

If med was just discontinued; then code yes GDR was attempted; and enter date discontinued. 53 54 FH6 - Developed by Polaris Group www.polaris-group.com Page 30 of 61

Section N Coding Tips and Special Populations section for N0450 (page N-13): Any medication that has a pharmacological classification or therapeutic category as an antipsychotic medication must be recorded in this section, regardless of why the medication is being used. In this section, the term physician also includes physician assistant, nurse practitioner, or clinical nurse specialist. Do not include Gradual Dose Reductions that occurred prior to admission to the facility (e.g., GDRs attempted during the resident s acute care stay prior to admission to the facility). 55 Section N Do not count an antipsychotic medication taper performed for the purpose of switching the resident from one antipsychotic medication to another as a GDR in this section. In cases where a resident is or was receiving multiple antipsychotic medications on a routine basis, and one medication was reduced or discontinued, record the date of the reduction attempt or discontinuation in N0450C, Date of last attempted GDR. If multiple dose reductions have been attempted since admission/entry or reentry or the prior OBRA assessment, record the date of the most recent reduction attempt in N0450C, Date of last attempted GDR. 56 FH6 - Developed by Polaris Group www.polaris-group.com Page 31 of 61

Section N Federal requirements regarding GDRs are found at 42 CFR 483.45(d) Unnecessary drugs and 483.45(e) Psychotropic drugs. See Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review CE Pathway, which instructs surveyors to ensure the facility does the following: Demonstrates a system for and documents gradual dose reduction (GDR) for psychotropic medications, unless contraindicated. Within the first year in which a resident is admitted on a psychotropic medication or after the facility has initiated a psychotropic medication: GDR attempts in two separate quarters with at least one month between the attempts. 57 Section N The GDR must be attempted annually thereafter unless clinically contraindicated. Non-pharmacological approaches must be attempted and documented instead of using psychotropic medications, along with use of psychotropic medications, and while GDR is attempted. See CMS Unnecessary Drug CE Pathway There is really no change in GDR rules and documentation of physician rationale, if not considering a GDR Expansion of Drug Regimen monthly reviews to include entire medical record and action taken. 58 FH6 - Developed by Polaris Group www.polaris-group.com Page 32 of 61

Section N Summary With the implementation of N0450, facilities will need to start systems for tracking their GDRs. Beginning Oct. 1, these dates will need to be reported in the MDS, so to avoid slowdowns, it s probably a good idea to collect those dates before Sept. 30. Keep dates as part of permanent part of EMR. Ensure Drug Regimen reviews have documented follow-up by attending if not agreeing to GDR oversight process. Ensure side effects are monitored effectively and care planned Consider non-drug interventions. No impact on short stay or long stay QMs for antipsychotics 59 Section P CMS states it is not prohibiting restraints but saying that residents should be free of physical restraint unless it is deemed necessary and appropriate as permitted by regulation. 60 FH6 - Developed by Polaris Group www.polaris-group.com Page 33 of 61

Section P CMS provides this definition of an alarm: Any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected, and may include bed, chair and floor sensor pads, cords that clip to the resident s clothing, motion sensors, door alarms, or elopement/wandering devices. 61 Section P It is noted that alarms have not been proven to be an effective intervention to prevent falls and as such must not be the primary or sole intervention in the care plan (p. P-8). The use of an alarm as part of the resident s plan of care does not eliminate the need for adequate supervision, nor does it replace individualized, personcentered care planning. 62 FH6 - Developed by Polaris Group www.polaris-group.com Page 34 of 61

Section P 63 Section P 64 FH6 - Developed by Polaris Group www.polaris-group.com Page 35 of 61

Section P Coding an Alarm, does not mean the Alarm is restrictive for that resident. Does not impact Restraint QM. Ensure on care plan 65 Section P Code as Other for Used in Bed or Used in Chair or Out of Bed; whichever applies or both if both applies. Await further clarification. FYI Other coded in Physical restraint section does not impact Restraint QM. 66 FH6 - Developed by Polaris Group www.polaris-group.com Page 36 of 61

