University of Minnesota Long Term Care Resource Center
http://www.sph.umn.edu/hpm/ltcresourcecenter/
612-624-5171

Physician Services

 

Description of Federal Requirements
Comparison of State Requirements
Table Comparing States
Complete Transcript of State Requirements on Physician Services (PDF)

Federal Regulations & Related F-tags for 483.40 Applicable Federal Regulation
(a) Physician Services | F385
(1) Physician visits | F386
(c) Frequency of physician visits | F387-F388
(d) Availability of physicians for emergency care | F389
(e) Physician delegation of tasks in SNFs | F390
 
  • 483.40 Physician Services
  •  

    Description of Federal Requirements    (TOP)    (NEXT)

    Section 483.40, the federal standard specifically pertaining to physician services, specifies that each resident must have an attending physician and a backup physician when that attending physician cannot be reached.  The attending physician must, in writing, recommend admission to the nursing home.  The facility is responsible for ensuring that each resident have an attending physician and a backup plan, and the attending physician is responsible for ongoing supervision and review of the resident’s “total program of care, including medications and treatments” at each visit.  During each visit, the physician must also sign and date progress notes and orders. 

    Residents must be seen by a physician once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.  Physician visits are considered timely if they occur no later than 10 days after the required date.   Physicians may opt to alternate their visits with a physician assistant, nurse practitioner, or clinical nurse specialist (as allowed by state law) as long as those individuals are overseen by the physician and not employed by the nursing home. Physicians may delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist who is licensed by the State, acts within the scope of practice for that occupation, and is not employed by the facility.

    This rather brief regulation places responsibility on both the physician and the facility: the facility must ensure that each resident has a physician and a backup physician, and the physicians are expected to meet regulatory expectations.

    Additionally, the federal regulation 483.75 on Administration, section (i) requires that the facility designate a physician as medical director, and that the medical director be responsible for implementing resident care policies and coordinating medical care in the facility.  Because medical directors often serve as attending physicians for high proportions of the residents in facilities where they hold that appointment, discussion of medical director and physician services are intertwined.

    Physicians are mentioned in many other sections of the federal regulations as well.  Under Residents Rights 483.10 (d) (1), the resident has the right to “choose a personal attending physician.”   Further, under 483.10 (j), the resident has the right to receive visits from his or her individual physician and the facility must permit immediate access for such visits.  Also under resident’s rights, the facility must inform the resident of the name, address, and way to reach his/her physician.   Under 483.12 (a) (3), a physician must document the need for a transfer as part of the standards for “Admission, transfer and discharge rights.”  Under 483.35 (e), therapeutic diets must be ordered by physicians, and under 483.45 (a) (1) (b), special rehabilitation services must be provided “under written order of a physician.”  Under 483.60 (c) (2), the pharmacist must report any drug irregularities noted during mandated drug reviews to the attending physician, and these must be “acted upon.”  As part of the quality assurance requirements under administration, a physician must be named to the quality assurance committee.  Other parts of the administration standard require that the physician be notified of laboratory or radiological results.  

    Comparison of State Requirements      (TOP)    (NEXT)

    NOTE:  The examples below may not list all States with similar language; always check your state for specifics

    The Federal regulations for the responsibility of attending physicians (and surrogate nurse practitioners, medical assistants, and clinical nurse specialists), the responsibilities of medical directors, and the responsibilities of the facility in relation to ensuring medical care are in most respects general and terse.  Ten (10) States have adopted these Federal rules, either by default (as with Arizona, Kansas, Missouri, and New Hampshire, who have no State rules regarding physician services and medical directors) or by including language that echoes some or all of the Federal requirements (as with Alabama, Florida, Mississippi, Nebraska, and Utah).   Forty States have added some content that is not in the federal regulations, such as slight specifications (e.g., how and where the names and telephone numbers of backup physicians should be posted) or substantial elaborations on the expectations governing medical care and relationships among the key actors (resident and family, attending physician, medical director, and facility staff).  Variations related to medical directors include minimal credentials and articulation of roles and responsibilities.  Below we illustrate some of the variation on specific topics.  For full accounts by State, consult the regulations themselves.

    The medical director roles and the roles of attending physicians are inter-related in State statutes.  Whereas attending physicians are assigned particular oversight responsibilities and nurses are often charged with reporting various circumstances to the attending physicians (e.g., incidents, falls, drug reaction), the medical director typically has overall responsibility in State statute for assuring the performance of attending physicians and the availability of medical backup.

    Timing of Initial Physician Assessment      (TOP)    (NEXT)

    The federal rules do not specify when a physician must conduct the first assessment and examination of a new resident, but several states have rules on the subject.  The examples below range from within 48 hours of admission to within 2 weeks of admission with other differences in how pre-admission physicals are to be utilized or counted for the admission physical.

    - In CaliforniaIdaho, Rhode Island, and South Dakota the initial medical examination and assessment must be done within 48 hours unless one was performed in the 5 days prior to admission.

    - In Vermont the physical examination should be available at admission or within 48 hours after admission.

    - In Illinois  and West Virginia, the physical examination must be complete 72 hours after admission unless performed in the previous 5 days before admission.  In Louisiana, it must be done within 72 hours unless performed in the previous 30 days.  In Arkansas, the medical evaluation must be done within 72 hours of admission, unless performed within 15 days prior (or 20 days prior if the resident was admitted from the hospital, in which case the hospital discharge summary must be forwarded to the nursing home.

    - HawaiiMinnesota, and Maine all require the physical examination and assessment within a week of admission unless it had been done in the 5 days prior to admission.

    - Iowa states that each resident admitted to a nursing home must have had a physical examination prior to admission, but that for residents admitted directly from a hospital, “a copy of the hospital admission physical and discharge summary may be made part of the record in lieu of an additional physical examination.”

    - Oklahoma requires an admission history and physical within 2 weeks of admission unless such an assessment had been conducted in the previous 60 days. In Pennsylvania, the initial assessment needs to be on hand at admission or also be conducted no later than 14 days after admission.

    A few states have requirements about the time by which a discharge summary must be complete.  For example, inTexas, the attending physician must write, sign, and date a physician's discharge summary within 20 workdays of being notified by the facility of the discharge.  In Maryland, the attending physicians must provide a pertinent medical discharge summary within 30 days of discharge or transfer of the resident. 

    Authorizing and Signing Medical Orders      (TOP)    (NEXT)

    Federal requirements simply specify that physician orders, including medication orders, must be signed and dated.  States often provide detail on the timing and nature of ongoing medical orders.  These include specifications about telephone orders, such as who may receive them (typically a licensed nurse), how quickly signed orders must be in the chart, and what constitutes an acceptable signature.  Some states elaborate on orders by FAX.  In several states faxed or electronic signatures are specifically prohibited (e.g., Illinois), whereas Texas specifically permits Faxed and stamped signatures under particular conditions. Ohio recognizes the possibility of an electronic record with electronically signed notes.  Some states prohibit standing orders in most circumstances in some states.  Below are some examples of variation related to medical orders from 12 States that deal with the topic.

