Initial Physician Assessment Not Completed for Medicare Part A Admission
Penalty
Summary
The facility failed to ensure that the initial comprehensive visit for a resident admitted under Medicare Part A was completed by a physician, as required by federal regulations. Instead, the initial assessment and admission orders for the resident were performed by a nurse practitioner. This was confirmed through interviews and record reviews with facility staff, including the LN, DON, and Administrator, all of whom acknowledged that the physician did not personally conduct the initial assessment. The facility's own policy and procedure, as well as CMS guidance, specify that the initial comprehensive visit in a skilled nursing facility (SNF) must be performed by a physician and cannot be delegated to a non-physician practitioner. The deficiency was identified for one of three sampled residents, with documentation showing that the nurse practitioner completed the initial assessment and 72-hour charting. Staff interviews further confirmed the importance of the physician's role in establishing a baseline, reviewing and reconciling medications, and developing the plan of care during the initial assessment. The facility is dually certified under Medicare and Medicaid, and the failure to have the physician personally complete the required initial visit was verified by the Administrator.