In calendar year 2023, F712 (Physician Visits – Frequency/Timeliness/Alternate Nonphysician Practitioners (NPPs)) was the most frequently cited F-tag among the six physician services citations—and only 0.8 percent of nursing homes received that citation, according to QCOR data released April 10, 2024. For immediate jeopardy citations, F710 (Resident’s Care Supervised by a Physician) led the pack at a miniscule 0.01 percent of providers being cited.
“It’s very rare for surveyors to issue citations for physician services because the federal regulations are clear,” acknowledges Liz Wheeler, BSN, RN, CHPN, CDP, IPCO, QCP, a nurse consultant with LeaderStat in Powell, OH. “For example, physician visits must occur—and orders must be signed—at least every 30 days for the first 90 days after admission and then a minimum of every 60 days. And in a skilled nursing facility (SNF), an NPP can make alternate required visits and sign orders at those visits after the initial physician visit if that’s allowed by the state.”
CMS actually defers to state regulations quite often in the physician services F-tags, adds Wheeler. “So, a lot of the requirements that facilities must follow change from state to state even though there are federal regulations.”
The primary federal requirements for physician services in nursing homes are laid out under §483.30 of 42 Code of Federal Regulations (CFR) subpart B. (See the excerpt at the end of this article.) These regulations are explained further in Appendix PP of the State Operations Manual in the following F-tags:
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Despite how uncommon physician services citations are, the director of nursing services (DNS) still can reap benefits from paying a little extra attention to physicians, suggests Wheeler. “The intent of these regulations boils down to quality of care. Sometimes, that intent can be missed when nursing homes never look past the technical requirements of the F-tags (e.g., the timing and documentation requirements for physician visits).”
The DNS’s goal should be to create a relationship with physicians that is not just about paperwork, suggests Wheeler. “Your relationship should be centered around a team focus on quality of care. If you make the physicians a part of your team and involve them in your quality initiatives, that will not only improve your quality of care. It also will make the conversation easier when you do have to ask a physician, ‘We’re still waiting on your progress notes from last month. Can you send them?’”
Some steps that the DNS may be able to take (depending on the situation at each facility) to collaborate with attending physicians and NPPs to improve quality of care include the following:
Set up regular meetings with the medical director
The medical director plays a key role in the DNS’s ability to work effectively with physicians, says Wheeler. Under §483.70(h)(2) in 42 Code of Federal Regulations (CFR) subpart B, the medical director is responsible for both “implementation of resident care policies” and “the coordination of medical care in the facility.”
F-tag 841 (Responsibilities of Medical Director) in Appendix PP of the State Operations Manual expands upon those regulatory requirements, noting that, among other responsibilities, the medical director must take on the following duties:
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“You can’t afford to have a culture of ‘We only call the medical director when, for example, we need this signed or when we need them to attend quarterly Quality Assessment and Assurance (QAA) committee meetings,’” explains Wheeler. “Getting the medical director more involved with the physicians is directly related to increasing your quality of care.”
So, it’s imperative that the DNS have some type of periodic meeting scheduled with the medical director, stresses Wheeler. “That meeting can be virtual or in person. But, you want to sit down and have that conversation: What are the facility’s current quality initiatives? What are some of your clinical concerns as the DNS? Or, have there been regulatory updates that will impact what you need from the medical director or the attending physicians?”
Many medical directors do want to be actively involved in improving the quality of care provided to nursing home residents, says Wheeler. “In my experience, they often just don’t necessarily know what their role could be above and beyond the regulations. So, it falls on you to extend the olive branch and initiate that conversation to move forward as a team.”
However, some medical directors may not want to have another meeting added to their workload, points out Wheeler. “In that situation, you can work with the medical director to find different ways to communicate. For example, you could send them a snapshot e-mail or some type of brief summary of the data points that you want them to review and provide input on.”
Invite physicians to QAA meetings and beyond
The first step toward promoting the active involvement of physicians is to invite them to participate in QAA meetings, suggests Wheeler. “In fact, it’s a good idea to invite them to participate in any initiatives you have that relate to clinical quality.”
Another option is to organize monthly physician meetings, says Wheeler. “You can discuss clinical concerns, as well as regulatory updates, directly with the physicians, and this will ensure that you get their perspective on those areas of focus.”
