481—58.14 (135C) Medical services.
	 58.14(1) Each resident in a nursing facility shall designate a licensed physician who may be called when needed. Professional management of a resident’s care shall be the responsibility of the hospice program when:
	  a.   	 The resident is terminally ill, and
	  b.   	 The resident has elected to receive hospice services under the federal Medicare program from a Medicare-certified hospice program, and
	  c.   	 The facility and the hospice program have entered into a written agreement under which the hospice program takes full responsibility for the professional management of hospice care.
	 58.14(2) Each resident admitted to a nursing facility shall have had a physical examination prior to admission. If the resident is admitted directly from a hospital, a copy of the hospital admission physical and discharge summary may be made part of the record in lieu of an additional physical examination. A record of the examination, signed by the physician, shall be a part of the resident’s record. (III)
	 58.14(3) Arrangements shall be made to have a physician available to furnish medical care in case of emergency. (II, III)
	 58.14(4) Rescinded, effective 7/14/82.
	 58.14(5) The person in charge shall immediately notify the physician of any accident, injury, or adverse change in the resident’s condition. (I, II, III)
	 58.14(6) A schedule listing the names and telephone numbers of the physicians shall be posted in each nursing station. (III)
	 58.14(7) Residents shall be admitted to a nursing facility only on a written order signed by a physician certifying that the individual being admitted requires no greater degree of nursing care than the facility is licensed to provide. (III)
	 58.14(8) Physician delegation of tasks. Each resident shall be visited by or shall visit the resident’s physician at least twice a year. The year period shall be measured from the date of admission and is not to include preadmission physicals.
	  a.   	 For a skilled nursing patient, the resident must be seen by a physician for the initial comprehensive visit. Additional visits are required at least once every 30 days for 90 days after admission and at least once every 60 days thereafter. After the initial comprehensive visit, alternate required visits may be performed by an advanced registered nurse practitioner, clinical nurse specialist or physician assistant who is working in collaboration with a physician, as outlined in Table 1. (III)
	  b.   	 Notwithstanding the provisions of 42 CFR 483.40, any required physician task or visit in a nursing facility may also be performed by an advanced registered nurse practitioner, clinical nurse specialist, or physician assistant who is working in collaboration with a physician, as outlined in Table 1. (III)
	  c.   	 In dually certified skilled nursing/nursing facilities, the advanced registered nurse practitioner, clinical nurse specialist, and physician assistant must follow the skilled nursing facility requirements for services for skilled nursing facility stays. For nursing facility stays in skilled nursing/nursing facilities, any required physician task or visit may be performed by an advanced registered nurse practitioner, clinical nurse specialist, or physician assistant working in collaboration with the physician. (III)
	  d.   	 Nurse practitioners, clinical nurse specialists, and physician assistants 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. (III)
Table 1:	Authority for non-physician practitioners to perform visits, sign orders, and sign certifications/recertifications when permitted by state law*

 	Initial Comprehensive Visit/Orders	Other Required Visits<fo:wrapper font-size=".69em" baseline-shift=".33em">1</fo:wrapper>	Other Medically Necessary Visits and Orders<fo:wrapper font-size=".69em" baseline-shift=".33em">2</fo:wrapper>	Certification/
Recertification	
Skilled Nursing Facilities	
Physician assistant, nurse practitioner and clinical nurse specialist employed by the facility	May not perform/May not sign	May perform alternate visits	May perform and sign	May not sign	
Physician assistant, nurse practitioner and clinical nurse specialist not a facility employee	May not perform/May not sign	May perform alternate visits	May perform and sign	May sign subject to state requirements	

Nursing Facilities	
Nurse practitioner, clinical nurse specialist, and physician assistant employed by the facility	May not perform/May not sign	May not perform	May perform and sign	Not applicable<fo:wrapper font-size=".69em" baseline-shift=".33em">+</fo:wrapper>	
Nurse practitioner, clinical nurse specialist, and physician assistant not a facility employee	May perform/May sign	May perform	May perform and sign	Not applicable<fo:wrapper font-size=".69em" baseline-shift=".33em">+</fo:wrapper>	
*As permitted by state law governing the scope and practice of nurse practitioners, clinical nurse specialists, and physician assistants.
1 Other required visits include the skilled nursing resident monthly visits that may be alternated between physician and advanced registered nurse practitioners, clinical nurse specialists, or physician assistants after the initial comprehensive visit is completed.
2 Medically necessary visits may be performed prior to the initial comprehensive visit.
+ This requirement relates specifically to coverage of Part A Medicare stays, which can take place only in a Medicare-certified skilled nursing facility.
[ARC 1048C, IAB 10/2/13, effective 11/6/13]