Deficiency in Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. This deficiency was observed in several residents, including one who had not seen a doctor regularly and only met their physician for the first time in four years. The medical records revealed late entries and inconsistencies in documentation, with some residents not having a documented History and Physical (H&P) within the required timeframe of 72 hours after admission. Another resident's records showed that the attending physician and nurse practitioner did not consistently alternate monthly visits, with missing progress notes for several months. Additionally, a resident admitted in October 2024 did not have any physician progress notes beyond the initial H&P, indicating a lack of regular physician oversight. Interviews with facility staff revealed uncertainty about the timelines for completing H&P documentation and the frequency of physician visits, further highlighting the facility's failure to adhere to regulatory requirements. The survey also uncovered instances where a physician documented a visit after a resident had been discharged, which was deemed inappropriate by the Medical Director. The facility's policy on physician visits was outdated and did not address the requirement for a physician visit upon admission. The survey team presented these findings to the facility's management, who did not provide additional information or refute the findings.
Plan Of Correction
Rose Mountain Care Center Facility ID: 315384 Survey Completion date: 12-12-2024 **F712 SS-F Physician visits - frequency/Timeliness/ALT NPP** **ELEMENT ONE: CORRECTIVE ACTION:** It is the practice of the Center to ensure that all residents are seen by a physician every 30 days for the first 90 days and at least every 60 days thereafter. An audit was completed by the Regional DON of the last 30 days of physician visits to ensure that all physician visits were completed by their primary designated physician within the required time frame. **ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS:** The standard was not met for residents #13, #33, #81, #83 and #85. Any resident which is assigned to a physician has the potential to be affected. **ELEMENT THREE: SYSTEMIC CHANGES:** All RN/LPNOs, Physicians and APNs were educated on the facilities policy regarding Physician visits. A certified letter was also sent to all Primary Physicians/APNs to ensure they received a copy of the policy. **QUALITY ASSURANCE:** To maintain and monitor ongoing compliance, Administrator/DON and or designee will audit monthly x 3 months, 10 random residents per unit and quarterly thereafter to ensure all primary physicians monthly visits are completed timely. Needed corrections will be addressed as they are discovered. Results will be reported to the QAPI team for review. Date of Compliance: 12/25/24