CMS SOM App. PP, Tag F712

§483.30(c)(1) The resident must be seen by a physician at least once every 30 days

for the first 90 days after admission, and at least once every 60 days thereafter.

§483.30(c)(2) A physician visit is considered timely if it occurs not later than 10 days

after the date the visit was required.

§483.30(c)(3) Except as provided in paragraphs (c)(4) and (f) of this section, all

require physician visits must be made by the physician personally.

DEFINITIONS §483.30(c)

Must be seen, for purposes of the visits required by §483.30(c)(1), means that the

physician or NPP must make actual face-to-face contact with the resident, and at the

same physical location, not via a telehealth arrangement. There is no requirement for

this type of contact at the time of admission, since the decision to admit an individual

to a nursing facility (whether from a hospital or from the individual’s own residence)

generally involves physician contact during the period immediately preceding the

admission.

“Non-physician practitioner (NPP)” means a nurse practitioner (NP), clinical nurse

specialist (CNS) or physician assistant (PA).

GUIDANCE §483.30(c)

The timing of physician visits is based on the admission date of the resident.

In a SNF, the first physician visit (this includes the initial comprehensive visit) must

be conducted within the first 30 days after admission, and then at 30 day intervals up

until 90 days after the admission date. After the first 90 days, visits must be conducted

at least once every 60 days thereafter.

Permitting up to 10 days’ slippage of a due date will not affect the next due date.

However, do not specifically look at the timetables for physician visits unless there is

indication of inadequate medical care. The regulation states that the physician (or

his/her delegate) must visit the resident at least every 30 or 60 days. There is no

provision for physicians to use discretion in visiting at intervals longer than those

specified at §483.30(c), F712. Although the physician may not delegate the

responsibility for conducting the initial visit in a SNF, NPPs may perform other

medically necessary visits prior to and after the physician’s initial visit, as allowed by

State law.

After the initial physician visit in SNFs, where States allow their use, an NPP may

make every other required visit. (See §483.30(e), F714 Physician delegation of tasks in

SNFs.) These alternate visits, as well as medically necessary visits, may be performed

and signed by the NPP. (Physician co-signature is not required, unless required by

State law).

In a NF, the physician visit requirement may be satisfied in accordance with State law

by an NPP who is not an employee of the facility but who is working in collaboration

with a physician and who is licensed by the State and performing within the state’s scope

of practice. (See §483.30(f)).

In a NF, medically necessary visits performed by NPPs employed by the facility, may

not take the place of physician required visits, nor may the visit count towards meeting

the physician visit schedule prescribed at §483.20(c)(1).

In SNFs and NFs, facility policy that allows NPPs to conduct required visits,

and/or allows a 10-day slippage in the time of the required visit, does not

relieve the physician of the obligation to visit a resident personally when the

resident’s medical condition makes that visit necessary.

Table 1: Authority for Non-Physician Practitioners to Perform Visits,

Sign Orders and Sign Medicare Part A Certifications/Re-certifications

when Permitted by the State

Initial

Comprehensive

Visit

Admission

Orders*

Other

Required

Visits &

Orders^

Other

Medically

Necessary

Visits &

Orders+

Certification/

Recertification

±

SNFs

PA, NP &

CNS

employed by

the facility

May not perform May not

provide

May

perform

alternate

visits and

sign

May perform

and sign May not sign

PA, NP &

CNS not a

facility

employee

May not perform May not

provide

May

perform

alternate

visits and

sign

May perform

and sign

May sign as

permitted under

State laws.

NFs

PA, NP, &

CNS

employed

by the

facility

May not perform May not

provide

May not

perform or

sign

May perform

and sign Not applicable

PA, NP, &

CNS not a

facility

employee

May perform

May provide* May perform

and sign

May perform

and sign Not applicable

*A NPP may provide admission orders if a physician personally approved in writing a

recommendation for admission to the facility prior to the resident’s admission. For

additional requirements on physician recommendation for admission and admission

orders, see §483.30(a), F710.

^ Other required visits are the physician visits required by §483.30(c)(1) other than the

initial comprehensive visit.

+ Medically necessary visits are independent of required physician visits §483.30(c)(1)

and may be performed prior to the initial comprehensive visit as permitted under state

laws.

