§483.30(b) Physician Visits
The physician must-
§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;
§483.30(b)(2) Write, sign, and date progress notes at each visit; and
§483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
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Observations:
Based on review of facility policy, facility documents, clinical records, and staff interview, it was determined that the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit for 22 of 26 Residents reviewed (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R12, R13, R14, R18, R20, R23, R26, R36, R49, R59, R76, and R85).
Findings include:
Facility policy entitled "Physician Visits" dated 5/13/26, revealed "The attending physician must make visits in accordance with applicable state and federal regulation." "The attending physician must visit his/her patient at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter." "A physician assistant or nurse practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation." and "A physician visit is considered timely if it occur not later than ten (10) days after the date the visit was required. However, the subsequent visit must be timed in relation to when the previous one was due, not to when it was made."
Review of Medical Director Agreement dated 9/16/26, indicated "Duties and Responsibilities of a Medical Director:
-Coordinate and oversee medical care and treatment, including physician services ...
-Monitor provision of physician services to provide services to meet the highest practicable physical, mental, and psychosocial well-being of each resident.
-Frequency of physician visits
Resident R1's clinical record revealed an admission date of 10/7/25, with diagnoses that included benign prostatic hyperplasia (BPH - a noncancerous enlargement of the prostate gland, which can result in frequent urination, difficulty starting or stopping urination and a weak urine stream), transient ischemic attack (TIA occurs when there is a brief interruption of blood flow to a part of the brain, leading to symptoms similar to those of a stroke that are temporary, typically lasting only a few minutes to a maximum of 24-hours), and dementia (loss of cognitive functioning affecting a person's memory and behaviors).
Resident R1's clinical record revealed physician progress note dated 12/5/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 12/5/25, and 3/10/26, a span of 95 days.
Resident R2's clinical record revealed an admission date of 7/19/24, with diagnoses that included schizoaffective disorder (a mental health condition that can be a mix of symptoms such as hallucinations [seeing things or hearing voices that other don't], delusions [believing things that are not real or true], and depression [persistent feeling of sadness loss of interest in activities once enjoyed]), Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time), and dementia.
Resident R2's clinical record revealed physician progress note dated 9/26/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 9/26/25, and 3/10/26, a span of 165 days.
Resident R3's clinical record revealed an admission date of 6/16/23, with diagnoses that included dementia, hypertension (high blood pressure), and atrial fibrillation (irregular heartbeat).
Resident R3's clinical record revealed physician progress note dated 3/6/26. The clinical record lacked evidence of any physician progress notes being completed since the 3/6/26 visit, which is greater than the required 60 days (70 days including the 10-day grace period).
Review of Resident R4's clinical record revealed an admission date of 12/23/24, with diagnoses that included Paraplegia (a condition where a person is paralyzed from the waist down), acute kidney failure (a sudden loss of the kidney's ability to filter waste products and extra fluid from the body), and idiopathic hypotension (a condition with abnormally low blood pressure without a known cause).
Resident R4's clinical record revealed physician progress note dated 12/5/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 12/5/25, and 3/10/26, a span of 95 days.
Review of Resident R5's clinical record revealed an admission date of 10/23/23, with diagnoses that included seizure (a sudden, temporary disruption in the brains normal electrical activity that can cause symptoms such as changes in movement jerking or twitching, changes in awareness such as staring or loss on consciousness), and sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping).
Resident R5's clinical record revealed physician progress note dated 10/29/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 10/29/25, and 3/10/26, a span of 132 days.
Review of Resident R6's clinical record revealed an admission date of 12/21/12, with diagnoses that included hydronephrosis with renal and ureteral calculous obstruction (a condition where urine cannot properly drain from the kidney due to blockage), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure).
Resident R6's clinical record revealed physician progress note dated 10/7/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 10/7/25, and 3/6/26, a span of 150 days.
Resident R7's clinical record revealed an admission date of 10/10/19, with diagnoses that included congestive heart failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), diabetes (a health condition caused by the body's inability to produce enough insulin), and TIA.
