Ftag of the Week – F711 Physician Visits – Review Care/Notes/ Order

This week’s “Ftag of the Week” on the CMSCG Blog is part of the Physician Services regulatory group, F711 Physician Visits – Review Care/Notes/Order. The intent of this regulation is to ensure that physicians have an active role in the supervision of resident care and visits are not “superficial.” F711 addresses tasks that must be personally completed by the physician, and the Interpretive Guidance (IG) notes that non-physician practitioners are included, to the extent permitted by State law.

F711 – Regulatory Requirements

There are several regulatory requirements to be aware of related to physician visits, so we’ll review those first.

Total Plan of Care Review

Per Appendix PP of the State Operations Manual (SOM):

• The physician must review the resident’s total plan of care, including medications and treatments, during each visit required per F712 Physician Visits – Frequency/ Timeliness/ Alternate NPPs. (Want to know what’s required? There’s a Ftag of the Week for that!)

The IG states that the “total plan of care” means all of the care that is provided, per the comprehensive assessment and plan of care, to a resident to maintain or improve his/her highest practicable physical, mental and psychosocial well-being. This includes:

• Medical services
• Medication management
• Therapy (PT/OT/SLP)
• Nursing care
• Nutritional interventions
• Social Work
• Activities services

Let’s see how failure to review the total plan of care could result in a citation at a scope and severity you’d rather not see.

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F711 – Recertification Survey Citation – S/S: J (Immediate Jeopardy)

A facility failed to ensure that a resident’s total program of care was accurately evaluated on re-admission from the hospital and throughout the resident’s stay after it was identified that the physician failure to order sliding scale insulin, FSBS checks, insulin and the correct frequency of a combination anti-diabetic medication. This resulted in the resident being transferred to the hospital five days after being admitted to the nursing home and ultimately being admitted to ICU with a diagnosis of diabetic ketoacidosis which required a continuous insulin drip. Once this was identified, the facility was placed in Immediate Jeopardy. A review of the medical record also identified several progress notes with inaccurate documentation regarding the resident not being on insulin, having a weight loss which did not occur, and that the resident was on Remeron for appetite stimulation, which he never had an order for.

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F711 lends itself to high-level citations as well as issues of a lower scope and severity, but all the same, those “smaller” issues can also become bigger issues if not addressed, so it’s important to ensure that your physicians are being thorough during their visits. 

Progress Notes Requirements

Per Appendix PP:

• The physician must write, sign and date progress notes during each visit

The physician must write, sign and date progress notes either in the physical chart or EMR, depending on the documentation system the facility is using.

The last bullet is particularly problematic, as the same content is often repeated and is not always current and reflective of the resident’s current status. Here’s another way those notes can get a facility in trouble.

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F711 S/S: E – Recertification Survey

A facility was cited for failure to “document in a manner that would demonstrate the physician’s decisions about a resident’s course of treatment” for multiple residents. During a review for physician services, it was determined that due to these documentation issues, residents could likely receive unnecessary medications and/or not receive appropriate care to meet their needs.

For one resident who was admitted with diagnoses of dementia and unspecified altered mental status, it was identified that there were multiple discontinued PRN orders for Haldol for anxiety/agitation. Further review of the resident record identified that the resident was not receiving any behavior monitoring or monitoring for side effects that Haldol could potentially cause. Review of the physician’s documentation lacked any information on how the physician planned to treat the resident’s diagnoses/concerns or the need for Haldol.

Further review of the record identified a Nurses’ Note indicating that the resident was “paranoid” and wanted staff to give her a second Covid test because she did not believe her first result. The note indicated that the behavior supported the need for Seroquel – which the physician ordered for Schizoaffective Disorder. The facility was unable to provide any prior documentation related to this diagnosis.

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Requirements for Orders

Per Appendix, PP:

• The physician must sign and date all orders, with the exception of flu and pneumococcal vaccines, since these may be administered per physician-approved facility policy once an assessment for contraindications has been made.

Don’t forget – this includes all orders that a physician is required to co-sign, in accordance with State law.

One area where CMSCG consultants often identify issues during medical record reviews is orders that are left in the queue without being addressed or signed, even though there is evidence the physician made a visit.

Miscellaneous Guidance for Orders and Signatures

The IG includes a lot of information about orders and signatures, which can be summarized as follows:

• Physician orders may be sent via fax, but the physician needs to have signed and retained the original order so it can be provided on request. The original could also be sent to the facility at a later time.
• Faxed physician orders should be copied by the facility “if the faxed order is subject to fading over time.” Once a photocopy is made, the potentially-faded fax can be discarded.
• Electronic signatures are acceptable for electronic medical records
• Faxed orders do not need to be re-signed by the physician during a visit to the facility.
• If a rubber stamp signature is used, there must be a signed statement retained in administration where the physician attests that he/she is the only one who uses the stamp. The stamp must be kept adequately safeguarded, such as in a locked location with limited staff access. Written signatures, ID numbers and/or computer codes must also be kept secure but readily available upon request.

Here’s a compliance tip from CMSCG President Linda Elizaitis to wrap up this post:

If you don’t routinely assess the ‘quality” of your medical staff’s documentation, it is something that you should consider doing. Simply choose a resident on your dementia/secure unit with exhibited behaviors, a resident with a pressure injury and a resident with multiple comorbidities that require ongoing assessment and revisions to the plan of care. Once your choices are made take a “walk” through their progress notes and see what issues you identify.