    - In Colorado, the facility shall take all necessary steps to assure  that telephone orders are received by a physician, licensed nurse or other appropriate disciplines as authorized by their professional licensure and are countersigned by the attending physician or dentist and entered in the record within 2 weeks.

    - Delaware requires that “all orders for medications, treatments, diets, diagnostic services, etc. shall be in writing and signed by the attending physician” and that all telephone orders be countersigned by the physician within 48 hours.”

    - In Illinois, physician treatment plans, orders and similar documentation shall have an original written signature of the physician.  Illinois regulations specifically state “a stamp signature, with or without initials, is not sufficient.”

    - In Indiana, verbal/telephone orders shall contain the date and time, physician's order, signature of the licensed nurse accepting the order, and the name of the physician giving the order. The physician must review the resident's total program of care as defined by the comprehensive assessment and care plan, including medications, and treatments, by signing and dating a recap of all current orders at each visit, and write, or cause to be written, sign, and date progress notes at each visit. Dictated notes must be filed in the clinical record within seventy-two (72) hours of the visit and signed within seven (7) days of the time the transcription is completed, and notes shall become part of the permanent record within seventy-two (72) hours unless an emergency situation warrants immediate documentation.  Verbal orders shall be countersigned and dated on the clinical record at the physician's next visit. The use of facsimile to transmit physicians’ orders is permissible.   Indiana also notes that “all matters of privacy and confidentiality of records shall be maintained.”

    - In Louisiana, if the orders are from a physician other than the resident's attending physician, they shall be communicated to the attending physician and verification entered into the resident's clinical record by the nurse who took the orders. Physician telephone/verbal orders shall be received only by physicians, pharmacists, or licensed nurses. These orders shall be reduced to writing in the resident's clinical record and signed and dated by the authorized individual receiving the order. Telephone/verbal orders shall be countersigned by the physician within seven days. Use of signature stamps by physicians is allowed when the signature stamp is authorized by the individual whose signature the stamp represents. The administrative office of the nursing home shall have on file a signed statement to the effect that the physician is the only one who has the stamp and uses it. There shall be no delegation of signature stamps to another individual.

    - In Maine, orders concerning medications and treatments shall be in writing, signed and dated by a physician and shall be in effect for the time specified by the physician, but in no case to exceed a period of sixty (60) days unless there is a written reorder. Further orders for Schedule II controlled substances shall be in effect for no longer than one (1) week, unless there are specific written orders to the contrary, and in no case be in effect for a period of more than thirty (30) days.

    - In North Carolina, medical orders, given orally by the physician, nurse practitioner or physician assistant, shall be given only to a licensed nurse or other licensed professional who by law is allowed to accept physician's orders, except orders for therapeutic diets which shall be given either to a dietitian or licensed nurse.  The record of each telephone order shall include the name of physician giving the order, or other person legally authorized to prescribe, date and time of order, content of order and name of person receiving the order.  The physician, or other person legally authorized to prescribe, who gives oral orders shall sign the orders within five days.

    - In Ohio, the nursing home shall not give any medication or treatment to any resident unless ordered by a physician or by other licensed health professionals, acting within their applicable scope of practice. If orders are given by telephone, they shall be recorded with the licensed health professional’s name and the date, and the order and signed by the person who accepted the order. All orders, including facsimile, telephone, or verbal orders, shall be signed and dated by the physician or other licensed health professional working in collaboration with the physician who gave the order within fourteen days after the order was given. Telephone orders shall not be accepted by a person other than a licensed nurse on duty, another physician or a pharmacist,  except that a licensed physical, occupational or respiratory therapist, audiologist, speech pathologist, dietitian, or other licensed health professional may receive, document and date medication and treatment orders concerning his or her specific discipline for residents under their care. The nursing home may accept signed orders issued by a licensed health professional having prescriptive authority by facsimile transmission if the home has instituted procedural safeguards for authenticating and maintaining confidentiality of the facsimile order, and for handling it in an expedient and priority manner.

    - In Oregon, physician's orders shall either be initially written and signed by the physician, nurse practitioner (NP) or physician assistant (PA), or given verbally or by telephone.  If given verbally or by telephone, the orders shall be accepted only by a licensed nurse and must be written and mailed to the physician, NP or PA within 72 hours to be signed and returned to the facility for filing in the resident's chart. Therapies and drugs not requiring prescription under ORS 689 may be ordered from standing orders of the attending physician, NP or PA.  Therapies and drugs so ordered shall be reviewed and signed at least annually by the attending physician.  Use of standing orders shall be authorized by licensed personnel and transcribed to the physician order form.

    - In Rhode Island, standing orders shall not be permitted.  All orders shall be recorded in the resident's medical record and shall be properly signed.  However, a physician's order for an individual resident may refer to treatments described in a written protocol that has been adopted by the facility. (Rhode Island allows an exception to prohibition of standing orders to permit standing orders for the administration of influenza and pneumococcal immunizations.

    - South Dakota treats medical orders in hospitals and nursing facilities together.  In each case, all medical orders must be in writing and signed by the physician or the physician extender.  Telephone orders may be taken only when there is an urgent need to initiate or change a medical order.  The physician or physician extender shall sign or initial the orders for nursing facility residents on the next visit to the facility.   

    - In Texas, attending physicians must write, sign, and date a physician's discharge summary within 20 workdays of being notified by the facility of the discharge, except as specified in §19.1912(e) of this title (relating to Additional Clinical Record Service Requirements), if the resident has been temporarily discharged for 30 days or less, and readmitted to the same facility; and  . . . Signature stamps and faxed signed documents are acceptable if used as described in §19.1912(f)(2) of this title (relating to Additional Clinical Record Service Requirements).

    - In Virginia, all verbal orders shall be immediately recorded and signed by the individual receiving them, and shall be countersigned by the prescribing person.  No further specificity is offered for when orders must be countersigned.

    Choice of Physician      (TOP)    (NEXT)

    A few states reiterate and clarify the resident’s right to choice of physician or describe limits to that choice (e.g., a teaching nursing home disclosed in advance to have a closed staff, or physician willingness to care for the resident) Some States specify responsibilities of the facility if the resident does not or cannot choose a physician or if the chosen physician fails to deliver care adequately.  For example:

    - In Idaho, each patient/resident shall be under the direct and continuing supervision of a physician of his own choice licensed by the Idaho Board of Medicine.

    - In Illinois, all residents, or their guardians, shall be permitted their choice of a physician.

    - In Louisianaeach resident shall remain under the care of a physician licensed to practice in Louisiana and shall have freedom of choice in selecting his/her attending physician.  

    - In Virginia, prior to, or at the time of admission, each resident, his designated representative, or the entity responsible for his care shall designate an attending physician.

    - In Rhode Island, all residents shall remain or be under the care of a physician of his or her choice, subject to the physician's concurrence.

    - In South Carolina, a facility shall not restrict a resident's, guardian's or representative's choice in attending physician coverage, provided that the physician agrees to, and demonstrates that he will, provide care in accordance with facility policy.

