CMS SOM App. A, Tag A-0133

choice and his or her own physician notified promptly of his or her admission to the hospital.

Interpretive Guidelines §482.13(b)(4)

Identifying Who Is to Be Notified

For every inpatient admission, the hospital must ask the patient whether the hospital should notify a

family member or representative about the admission. If the patient requests such notice and identifies

the family member or representative to be notified, the hospital must provide such notice promptly to the

designated individual. The explicit designation of a family member or representative by the patient

takes precedence over any non-designated relationship.

The hospital must also ask the patient whether the hospital should notify his/her own physician. In the

case of scheduled admissions, the patient’s own physician likely is already aware of the admission.

However, if the patient requests notice to and identifies the physician, the hospital must provide such

notice promptly to the designated physician, regardless of whether the admission was scheduled in

advance or emergent.

When a patient is incapacitated or otherwise unable to communicate and to identify a family member or

representative to be notified, the hospital must make reasonable efforts to identify and promptly notify a

family member or patient’s representative. If an individual who has accompanied the patient to the

hospital, or who comes to or contacts the hospital after the patient has been admitted, asserts that he or

she is the patient’s spouse, domestic partner (whether or not formally established and including a same-sex domestic partner), parent (including someone who has stood in loco parentis for the patient who is a

minor child), or other family member, the hospital is expected to accept this assertion, without

demanding supporting documentation, and provide this individual information about the patient’s

admission, unless:

• More than one individual claims to be the patient’s family member or representative. In such

cases it would not be inappropriate for the hospital to ask each individual for documentation

supporting his/her claim to be the patient’s family member or representative. The hospital

should make its determination of who is the patient’s representative based upon the hospital’s

determination of who the patient would most want to make decisions on his/her behalf.

Examples of documentation a hospital might consider could include, but are not limited to, the

following: proof of a legally recognized marriage, domestic partnership, or civil union; proof of

a joint household; proof of shared or co-mingled finances; and any other documentation the

hospital considers evidence of a special relationship that indicates familiarity with the patient’s

preferences concerning medical treatment ;

• Treating the individual as the patient’s family member or representative without requesting

supporting documentation would result in the hospital violating State law. State laws, including

State regulations, may specify a procedure for determining who may be considered to be the

incapacitated patient’s family member or representative, and may specify when documentation is

or is not required; or

• The hospital has reasonable cause to believe that the individual is falsely claiming to be the

patient’s spouse, domestic partner, parent or other family member.

Hospitals are expected to adopt policies and procedures that facilitate expeditious and non-discriminatory resolution of disputes about whether an individual should be notified as the patient’s

family member or representative, given the critical role of the representative in exercising the patient’s

rights. Hospitals may also choose to provide notice to more than one family member.

When a patient is incapacitated and the hospital is able through reasonable efforts to identify the

patient’s own physician – e.g., through information obtained from a family member, or from review of

prior admissions or outpatient encounters, or through access to the patient’s records in a regional system

of electronic patient medical records in which the hospital participates – the hospital must promptly

notify the patient’s physician of the admission.

Prompt Notice

The hospital must provide the required notice promptly. “Promptly” means as soon as possible after the

physician’s or other qualified practitioner’s order to admit the patient has been given. Notice may be

given orally in person, by telephone, by e-mail or other electronic means, or by other methods that

achieve prompt notification. It is not acceptable for the hospital to send a letter by regular mail.

Medical Record Documentation

The hospital must document that the patient, unless incapacitated, was asked no later than the time of

admission whether he or she wanted a family member/representative notified, the date, time and method

of notification when the patient requested such, or whether the patient declined to have notice provided.

If the patient was incapacitated at the time of admission, the medical record must indicate what steps

were taken to identify and provide notice to a family member/representative and to the patient’s

physician.

Survey Procedures §482.13(b)(4)

• Determine if the hospital has policies that address notification of a patient’s family or representative

and physician when the patient is admitted as an inpatient.

• Ask the hospital who is responsible for providing the required notice. Interview person(s)

responsible for providing the notice to determine how they identify the persons to be notified and the

means of notification. What do they do in the case of an incapacitated person to identify a family

member/representative and the patient’s physician?

• Review a sample of inpatient medical records. Do the medical records provide evidence that the

patient was asked about notifying a family member/representative and his/her physician? Is there a

record of when and how notice was provided? Was notice provided promptly? Is there a record of

the patient declining to have notice provided to a family member/representative and his/her

physician? Is there documentation of whether the patient was incapacitated at the time of admission,

and if so, what steps were taken to identify a family member/representative and the patient’s

physician?