Section P 67 Section P Accurately capturing position change alarms in P0200 and P0100 (as appropriate) is critical because position change alarms come under significant scrutiny in the new survey process. The new interpretive guidance in Appendix PP discusses position change alarms both in the context of accidents (F689) and physical restraints (F604). As a result, they are incorporated into investigations via the following survey tools: Physical Restraints Critical Element Pathway (Form CMS-20077); Accidents Critical Element Pathway (form CMS-20127); and Sufficient and Competent Nurse Staffing Review (form CMS- 20062). 68 FH6 - Developed by Polaris Group www.polaris-group.com Page 37 of 61

Freedom from Abuse, Neglect, Exploitation F604 CMS indicates that at times the use of an alarm may meet the definition of a restraint. F604 (old F221, 222) Physical Restraints. Least restrictive, least amount of time, and ongoing evaluation of need. Surveyors need to document the impact of inappropriate use physical restraint. Care Plan goal should include no decline/negative affect of restraint. Position change alarms added. Sounds have psychological effect, that cause resident to not rise. 69 Freedom from Abuse, Neglect, Exploitation F604 F604 Physical Restraints Examples of negative potential or actual outcomes which may result from the use of position change alarms as a physical restraint, include: Will use Physical Restraint CE Pathway CMS-20077 Loss of dignity; Decreased mobility; Bowel and bladder incontinence; Sleep disturbances due to the sound of the alarm or because the resident is afraid to move in bed thereby setting off the alarm; and Confusion, fear, agitation, anxiety, or irritation in response to the sound of the alarm as residents may mistake the alarm as a warning or as something they need to get away from. 70 FH6 - Developed by Polaris Group www.polaris-group.com Page 38 of 61

Alarms Summary Ensure assessments include rationale for using an alarm. Care plan should include alarm Care plan and/or MAR should monitor for adverse consequences of use of rise alarm. If adverse consequences are noted after alarm is initiated, stop use, or consider it a restraint if noise prevents resident from rising. If resident asks for the alarm as a reminder, ensure assessment and care plan indicate resident wishes and that resident is self-directing care. 71 QUESTIONS? GOOD LUCK 72 FH6 - Developed by Polaris Group www.polaris-group.com Page 39 of 61

MDS 3.0 Item Set Change History for October 2017 Version 1.15.1 Table of Contents Version 1.15.0 Changes...1 Section N Items... 1 Section P Items... 2 Version 1.15.1 Changes...3 Legend: X = item set impacted na = not applicable; changed item does not impact this item set Version 1.15.0 Changes Section N Items Item Change Description NC ND N0410H N0450 N0450A N0450B N0450C New item: Opioid New items: Antipsychotic Medication Review New item: Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? Options: 0. No- Antipsychotics were not received -> Skip to next active section 1. Yes Antipsychotics were received on a routine basis -> Continue to N0450B 2. Yes Antipsychotics were received on a PRN basis only -> Continue to N0450B 3. Yes Antipsychotics were received on a routine and PRN basis -> Continue to N0450B New item: Has a gradual dose reduction (GDR) been attempted? Options: 0. No -> Skip to N0450D 1. Yes -> Continue to N0450C New item: Date of last attempted GDR NO/ SO NOD NP NPE NQ NS/ SS NSD NT/ ST SD SOD SP SSD X X na X X na X na X na X X X X X na na na na na X na na na na na na na X na na na na na X na na na na na na na X na na na na na X na na na na na na na X na na na na na X na na na na na na na FH6 - Developed by Polaris Group www.polaris-group.com Page 40 of 61

Item Change Description NC ND N0450D N0450E Section P Items New item: Physician documented GDR as clinically contraindicated Options: 0. No GDR has not been documented by a physician as clinically contraindicated -> Skip to [next active section] 1. Yes GDR has been documented by a physician as clinically contraindicated -> Continue to N0450E New item: Date physician documented GDR as clinically contraindicated NO/ SO NOD NP NPE NQ NS/ SS NSD NT/ ST SD SOD SP SSD X na na na na na X na na na na na na na X na na na na na X na na na na na na na Item Change Description NC ND NO/ NS/ NT/ NOD NP NPE NQ NSD SO SS ST SD SOD SP SSD Section P Changed Section P title from Restraints to Restraints and Alarms X X na X X na X na X na X X X X P0200 New items: Alarms Instruction: An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected X na na na na na X na na na na na na na Enter Codes in Boxes P0200A New item: Bed alarm X na na na na na X na na na na na na na P0200B New item: Chair alarm X na na na na na X na na na na na na na P0200C New item: Floor mat alarm X na na na na na X na na na na na na na P0200D New item: Motion sensor alarm X na na na na na X na na na na na na na P0200E New item: Wander/elopement alarm X na na na na na X na na na na na na na P0200F New item: Other alarm X na na na na na X na na na na na na na FH6 - Developed by Polaris Group www.polaris-group.com Page 41 of 61