    The above-referenced six States express the right to choice simply, a few with additional caveats, such as (in Rhode Island and South Carolina) that the physician has to agree to accept the case and, as in South Carolina, that the physician must agree to follow facility policy.  Below are examples of States that incorporate instructions about the selection of a physician when the resident makes not choice.

    -  In New Mexico, each resident shall be under the supervision of a physician of the resident's or guardian's choice who evaluates and monitors the resident's immediate and long-term needs and prescribes measures necessary for the health, safety and welfare of the resident, but the nursing home shall be responsible for assisting in obtaining an attending physician, with the resident's or sponsor's approval, when the resident or sponsor is unable to find one.  

    - In Massachusetts, each patient or resident or (if he is not competent) his next of kin or sponsor shall on admission designate a physician, physician-physician assistant team or physician-nurse practitioner team to serve as his attending physician.  If the patient or resident does not have a physician, an attending physician or physician-physician assistant team or physician nurse practitioner team shall be designated by the facility with the approval of the patient or resident or his next of kin or sponsor. 

    - In North Carolinathe following rules are found under the heading “Private Physician:” (a) Each patient or legal representative shall be allowed to select his or her private physician except in those facilities affiliated with medical teaching programs and having written policies requiring all patients to participate in the medical teaching program.  (b)  The private physician shall fulfill given requirements as determined by applicable state and federal regulations and the facility's policies and procedures pertaining to physician services.  (c) The facility shall have the right, after informing the patient, to seek an alternative physician, when requirements are not being met and to ensure that the patient is provided with appropriate, adequate care and treatment.  [NH Regs Plus Comment: When a State requires an organized medical staff with standards established for acceptance as qualified to practice in the facility, the resident’s right to choice of physician is further qualified.  (At least 7 States, including Massachusetts, have rules that require or allow for an organized medical staff, described below.) In reality, the choice of physician tends to be far from absolute because of facility selection and physician self-selection; in turn, residents and their family members have an incentive to “choose” a physician who maintains a sizable presence in the nursing home if and when the resident’s physician prior to admission opts not to follow the patient to the facility.]

    Elements of Assessments and Medical Plan of Care      (TOP)    (NEXT)

    The Federal regulations hold physicians responsible for a total program of care.  By specifying elements of the initial medical examination or ongoing assessment and care plans, some States further suggest the components of a total program of care.  These elaborations are sometimes brief and sometimes quite detailed. 

    - Arkansas requires that the care be under the supervision of a physician, who based on a medical evaluation of the patient's immediate and long term needs (AR, prescribes a planned regimen of total care.  A Certification Statement by the physician explaining the reason for nursing home placement should be obtained on the date of admission and a re-certification statement obtained every sixty (60) days (AR).  

    - Colorado specifies that the facility shall take all necessary steps to assure that upon admission, the physician provides to the facility sufficient information to validate the admission and identify the resident and a medical plan of therapy to include diet, medications, treatments, special procedures, activities, specialized rehabilitative services, if applicable, and potential for discharge.

    - Illinois states that the medical examination report shall include at a minimum each of the following: 1) An evaluation of the resident's condition, including height and weight, diagnoses, plan of treatment, recommendations, treatment orders, personal care needs, and permission for participation in activity programs as appropriate; 2) Documentation of the presence or absence of tuberculosis infection by tuberculin skin test; 3) Documentation of the presence or absence of incipient or manifest decubitus ulcers with grade, size and location specified, and orders for treatment, if present.  (A photograph of incipient or manifest decubitus ulcers is recommended on admission.); 4) Orders from the physician regarding weighing of the resident, and the frequency of such weighing, if ordered.

    - In Kentuckythe health care of each patient shall be under supervision of a physician who, based on an evaluation of the patient's immediate and long-term needs, prescribes a planned regimen of medical care which covers indicated medications, treatments, rehabilitative services, diet, special procedures recommended for the health and safety of the patient, activities, plans for continuing care and discharge.

    - In Massachusetts, every patient or resident shall have a complete admission physical exam and medical evaluation.  Based on this information, the attending physician or physician-physician assistant team or physician-nurse practitioner team shall develop a medical care plan that shall include such information as the following: Primary diagnosis; Other diagnoses or associated conditions; Pertinent findings of physical exam (including vital signs and weight, if ambulatory); Weight shall be included for non-ambulatory patients in a SNCFC; Significant past history; Significant special conditions, disabilities or limitations; Prognosis; Assessment of physical capability (ambulation, feeding assistance bowel and bladder control); Assessment of mental capacity.  Further the Treatment Plan will include Medications, Special treatments or procedures, Restorative services, Dietary needs, Order of ambulation and activities, Special requirements necessary for the individual’s health or safety; Preventive or maintenance measures; Short and long term goals; Estimated length of stay.  [NH Regs Plus Comment: The inclusion of short and long term goals and estimate length of stay is unusual.]

    - In Minnesota, a physician or physician designee must provide the following information for the clinical record: A. the report of the admission history and physical examination; B.  the admitting diagnosis; C.  a description of the general medical condition, including disabilities and limitations; D. a report of subsequent physical examinations; E. instructions relative to the resident's total program of care; F.  written orders for all medications with stop dates, treatments, rehabilitations, and any medically prescribed special diets; G.  progress notes; H. any advanced directives; and I. condition on discharge or transfer, or cause of death.

    - In Oklahoma, the physician completes an admission history and physical that includes chief complaints, course of present illness, past medical history, and examination findings by body systems and diagnosis.

    - In Virginia a complete medical plan of care includes: 1. Primary diagnosis; 2. Identification of resident problems; 3. Medical history and physical exam; 4. Orders for medications; 5. Treatments; 6. Restorative services; 7. Activity levels; 8. Diet;  9. Special procedures recommended for health and safety of the resident; and 10. Advance directives, if known. [NH Regs Plus Comment: Note that Colorado, Illinois, Kentucky, Minnesota, and Virginia all envisage activities as part of the physician assessment and documentation, with Illinois specifying that “permission to participate in activities” be documented.  Such provisions may invite the physician to limit individual choice of residents.  Note, also that Minnesota and Virginia require inclusion of information on advance directives (in Virginia “if known), an area directly related to resident autonomy.   Colorado included potential for discharge in the assessment, which, combined with the inclusion of special rehabilitation, suggests a dynamic focus on helping residents to leave the nursing home, if they desire.]

    Medical Director      (TOP)    (NEXT)

    Federal regulations require the each nursing home have a medical director and that the medical director have responsibility for policy development and coordination of medical care.  Beyond requirements that many specialist referrals and referrals to ancillary health care be authorized by an physician, federal rules provide no detail on the scope of policy development or coordination, or the coordination between the attending physicians with, on the one hand, nursing home staff, and, on the other hand, specialists caring for the patient.   General federal requirements under Administration also call for the medical director to be legally qualified and licensed to practice in the State.  Some States amplify the credentials required.  For example, in New Jersey, the medical director is board-certified in a primary care specialty, such as family medicine, gerontology, or general internal medicine.  In Massachusetts, the medical director, who could be a staff or an advisory physician, shall spend at least four hours per month in the facility devoted to supervisory and advisory functions apart from any roles in patient care as attending physician.

