CMS SOM App. PP, Tag F637

that there has been a significant change in the resident’s physical or mental condition. (For

purpose of this section, a “significant change” means a major decline or improvement in

the resident’s status that will not normally resolve itself without further intervention by

staff or by implementing standard disease-related clinical interventions, that has an impact

on more than one area of the resident’s health status, and requires interdisciplinary review

or revision of the care plan, or both.)

INTENT

To ensure that each resident who experiences a significant change in status is comprehensively

assessed using the CMS-specified Resident Assessment Instrument (RAI) process.

DEFINITIONS

“Significant Change” refers to a major decline or improvement in a resident’s status that 1) will

not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; the decline is not considered “self-limiting” (NOTE: Self-limiting

is when the condition will normally resolve itself without further intervention or by staff

implementing standard clinical interventions to resolve the condition.); 2) impacts more than one

area of the resident’s health status; and 3) requires interdisciplinary review and/or revision of the

care plan. This does not change the facility’s requirement to immediately consult with a

resident’s physician of changes as required under 42 CFR §483.10(i)(14), F580.

“Significant Change in Status Assessment (SCSA)” refers to a comprehensive assessment that

must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets

the significant change guidelines for either major improvement or decline.

“Assessment Reference Date (ARD)” refers to the specific end point for the look-back periods

in the Minimum Data Set (MDS) assessment process. This look-back period is also called the

observation or assessment period.

GUIDANCE

A SCSA including Care Area Assessments (CAAs) must be completed within 14 days after a

determination has been made that a significant change in the resident’s status from baseline

occurred. This may be determined by comparison of the resident’s current status to the most

recent comprehensive assessment and most recent Quarterly assessment, and the resident’s

condition is not expected to return to baseline within 2 weeks. A SCSA is appropriate if there

are either two or more MDS areas of decline or two or more MDS areas of improvement or if the

IDT determines that the resident would benefit from the SCSA assessment and subsequent care

plan revision. The facility should document in the medical record when the determination is

made that the resident meets the criteria for a Significant Change in Status Assessment.

A Significant Change in Status MDS is required when:

• A resident enrolls in a hospice program; or

• A resident changes hospice providers and remains in the facility; or

• A resident receiving hospice services discontinues those services; or

• A resident experiences a consistent pattern of changes, with either two or more areas of

decline or two or more areas of improvement, from baseline (as indicated by comparison

of the resident’s current status to the most recent CMS-required MDS).

Examples of Decline include, but are not limited to:

• Resident’s decision-making ability has changed;

• Presence of a resident mood item not previously reported by the resident or staff and/or

an increase in the symptom frequency, e.g., increase in the number of areas where

behavioral symptoms are coded as being present and/or the frequency of a symptom

increases for items in Section E Behavior;

• Changes in frequency or severity of behavioral symptoms of dementia that indicate

progression of the disease process since last assessment;

• Any decline in an ADL physical functioning area (at least 1) where a resident is newly

coded as partial/moderate assist, substantial/maximal assistance, dependent, resident

refused, or not attempted since last assessment and does not reflect normal fluctuations in

that individual’s functioning;

• Resident’s incontinence pattern changes or there was placement of an indwelling

catheter;

• Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in

180 days).

• Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure

ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status;

• Resident begins to use a restraint of any type, when it was not used before;

• Emergence of a condition/disease in which a resident is judged to be unstable.

Examples of Improvement include, but are not limited to:

• Any improvement in ADL physical functioning area (at least 1) where a resident is newly

coded as Independent, Setup or clean-up assistance, or Supervision or touching assistance

since last assessment and does not reflect normal fluctuations in that individual’s

functioning;

• Decrease in the number of areas where behavioral symptoms are coded as being present

and/or the frequency of a symptom decreases;

• Resident’s decision making ability improves;

• Resident’s incontinence pattern improves;

If there is only one change, the resident may still benefit from a SCSA as determined by the IDT or

as initiated by the resident based on changes in the care plan. It is important to remember that each

resident’s situation is unique. The facility must document a rationale, in the resident’s medical

record, for completing a SCSA that does not meet the criteria for completion.

The facility may not complete a SCSA until after a Comprehensive Admission assessment has

been completed.

A Significant Change in Status MDS is considered timely when:

• The RN Assessment Coordinator signs the MDS as complete at section Z0500B &

V0200B2 by the 14

th calendar day after the determination that a significant change has

occurred (determination date + 14 calendar days).

If a SCSA MDS is completed, the next annual assessment is not due until 366 days after the

ARD of the significant change in status assessment.

NOTE: For information on assessment scheduling for the MDS, see Chapter 2 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. Link to the LTCF RAI

User’s Manual:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html.

Circumstances when a change in resident status is not significant include, but are not limited to:

• Short-term acute illness, such as a mild fever secondary to a cold from which the IDT

expects the resident to fully recover.

• Well-established, predictable cyclical patterns of clinical signs and symptoms associated

with previously diagnosed conditions (e.g., depressive symptoms in a resident previously

diagnosed with bipolar disease would not precipitate a Significant Change Assessment).

• Instances in which the resident continues to make steady progress under the current

course of care. Reassessment is required only when the condition has stabilized.

• Instances in which the resident has stabilized but is expected to be discharged in the

immediate future. The facility has engaged in discharge planning with the resident and

family, and a comprehensive reassessment is not necessary to facilitate discharge

planning.

PROBES

• Did the facility identify, in a timely manner, those residents who experienced a

significant change in status?

• Is there documentation in the medical record when the determination was made that the

resident met the criteria for a Significant Change in Status Assessment?

• Did the facility reassess residents who had a significant change in status, using the CMS-specified RAI, within 14 days after determining the change was significant?