Failure to Complete Timely Initial Physician Visit
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of a resident conducted an initial comprehensive visit within the required 30-day time period after admission. Review of the electronic medical record and progress notes revealed that the initial physician visit for the resident was not completed within 30 days of admission, as required by federal regulations. The only available documentation was a "HISTORY AND PHYSICAL" signed by an advanced practice nurse, with no further documentation from the physician since the resident's arrival. Interviews with facility staff confirmed that there were no additional physician notes available for the resident during the required timeframe. The facility's own policy, which aligns with federal requirements, states that the attending physician must visit patients at least once every 30 days for the first 90 days following admission. This policy was not followed in the case of the resident identified in the report.
Plan Of Correction
1. Resident #2's initial comprehensive physician visit was completed on 01/07/2024, and as recently as 6/11/25, no negative concerns were identified. 2. All residents have the potential to be affected by this practice. An audit was completed of all current residents to ensure that physician visits occurred within the required time frame. Any inconsistencies were addressed immediately. 3. The facility's admission process has been updated to include a physician visit tracker that flags any upcoming 30-day deadlines for new admissions. U.S. FOIA (b) (6) educated Ex Order 26. 4B1 and medical staff, on facility policy regarding the timeliness of physician visits. 4. The DON or designee will monitor all new admissions weekly for 4 weeks, followed by a monthly audit for 3 months to ensure a physician visit occurs in accordance with facility policy and reported to the Committee for review and action. The QAPI Committee, including the NHA, DON, Medical Director, and Admissions Coordinator, will evaluate trends and determine whether additional interventions or education are needed.