411-086-0200 Physician Services (1) MEDICAL DIRECTOR. Each nursing facility shall have a physician medical director designated in writing. The medical director shall: (a) Serve on the Quality Assessment and Assurance Committee; (b) Assist the facility to assure that adequate medical care is provided on a timely basis in accordance with OAR 411-085-0210 (Facility Policies); and (c) Serve as attending physician for those residents who are not able to obtain services of another physician or ensure another physician is available to serve as attending physician. (2) ATTENDING PHYSICIAN. Each resident shall be under the care of a physician who is responsible for the resident's medical care. (a) Physician Assistant. The physician may delegate tasks to a physician assistant pursuant to ORS Chapter 677 and rules adopted by the Board of Medical Examiners. The physician assistant must be under the direction and supervision of the resident's physician. (b) Nurse Practitioner. The physician may delegate tasks to a nurse practitioner pursuant to ORS Chapter 678 and the rules adopted by the Oregon State Board of Nursing. (c) Clinical Nurse Specialist in Gerontological Nursing. The physician may delegate responsibilities identified in section (4)(a) of this rule to a registered nurse who is certified by the American Nurses Association's Credentialing Center as a "Clinical Specialist in Gerontological Nursing." The specific tasks which may be delegated to the clinical nurse specialist are governed by the scope of practice as specified by the Oregon State Board of Nursing. (d) Delegation. (A) Except as provided in section (4) of this rule, a physician may delegate tasks to a physician assistant, nurse practitioner or clinical nurse specialist who is acting within the scope of practice as defined by Oregon law and who is under the supervision of a physician. EXCEPTION: A physician may not delegate a task in a Medicare-certified facility when federal regulations specify the physician must perform it personally. (B) The physician assistant, nurse practitioner or clinical nurse specialist substituting for physician visits as described in section (4)(a) of this rule may not be an employee of the nursing facility. (3) MEDICATIONS AND TREATMENTS. (a) Authorization. Physician's orders shall either be initially written and signed by the physician, nurse practitioner (NP) or physician assistant (PA), or given verbally or by telephone. If given verbally or by telephone, the orders shall be accepted only by a licensed nurse and must be written and mailed to the physician, NP or PA within 72 hours to be signed and returned to the facility for filing in the resident's chart. (b) Promptly Carried Out. All physician orders shall be promptly carried out unless inconsistent with the resident's expressed wishes. (c) Orders Required. Medications and treatments shall be administered only on the order of a physician or a designee pursuant to ORS Chapters 677, 678, and 679. (d) Standing Orders. Therapies and drugs not requiring prescription under ORS Chapter 689 may be ordered from standing orders of the attending physician, NP or PA. Therapies and drugs so ordered shall be reviewed and signed at least annually by the attending physician. Use of standing orders shall be authorized by licensed personnel and transcribed to the physician order form. (4) PHYSICIAN VISITS. (a) Frequency. Physician visits shall be according to resident's needs. The physician shall comply with Medicare or Medicaid requirements when applicable. Physician visits shall conform to the following schedule. (A) Medicare Covered Stay. When Medicare is the primary payor source for a resident’s stay, the resident must be seen by the physician at least every 30 days for the first 90 days after admission, then every 60 days thereafter. If authorized by the physician, every other visit after the first visit may be conducted by a physician's assistant, a clinical nurse specialist as specified in section (2) of this rule, or nurse practitioner. (B) Medicare and/or Medicaid Certified Facilities. For residents in facilities which are certified for Medicare and/or Medicaid, and Medicare is not the primary payor source, each resident must be seen by the physician at least every 30 days for the first 90 days after admission, then every 60 days thereafter. If authorized by the physician, all visits may be conducted by a physician's assistant, a clinical nurse specialist as specified in section (2) of this rule, or nurse practitioner. (C) Licensed Only Facilities. For residents in all facilities which are not certified for either Medicaid or Medicare, each resident shall be visited by the physician every 30 days for the first 90 days, then every 180 days thereafter. If authorized by the physician, all visits may be conducted by a physician's assistant, a clinical nurse specialist as specified in section (2) of this rule, or nurse practitioner. (D) Timely Visit. A visit required pursuant to sections (4)(a)(A), (B), or (C) of this rule will be considered "timely" if it occurs not later than ten days after the date the visit was required. (b) Assessments, Observation. The facility shall ensure a physician's assessment and determination of type of care needed is performed for each resident. The results and observations shall be recorded in the physician's progress notes at time of admission and at least annually thereafter. (c) Policies. The facility shall establish policies to assure physician services are provided in all cases when the attending physician or the attending physician's alternate cannot or does not respond to the resident's needs. (d) Failure to Visit. If the physician or physician designee fails to visit the resident according to resident's need, fails to respond to requests for assistance in resident's care, or fails to return verbal or telephone orders reduced to writing and forwarded to the physician by the facility, then the facility administrator shall ensure: (A) Reasonable and repeated attempts are made and documented in the clinical record to get the physician or physician designee to visit resident or return signed orders; (B) The medical director is notified and the Quality Assessment and Assurance Committee reviews the situation; (C) The County Medical Society, State Medical Society, and the Board of Medical Examiners are notified in writing of the problem; (D) The Seniors and People with Disabilities Division is notified in writing of the physician's failure to visit resident(s) or complete progress notes or signed orders; and (E) The resident and the resident's significant other(s) are notified. (e) Emergency Backup. Each facility shall provide for one or more physicians to be called in the event of a medical emergency. The names and telephone numbers of such physicians shall be posted at each nurses' station. (5) DOCUMENTATION. All physician orders, physician visits, and responses thereto shall be promptly documented in the resident's clinical record. Statutory/Other Authority: ORS 410.070, 410.090 & 441.055 Statutes/Other Implemented: ORS 441.055 & 441.615 History: SPD 3-2008, f. & cert. ef. 3-6-08 SSD 11-1992, f. 10-30-92, cert. ef. 11-1-92 SSD 19-1990, f. 8-29-90, cert. ef. 10-1-90