Tool:Notification of Changes Policy and Procedurechecklist

Tool:Notification of Changes Policy and ProcedureChecklist

483.10(g)(14)

A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s), when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; A significant change in the resident’s physical, mental, or psychosocial status; A need to alter treatment significantly; orA decision to transfer or dischargethe resident from the facility. When making notification, thefacility must ensure that all pertinentinformation isavailable and provided upon request tothe physician. The facility must also promptlynotify the resident and the residentrepresentative, if any, when there is: A change in room or roommateassignment; or a change in resident rights underFederal or State law or regulations. The facility must record andperiodically update the address (mailingand email) and phone number of theresident representative(s).

Purpose and Intent of 483.10(g)(14)

The purpose of the notification of changes policy and procedure is to develop guidelines about notification of changes to the resident, the resident’s representative and the resident’s provider.

To assure that the individual facility has followed all the required steps for the development and implementation of a comprehensive notification of change policy in accordance to the new Requirements of Participation (RoP), the following checklist captures specific action items for successful completion. The left column represents the actual Requirements of Participation (RoP) language and the right column indicates specific leadership strategies for successful completion and implementation of the revised RoP. When preparing updated policies and procedures, it is recommended to include actual RoP language as applicable. Please note that CMS has not issued its interpretative guidance for the new Requirements of Participation (RoP), therefore additional updates may be necessary once the guidance is released.

Suggested Checklist:

Programand Policy andProcedure

Regulation / Recommended Actions
483.10(g)(14) Notification of changes
(i) A facility mustimmediately inform the resident; consult with the resident’s physician;and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention:
(B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g) (14) (i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) change in room or roommate assignment as specified in 483.10 (e) (6): or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e) (10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). / Review, revise and institute a Notification of Change Policy and Procedure in accordance with the (RoP). See regulatory requirements as well as template policy and procedure.
Update definitions and new terms
Update staff education materials for orientation, annual education, and agency staff orientation, as needed.
Educate nursing staff and the interdisciplinary team about the Notification of Change Policy and Procedure.
Conduct updated training for nursing leaders about supervising and monitoring for change in condition notification requirements.
Conduct education for providers about the requirements for notification of changes and the facility’s policy and procedure.
Update and review reference material and tools monitoring to identify concerns about Notification of Change reporting and requirements.
Track and update address, email and phone numbers of residents’ representatives and providers.

The below areas serves as a cross reference for facility leaders to conduct addition policy and procedure review across departments to incorporate the changes set forth in § 483.10(g)(14) Notification of Changes. This listing is not all encompassing however should serve as a resource for leaders as they update their internal policies, procedures and operational processes.

Cross Reference

Resident Rights

CMS Definitions

Notification Policy and Procedures

Employee Orientation

Annual Training Requirements

Quality Assurance and Performance Improvement

Staff Training and Education

Incident Accident Policy and Procedure

Laboratory and Diagnostic Test Results Reporting

Physician Services

Admission Policy and Procedure

Resident Postings

Medical Director Services

Business Office Responsible party contact

This document is for general informational purposes only.

It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.