CMS SOM App. PP, Tag F551

court, the resident has the right to designate a representative, in accordance with State law

and any legal surrogate so designated may exercise the resident’s rights to the extent

provided by state law. The same-sex spouse of a resident must be afforded treatment equal

to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in

which it was celebrated.

(i) The resident representative has the right to exercise the resident’s rights to the

extent those rights are delegated to the representative.

(ii) The resident retains the right to exercise those rights not delegated to a resident

representative, including the right to revoke a delegation of rights, except as limited

by State law.

§483.10(b)(4) The facility must treat the decisions of a resident representative as the

decisions of the resident to the extent required by the court or delegated by the resident, in

accordance with applicable law.

§483.10(b)(5) The facility shall not extend the resident representative the right to make

decisions on behalf of the resident beyond the extent required by the court or delegated by

the resident, in accordance with applicable law.

§483.10(b)(6) If the facility has reason to believe that a resident representative is making

decisions or taking actions that are not in the best interests of a resident, the facility shall

report such concerns when and in the manner required under State law.

§483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a

court of competent jurisdiction, the rights of the resident devolve to and are exercised by

the resident representative appointed under State law to act on the resident’s behalf. The

court-appointed resident representative exercises the resident’s rights to the extent judged

necessary by a court of competent jurisdiction, in accordance with State law.

(i) In the case of a resident representative whose decision-making authority is limited by

State law or court appointment, the resident retains the right to make those

decisions outside the representative’s authority.

(ii) The resident’s wishes and preferences must be considered in the exercise of rights

by the representative.

(iii) To the extent practicable, the resident must be provided with opportunities to

participate in the care planning process.

DEFINITIONS §483.10(b)(3)-(7)

“Court of competent jurisdiction” means any court with the authority to hear and determine a

case or suit with the matter in question.

“Resident representative” For purposes of this subpart, the term resident representative may

mean any of the following:

1. An individual chosen by the resident to act on behalf of the resident in order to support the

resident in decision-making; access medical, social or other personal information of the

resident; manage financial matters; or receive notifications;

2. A person authorized by State or Federal law (including but not limited to agents under

power of attorney, representative payees, and other fiduciaries) to act on behalf of the

resident in order to support the resident in decision-making; access medical, social or

other personal information of the resident; manage financial matters; or receive

notifications; or

3. Legal representative, as used in section 712 of the Older Americans Act; or

4. The court-appointed guardian or conservator of a resident.

5. Nothing in this rule is intended to expand the scope of authority of any resident

representative beyond that authority specifically authorized by the resident, State or

Federal law, or a court of competent jurisdiction.

GUIDANCE §483.10(b)(3)-(7)

When reference is made to “resident” in the Guidance, it also refers to any person who may,

under State law, act on the resident’s behalf when the resident is unable to act for themselves.

That person is referred to as the resident representative. If the resident has been formally

declared incompetent by a court, the representative is whomever the court appoints (for example,

a guardian or conservator).

A competent resident may wish to delegate decision-making to specific persons, or the resident

and family may have agreed among themselves on a decision-making process. To the degree

permitted by State law, the facility staff must respect the delegated resident representative’s

decisions regarding the resident’s wishes and preferences so long as the resident representative is

acting within the scope of authority contemplated by the agreement authorizing the person to act

as the resident’s representative.

In the case of a resident who has been formally declared incompetent by a court, a court

appointed resident representative may be assigned. Facility staff must confer with the appointed

resident representative.

State laws and court orders authorizing guardians, conservators, etc., vary considerably. Many

statutes and court orders limit the scope of the authority of the representative to act on behalf of

the resident.

Facility staff must obtain documentation that the resident’s representative has been delegated the

necessary authority to exercise the resident’s rights and must verify that a court-appointed

representative has the necessary authority for the decision-making at issue as determined by the

court. For example, a court-appointed representative might have the power to make financial

decisions, but not health care decisions. Additionally, the facility must make reasonable efforts

to ensure that it has access to documentation of any change related to the delegation of rights,

including a resident’s revocation of delegated rights, to ensure that the resident’s preferences, are

being upheld.