Version 1.15.1 Changes Item Change Description NC ND NO/ NS/ NT/ NOD NP NPE NQ NSD SO SS ST SD SOD SP SSD NA DRAFT verbiage removed and version number incremented X X X X X X X X X X X X X X C0100 Restored verbiage inadvertently changed in v1.15.0 X na na X X na X na X na na X X na C0800 Restored item inadvertently omitted from v1.15.0 na na na na X na na na na na na na X na C0900 Restored item inadvertently omitted from v1.15.0 na na na na X na na na na na na na X na D0100 Restored verbiage inadvertently changed in v1.15.0 na na na na na na na na na na X na na na J0200 Restored verbiage inadvertently changed in v1.15.0 X na na X X na X na X na na X X X M0300C2 Restored verbiage inadvertently changed in v1.15.0 na na na na X na X na na na na na X na M0300D2 Restored verbiage inadvertently changed in v1.15.0 na n na na X na X na na na na na X na FH6 - Developed by Polaris Group www.polaris-group.com Page 42 of 61

CMS s RAI Version 3.0 Manual CH 3: MDS Items [G] ADL Self-Performance Rule of 3 Algorithm START HERE Review these instructions for Rule of 3 before using the algorithm. Follow steps in sequence and stop at first level that applies. Start by counting the number of episodes at each ADL Self-Performance Level. * Exceptions to Rule of 3: - The Rule of 3 does not apply when coding Independent (0), Total Dependence (4) or Activity Did Not Occur (8), since these levels must be EVERY time the ADL occurred during the look-back period. - The Rule of 3 does not apply when Activity Occurred Only Once or Twice (7), since the activity did not occur at least 3 times. Rule of 3: 1. When an activity occurs 3 or more times at any one level, code that level *note exceptions for Independent (0) and Total Dependence (4). 2. When an activity occurs 3 or more times at multiple levels, code the most dependent level that occurs 3 or more times *note exceptions for Independent (0) and Total Dependence (4). 3. When an activity occurs 3 or more times and at multiple levels, but NOT 3 times at any one level, apply the following in sequence as listed stop at the first level that applies: (NOTE: This 3rd rule only applies if there are NOT ANY LEVELS that are 3 or more episodes at any one level. DO NOT proceed to 3a, 3b or 3c unless this criteria is met.) a. Convert episodes of Total Dependence (4) to Extensive Assistance (3) if this change makes 3 episodes at Extensive Assistance (3), code as Extensive Assistance (3). b. When there is a combination of Total Dependence (4) and Extensive Assist (3) that total 3 or more times code Extensive Assistance (3). c. When there is a combination of Total Dependence (4) and Extensive Assist (3) and/or Limited Assistance (2) that total 3 or more times, code Limited Assistance (2). If none of the above are met, code Supervision (1). Start algorithm here - STOP at the First Code That Applies Did the activity occur at least 1 time? Yes Did the activity occur 3 or more times? No No Code 8: Activity Did Not Occur Code 7: Activity Occurred Once or Twice Yes Code 0: Independent Code 1: Supervision Code 4: Total Dependence Code 3: Extensive Assistance Code 2: Limited Assistance Code 1: Supervision Code 3: Extensive Assistance Code 2: Limited Assistance Yes Yes Yes Yes Yes Yes Yes Yes Did the resident fully perform the ADL activity without ANY help or oversight from staff EVERY time? Did the resident fully perform the ADL activity without ANY help or oversight at least 3 times AND require help or oversight at any other level, but not 3 times at any other level? (Item 1 Rule of 3 with Independent* exception) Did resident require Total Dependence EVERY time? (Item 1 Rule of 3, Total Dependence* exception) Did the resident require Total Dependence 3 or more times, but not every time? Did the resident require Extensive Assistance 3 or more times? Did the resident require oversight, encouragement or cueing 3 or more times? Did the resident require a combination of Total Dependence and Extensive Assistance 3 or more times but not 3 times at any one level? (Item 3a Rule of 3) No No No No No Did the resident require Limited Assistance 3 or more times? Did the resident require a combination of Total Dependence, Extensive Assistance, and/or Limited Assistance that total 3 or more times but not 3 times at any one level? (Item 3b Rule of 3) No No No October 2017 Page G-8 FH6 - Developed by Polaris Group www.polaris-group.com Page 43 of 61