Resident R7's clinical record revealed physician progress note dated 9/19/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 9/19/25, and 3/10/26, a span of 172 days.
Review of Resident R8's clinical record revealed an admission date of 3/9/26, with diagnoses that included schizoaffective disorder bipolar type (a mental illness that causes impaired thinking process with episodes of extreme mood swings with emotional highs and emotional lows), hypertension, and gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat).
Resident R8's clinical record lacked any evidence of a physician progress note being completed at least once every thirty (30) days for the first ninety (90) days after Resident R8's admission.
Resident R9's clinical record revealed an admission date of 10/18/12, with diagnoses that included schizoaffective disorder, gastroesophageal reflux disease (GERD-happens when stomach acid flows back up into the esophagus and causes heartburn), and dysphagia (a medical condition characterized by difficulty swallowing solids, liquids, or both, which can lead to choking, coughing, or the sensation of food being stuck in the throat).
Resident R9's clinical record revealed physician progress note dated 9/19/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 9/19/25, and 3/6/26, a span of 168 days.
Resident R10's clinical record revealed an admission date of 11/19/18, with diagnoses that included dysphagia, intellectual disabilities, and impulse disorder.
Resident R10's clinical record revealed a physician progress note dated 11/5/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 11/5/25, and 3/10/26, a span of 125 days.
Resident R11's clinical record revealed an admission date of 5/22/24, with diagnoses that included bi-polar disorder (a lifelong mental condition that causes extreme changes in mood and activity), anxiety, and depression.
Resident R11's clinical record revealed a physician progress note dated 11/5/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 11/5/25, and 3/10/26, a span of 125 days.
Resident R12's clinical record revealed an admission date of 3/5/11, with diagnoses that included dementia, hypertension, and diabetes.
Resident R12's clinical record revealed a physician progress note dated 10/3/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 10/3/25, and 3/6/26, a span of 154 days.
Review of resident R13's clinical record revealed an admission date of 7/20/23, with diagnoses that included quadriplegia (a condition where a person is paralyzed and unable to move their body from the neck down), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and edema (swelling to an area of body due to holding excessive fluid).
Resident R13's clinical record revealed physician progress note dated 9/8/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 9/8/25, and 3/6/26, a span of 179 days.
Review of Resident R14's clinical record revealed an admission date of 5/14/25, with diagnoses that included Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), hyperlipidemia (high cholesterol), and gastro esophageal reflux disease.
Resident R14's clinical record revealed physician progress note dated 10/2/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 10/2/25, and 3/6/26, a span of 155 days.
Resident R18's clinical record revealed an admission date of 1/9/26, with diagnoses that included anxiety, depression, and dementia.
Resident R18's clinical record revealed a physician progress note dated 3/6/26, and then again on 4/14/26. The clinical record lacked evidence of any physician progress notes being completed upon admission at least once within the first 30 days.
Review of Resident R20's clinical record revealed an admission date of 11/1/23, with diagnoses that included gastro esophageal reflux disease, hypertension, and peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs).
Resident R20's clinical record revealed physician progress note dated 10/29/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 10/29/25, and 3/10/26, a span of 132 days.
Resident R23's clinical record revealed an admission date of 12/26/25, with diagnoses that included panic disorder, hypertension, and depression.
Resident R23's clinical record revealed physician progress note dated 3/6/26. The clinical record lacked evidence of any physician progress notes being completed upon admission within the first 30 days, again at 60 days, and since the 3/6/26 visit, which is greater than the required 60 days (70 days including the 10-day grace period).
Resident R26's clinical record revealed an admission date of 7/6/23, with diagnoses that included diabetes, hypertension, and atrial fibrillation.
Resident R26's clinical record revealed a physician progress note dated 10/1/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 10/1/25, and 3/6/26, a span of 156 days.
Resident R36's clinical record revealed an admission date of 1/25/25, with diagnoses that included COPD, diabetes, and osteoporosis (a condition where bone strength weakens and is susceptible to breaking).