Whether a resident has or has not been judged incompetent by a court of law, if it is determined

that the resident understands the risks, benefits, and alternatives to proposed health care and

expresses a preference, then the resident’s wishes should be considered to the degree practicable,

including resident input into the care planning process.

The involvement of a representative does not relieve facility staff of their duty to protect and

promote the resident’s interests. For example, a representative does not have the right to insist

that a treatment be performed that is not medically appropriate or reject a treatment that may be

subject to State law. Surveyors must confirm delegation of resident rights to a resident

representative. Surveyors must also determine, through interview and record reviews, whether or

not the resident’s delegation of rights has been followed by facility staff.

If a resident’s representative is a same-sex spouse, he or she must be treated the same as an

opposite-sex spouse with regard to exercising the resident’s rights. In Obergefell v. Hodges, 576

U.S.___ (2015), the Supreme Court of the United States also ruled that all States must recognize

a marriage between two people of the same sex when their marriage was lawfully licensed and

performed out-of-state.

PROCEDURES §483.10(b)(3)-(7)

Surveyors must check whether there has been a delegation of resident rights or designation of a

resident representative. Surveyors must also determine, through interview and record reviews,

whether or not the resident’s delegation of rights has been followed by facility staff.

Determine through interview and record review if the resident has been found to be legally

incompetent by a court in accordance with state law.

If yes:

• Verify the appropriate legal documentation for a court-appointed resident representative

is present in the resident’s medical record.

• Review court orders or other legal documentation to determine the extent of the court-appointed resident representative’s authority to make decision on behalf of the resident

and any limitations on that authority that may have been ordered by the court.

• Determine if the court-appointed representative is making decisions for the resident

beyond the scope of the resident representative’s decision-making authority and the

facility is relying on that authority as the basis of a practice (e.g., health care treatment,

managing resident funds, discharge decision). If so, a deficiency may be cited under this

regulation.

• Determine if the resident was involved in care planning activities and able to make

choices, to the extent possible.

• Observe resident care and daily activities (e.g., participation in activities) for adherence

to resident’s or court-appointed resident representative’s goals, choices, and preferences.

Even when there is a court-appointed resident representative, the facility should seek to

understand the resident’s goals, choices, and preferences and have honored them to the

extent legally possible.

If no:

• Determine how decisions are being made for the resident. Does the resident maintain all

of his/her rights, even if he/she has designated a representative to assist with decision-making unless a court has limited those rights under state law, and only to the extent that

has been specified by a court under state law? Has the resident designated a resident

representative and is facility staff respecting the authority of this designate surrogate

decision-maker to act on behalf of the resident?

• Are all residents informed of their plan of care or treatment in the most understandable

manner possible, and given an opportunity to voice their views? Autonomy is also

expressed through gestures and actions and this also should be recognized. Residents

even without capacity or declared incompetent may be able to express their needs and

desires.

• Determine whether same-sex spouses are treated in the same manner as an opposite-sex

spouse in all states and territories.

• If the resident has delegated a resident representative, verify the appropriate

documentation is present in the resident’s medical record.

KEY ELEMENTS OF NONCOMPLIANCE §483.10(b)(3)-(7)

To cite deficient practice at F551, the surveyor’s investigation will generally show that the

facility failed to do any one or more of the following:

• Ensure a competent resident’s choice for a representative is honored or

• Ensure that treatment of a same-sex spouse was the same as treatment of an opposite-sex

spouse; or

• Ensure the resident representative did not make decisions beyond the extent allowed by

the court or delegated by the resident; or

• Ensure the resident’s wishes and preferences were considered when decisions were made

by the resident representative; or

• Ensure the decisions of the resident representative are given the same consideration as if

the resident made the decision themselves; or

• Honor the resident’s authority to exercise his or her rights, even when he or she has

delegated those rights, including the right to revoke a delegation of rights; or

• Ensure the resident representative was reported as State law required when not acting in

the best interest of the resident; or

• Ensure a resident who was found incompetent by the court is provided with opportunities

to participate in the care planning process.