    Below are examples of the way the role of medical director has been elaborated in various States:

    -  Ohio envisages an ambitious role for the medical director, summarized below (with omissions of some detail and statutory authorities, which are part of the full text) which includes leadership of a multidisciplinary care team, ongoing policy involvement, and substantial monitoring for quality. According to the rules, the Ohio medical director shall:

    (1) in collaboration with the administrator, the nursing director, and other health professionals, develop formal resident care policies for the nursing home that: (a)  Provide for the total medical and psycho-social needs of the resident, including admissions, transfer, discharge planning, range of services available to the resident, emergency procedures and frequency of physician visits in accordance with resident needs; b)  Promote resident rights;

    (2) Make available medical care for residents not under the care of their own physicians and to make available emergency medical care to all residents, provided their personal physicians are not readily available;

    (3)  Meet periodically with nursing and other professional staff to discuss clinical and administrative issues, including the need for additional staff, specific resident care problems and professional staff needs for education or consultants to assist in meeting special needs such as dentistry, podiatry, dermatology, and orthopedics, offer solutions to problems, and identify areas where policy should be developed. In carrying out this function, the medical director shall: (a)  Observe residents and facilities at least quarterly or more frequently as needed; and (b)  Review pharmacy reports, at least quarterly, including summaries of drug regimen reviews, and take appropriate and timely action as needed to implement recommendations;

    (4)  Monitor the clinical practices of, and discuss identified problems with, attending physicians; act as a liaison between the attending physicians and other health professionals caring for residents and the residents’ families; and intervene as needed on behalf of residents or the home’s administration;

    (5)  Maintain surveillance of the health of the nursing home's staff. 

    (6)  Assist the administrator and professional staff in ensuring a safe and sanitary environment for residents and staff by reviewing incidents and accidents, identifying hazards to health and safety, and advising about possible correction or improvement of the environment.

    Less elaborate statements in other States mandate similar activities:

    - In Oregon the medical director shall: (a) Serve on the Quality Assessment and Assurance Committee; (b) Assist the facility to assure that adequate medical care is provided on a timely basis in accordance with facility policy;  and (c) Serve as attending physician for those residents who are not able to obtain services of another physician or ensure another physician is available to serve as attending physician.

    - In Pennsylvaniathe medical director responsible for the overall coordination of the medical care in the facility to ensure the adequacy and appropriateness of the medical services provided to the residents. He or she  may serve on a full- or part-time basis depending on the needs of the residents and the facility and may be designated for single or multiple facilities. A written agreement will exist between him/her and the facility. The medical director’s responsibilities shall include at least the following:

    (1) Review of incidents and accidents that occur on the premises and addressing the health and safety hazards of the facility and giving the administrator appropriate information from the medical director to help insure a safe and sanitary environment for residents and personnel;

    (2) Development of written policies which are approved by the governing body that delineate the responsibilities of attending physicians.

    - In South Dakotathe medical director shall assure physician services are provided only by qualified caregivers.

    - Tennessee and Wisconsin illustrate more extensive lists of responsibilities (similar in scope to Ohio).  Both explicitly include monitoring the health status of employees to ensure that they pose no safety hazards to residents.

    - In Tennesseethe Medical Director shall: 1. Delineate the responsibilities of and communicate with attending physicians to ensure that each resident receives medical care; 2. Ensure the delivery of emergency and medical care when the resident’s attending physician or his/her designated alternate is unavailable; 3. Review reports of all accidents or unusual incidents occurring on the premises, identifying hazards to health and safety and recommending corrective action to the administrator; 4. Make periodic visits to the nursing home to evaluate the existing conditions and make recommendations for improvements; 5. Review and take appropriate action on reports from the Director of Nursing regarding significant clinical developments; 6. Monitor the health status of nursing home personnel to ensure  that  no health conditions exist which would adversely affect residents; and, 7. Advise and provide consultation on matters regarding medical care, standards of care, surveillance and infection control.

    - In Wisconsinthe Medical Director, pursuant to a written agreement with the facility, serves on a part-time or full-time basis.  He/she is responsible to coordinate medical care by developing written rules and regulations for attending physicians, and liaison with attending physicians to provide that physicians’ orders are written promptly upon admission of a resident, that periodic evaluations of the adequacy and appropriateness of health professional and supportive staff and services are conducted, and that the medical needs of the residents are met. Responsibilities to the facility include monitoring the health status of the facility’s employees, and reviewing incidents and accidents that occur on the premises to identify hazards to health and safety.

    Responsibilities of Attending Physician      (TOP)    (NEXT)

    Responsibilities for attending physicians need to be considered in tandem with those of the Medical Director, who often has explicit responsibility for ensuring that the attending physicians meet the responsibility.   [NH Regs Plus Comment: In actuality, the Medical Director often serves as attending physician for large proportions of the residents and must, in that capacity, meet attending physician standards.]

    - In Massachusetts, the medical director must spend at least four hours per month in the facility devoted to supervisory and advisory functions apart from any roles in patient care as attending physician. The specific requirements for timing of the initial physical examination and recording of progress notes described above can be embedded in a more general.   As seen in the previous section, some States require the Medical Director to serve as a backup attending physician when necessary; however, the attending physician is often also assigned responsibility for having backup coverage.  The facility may also have specific duties to notify the attending physician of various events or changes affecting their patients.  Some examples of duties related to attending physician follow;

    -  In California , 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 additional requirements cross-referenced to another section; (6) 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.

    - In Illinois, the facility shall notify the resident's physician of any accident, injury, or significant change in a resident's condition that threatens the health, safety or welfare of a resident, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days.  The facility shall obtain and record the physician's plan of care for the care or treatment of such accident, injury or change in condition at the time of notification. At the time of an accident or injury, immediate treatment shall be provided by personnel trained in first aid procedures.

    - In Iowa, the person in charge of the facility shall immediately notify the physician of any accident, injury, or adverse change in the resident’s condition. 

    - In Maryland, in care to a newly admitted resident, the attending physician shall:

    (1) Assess a new admission in a timely manner, based on a facility-developed protocol, depending on: (a) The individual's medical stability; (b) Recent and previous medical history; (c) Presence of significant or previously unidentified medical conditions; or  (d) Problems that cannot be handled readily by phone;

    (2) Seek, provide, and analyze needed information regarding a resident's current status, recent history, and medications and treatments, to enable safe, effective continuing care and appropriate regulatory compliance;

    (3) Provide appropriate information and documentation to support a facility-determined level of care for a new admission;

    (4) Provide for the authorization of admission orders in a timely manner, based on a facility-developed protocol, to enable the nursing facility to provide safe, appropriate, and timely care; and

    (5) For a resident who is to be transferred to the care of another health care practitioner, continue to provide all necessary medical care and services pending transfer until another physician has accepted responsibility for the resident.