Resident R36's clinical record revealed a physician progress note dated 9/8/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 9/8/25, and 3/6/26, a span of 179 days.
Resident R49's clinical record revealed an admission date of 3/10/25, with diagnoses that included paranoid schizophrenia (a type of severe brain disorder in which a person suffers from paranoia, hallucinations, and delusions), dysphagia, and anxiety.
Resident R49's clinical record revealed a physician progress note dated 11/21/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 11/21/25, and 3/10/26, a span of 109 days.
Resident R59's clinical record revealed an admission date of 2/6/26, with diagnoses that included dementia related to alcohol abuse, anxiety, and depression.
Resident R59's clinical record revealed a physician progress note dated 3/6/26, and then again on 4/14/26. The clinical record lacked evidence of any physician progress notes being completed since the 4/14/26, visit which is greater than the required 90 days following and admission.
Resident R76's clinical record revealed an admission date of 10/9/25, with diagnoses that included hypothyroidism (thyroid does not produce enough hormones for the body), dysphagia, and dementia.
Resident R76's clinical record revealed a physician progress note dated 11/21/25, and then again on 3/10/26. The clinical record lacked evidence of any physician progress notes being completed upon admission at least once within the first 30 days, at 60 days, at 90 days, and since the 3/10/26, visit which is greater than the required 60 days (70 days including the 10-day grace period).
Resident R85's clinical record revealed an admission date of 9/1/22, with diagnoses that included COPD, osteoporosis, and schizoaffective disorder.
Resident R85's clinical record revealed a physician progress note dated 9/26/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 9/26/25, and 3/10/26, a span of 165 days.
During an interview on 5/29/26, at 11:40 a.m. the Director of Nursing confirmed that Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R12, R13, R14, R18, R20, R23, R26, R36, R49, R59, R76, and R85 clinical records lacked evidence of the required physician visit progress notes. He/she also confirmed that physician progress notes should be completed at every required visit.
28 Pa. Code 201.14(a) Responsibility of Licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.2 (d)(8) Medical director
28 Pa. Code 211.5 (f)(ii)(iv) Medical records
| | Plan of Correction - To be completed: 06/30/2026
For Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 18, 20, 23, 26, 36, 49, 59, 76, and 85, the facility reviewed each resident's clinical record to identify missing or untimely physician visit progress notes. The attending physician and/or authorized practitioner was notified of the identified documentation concerns. Each affected resident's current condition, medications, treatments, orders, and total program of care will be reviewed by the physician and/or authorized practitioner, as applicable, and current physician progress notes will be completed, signed, and dated in the clinical record. Current orders were reviewed for signature and date requirements, as applicable. No adverse resident outcome was identified related to the missing physician progress note documentation.
To identify other residents who may have the potential to be affected by the same deficient practice, nursing will review current resident clinical records to determine whether required physician visits were documented by a written, signed, and dated progress note and whether required visits occurred according to the physician visit schedule. Any identified missing or untimely physician progress note documentation was addressed with the attending physician and/or authorized practitioner, and current resident review and documentation were completed as applicable.
To prevent recurrence, the Administrator will re-educate the Medical Director on the requirement that the physician must review the resident's total program of care, including medications and treatments, at required visits; write, sign, and date progress notes at each visit; and sign and date orders as required. Education will also include the required visit schedule of at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, including the 10-day allowance for timely visits, where applicable. Nursing will utilize a physician tracking tool within the medical record to monitor future visits.
To monitor continued compliance, the Corporate Auditor/Administrator or designee will audit physician visit documentation for all of current residents to verify that required visits are documented with written, signed, and dated progress notes and that the notes reflect review of the resident's current condition, medications, treatments, and total program of care. Audits will also verify that physician visit dates are tracked according to regulatory timeframes and that missing documentation is followed up timely. Audits will be completed weekly for four weeks, then monthly for two months, or until substantial compliance is sustained. Findings will be reported to the Quality Assurance and Performance Improvement Committee for review and additional action as needed, including Medical Director follow-up when patterns or barriers are identified.
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