±Though not part of a compliance determination for this section, this column is provided

for clarification and relates specifically to coverage of a Part A Medicare stay

requirements, which can take place only in a Medicare-certified SNF.

In a facility where beds are dually-certified under Medicare and Medicaid, the facility

must determine how the particular resident stay is being paid in order to identify

whether physician delegation of tasks is permissible and if an NPP may perform the

tasks. For example:

• For residents in a Part A Medicare stay, the NPP must follow the requirements

for physician services in a SNF. This includes, at the option of a physician,

required physician visits alternated between personal visits by the physician and

visits by an NPP after the physician makes the initial comprehensive visit; and

• For residents in a Medicaid stay, the NPP must follow the requirements for

physician services in a NF. An NPP who is not employed by the facility and is

working in collaboration with a physician may perform any required physician

task for a resident in a Medicaid-stay, at the option of the State. (NPPs

employed by the facility may not perform required physician visits but may

perform other medically necessary visits)

It is expected that visits will occur at the facility rather than the doctor’s office unless

office equipment is needed or a resident specifically requests an office visit. If the

facility has established policy that residents leave the grounds for medical care, the

resident does not object, and this policy does not infringe on his/her rights including the

right to privacy, there is no prohibition to this practice. The facility should inform the

resident of this practice, in accordance with §483.10(g)(16), F581, Notice of rights and

services.

Certifications/Re-certifications in SNFs: Under 42 CFR §424.20, certifications and re-certifications are required to verify that a resident requires daily skilled nursing care or

rehabilitation services. NPs, CNSs, and PAs who are not employed by the facility and

who are working in collaboration with a physician may sign the required initial

certification and re- certifications when permitted under the scope of practice for the

State. 42 CFR §424.20(e)(2).

PROBES §483.30(c)

• Does the scheduling and frequency of physician visits relate to any identified

quality of care problems?

• If the resident is admitted under a SNF stay, did the physician conduct the initial

comprehensive visit, in-person, within the first 30 days?

• If the resident is admitted under a NF stay, did the physician or an NPP who is

not employed by the facility but who is working in collaboration with a

physician conduct the initial comprehensive visit, in-person, within the first 30

days?

• Are physician visits conducted at the required intervals, with no more than 10

days slippage from the due date?

• In a SNF, if the physician delegates required visits to an NPP, does the

physician personally conduct alternate visits with the NPP as required?

• Does the resident or resident representative report meeting with the physician?

If so, how often?

POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION

If the failure of the physician to visit the resident at the required intervals resulted in a

negative outcome to the resident, also investigate compliance with §483.30(a), F710,

Resident’s care supervised by a physician.

DEFICIENCY CATEGORIZATION

An example of Level 4, immediate jeopardy to resident health and safety, includes,

but is not limited to:

• The facility failed to ensure the attending physician conducted required visits

for several consecutive months in the facility. The physician responded to

phone calls and provided verbal orders during this time-frame, however did not

visit and make face-to-face contact with the resident, who experienced a

significant negative change in status. No other physicians or NPPs visited the

resident. This placed the resident at risk for serious harm or death.

An example of level 3, actual harm that is not immediate jeopardy, includes, but is

not limited to:

• A resident newly admitted to the facility and determined to be at high risk of

developing a pressure ulcer/injury, developed an unstageable pressure ulcer

during the first 30 days. While the physician was consulted by telephone, the

facility failed to ensure the physician conducted an initial comprehensive visit

for over 40 days, contributing to the decline in the resident’s skin status.

Examples of Level 2, no actual harm, with potential for than more than minimal

harm, that is not immediate jeopardy, includes, but is not limited to:

• The facility failed to ensure the physician personally conducted an initial

comprehensive visit within the first 30 days after admission, for a resident

under a Medicare Part A stay.

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 facility failed to ensure that the attending physician alternated required

monthly visits with the Nurse Practitioner (NP) as required for a resident under

a SNF stay. A review of the Progress Notes revealed that notes were written,

signed and dated by the NP for several consecutive visits, and all of the

resident’s needs were met. No documentation was found to indicate that the

attending physician had visited and examined the resident at least once every

30 days for the first 90 days after admission or at least once every 60 days

thereafter during this time.