This regulation requires nursing facilities to ensure each resident's medical care is supervised by a physician throughout their stay, including written physician approval for admission and coverage by another physician when the attending is unavailable. Facilities must maintain physician orders for each resident's immediate care and needs, and must have systems in place to reach a covering physician at all times. Non-physician practitioners (nurse practitioners, clinical nurse specialists, physician assistants) may assist with care management to the extent permitted by state law, but certain tasks—such as written admission approval—must be performed personally by a physician.
View official sourceF710 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.30 Physician Services A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident’s immediate care and needs. §483.30(a) Physician Supervision. The facility must ensure that— §483.30(a)(1) The medical care of each resident is supervised by a physician; §483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable. INTENT §483.30(a) The intent of this regulation is to ensure the medical supervision of the care of each resident by a physician and that orders for the resident’s immediate care and needs are provided throughout the resident’s stay. DEFINITIONS §483.30(a) “Attending physician” refers to the primary physician who is responsible for managing the resident’s medical care. This does not include other physicians whom the resident may see periodically, such as specialists. “Non-physician practitioner (NPP)” is a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA). “Nurse practitioner” is a registered professional nurse currently licensed to practice in the State and who meets the State’s requirements governing the qualification of nurse practitioners. “Clinical nurse specialist” is a registered professional nurse currently licensed to practice in the State and who meets the State’s requirements governing the qualifications of clinical nurse specialists. “Physician assistant” is a person who meets the applicable State requirements governing the qualifications for assistants to primary care physicians. GUIDANCE §483.30(a) A physician’s personal approval of an admission recommendation must be in written form. The written recommendation for admission to the facility must be provided by a physician and cannot be provided by a NPP. This may be accomplished through a hospital transfer summary written by a physician, paperwork completed by the resident’s physician in the community, or other written form by a physician. If a physician does not provide a written recommendation that the individual be admitted to the facility prior to the resident’s admission, the physician’s admission orders for the resident’s immediate care as required in §483.20(a) will be accepted as “personal approval” of the admission if the orders are provided by a physician. Admission orders in lieu of a physician’s written recommendation for admission to the facility cannot be provided by a NPP. Generally, the term “attending physician” or “physician” may also include a NPP involved in the management of the resident’s care, to the extent permitted by State law. However, when the regulation specifies a task to be completed “personally” by the physician, that task may not be delegated to a NPP. Supervising the medical care of residents means participating in the resident’s assessment and care planning, monitoring changes in resident’s medical status, and providing consultation or treatment when contacted by the facility. It also includes, but is not limited to, prescribing medications and therapy, ordering a resident’s transfer to the hospital, conducting required routine visits or delegating to and supervising follow-up visits by NPPs. It is the responsibility of the facility to ensure that another physician supervises the care of residents when the attending physician is unavailable. The attending physician may designate another physician to act on his/her behalf when unavailable. If the attending physician is unavailable and does not designate another physician to act on his/her behalf, or the designated physician is unavailable, the facility must have a physician available who will supervise the care of the attending physician’s residents. There may be examples of physician orders in the medical record that would not impact a resident’s medical care, such as instructions to contact a family member or providing date/time of an order; concerns related to these types of orders do not fall under the category of a physician’s supervision of medical care and would not be cited here. PROBES §483.30(a) • Is there evidence that the attending physician supervises the resident’s medical care? If not, what did the facility do? • If the physician makes a change to the residents’ plan of care, e.g. orders a new medication or changes a medication, is there evidence that the physician re- evaluated the effectiveness of the intervention and the resident’s response? NOTE: the timing of the re-evaluation may vary depending upon the type of change, type of medication. • If staff reported a change in medical status to the physician, how did the physician respond? • If the attending physician was unavailable and could not respond, did the facility have a physician available to supervise the medical care of the resident? How did this physician respond? • When a NPP performs a delegate physician visit, and determines that the resident’s condition warrants direct contact between the physician and the resident, does the physician follow-up promptly with a personal visit? POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION The facility must ensure each resident has the right to designate an attending physician For potential concerns related to the resident having the choice of attending physician who is able and willing to meet the physician services requirements, see §483.10(d), F555, for additional guidance. For concerns related to admission orders, see §483.20(a), F635. At the time each resident is admitted, the facility must have physician’s orders for the resident’s immediate care. For concerns related to physician availability for emergencies 24 hours a day, see §483.30(d), F713. DEFICIENCY CATEGORIZATION §483.30(a) Examples of Level 4, immediate jeopardy to resident health and safety include, but are not limited to: • The facility failed to ensure the physician conducted a medical evaluation of a resident with a new onset of seizures. As a result, anticonvulsant medications were prescribed, but the primary cause of the seizures was not evaluated to determine if it was neurological or secondary to another condition, such as infection or drug interaction. This placed the resident at risk for serious harm or death. • The physician failed to provide laboratory orders for routine monitoring for a resident receiving anticoagulant medication, placing the resident at risk for significant adverse side effects including the risk for serious injury or death, such as gastrointestinal bleeding or stroke. The facility failed to follow up with the physician regarding the absence of laboratory orders and administered the anticoagulant medication as ordered. An example of level 3, actual harm that is not immediate jeopardy includes, but is not limited to: • The facility failed to ensure the physician supervised the resident’s medical care, when the physician did not evaluate the effectiveness of treatments ordered for a skin condition, resulting in the development of a localized skin infection causing significant pain for the resident. An example of Level 2, no actual harm, with potential for no more than minimal harm, that is not immediate jeopardy includes, but is not limited to: • The facility failed to follow-up on recommendations from the dietitian for diet liberalization for a resident whose attending physician did not respond to phone calls. The facility then failed to contact another physician to assist with providing care for the resident when the facility was unable to reach the attending physician. An example of Level 1, no actual harm with potential for no more than a minor negative impact on the resident includes, but is not limited to: • The failure of the facility to ensure a resident’s medical care is supervised by a physician or to ensure that the resident has orders for immediate care and needs always places the resident at risk for more than minimal harm. Therefore, Severity Level 1 does not apply for this regulatory requirement.