    Additionally, to support Resident Discharges and Transfers, the attending physician shall:

    (1) Follow-up as needed with a physician or another health care practitioner at a receiving hospital within 24 hours of the transfer of an acutely ill or unstable resident;

    (2) Provide whatever summary or documentation may be needed at the time of transfer to enable care continuity at a receiving facility and to allow the nursing facility to meet its legal, regulatory, and clinical responsibilities for a discharged individual; and

    (3) Provide a pertinent medical discharge summary within 30 days of discharge or transfer of the resident.

    In terms of periodic, on-site visits to residents, the attending physician or licensed or certified professional health care practitioner shall

    (1) Visit a resident as frequently as the resident's condition requires, consistent with reasonable facility policies;

    (2) Determine the progress of each resident's condition at the time of a visit by evaluating the resident, talking with staff as needed, and reviewing relevant information, as needed;

    (3) Review and respond to issues requiring a physician's expertise, including: (a) The resident's current condition; (b) The status of any acute episodes of illness since the last visit; (c) Test results; (d) Other actual or high-risk potential medical problems that may affect the individual's functional, physical, or cognitive status; and (e) Staff, resident, or family questions regarding the individual's care and treatments; and

    (4) At each visit, provide a legible progress note in a timely manner for placement on the chart, which includes relevant information about significant ongoing, active, or potential problems, including: (a) Reasons for changing or maintaining current treatments or medications; and (b) A plan to address relevant medical issues. [NH Regs Plus Comment: Provision  (2) (e) could be interpreted as requiring the physician to respond directly to resident or family questions, which in turn is a mechanism to promote autonomous decision-making.  It is not clear how such a provision could be enforced.  Taken together, the various elements in the Maryland provisions, if followed, would result in proactive management of diseases and health problems.]

    - In New Yorkthe  facility shall ensure that the responsible physician:(i) participates as a member of the interdisciplinary care team in the development and review of the resident's comprehensive care plan with the understanding that the minimum level of physician participation in interdisciplinary development and review of the care plan shall be a person-to-person conference with the registered professional nurse who has principal responsibility for development and implementation of the resident's care plan;(ii) visits the resident whenever the resident's medical condition warrants medical attention and establishes and maintains a schedule of visits appropriate to the resident's medical condition; (iii) reviews the resident's total program of care, including medications and treatments, at each regularly scheduled visit;(iv) prepares, authenticates and dates progress notes at each visit; (v) authenticates and dates all orders; (vi) provides residents and designated representatives with his or her name, office address and telephone number and responds to calls from residents to discuss the resident's medical care; (vii) participates in facility training programs to familiarize him or herself with State regulations and facility policies; and (viii) is informed of the results of all Department of Health surveys related to medical service deficiencies and is involved in resolving such problems. [NH Regs Plus Comment: As with Maryland, provision (vi) envisages that the attending physician will respond directly to calls from resident’s.  If followed, this would address a common complaint of residents that once in a nursing home their medical information tends to be mediated through facility personnel rather than conveyed directly by their doctors.  The provision for a person-to-person conference with the charge nurse regarding the care plan is an unusually strong endorsement for interdisciplinary collaboration; in other states, it is the medical director only who is required formally to collaborate on the care plan.  Another unusual component is the provision that attending physicians be informed of regulatory survey deficiencies related to medical care; presumably the medical director would provide the vehicle for such communication.]

    - In Oregon, the facility has the duty to see that all physician orders shall be promptly carried out unless inconsistent with the resident's expressed wishes.  [NH Regs Plus Comment: This intriguing caveat recognizes a resident’s right not to comply with physician orders.  It might be of interest to explore the extent to which facility personnel, residents, and families are aware of this caveat, and how it might be interpreted in specific cases because ethical dilemmas could arise over the judgments made regarding the tension between medical orders and resident wishes.]

    - In Texas, elaborate rules have been developed for routine and emergency prescription of and discontinuing of psychoactive medications, including informed consent for such medications. A psychoactive medication is any medication prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorders and used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state when treating the symptoms of mental illness, and specifically includes: (A) anti-psychotics or neuroleptics; (B) antidepressants; (C) agents for control of mania or depression; (D) anti-anxiety agents; (E) sedatives, hypnotics, or other sleep-promoting drugs; and (F) psychomotor stimulants.

    A person may not administer a psychoactive medication to a resident who does not consent to the prescription unless:

    (1) the resident is having a medication-related emergency (defined clearly in the provision); or

    (2) the person authorized by law to consent on behalf of the resident has consented to the prescription.

    Consent to the prescription of psychoactive medication given by a resident, or by a person authorized by law to consent on behalf of the resident, is valid only if:

    (1) the consent is given voluntarily and without coercive or undue influence;

    (2) the person who prescribes the medication, or that person's designee, provides the resident and, if applicable, the person authorized by law to consent on behalf of the resident, with the following information in a single document identified as being for the purpose of consent to treatment with psychoactive medication: (A) the specific condition to be treated; (B) the beneficial effects on that condition expected from the medication; (C) the probable clinically significant side effects and risks associated with the medication, as reported in widely available pharmacy databases or the manufacturer's package insert; and (D) the proposed course of the medication;

    (3) the resident and, if appropriate, the person authorized by law to consent on behalf of the resident, are informed in writing that consent may be revoked; and

    (4) the consent is evidenced in the resident's clinical record by a signed form prescribed by the facility, or by a statement of the person who prescribes the medication or that person's designee, that documents consent was given by the appropriate person and the circumstances under which the consent was obtained. (A) Consent is valid until: (i) consent is withdrawn; or (ii) the practitioner has discontinued the medication.  [NH Regs Plus Comment: These provisions are the most extensive safeguards we have noted regarding informed consent for psychoactive medication use in nursing homes.  They have the added benefit that, if followed, they would create conditions for clinically appropriate use of psychoactive drugs and avoidance of side-effects.  This example is one where State regulations are clearly supportive of resident autonomy.]

    Organized Medical Staff      (TOP)    (NEXT)

    Some States require an organized medical staff, whereas others (notably Massachusetts and Wisconsin) enunciate provisions for such an organized staff if the facility has an organized staff. The most elaborate of the mandatory requirements for organized medical staff is in Connecticut, which established criteria for the frequency of staff meetings, quorum definitions, and attendance requirements, and due process for revoking staff privileges.  The Connecticut rules provided with little editorial reduction below to illustrate he degree of formality built into the expectations.

    - In Connecticut,

    (1)   Each facility shall have an active organized medical staff with no less than three (3) physicians,

    (2)  The medical director shall approve or deny applications for membership on the active organized medical staff after consultation with the existing active organized medical staff, if any, and subject to the ratification of the governing body. In reviewing an applicant's qualifications for membership, the medical director shall consider whether the applicant: (A) satisfies specific standards and criteria set in the medical by-laws of the facility; and (b) is available by phone twenty-four (24) hours per day; is available to respond promptly in an emergency; and is able to provide an alternate physician or coverage whenever necessary;

    (3)  All appointments shall be made in writing and shall delineate the physician's duties and responsibilities. The letter of appointment shall be signed by the medical director and the applicant.

