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Intro by Flora Bessey, PharmD, CGP You asked and we answered!!! We have had great success with the ask a question feature of our website. Many of you have reached out asking questions of our editorial staff. We are happy to say we have kept our promise of trying to answer the question ourselves or referring them to one of our board members or colleagues. This is one of the great benefits of CALTCM and the Wave...you have a virtual panel of experts at your fingertips. Take a look at the question/answers as a result of the ASK feature...and keep your questions coming because we love to learn from you as we investigate the answer. Question:In our facility we are now using Electronic Medical Records. However, for our physicians’ progress notes, we are allowed to dictate our notes, since doctors are not in the facility everyday, how many days usually is allowed from the time the transcription is done to the time it should be placed in EMR, since right now only the dictating doctor can enter his own note in EMR? Answer:To my knowledge, there is no explicit requirement in any of the regulations. Ideally it should be real-time, but in real life I know there are many healthcare systems (at least in my neighborhood) where it can take 5 days or more to get the dictated notes faxed to the facility from the transcription service or main office of the clinician. While that is not ideal--especially for more ill, post-acute patients who may be seeing multiple clinicians--I don't think it is unacceptable under our current system. A facility can create its own policy and try to require that docs follow it, to the extent they can enforce it. One thing we do in my buildings, mainly for compliance with CDPH purposes, is to require that if a doc or NP sees a patient and dictates a note, they need to hand-write something in the record documenting that they saw the patient and "dictated note to follow" or something along those lines. In an EHR, if there is a portal for physician progress notes, the same should probably apply. The CALTCM ASK Team Question:We have had some staffing challenges and wanted to be very clear on the required visits; We have always tried to see everyone within 72 hours and every 30 days, but can't now. I understand that for "skilled" patients the requirement is a comprehensive visit within 72 hours, visits every 30 days for the first 90 days then every 60 days if they are medically stable; One question that comes up is when one of our patients is transferred to a different SNF; Same doctor (or group of doctors). Do they need a new comprehensive eval? Can they just be seen in the usual rotation? Also for readmissions -- do we need to do another comprehensive eval? The other confusion is how the requirements differ if the patient is "custodial" (NF vs SNF). Do they have the same 72 hour rule for the comprehensive assessment or is it 5 days before or 30 days after admission? How about their re-admissions? and transfers from one facility to another? How about when a patient changes MD's? Can they be seen within 30 days of their last MD visit or do they need to be seen within 72 hours? Do they need to be seen every 30 days for the first 90 days as well? When we don't comply, what are the ramifications....... Answer:As far as we know: Operative regulations are the CFR483.40(c).
Frequency of physician visits Tag #: F387 for the Federal regulations:
A resident "must be seen" by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 days thereafter.
The timing of a physician visit is based on the admission date of the resident. Visits must be made within the first 30 days, and then at 30-day intervals up until 90 days after the admission date. Visits must then be at 60-day intervals. Permitting up to 10 days slippage of a due date will not affect the next due date. However, do not specifically look at timetables for physician visits unless there is indication of inadequate medical care. "Must be seen" means that a physician must make actual face-to-face contact with the resident. 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 generally involves physician contact during the period immediately preceding the admission. And the California regulations Title 22: §72303. Physician Services--General Requirements
(a) Physician services shall mean those services provided by physicians responsible for the care of individual patients in the facility. All persons admitted or accepted for care by the skilled nursing facility shall be under the care of a physician selected by the patient or patient's authorized representative.
(b) Physician services shall include but are not limited to:
(1) Patient evaluation including a written report of a physical examination within 5 days prior to admission or within 72 hours following admission
(2) An evaluation of the patient and review of orders for care and treatment on change of attending physicians.
(3) Patient diagnoses.
(4) Advice, treatment and determination of appropriate level of care needed for each patient.
(5) Written and signed orders for diet, care, diagnostic tests and treatment of patients by others. Orders for restraints shall meet the requirements of Section 72319(b).
(6) Health record progress notes and other appropriate entries in the patient's health records.
(7) Provision for alternate physician coverage in the event the attending physician is not available.
(c) Nonphysician practitioners may be permitted to render those medical services which they are legally authorized to perform. Nonphysician practitioners means any of the following:
(1) Physicians' assistants working under the responsibility and supervision of a physician approved as a supervisor by the Board of Medical Quality Assurance and performing only those selected diagnostic and therapeutic tasks identified in Title 16, California Administrative Code, Chapter 13, Subchapter 3, Article 5.
(2) Registered nurses may perform patient care services utilizing "Standardized Procedures" which have been approved by the medical staff, or by the medical director if there is no organized medical staff, the registered nurse and the administrator as authorized in the Business and Professions Code, Chapter 5, Article 2, Section 2725. and also: §72307. Physician Services--Supervision of Care.
(a) Each patient admitted to the skilled nursing facility shall be under the continuing supervision of a physician who evaluates the patient as needed and at least every 30 days unless there is an alternate schedule, and who documents the visits in the patient health record.
(b) Alternate schedules of visits shall be documented in the patient health record with a medical justification by the attending physician. The alternate schedule shall conform with facility policy.
I do not think that the destinations of NF versus SNF have anything to do with this - the requirements are the same. I do think that since visits are due “as needed” a sicker post acute patient may require more frequent visits, but the bare minimum is no different under the regulations. Since the initial evaluation is part of the facilities development of a comprehensive care plan, it is necessary for any readmission and any transfer to a new facility exactly as in the regulations above. Note that the timing of the initial visit is dictated by the more stringent California regulations not the Federal. Since these are regulations for the facility not the physician, actually the punishment for not abiding by them is meted out on the facility rather than the attending. Also, in legal cases the failure to abide by the regulations will not be viewed favorably by a jury. The CALTCM ASK Team
Question:May a Nurse Practitioner fill out and sign the State form for RCFE? Or should it be reserved for MD only? Answer:Yes, a nurse practitioner is allowed to sign a Physicians Report form. (See link for further details.) The CALTCM ASK Team Want to discuss this article in the CALTCM Blog? Click here now! |