CMS SOM App. PP, Tag F710

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.