Ref: S&C-03-18

DATE: April 10, 2003

FROM: Director

Survey and Certification Group

SUBJECT: Physician delegation of tasks in Skilled Nursing Facilities (SNFs) and

Nursing Facilities (NFs)

TO: Survey and Certification Regional Office Managers (G-5)

State Survey Agency Directors

This memo is to clarify the regulatory differences concerning physician delegation of tasks in SNFs and NFs. This memo addresses both the issue of the authority of physician extenders to perform physician visits and write orders and sign certifications and re-certifications in SNFs and NFs.

Physician delegation of tasks.

Section 483.40 of the Code of Federal Regulations (CFR) describes physician services provided in long-term care facilities and specifies which services that must be performed personally by physicians. For example, §483.40 of the CFR provides that a “physician must personally approve in writing a recommendation that an individual be admitted to a [long term care] facility.”

The regulations also provide that a physician may delegate tasks to a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS). However, a physician may not delegate a task “when the regulations specify that the physician must perform it personally or when the delegation is prohibited under State law or by the facility’s own policies [42 CFR 483.40(e)(2)].” Therefore, in accordance with the regulations, PAs, NPs, and CNSs may provide medically necessary care to long term care residents, except in those few situations where the regulations require that the task be personally performed by a physician or when prohibited by State law or facility policy.

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Directors

Physician delegation of tasks in SNFs.

The regulation at 42 CFR 483.40(e) states that, “A physician may not delegate a task when the regulations specify that the physician must perform it personally, or when the delegation is prohibited under State law or by the facility's own policies.” As shown in Table 1, §484.40(c)(3) requires that in a SNF the physician must provide the initial visit personally. However, §483.40(c)(4) states that physicians may then delegate alternate visits to a PA, NP or CNS who is licensed as such by the State and performing within the scope of practice in that State.

Performance of physician tasks in NFs.

The regulation at 42 CFR 483.40(f) states that “At the option of the State, any required physician task in a NF (including tasks which the regulations specify must be performed personally by the physician) may also be satisfied when performed by a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility but who is working in collaboration with a physician.”

Table 1:Authority for Physician Extenders to Make Visits to SNF and NF Residents

	Visits that are required to be personally performed by a physician	Other visits that are not required to be personally performed by a physician *
SNFs
NP, CNS, and PA employed by the facility	Must not perform the tasks	May perform the tasks
NP, CNS, and PA not a facility employee	Must not perform the tasks	May perform the tasks
NFs
NP, CNS, and PA employed by the facility	Must not perform the tasks	May perform the tasks
NP, CNS, and PA not a facility employee	May perform the tasks	May perform the tasks

* Physician extenders may perform other tasks that are not reserved to the physician such as visits outside the normal schedule needed to address new symptoms or other changes in medical status.

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Directors

Table 2 summarizes the requirements for physician extenders to write orders, when this function is permitted under the scope of practice for the State. In addition, §424.20(e)(2) states that NPs and CNSs who are not employed by the facility and are working in collaboration with a physician, when permitted under the scope of practice for the State, may sign the initial certifications and the required SNF re-certifications. Please note that PAs do not currently have the authority to sign either the initial certification or any re-certification.

Table 2: Authority for Physician Extenders to Write Orders and Sign Certifications/Recertifications

	Initial Visit & Initial Orders	Certification	Recertification	Subsequent Orders
SNFs
NP & CNS employed by the facility	May not sign	May not sign	May not sign	May sign
NP & CNS not a facility employee	May not sign	May sign	May sign	May sign
PA regardless of employment status	May not sign	May not sign	May not sign	May sign
NFs
NP & CNS employed by the facility	May not sign	May not sign	N/A	May sign
NP & CNS not a facility employee	May not sign	May sign	N/A	May sign
PA regardless of employment status	May not sign	May sign	N/A	May sign

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Dually certified facilities.

While the CFR does not address dually certified SNF/NFs directly, the CFR is clear about who can perform tasks in a SNF and in a NF. In a facility where beds are dually certified, the facility must determine how the resident stay is being paid. For residents in a Part A Medicare stay, the PA, NP and CNP must follow the guidelines for services in a SNF. For Medicaid stays, the PA, NP and CNP must follow the provisions outlined for care in NFs. As such, in a dually certified nursing home, any required physician task for a Medicaid beneficiary in a NF certified bed, at the option of the State, may be performed by a NP, CNS, or PA who is not an employee of the facility but who is working in collaboration with a physician. In addition, in a dually certified nursing home and at the option of a physician, required physician visits for a Medicare beneficiary in a SNF certified bed may be alternated between personal visits by the physician and visits by a PA, CNP, or NP after the physician makes the initial first visit.

Effective Date: This policy is in effect immediately.

Training: This policy should be shared with all appropriate survey and certification staff, their managers, and the state/regional office training coordinator.

/s/

Steven A. Pelovitz

Ref: S&C-03-18

Table 1:Authority for Physician Extenders to Make Visits to SNF and NF Residents

SNFs

NFs

SNFs

NP & CNS employed by the facility

NP & CNS not a facility employee

PA regardless of employment status

NFs

NP & CNS employed by the facility

NP & CNS not a facility employee

PA regardless of employment status

May not sign