Resident Identifier Date Section N. Medications. N0300. Injections. Enter Days Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. If 0 Skip to N0410, Medications Received. N0350. Insulin. Enter Days Enter Days A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. B. Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days. N0410. Medications Received. Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Enter "0" if medication was not received by the resident during the last 7 days. Enter Days A. Antipsychotic. Enter Days Enter Days Enter Days Enter Days Enter Days Enter Days Enter Days B. Antianxiety. C. Antidepressant. D. Hypnotic. E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin). F. Antibiotic. G. Diuretic. H. Opioid. N0450. Antipsychotic Medication Review. Enter Code A. Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? 0. No - Antipsychotics were not received. Skip to O0100, Special Treatments, Procedures, and Programs. 1. Yes - Antipsychotics were received on a routine basis only.. Continue to N0450B, Has a GDR been attempted? 2. Yes - Antipsychotics were received on a PRN basis only. Continue to N0450B, Has a GDR been attempted? 3. Yes - Antipsychotics were received on a routine and PRN basis.. Continue to N0450B, Has a GDR been attempted? Enter Code B. Has a gradual dose reduction (GDR) been attempted? 0. No Skip to N0450D, Physician documented GDR as clinically contraindicated. 1. Yes Continue to N0450C, Date of last attempted GDR. C. Date of last attempted GDR: Month Day N0450 continued on next page Year MDS 3.0 Nursing Home Comprehensive (NC) Version 1.15.1 Effective 10/01/2017 Page 32 of 47 FH6 - Developed by Polaris Group www.polaris-group.com Page 44 of 61

Resident Identifier Date Section N. Medications. N0450. Antipsychotic Medication Review - Continued. Enter Code D. Physician documented GDR as clinically contraindicated 0. No - GDR has not been documented by a physician as clinically contraindicated Skip to O0100, Special Treatments, Procedures,. and Programs 1. Yes - GDR has been documented by a physician as clinically contraindicated Continue to N0450E, Date physician documented. GDR as clinically contraindicated. E. Date physician documented GDR as clinically contraindicated: Month Day Year MDS 3.0 Nursing Home Comprehensive (NC) Version 1.15.1 Effective 10/01/2017 Page 33 of 47 FH6 - Developed by Polaris Group www.polaris-group.com Page 45 of 61

Resident Identifier Date Section P. Restraints and Alarms. P0100. Physical Restraints. Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Enter Codes in Boxes. Used in Bed. A. Bed rail. B. Trunk restraint. Coding: 0. Not used. 1. Used less than daily. 2. Used daily. C. Limb restraint. D. Other. Used in Chair or Out of Bed. E. Trunk restraint. F. Limb restraint. G. Chair prevents rising. H. Other. P0200. Alarms. An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. Enter Codes in Boxes. A. Bed alarm. Coding: 0. Not used. 1. Used less than daily. 2. Used daily. B. Chair alarm. C. Floor mat alarm. D. Motion sensor alarm. E. Wander/elopement alarm F. Other alarm. MDS 3.0 Nursing Home Comprehensive (NC) Version 1.15.1 Effective 10/01/2017 Page 38 of 47 FH6 - Developed by Polaris Group www.polaris-group.com Page 46 of 61