    (4) Requirements for active organized medical staff members. (A)  Members shall meet at least once every ninety (90) days.  Minutes shall be maintained for all such meetings. The regular business of the medical staff meetings shall include, but not be limited to, the hearing and consideration of reports and other communications from physicians, the director of nurses and other health professionals on: (i) patient care topics, including all deaths, accidents, complications, infections; (ii) medical quality of care evaluations; and  (iii) interdisciplinary care issues, including nursing, physical therapy, therapeutic recreation, social work, pharmacy, podiatry, or dentistry. (B)  Members shall attend at least fifty (50) percent of medical staff meetings per year. If two (2) or more members of the active medical staff are members of the same partnership or incorporated group practice, one (1) member of such an association may fulfill the attendance requirements for the other members of that association provided quorum requirements are met. In such case, the member in attendance shall be entitled to only one (1) vote. (C)  The active organized medical staff shall adopt written by-laws governing the medical care of the facility's patients. Such by-laws shall be approved by the medical director and the governing body. The by-laws shall include, but not necessarily be limited to: (i) acceptable standards of practice for the medical staff; (ii) criteria for evaluating the quality of medical care provided in the facility; (iii) criteria by which the medical director shall decide the admission or denial of admission of a patient based on the facility's ability to provide care; (iv) standards for the medical director to grant or deny privileges and to discipline or suspend the privileges of members of the medical staff, including assurance of a due process of appeal in the event of such actions; (v) quorum requirements for staff meetings, provided a quorum may not be less than fifty (50) percent of the physicians on the active medical staff; (vi) specific definition of services, if any, which may be provided by nonphysician health professionals such as physician's assistants or nurse practitioners; (vii) standards to assure that members of the medical staff request medical consultants where the diagnosis is obscure, or where there is doubt as to the serious nature of the illness or as to treatment. Such standards shall minimally mandate that the consultant be qualified to render an opinion in the field in which the opinion is sought, and that the consultation include examination of the patient and medical record; (viii) standards to assure that, in the event of the medical director's absence, inability to act, or vacancy of the medical director's office, another physician on the facility's active organized medical staff is temporarily appointed to serve in that capacity; and (ix) conditions for privileges for the medical staff other than the active organized medical staff.

    (5) Each member of the facility's medical staff shall sign a statement attesting to the fact that such member has read and understood the facility's medical and facility policies and procedures, and applicable statutes and regulations, and that such member will abide by such requirements to the best of his/her ability.

    Other examples are provided more briefly:

    - In Georgia, there shall be an organized professional staff, with one physician designated as chief of staff.  The professional staff shall consist of at least one physician, one dentist and one registered nurse.  Other professional personnel such as the dietitian, social worker, physical therapist, pharmacist, etc. may be included on the professional staff.  This organization shall function under appropriate bylaws and shall meet at regularly scheduled intervals not less than semiannually.  It shall be the responsibility of this staff to develop and review patient care policies and to advise administration on matters pertaining to patient care.  The minutes of the meetings of this staff shall be available for inspection by the Department.

    - In Illinois, (1) There shall be an advisory physician, or a medical advisory committee composed of physicians, who shall be responsible for advising the administrator on the overall medical management of the residents and the staff of the facility.  If the facility employs a house physician, he may be the advisory physician.  (2)  Additional for Skilled Nursing Facilities.  There shall be a medical advisory committee composed of two (2) or more physicians who shall be responsible for advising the administrator on the overall medical management of the residents and the staff in the facility. If the facility employs a house physician, the house physician may be one member of this committee. b)  The facility shall have and follow a written program of medical services which sets forth the following:  the philosophy of care and policies and procedures to implement it; the structure and function of the medical advisory committee if the facility has one; the health services provided; arrangements for transfer when medically indicated; and procedures for securing the cooperation of residents’ personal physicians.  The medical program shall be approved in writing by the advisory physician or the medical advisory committee. 

    In Massachusetts, North Dakota, and Wisconsin, an organized medical staff is specified as one alternative way to deliver services.

    - In Massachusetts, (A) Facilities shall establish written policies and procedures governing the delivery of physician and other medically related services; (B) Facilities shall provide medical supervision through a written agreement with (a) an organized medical staff of a hospital, (b) an organized medical staff within the facility, (c) a local medical society, or (d) two or more advisory physicians (at least one of whom does not have a proprietary interest in the facility). Supervisory and advisory functions shall include:  advice on the development of medical and patient care policies concerning patient admissions and discharge, medical records, responsibilities of attending physicians or physician-physician assistant team or physician-nurse practitioner team, supportive and preventive services, emergency medical care, and the review of the facility’s overall program of patient care.

    - In North Dakota , the facility shall have a licensed physician who is specified as the medical director or a medical staff organized under bylaws and rules approved by and responsible to the governing body. The medical director or medical staff shall be responsible for the quality of all medical care provided to residents and for the ethical and professional practices of its members. 2. The duties and responsibilities of the medical director or medical staff must be delineated in a formal agreement with the governing body. 3. The medical director or medical staff shall be involved in the development of written medical staff policies which are approved by the governing body, which delineate the responsibilities of licensed health care practitioners. 4. The medical director or a member of the medical staff shall participate in the quality improvement and infection control program meetings.

    - In Wisconsin, if facility has an organized medical staff, the medical director shall be designated by the medical staff with approval of the licensee.  Also if there is an organized medical staff, the staff will vote on approving the written rules and regulations required for attending physicians.

    Although not linked to an organized medical staff, States may have specific rules affecting medical care, such as mental health provision (New Jersey, Texas), hospice assumption of care (Iowa), pediatric care for children in nursing homes (Texas), and revocations of attending physician privileges (Oregon).   For example:

    - In New Jersey, the facility has a staff or consultant psychiatrist with admitting privileges to the inpatient psychiatric unit at a hospital.                       

    - In Idaho, in the event that neither the patient’s/resident’s attending physician nor the emergency physician can be contacted, the patient/resident in an emergent situation may be transferred to the emergency department of a nearby hospital.

    - In Iowa, professional management of a resident’s care shall be the responsibility of the hospice program when: the resident is terminally ill, and b. the resident has elected to receive hospice services under the federal Medicare program from a Medicare-certified hospice program, and c. the facility and the hospice program have entered into a written agreement under which the hospice program takes full responsibility for the professional management of hospice care.

    - In Texas, if children are admitted to the facility; (A) appropriate pediatric consultative services are utilized, in accordance with the comprehensive assessment and plan of care; and (B) a pediatrician or other physician with training or expertise in the clinical care of children with complex medical needs participates in all aspects of the medical care.

    - In Wisconsin, physician visits are not ordinarily required for respite care residents.

    Oregon has articulated a step-by-step procedure for policies to “assure physician services are provided in all cases when the attending physician or his/her alternate physician cannot or does not respond to the resident's needs.”

