CMS Clarifies Notification of State Ombudsman Requirement

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare®

CMS issued S&C: 17-27-NH on Friday May 12, 2017.  In this Survey and Certification notice, CMS provided clarification as to when the State LTC Ombudsman must be notified of a resident’s transfer or discharge from the facility.  This requirement in the RoPs, found at §483.15(c)(3)(i), raised many questions for LTC providers as to the need for notification of the State LTC Ombudsman when the resident planned to leave a facility.  Specific requirements for such notification are found on page 4 of this S&C and include this statement regarding resident-initiated transfers or discharge:

“A resident-initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility. The medical record must contain documentation or evidence of the resident’s or resident representative’s verbal or written notice of intent to leave the facility. A resident’s expression of a general desire or goal to return home or to the community or elopement of a resident who is cognitively impaired should not be taken as notice of intent to leave the facility. For resident-initiated transfers or discharges, sending a copy of the notice to the ombudsman is not required.”

A new definition for Substandard Quality of Care (SQC) was introduced into the Final Rule effective November 28, 2016.  This S&C speaks to that definition which is “one or more deficiencies which constitute either immediate jeopardy to resident health or safety; a pattern of or widespread actual harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm, related to participation requirements under:

  • §483.10 “Resident rights,” paragraphs:
    • (a)(1) through (a)(2)
    • (b)(1) through (b)(2),
    • (e) (except for (e)(2), (e)(7), and (e)(8)),
    • (f)(1) through (f)(3) and (f)(5) through (f)(8), and
    • (i)
  • §483.12 “Freedom from abuse, neglect, and exploitation;” 
  • §483.24 “Quality of life;”
  • §483.25 “Quality of care;” 
  • §483.40 “Behavioral health services,” paragraphs (b) and (d);
  • §483.45 “Pharmacy services,” paragraphs (d), (e), and (f);  
  • §483.70 “Administration,” paragraph (p), and
  • §483.80 “Infection control,” paragraph (d).”

This S&C addresses implementation of the SQC regulations for each of the 3 phases of implementation. It also speaks to the new F-tag numbering system that will be implemented in Phase 2, starting on November 28, 2017.

This S&C can be found at:

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