Use for a resident who has potentially unnecessary medications, is prescribed psychotropic medications or has the potential for an adverse outcome to determine whether facility practices are in place to identify, evaluate, and intervene for potential or actual unnecessary medications. Use also to evaluate the medication regimen review (MRR) process. NOTE: If the resident has a diagnosis of dementia and is receiving any psychotropic medications (including but not limited to antipsychotic medications) the surveyor should refer to the Dementia Care Critical Element Pathway as a guide to determine the facility s compliance at F744. Review the Following in Advance to Guide Observations and Interviews: Review the most current comprehensive and most recent quarterly (if the comprehensive isn t the most recent assessment) MDS/CAAs for areas pertinent to the medications ordered such as adverse consequences and behaviors. Review all medications currently ordered or discontinued going back to the most recent signed recapitulation. Determine if the facility: Documents an acceptable clinical indication for use. Medication is prescribed for a diagnosed condition and not being used for convenience or discipline. Medication is clinically indicated to manage a resident s symptoms or condition where other causes have been ruled out. Signs, symptoms, or related causes are persistent or clinically significant enough (e.g., causing functional decline) to warrant the initiation or continuation of medication therapy. Intended or actual benefit is sufficient to justify the potential risk(s) or adverse consequences associated with the medication, dose, and duration. Demonstrates use of written protocols or resources to guide antibiotic use. The use of infection assessment tools for antibiotic use for one or more infections (e.g., use of a Situation, Background, Assessment and Recommendation (SBAR) communication tool for UTI assessment, application of the Loeb minimum criteria for initiation of antibiotics). Demonstrates monitoring for each medication as appropriate. The following medications pose a high risk for adverse consequences and should be monitored: o Opioids assess pain, implement bowel program. o Anticoagulant bleeding/bruising, protime/international normalized ratio (PT/INR), interaction with other medications, facility must have policies around monitoring, lab work, communication of lab values, implementation of new orders in response to lab values and/or symptoms. o Diuretics edema, potassium level, signs of electrolyte imbalance. o Insulin monitoring of blood glucose levels, hemoglobin A1c (HbA1c), and symptoms of hyper/hypoglycemia. o Antibiotics interactions with other medications (e.g., warfarin), adverse events (e.g., rash, diarrhea); prescriptions must include documentation of indication, dose, route and duration and be reviewed 2-3 days after antibiotic initiation to assess response and labs, and prescriber should reassess antibiotic selection as appropriate. FH6 - Developed by Polaris Group www.polaris-group.com Page 47 of 61

o All psychotropics monitor behavioral expressions or indications of distress. Facility staff, along with the pharmacist and prescribing practitioner recognize and evaluate the onset or worsening of signs or symptoms, or a change in condition to determine whether these potentially may be related to the medication regimen; and follow up as necessary upon identifying adverse consequences. Facility staff monitor the effectiveness of each medication and make changes to the pharmacological intervention, when necessary. Demonstrates appropriate dosing for each medication. Is there documentation of a rationale for any medication that exceeds the manufacturer s recommendations, clinical practice guidelines, evidence based guidelines or standards of practice? Documents duration for each medication. Medications are not used for an excessive duration. Documents clinical rationale for continued use for the medications, as required. Tapering when clinically indicated in an effort to discontinue or reduce the dose. Concomitant use of two or more medications in the same pharmacological class. Potential incompatibilities between medications. Demonstrates a system that monitors and addresses the presence of or potential for adverse consequences. A clear clinical rationale from the attending physician/prescribing practitioner for continuing a medication that may be causing an adverse consequence, including risks and benefits. Demonstrates a system for and documents gradual dose reduction (GDR) for psychotropic medications, unless contraindicated. Within the first year in which a resident is admitted on a psychotropic medication or after the facility has initiated a psychotropic medication: o GDR attempts in two separate quarters with at least one month between the attempts. o The GDR must be attempted annually thereafter unless clinically contraindicated. o Non-pharmacological approaches must be attempted and documented instead of using psychotropic medications, along with use of psychotropic medications, and while GDR is attempted. Demonstrates adherence to requirements for as needed (PRN) psychotropic and antipsychotic medications. Residents do not receive PRN psychotropic medications unless necessary to treat a diagnosed specific condition which must be documented in the record. PRN orders for psychotropic medications which are not antipsychotic medications are limited to 14 days. The attending physician/prescriber may extend the order beyond 14 days if he or she believes it is appropriate. If the attending physician extends the PRN for the psychotropic medication, the medical record must contain a documented rationale and determined duration. PRN orders for psychotropic medications which are antipsychotic medications are limited to 14 days. A PRN order for an antipsychotic cannot be renewed unless the attending physician/prescriber evaluates the resident to determine if it is appropriate to write a new PRN order for the antipsychotic medication. The evaluation entails direct evaluation of the resident and assessment of the FH6 - Developed by Polaris Group www.polaris-group.com Page 48 of 61

