When reporting a change of administrator or director of nursing under 105 CMR 150.002(D)(11), a facility must:

  • Create a report in the DPH Health Care Facility Reporting System (HCFRS) using the code “Change in Administrator/DON”;
  • Enter a brief narrative into their report; and,
  • When reporting a new administrator or director of nursing, attach a scanned copy of the completed “New Administrator/DON Worksheet pdf format of New Administrator/DON Worksheet
doc format of                             New Administrator/DON Worksheet                ”. 

The Department will no longer accept paper reports from nursing homes on these change notices.  The following guidance may be helpful in when submitting a report:

  1. Reporting Resignations of an Administrator or Director of Nursing: Report the following for these required HCFRS fields:
    1. “Enter a Patient or Resident”: Indicate “No”.
    2. “Incident Date”: Indicate the effective date of the resignation.
    3. “Incident Type”: Indicate “Change in Administrator/DON”.
    4. “Incident Narrative”: Indicate the name and license number of the individual who resigned, and the date that he or she resigned.
  2. Reporting Dismissals of an Administrator or Director of Nursing: Report the following for these required HCFRS fields:
    1. “Enter a Patient or Resident”: Indicate “No”.
    2. “Incident Date”: Indicate the effective date of the dismissal.
    3. “Incident Type”: Indicate “Change in Administrator/DON”.
    4. “Incident Narrative”: Indicate the name and license number of the individual dismissed, the date that he or she was dismissed, and the reason or reasons for dismissal.
  3. Reporting a New Administrator or Director of Nursing: Report the following for these required HCFRS fields, and attach a completed “New Administrator/DON Worksheet:
    1. “Enter a Patient or Resident”: Indicate “No”.
    2. “Incident Date”: Indicate the start date.
    3. “Incident Type”: Indicate “Change in Administrator/DON”.
    4. “Incident Narrative”: Indicate the name and license number of the new administrator or director of nursing, and the date that he or she started or will start in that position.
    5. Complete, scan and attach a “New Administrator/DON Worksheet”.

In order to ensure new facility administrators and directors of nursing obtain access to critical information available from the Department, a “New Administrator/DON Worksheet” must be completed and attached to the report submitted when the Department is notified of a replacement. The consistent use of this form will ensure access to the following key resources:

  • Listserv for Long Term Care Facilities: As the Department no longer mails hard copies of circular letters to facilities, nursing home administrators and directors of nursing must sign up with listserv to receive these updates. Information regarding the long term care listserv is available on-line at: Facility Signup for Electronic Transmission of Correspondence (ListServ).
  • Health Care Facility Reporting System (HCFRS): This system is required to submit incident reports and make reports under the Patient Abuse Law. Detailed information regarding how to add or delete a user is available at: Facility Reporting to Department of Public Health.
  • Electronic Plan of Correction (ePOC) System: This system is required to receive statements of deficiencies and to submit plans of correction. All long term care facilities with Medicare and/or Medicaid certification are required to have at least two users enrolled in the ePOC system at all times. Enrollment occurs through CMS, and is a three-step process. Enrollment instructions are available at: Electronic Plan of Correction (ePOC).
  • Health and Homeland Alert Network (HHAN): This system is required to receive important communications from the Department during natural disasters and emergencies. Each facility must enroll its administrator and up to two additional facility leaders in accordance with 105 CMR 150.015(E)(5). Information and registration guidance is available at: Health and Homeland Alert Network (HHAN) Quick Reference Guide.

To register, each prospective user must send an email requesting enrollment to: Alert.Network@state.ma.us or dana.ohannessian@massmail.state.ma.us

  • Massachusetts Mutual Aid Program (MassMAP): The Division of Health Care Facility Licensure and Certification, and the Department’s Office of Preparedness and Emergency Management (OPEM) have partnered with MassMAP to implement a mutual aide system to respond to significant events or natural disasters which disrupt a facility’s operations. MassMAP Members participate in annual training exercises and respond with resources in time of disaster. Information regarding MassMAP is available at: The Massachusetts Long Term Care Mutual Aid Plan and Healthcare Mutual Aid Plan Website.

For additional information or questions on reporting a change of administrator and director of nursing, please contact the Department at 617-753-8000 and ask to speak to a representative of the Licensure Unit, or the Regional Manager for the area in which your facility is located.