    - In Oregon, if the physician or physician designee fails to visit the resident according to resident's need, fails to respond to requests for assistance in resident's care, or fails to return verbal or telephone orders reduced to writing and forwarded to the physician by the facility, then the facility administrator shall ensure: (A) Reasonable and repeated attempts are made and documented in the clinical record to get the physician or physician designee to visit resident or return signed orders; (B) The medical director is notified and the Quality Assessment and Assurance Committee reviews the situation; (C) The County Medical Society, State Medical Society, and the Board of Medical Examiners are notified in writing of the problem; (D) The Division is notified in writing of the physician's failure to visit resident(s) or complete his/her progress notes or signed orders; and (E) The resident and the resident's significant other(s) are notified.

    Delegation/Alternate Visit Schedule      (TOP)    (NEXT)

    Some States elaborate on the use of delegation and the qualifications of the physician assistant, nurse practitioner, or clinical nurse specialist who received delegated authority; sometimes other state statutes are typically cited.  The State of Washington provides a table describing permissible delegation according to the funding stream for the resident’s care (see Washington rules).  Delegation typically refers to individuals hired by the physician to whom care is delegated, but North Carolina also refers to physician assistants or nurse practitioners employed by the facility.

    Regarding alternative schedules for medical or medical surrogate visits, some States explicitly permit an alternative visit schedule other than the one required in the federal regulations but require that the physician state the reasons for the alternative schedule.  Those States articulating permissive rules regarding delegation and alternative visits generally require that the physician conduct a visit and a medical examination personally at least annually.

    - In Alabama, a physician may delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist who agrees to and has signed specific protocols established by the facility and the physician and is on file in the facility;

    - In California, 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.


    - In Georgia, subsequent to the ninetieth day following admission, an alternate schedule for physician visits may be adopted where the attending physician determines and so justifies in the patient's medical record that the patient's condition does not necessitate visits at thirty-day intervals.

    - In Hawaii, after ninety days, an alternate schedule of visits at sixty day intervals may be adopted where the attending physician justifies this in writing.  This alternate schedule is not permitted when patients require specialized rehabilitative services.

    - In Indiana, a physician may delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist who: (1) is acting within the scope of practice as defined by state law; and (2) is under the supervision of the physician. If the physician employs other licensed or certified personnel, the administrator of the facility shall ensure that the means of supervision and duties delegated are filed in writing with the facility. The scope and content of their practice shall be within that specified by appropriate statutes governing each profession.

    - In North Carolina, if a facility employs physician assistants or nurse practitioners it shall maintain the following information for each nurse practitioner and physician assistant:  (1)  a statement of approval to practice as a nurse practitioner by the Board of Medical Examiners and Board of Nursing for each practitioner, or a statement of approval to practice as a physician assistant by the Board of Medical Examiners for each physician assistant; (2)  verification of current approval to practice; and (3)  a copy of instructions or written protocols signed by the nurse practitioner or physician assistant and the supervising physicians.

    - In Oregon, the physician may delegate tasks to a physician assistant pursuant to ORS Chapter 677 and rules adopted by the Board of Medical Examiners.  The physician assistant must be under the direction and supervision of the resident's physician. The physician may delegate tasks to a nurse practitioner pursuant to ORS Chapter 678 and the rules adopted by the Oregon State Board of Nursing.

    (c) Clinical Nurse Specialist in Gerontological Nursing.  The physician may delegate responsibilities to a registered nurse who is certified by the American Nurses Association's Credentialing Center as a "Clinical Specialist in Gerontological Nursing."  The specific tasks which may be delegated to the clinical nurse specialist are governed by the scope of practice as specified by the Oregon State Board of Nursing. However, a physician may not delegate a task in a Medicare-certified facility when federal regulations specify the physician must perform it personally

    - In South Dakota, if the services of a physician extender are utilized, the facility must develop written policies regarding the extender's role in the care of the patient or resident.

    Notification on How to Contact Physicians      (TOP)    (NEXT)

    In several States, the facility must notify residents, family, and staff of the list of attending physicians and/or emergency physicians.  Sometimes, the rules are explicit about posting such notifications in the nurse’s station.  The intent of most of these contact notice policies seems to be to achieve clarity and effective responses for staff in reaching doctors.  It is not always clear whether residents and families can gain access to the posted lists, though under the duties of attending physicians (above), we noted some States required that physicians make their phone numbers available to residents and their families and respond to queries.  Louisiana is explicit about the posting of physician rosters for staff but makes the phone numbers of attending and backup physicians available to residents, guardians, and sponsors “on request.”  For example:

    - In Iowa, a schedule listing the names and telephone numbers of the physicians shall be posted in each nursing station. 

    - In Louisiana, the name and telephone numbers of the attending physicians and the physicians to be called in case of emergency, when the attending physician is not available, shall be posted at each nursing station. Upon request, the telephone numbers of the attending physician or his/her replacement in case of emergency shall be provided to the resident, guardian, or sponsor.

    - In Kentucky, the facility shall have arrangements with one (1) or more physicians who will be available to furnish necessary medical care in case of an emergency if the physician responsible for the care of the patient is not immediately available. A schedule listing the names and telephone numbers of these physicians and the specific days each shall be on call shall be posted in each nursing station. There shall be established procedures to be followed in an emergency, which cover immediate care of the patient, persons to be notified, and reports to be prepared.

    - In Massachusetts, the addresses and telephone numbers of attending physicians, physician-physician assistant teams or physician-nurse practitioner teams at which they can be routinely reached for emergencies, and the addresses and telephone numbers of alternate physicians or physician-physician assistant teams or physician-nurse practitioner teams, providing coverage for an attending physician, physician-physician assistant team or physician-nurse practitioner team in his/their absence shall be recorded in the patient’s or resident’s record and be readily available to personnel on duty in case of emergencies. A schedule listing the names and telephone numbers of “emergency” physicians or physician-physician assistant teams or physician-nurse practitioner teams and the specific days each is on call shall be posted at each nurses’ or attendants’ station. 2)  If medical orders for the immediate care of a patient or resident are not available at the time of admission, the emergency or advisory physician shall be contacted to provide temporary orders until the attending physician assumes responsibility.

    - In Minnesota, the name and telephone number of the emergency physician must be readily available at all times.

    - In New Mexico, the facility shall have written procedures, available at each nurse's station, for procuring a physician to furnish necessary medical care in emergencies and for providing care pending arrival of a physician. The names and telephone numbers of the physicians or medical service personnel available for emergency care shall be posted at each nursing station.

    - In Wisconsin, the facility shall have written procedures, available at each nurse’s station, for procuring a physician to furnish necessary medical care in emergencies and for providing care pending arrival of a physician. The names and telephone numbers of the physicians or medical service personnel available for emergency calls shall be posted at each nursing station.

    - In Wyoming, a list of physicians to be called in case the resident’s physician or his designated substi­tute cannot be found shall be posted at every nursing station. Such roster shall include telephone numbers of the physicians.