resident s current conditions and progress to determine if the PRN antipsychotic medication is still needed. Attending physician/prescribing practitioner documentation of the evaluation should address: o Whether the antipsychotic medication is still needed on a PRN basis? o What is the benefit of the medication to the resident? o Have the resident s expressions or indications of distress improved as a result of the PRN antipsychotic medication? Review the care plan for medications, especially high risk medications, and individualized approaches to care, including non-pharmacological interventions. Observations: Are care planned interventions implemented for medications that pose a high risk for adverse consequences? What non-pharmacological approaches to care are used? Are they effective? What pharmacological interventions are used? Why was the medication used and was it effective (e.g., pain is relieved, distress is addressed)? How does staff respond and interact with the resident? Does the resident continue to show expressions or indications of distress? If so, how does staff respond? Are staff using a medication for convenience or discipline? If so, describe. (For concerns related to a medication that involves an inadequate indication for use and evidence shows the medication is also being used for the purpose of discipline or convenience rather than to treat the resident's medical symptoms, surveyors should assess compliance with 483.10(e)(1) and 483.12(a)(2), F605, Right to Be Free From Chemical Restraints.) Does the resident have psychosocial, behavioral, mental, or physical adverse consequences that may be related to a medication: Anorexia/unplanned weight changes, edema; Decline in physical functioning (e.g., mobility or activities of daily living (ADLs)); Rash, pruritus; Bleeding or bruising, spontaneous or unexplained; Respiratory changes; Bowel dysfunction (e.g., cramping abdominal pain); Urinary retention, incontinence; Dehydration or swallowing difficulty; Falls, dizziness, or headaches; Muscle/nonspecific pain or unexplained abnormal movement; Psychomotor agitation (restlessness, pacing, hand wringing); Psychomotor retardation (slowed speech, thinking, movement); Subdued, sedated, lethargic, or withdrawn; Insomnia or sleep disturbances; Mental status changes; Behavioral changes or unusual behavior patterns; or Depression, apathy or mood disturbance. FH6 - Developed by Polaris Group www.polaris-group.com Page 49 of 61

Resident, Family or Resident Representative Interview: What medications do you get and why do you need to take them? What are your goals for your medications? What information on the risk, benefits and potential side effects of medications were you provided? What changes in your medications have occurred, including gradual dose reductions for psychotropic medications? NOTE: Permission given by or a request made by the resident and/or representative does not serve as a sole justification for the medication itself. What alternatives to taking some of the medications, including non-pharmacological approaches, has staff told you about? Do you think the medication has helped (e.g., pain control, improvements in function, decrease in edema, mood)? If not, why? What side effects have you had from the medication (ask about specific medications)? Have you experienced any changes in what you are able to do since starting or changing a medication(s)? Do you have allergies to any medication(s)? Have you participated in discussions and/or care plan meetings about your medications? Staff Interviews (Nursing Aides, Nurse, Director of Nursing (DON), Social Services): What, when, and to whom do you report changes in the resident s Why does the resident have two medications in the same class? status (e.g., indications of distress or pain)? How does the IDT determine what dose and duration is clinically How do you learn what the resident s daily care needs are? indicated? What non-pharmacological approaches are used? If the amount of any medication exceeds the manufacturer s What is the clinical indication for the medication? recommendations, clinical or evidence-based practice guidelines, or standards of practice, what is the rationale? How does the facility monitor the medication? How do you monitor for significant adverse consequences? What monitoring tools or systems are used? Has the resident had a change in condition, diet, weight loss, How did the interdisciplinary team (IDT) determine what should dehydration, or acute illness? If so, what was done to assess the be monitored? possible complications for these changes due to medications? For psychotropic medications, how did you determine what Has the resident had an adverse reaction? If so, what and how was behavior to monitor? the adverse reaction addressed? How do you assure orders for medication monitoring are How do you evaluate whether medications should be initiated, implemented (e.g., HbA1c, PT/INR)? continued, reduced, discontinued, or otherwise modified? How How do you communicate relevant information regarding often is the evaluation for modification conducted? medication monitoring for this resident to other team members? How do you assess whether each medication is effective? FH6 - Developed by Polaris Group www.polaris-group.com Page 50 of 61