This regulation governs physician delegation of tasks to non-physician practitioners (nurse practitioners, clinical nurse specialists, and physician assistants) in skilled nursing facilities (SNFs) and nursing facilities (NFs). It sets conditions under which delegation is permitted, defines qualifying credentials for each NPP type, and specifies tasks that cannot be delegated. Facility operators must ensure NPPs meet state licensure and scope-of-practice requirements, that physicians maintain appropriate supervision, and that any delegation complies with both federal regulations and facility policies.
View official sourceF714 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.30(e) Physician delegation of tasks in SNFs. §483.30(e)(1) Except as specified in paragraph (e)(4) of this section, a physician may delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist who— (i) Meets the applicable definition in §491.2 of this chapter or, in the case of a clinical nurse specialist, is licensed as such by the State; (ii) Is acting within the scope of practice as defined by State law; and (iii) Is under the supervision of the physician. *** §483.30(e)(4) A physician may not delegate a task when the regulations specify that the physician must perform it personally, or when the delegation is prohibited under State law or by the facility’s own policies. §483.30(f) Performance of physician tasks in NFs. At the option of State, any required physician task in a NF (including tasks which the regulations specify must be performed personally by the physician) may also be satisfied when performed by a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility but who is working in collaboration with a physician. INTENT §483.30(e)(1)&(4) To allow the physician, under certain conditions, to delegate tasks to a nurse practitioner, clinical nurse specialist or physician assistant, working under the physician’s supervision. DEFINITIONS §483.30(e)(1) & (4) “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. “Nurse practitioner” is a registered professional nurse who is currently licensed to practice in the State, who meets the State’s requirements governing the qualification of nurse practitioners and who meets one of the following conditions: (1) is currently certified as a primary care nurse practitioner by the American Nurses’ Association or by the National Board of Pediatric Nurse Practitioners and Associates; or (2) has satisfactorily completed a formal 1 academic year educational program that (i) prepares registered nurses to perform an expanded role in the delivery of primary care; (ii) includes at least 4 months (in the aggregate) of classroom instruction and a component of supervised clinical practice; and (iii) awards a degree, diploma or certificate to persons who successfully complete the program; or (3) has successfully completed a formal educational program (for preparing registered nurses to perform an expanded role in the delivery of primary care) that does not meet the requirements above and has been performing an expanded role in the delivery of primary care for a total of 12 months during the 18-month period immediately preceding September 22, 2006. “Physician assistant” is a person who meets the applicable State requirements governing the qualifications for assistants to primary care physicians, and who meets at least one of the following conditions: (1) is currently certified by the National Commission on Certification of Physician Assistants to assist primary care physicians; or (2) has satisfactorily completed a program for preparing physician’s assistants that (i) was at least 1 academic year in length; (ii) consisted of supervised clinical practice and at least 4 months (in the aggregate) of classroom instruction directed toward preparing students to deliver health care; and (iii) was accredited by the American Medical Association’s Committee on Allied Health Education and Accreditation; or (3) Has satisfactorily completed a formal educational program (for preparing physician assistants) that does not meet the requirements above and has been assisting physicians for a total of 12 months during the 18-month period that ended on December 31, 1986. “Non-physician practitioner (NPP)” is a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA) as defined above. GUIDANCE §483.30(e)(1) & (4) The extent to which physician services may be delegated to NPPs in SNFs is governed by the provisions of §483.30(e), while the extent to which these services may be performed by NPPs in NFs is governed by the provisions of §483.30(f). (Refer to table in F712). In SNFs, when personal performance of a particular task by a physician is specified in the regulations, performance of that task cannot be delegated to anyone else. The tasks of examining the resident, reviewing the resident’s total program of care, writing progress notes, and signing orders may be delegated unless prohibited by State law or facility policies. PROBES §483.30(e)(1) & (4) • Do the attending physicians delegate tasks to NPPs? • If the physician delegates tasks to NPs or PAs, does the NP or PA meet the requirements in §491.2? • If the physician delegates tasks to CNSs, is the CNS licensed as such by the State? • Do NPPs follow the scope of practice allowed by State law in conducting examinations, evaluations, writing progress notes and orders? • Does the physician supervise the NPP in the SNF? Examples of supervision may include face-to-face encounters, clinical record reviews, telephone consults, e- mail, telehealth, and electronic health records. DEFINITIONS §483.30(f) “Collaboration” is a process often governed by the laws of a given State in which a non- physician practitioner (NPP) works with one or more physicians to deliver health care services within the scope of the NPP’s expertise, with medical direction and appropriate supervision as provided for in jointly developed guidelines or other mechanisms. In the absence of State law governing collaboration, such collaboration is to be evidenced by NPPs documenting the NPP’s scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice. The collaborating physician does not need to be present with the NPP when the services are furnished or to make an independent evaluation of each resident who is seen by the NPP. GUIDANCE §483.30(f) At the option of the State, NPPs in a NF, who are not employees of the facility, may perform physician tasks including performing examinations, evaluations, required visits and writing orders. If the physician delegates the task of performing visits to the NPP, the NPP must meet all of the requirements for • §483.30(a), F710, physician supervision • §483.30(b), F711, physician visits • §483.30(c), F712, physician frequency and timeliness of visits NOTE: If concerns are identified regarding the NPP meeting the requirements for physician supervision, physician visits or frequency and timeliness of visits, investigate under the corresponding regulation. Orders written by a NPP who is employed by the NF and are written during visits that are not required visits, and are therefore “other medically necessary visits,” do not require physician co-signature except as mandated by State law. PROBES: §483.30(f) • If the physician delegates the performance of required physician tasks to the NPP in the NF, is the delegation allowed by the State? • When performing physician tasks in the NF, is the NPP functioning within their scope of practice as permitted in their State? • If a NPP is performing required physician visits in the NF, is the NPP an employee of the facility? (Facility employees are prohibited from serving in this capacity.) • How does the facility ensure the NPP is working in collaboration with the physician?