In nursing homes where physicians are more readily available throughout the week, involving them in interdisciplinary meetings also can be beneficial, adds Wheeler. “This won’t work in nursing homes where physicians visit only on the schedule driven by the regulations, such as those located in rural areas. However, in centers where physicians are available, you also could invite them to provide feedback when, for example, the interdisciplinary team meets because one of their residents has been falling frequently, or you could even invite one or two to an interdisciplinary falls meeting if you begin triggering for falls with major injury.”
Be consistent and goal-specific in meetings
The DNS should ensure that the entire interdisciplinary team uses consistent data across all meetings, says Wheeler. “For example, if you hold a monthly physician meeting and use data points of high-risk areas (e.g., weight loss or skin issues), you want to use the same data that you are using for your Quality Assurance and Performance Improvement (QAPI) program in QAA meetings. Whether you are using your own data pulled from your electronic medical record (EMR) or Nursing Home Quality Initiative (NHQI) or Skilled Nursing Facility Quality Reporting Program (SNF QRP) quality measure (QM) reports from iQIES, consistency is what’s important. The physicians should be reviewing the same data as the rest of the interdisciplinary team.”
In addition, the DNS needs to clarify the facility’s goals for the physicians, says Wheeler. “If physicians understand your goals, they can be aligned and make valuable contributions. If they aren’t sure what your goals are, it’s difficult for them to be a part of the conversation.”
Note: The AAPACN article “How to Lead Effective Meetings” can help the DNS ensure that the medical director and other physicians find facility meetings productive. Additional resources include the American Medical Association’s educational module Team Meetings: Strengthen Relationships and Increase Productivity; module 22, Running Effective Meetings and Creating Capacity for Practices to Run Effective Meetings, in the Primary Care Practice Facilitation Curriculum from the Agency for Healthcare Research and Quality (AHRQ); and the article “How to Hold an Effective Meeting” from the International Journal of Surgery: Oncology.
Encourage virtual participation in meetings
“You should always offer a virtual option for physician participation,” says Wheeler. “Whatever software you have available, giving physicians the choice to participate virtually in any meeting that you invite them to—whether that’s a QAA meeting, an interdisciplinary team meeting, or a monthly physician meeting—can open up some additional opportunities to build a relationship and obtain their feedback.”
Implement nurse/physician rounding
A long-term goal for some nursing homes could be to initiate nurse/physician rounding, says Wheeler. “When nursing professionals and physicians round together, it’s an opportunity to exchange information, and that alone can directly equate to better quality of care. In addition, the physicians can show nurses different assessment techniques, or they can provide real-time education about medications or disease progression.”
Nursing homes across the country have implemented nurse/physician rounding, says Wheeler.
“However, it may not be feasible for all facilities. For example, if you are in a rural area, you may not have the ability to have a nurse manager round when the physician comes in.”
If rounding is possible, the DNS should meet with the physicians and the medical director to discuss this potential initiative, says Wheeler. “You want to share the goals that you are trying to achieve, such as better quality of care, nurse education, and clearer communication.”
Most physicians are open to having a nurse take them room to room to give clear assessment data for each resident’s care and assist with documentation, notes Wheeler. “However, everyone has a different personality. So, you need to be sure that you choose the best nurses to round with physicians. Any participating nurse will need to have the appropriate data (e.g., vitals, medication changes, and any changes in condition) readily available to discuss when the physician is ready to round.”
In addition, both the nurses and the physicians must understand why they will round together, says Wheeler. “You should share your expectations and goals because you need buy-in from both groups to be successful.”
| §483.30 (Physician Services) 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. a) Physician supervision. The facility must ensure that— 1. The medical care of each resident is supervised by a physician; and 2. Another physician supervises the medical care of residents when their attending physician is unavailable. b) Physician visits. The physician must— 1. Review the resident’s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; 2. Write, sign, and date progress notes at each visit; and 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. c) Frequency of physician visits. 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. 2. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. 3. Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally. 4. At the option of the physician, required visits in SNFs after the initial visit may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist in accordance with paragraph (e) of this section. d) Availability of physicians for emergency care. The facility must provide or arrange for the provision of physician services 24 hours a day, in case of an emergency. e) Physician delegation of tasks in SNFs. 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. 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. 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. 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. f) Performance of physician tasks in NFs. At the option of the 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. |
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