This regulation requires physicians (or authorized non-physician practitioners) in nursing facilities to actively supervise resident care during each required visit by reviewing the resident's total program of care including medications and treatments, writing signed and dated progress notes, and signing and dating all orders (except influenza and pneumococcal vaccines administered per facility policy). Facilities must ensure physicians document their review of the resident's current condition, progress, and decisions about the continued appropriateness of the medical regimen. The regulation also addresses acceptable documentation methods including electronic records, facsimile orders, and rubber stamp signatures with appropriate safeguards.
View official sourceF711 (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) §483.30(b) Physician Visits The physician must— §483.30(b)(1) Review the resident’s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. INTENT §483.30(b) The intent of this regulation is to have the physician take an active role in supervising the care of the residents. Physician visits should not be superficial visits, but must include an evaluation of the resident’s condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident’s current medical regimen. GUIDANCE §483.30(b) Except where the regulation specifies the task must be completed personally by the physician, the term “attending physician” or “physician” also includes a non-physician practitioner (NPP) involved in the management of the resident’s care, to the extent permitted by State law. Total program of care includes all care the facility provides residents to maintain or improve their highest practicable physical, mental and psychosocial well-being, as defined by the comprehensive assessment and plan of care. Care includes medical services and medication management, physical, occupational, and speech/language therapy, nursing care, nutritional interventions, social work and activity services that maintain or improve psychosocial functioning. During required visits, the physician must document a review of the resident’s total program of care, including the resident’s current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident’s current medical regimen. The physician need not review the total plan of care at each visit, but must review the total plan of care at visits required by §483.30(c), F712. Progress notes must be written, signed and dated at each physician visit, which may be done in a physical chart or electronic record, in keeping with facility practices. During visits, the physician must also sign and date all orders, with the exception of influenza and pneumococcal vaccinations, which may be administered per physician- approved facility policy after an assessment for contraindications. This includes co- signing orders written by NPPs, qualified dietitians, other clinically qualified nutrition professionals and qualified therapists, as required by state law. In cases where facilities have created the option for a resident’s record to be maintained by computer, rather than hard copy, electronic signatures are acceptable. See Guidelines for §483.70(h)(1), F842, for information on facility safeguards concerning electronic signatures. Physician orders may be transmitted by facsimile machine if the following conditions are met: • The physician should have signed and retained the original order from which the facsimile was transmitted and be able to provide it upon request. Alternatively, the original may be sent to the facility at a later time and substituted for the facsimile. • The facility should photocopy the faxed order, if the faxed order is subject to fading over time. The facsimile copy can be discarded after facility photocopies it. • It is not necessary for a physician to re-sign the facsimile order when he/she visits the facility. When rubber stamp signatures are authorized by the facility’s management, the individual whose signature the stamp represents shall place in the administrative offices of the facility a signed statement to the effect that he/she is the only one who has the stamp and uses it. A list of computer codes, identification numbers and/or written signatures must be readily available and maintained under adequate safeguards. Adequate safeguards may include, but are not limited to, locked in a drawer; locked in a location that is accessible only by appropriate staff as defined by the facility; or available on a protected electronic site accessible by appropriate staff as defined by the facility. PROBES §483.30(b) • Are physician progress notes written, signed and dated during each physician visit? • For visits required by §483.30(c), do physician progress notes reflect a review of the resident’s total program of care and current condition, including medications and treatments? • Do physician progress notes reflect the physician’s decisions about the continued appropriateness of the resident’s current medical regimen? • Does the physician sign and date all physician orders, during visits, with the exception of influenza and pneumococcal vaccines as outlined above? • If the physician has not met the requirements of physician visits, how has the facility worked with the physician or sought alternate physician participation to assure that the resident receives appropriate care and treatment? • If facility management allows for the use of rubber stamp signatures, are adequate safeguards in place to ensure the security of the stamps? POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION If concerns regarding physician supervision of the resident’s care are identified, investigate §483.30(a), F710. For concerns related to admission orders, see §483.20(a), F635. For concerns related to the frequency of physician visits, see §483.30(c), F712. For concerns related to the medical director’s follow-up on clinical issues or physician activities, see §483.70(g), F841. DEFICIENCY CATEGORIZATION §483.30(b) Examples of Level 4, immediate jeopardy to resident health and safety, include, but are not limited to: • After a recent hospitalization, the facility failed to ensure the attending physician reviewed the hospital discharge summary or hospital progress notes. This lack of review of the resident’s total program of care, including medications and treatments, resulted in the resident not receiving orders for new medications essential to the resident’s medical treatment. As a result of the lack of essential medications, serious harm or death occurred or was likely to occur. • Facility staff contacted the physician on multiple occasions regarding the resident’s elevated blood sugar levels. During a visit, the physician did not review the resident’s recorded blood sugar values, or talk to the nurse regarding the resident’s status or order changes to the resident’s treatment regimen. The facility’s failure to intervene when the physician was onsite or to seek alternate intervention resulted in the resident experiencing diabetic ketoacidosis which required hospitalization for management. Example of level 3, actual harm that is not immediate jeopardy, includes, but is not limited to: • The facility failed to ensure the physician completed a medical evaluation of a resident's condition and review the appropriateness of the resident's medical regimen. Specifically, a resident who had executed a Living Will at a time when he had capacity, indicated that it was his desire to refuse any treatment, other than comfort measures, in the event of an irreversible terminal illness from which there was no hope of recovery. Despite documentation from the pulmonologist that there was no expectation that the resident could survive without artificial means and contrary to the resident's wishes, the attending physician ordered, and the facility provided, aggressive, life-sustaining treatment including artificial ventilation and feeding. As a result, the resident received unwanted treatment in the facility. Examples of Level 2, no actual harm, with potential for than more than minimal harm, that is not immediate jeopardy, include, but are not limited to: • While the physician reviewed areas identified as high priority for the physician to address in the resident’s program of care, the facility failed to ensure the physician reviewed the resident’s total program of care or wrote, signed and dated progress notes with each visit. • The facility failed to ensure physician progress notes that documented the physician's involvement in the assessment and care of residents were completed as required. 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: • During a physician visit, the physician failed to sign and date new orders, however the orders were followed as intended and no adverse outcome was experienced by the resident.