This F-Tag governs nursing facilities (skilled nursing facilities/nursing homes) under 42 CFR §483.30 and §483.35, addressing physician delegation of dietary and therapy order-writing to qualified dietitians and therapists, and nursing services staffing requirements. Facility operators must ensure that any delegation of order-writing is authorized by state law, that the delegating physician maintains supervisory responsibility, and that physician co-signature is obtained when required by state law. Facilities must also maintain sufficient nursing staff with appropriate competencies to meet resident needs as determined by assessments and care plans.
View official sourceF715 (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) §483.30(e)(2) A resident’s attending physician may delegate the task of writing dietary orders, consistent with §483.60, to a qualified dietitian or other clinically qualified nutrition professional who— (i) Is acting within the scope of practice as defined by State law; and (ii) Is under the supervision of the physician. §483.30(e)(3) A resident’s attending physician may delegate the task of writing therapy orders, consistent with §483.65, to a qualified therapist who— (i) Is acting within the scope of practice as defined by State law; and (ii) Is under the supervision of the physician INTENT §483.30(e)(2)-(3) To provide physicians with the flexibility to delegate to a qualified dietitian/other clinically qualified nutrition professional the task of writing dietary orders, and to delegate to a qualified therapist the task of writing therapy orders. This flexibility is beneficial to the physician and the resident, allowing the physician to determine how to best use his or her time and allowing the resident to have more frequent adjustments to nutritional needs and therapy as his or her condition or abilities change. DEFINITIONS §483.30(e)(2)-(3) “Qualified dietitian” – is defined in §483.60 as follows: §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who— (i) Holds a bachelor’s or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a “registered dietitian” by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. “Qualified therapist” – professional staff, licensed, certified or registered to provide specialized therapy/rehabilitative services in accordance with State laws. Includes: Physical, Occupational, and Respiratory therapists and Speech-Language Pathologists. GUIDANCE §483.30(e)(2)-(3) Physicians and NPPs may delegate the task of writing orders to qualified dietitians or clinically qualified nutrition professionals and qualified therapists if the State practice act allows the delegation of the task, and the State practice act for the qualified individual being delegated the task of writing orders permits such performance. Delegation of this task does not relieve the physician of the obligation to supervise the medical care of his/her residents. Physician responsibilities related to physician supervision of resident care are located in §483.30(a), F710, and physician obligations for conducting resident visits are located at §483.30(b), F711. Dietary orders written by a qualified dietitian/clinically qualified nutritional professional, or therapy orders written by therapists, do not require physician co-signature, except as required by State law. PROBES 483.30(e)(2)-(3) • If the dietitian/other clinically qualified nutrition professional is writing dietary orders, or a qualified therapist is writing therapy orders, did the attending physician delegate this task? • If State law allows dietitians or other clinically qualified nutrition professionals to write dietary orders, are they functioning within the scope of practice defined by State law? • If State law allows therapists to write therapy orders, are they functioning within the scope of practice defined by State law? • Do physicians cosign dietitian/other clinically qualified nutrition professional orders and/or therapists orders, if required by State law? • Is there evidence of physician supervision of dietitians/other clinically qualified nutritional professionals and/or qualified therapists who write orders? Examples of supervision may include face-to-face encounters, clinical record reviews, telephone consults, e-mail, telehealth, and electronic health records. • When facility policy and State law allows physicians to delegate the task of writing orders to qualified dietitians, other clinically qualified nutrition professionals and qualified therapists, how does the facility ensure the physician supervision of individuals performing these tasks? §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well- being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.71. Always, review nursing services requirements under §483.35 during a standard or extended survey, when a waiver of RN and/or licensed nurse (RN/LPN) staffing has been requested or granted, or if a complaint has been received regarding nursing services. If the survey investigation reveals that there are not sufficient or competent staff refer to: • F725 or 726, §483.35(a),(c) for any nursing services not related to behavioral health care or dementia care; • F741, §483.40(a) for any staff caring for residents with dementia or a history of trauma and/or post-traumatic stress disorder; • F801, §483.60(a) for Food and Nutrition staff; • F826, §483.65(b), Specialized rehabilitative services; • F839, §483.70(e), Administration for any other staff not referenced above. Potential Requirements for Additional Investigation If noncompliance with §483.35 has been identified, the surveyor may have identified concerns with related structure, process, and/or outcome requirements. If any additional concerns have been identified, the surveyor must investigate the identified concern. Do not cite any related or associated requirements before first investigating to determine compliance or noncompliance with the related or associated requirement. Examples include, but are not limited to, the following: • Freedom from abuse, neglect, and exploitation, §483.12; • Quality of Life, §483.24; • Quality of Care, §483.25; • Behavioral Health Services, §483.40; • Administration §483.70, Staff Qualifications §483.70(e), or Use of Outside Resources §483.70(f); • §483.71 Facility Assessment • Quality Assurance and Performance Improvement §483.75; • Training, §483.95.