    Table Comparing States    (TOP)

    Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Physician Services by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State requirements on Physican Services.

    483.40 Physician Services

    State Goes beyond Federal Regulations? Subjects Addressed: How State Differs From or Expands On Federal Regulations
    Alabama No Alabama mirrors federal regulations.
    Alaska Yes Slight amplification stating that if a resident’s condition warrants, the physician shall visit as often as necessary. Medical Director;
    Arizona Yes Medical Services requirements.
    Arkansas Yes Elements of total assessment; timing of initial examination; further detail on emergency coverage. Treatment and medications.
    California Yes Elements of assessment, delegation of services, timing of initial exam, facility responsibility for backup physician services if physician cannot be located. Patient care policies and procedures.
    Colorado Yes Written policies when more than one physician is treating a patient; anticipated schedule of physician visits; telephone orders. Emergency services.
    Connecticut Yes Extensive discussion of an “active organized medical staff” and policies for joining medical staff; policies governing frequency of medical staff meetings, required attendance, and duties. Physician visits.
    Delaware Yes Countersigning of telephone orders Services to residents.
    District of Columbia Yes Delegation of tasks, physician notes, physician services and medical supervision of residents.
    Florida Yes Physician services and requirements.
    Georgia Yes Organized professional staff with one physician as “chief of staff.”  Alternate schedule for visits. Medical, dental and nursing care.
    Hawaii Yes Alternate schedule for visits; participation of physician on interdisciplinary team; timing to complete initial physical examination; tuberculosis clearance for patient; physician notified in case of accidents.  Emergency care of patients. Medical emergencies and medical and personal care program.
    Idaho Yes Timing of first assessment; content of overall plan; information that physician must provide the facility; provision for emergency transfer if physician cannot be located. Medical emergencies.
    Illinois Yes Medical advisory committee; details on “written program of medical services,” details on required facility notifications to the physician; first aid duties of facility, detailed elements of physician assessment.
    Indiana Yes Verbal and telephone orders; progress notes timing and signing; specification on facility policies for physician supervision of delegation; Medical Director.
    Iowa Yes Specifics about hospice provision of medical services; preadmission physical; posting of physician’s names & phone numbers. Any required physician task or visit may also be performed by an advanced registered nurse practitioner, clinical nurse specialist or physician assistant.
    Kansas Yes Physician services
    Kentucky Yes Content of comprehensive assessment; charting at intervals; development and charting of emergency coverage plan
    Louisiana Yes Freedom of resident choice of physician; NH chooses MD if resident or his/her sponsor cannot find physician; posting of MD and backup MD phone numbers at nurse’s station; must make phone numbers available to resident or guardian on their request. Standing orders.
    Maine Yes Timing of initial physical; medication orders and notes; use of controlled substances.
    Maryland Yes Content of initial and ongoing physician assessments; progress notes; emergency backup provisions; physician obligations to respond to queries; care management; discharge summaries, responsibilities for continuity of care after transfer; Medical Director. Maryland’s provisions for physician services are particularly detailed. Special care units – physician coordinator.
    Massachusetts Yes Content of assessments.  Organized medical staff.  Duties in care planning and supervision of plan.  Amount of time medical director must spend in facility.  Emergency backup provisions.  Facility selection of MD if resident or guardians cannot.  Massachusetts’ provisions for physician services are particularly detailed.
    Michigan Yes Not addressed at all in state regulations. Admission policies, medical direction of patients, medical examination of patients, medical visits to patients, treatment of patients, physicians’ assistants, medical audits.
    Minnesota Yes Emergency policies; posting of physician names; detailed content for clinical record; Medical Director.
    Mississippi Yes State regulations basically echo federal provisions.
    Missouri Yes Supervising physician requirements.
    Montana No Montana regulations do not include specific content for physician services.
    Nebraska Yes Nebraska mirrors the federal regulations.
    Nevada Yes Very close to federal with some additional detail on signing of notes.
    New Hampshire Yes Duties and responsibilities.
    New Jersey Yes Facility maintenance of a list of consultants available to attending physicians; arrangements for admission to psychiatric hospitals. Defibrillator regulations.
    New Mexico Yes Emergency backup system, physician orders and treatment and orders.
    New York Yes Physician services meeting “prevailing standards” of quality; duties of physician related to interdisciplinary team; requirements to be available to calls from residents and families, to become informed on relevant regulations; be informed of problems on surveys; receive medical education; Medical Director – diagnostic services.
    North Carolina Yes Posting of doctor’s names and phone numbers at nurse’s station; more detail on medical orders to nursing home staff; resident choice of private physician and exceptions for that choice protocols for delegation to nurse practitioners. Physician services for ventilator.
    North Dakota Yes Medical staff rules; medical director role in relation to governing body of nursing home; participation in quality assurance and infection control. Resident admission.
    Ohio Yes Extensive section on medical director duties (review of pharmacist reviews; overseeing employee health; monitoring and feedback to attending physicians; liaison function with attending physicians, facility staff, residents and families).  Medical supervision.
    Oklahoma Yes Timing for initial exam and plan for overall care; required minimum content of overall plan; continuing supervision related to care plan development and review.
    Oregon Yes Medical director duties; delegation.  Authorization and signing of orders; obligation of facility to carry out doctors orders; frequency of visits; emergency procedures; policies when attending physician and backup fail to visit.
    Pennsylvania Yes Timing of initial medical assessment; content of initial medical assessment.
    Rhode Island Yes Initial exam timing; admitting information required to be supplied to facility; medical management, including approval of consultant referrals to be approved by attending physician; standing orders; emergency backup policies; Medical Director.
    South Carolina Yes Choice of physician cannot be denied (provided the physician agrees). Standing orders, verbal orders,
    South Dakota Yes Timing of initial exam, phone orders and countersigning; emergency coverage.
    Tennessee Yes Admissions, discharges and transfers, basic services.
    Texas Yes Ordering medical consultations; medical care for children in the nursing home; discharge summary; Prescription of psychoactive drugs (including related consent issues); liability issues; reporting of communicable diseases; signature stamps & faxed signatures; recertification requirements policies and payment for recertification.
    Utah Yes Physician Services, administration and organization,
    Vermont Yes Time requirement for initial medical exam; Short additions on Medical Director.
    Virginia Yes Time to generate “complete medical plan;” content of “complete medical plan;” receipt and countersigning of verbal orders; Medical Director.
    Washington Yes Nursing home responsibility for resident to be seen by physician “whenever necessary;” complex rules for delegation of visits and tasks according to payer source and area of nursing home; duties related to multidisciplinary team; specificity on content of medical assessment, physician services.
    West Virginia Yes Timing of initial medical examination, physician supervision.
    Wisconsin Yes Responsibilities of medical director; coordination of organized staff (if there is an organized staff); alternative physician visit schedule; emergency backup policies.
    Wyoming Yes Short additions on temporary medical orders on admission, nature of emergency coverage policies and Medical Director.

    Complete Transcript of State Requirements on Physician Services    (TOP)