Failure to Ensure Physician-Completed Initial Visits
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician completed required initial comprehensive visits, as mandated by facility policy and state regulations. The facility’s “Physician Visits and Physician Delegation” policy, dated 6/1/24 and last reviewed 1/21/26, specifies that a PA, NP, or CNS may not perform initial comprehensive visits. Despite this, review of clinical records showed that initial visits for three residents were conducted by a Certified Registered Nurse Practitioner (CRNP), identified as Employee E20, rather than by a physician. For one resident admitted with anxiety, depression, and lung cancer, a late entry note dated 3/1/26 (effective 2/25/26) documented that the CRNP completed the initial admission visit. For another resident with gastroparesis, anemia, and esophagitis with bleeding, who had been discharged home and then readmitted, a late entry note entered on 2/25/26 (effective 2/23/26) showed that the CRNP assessed the resident following readmission, constituting the initial visit. For a third resident admitted with emphysema, oxygen dependence, and alcohol dependence with withdrawal, a late entry note entered on 6/26/26 (effective 6/25/26) documented that the CRNP performed the initial visit. During an interview, the DON and Interim Nursing Home Administrator acknowledged that the facility failed to ensure a physician completed the initial visits for these three residents.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.