Utah Admin. Code 432-200-15

Current through Bulletin 2024-23, December 1, 2024

Section R432-200-15 - Physician Services

(1) A licensed physician shall provide the care for each resident in need of nursing services, habilitative, or rehabilitative care.

(2) The licensee shall permit each resident to choose their physician.

(3) The licensee shall ensure that the following physician responsibilities are met:

(a) each resident has a medical history and pertinent physical examination at least annually;

(b) each intermediate care resident is seen at least once during the first 60 days of residency;

(c) the attending physician or medical practitioner sees the resident when necessary but at least every 60 days, unless the attending physician or practitioner documents in the resident's record why the resident does not need to be seen this frequently;

(d) the physician or practitioner establishes and follows a schedule alternating visits; and

(e) each visit and evaluation is documented in the resident's record.

(4) The licensee shall develop policies and procedures that outline:

(a) access to physician services in case of medical emergency or when the attending physician is not available;

(b) names and telephone numbers of on-call physicians in the health services supervisor's office; and

(c) requirement for reevaluation of the resident and review of care and treatment orders when there is a change of attending physician that is completed within 15 days of the change.

(5) The following practitioners may provide medical services according to state law:

(a) a nurse practitioner licensed to practice in Utah; and

(b) a physician's assistant working under the supervision of a licensed physician and performing only those selected diagnostic and therapeutic tasks identified in Title 58, Chapter 70a, The Utah Physician's Assistant Act.

(6) The licensee shall ensure that any of the following physician orders and notes are signed and dated by a physician and maintained as part of each treatment record:

(a) admission orders;

(b) medication, treatment, therapy, laboratory, and diet orders;

(c) history and physical examinations;

(d) physician's progress notes;

(e) the discharge summary;

(f) discharge orders;

(g) telephone orders are immediately recorded in the treatment record by the recipient and include:

(i) date and time of order;

(ii) the recipient's signature and title; and

(iii) the order is countersigned and dated within 15 days by the physician who prescribed the order; and

(h) the attending physician shall complete the resident's medical record within 60 days of the resident's discharge, transfer, or death.

(7) The licensee shall promptly notify the attending physician and document the following:

(a) admission of the resident;

(b) a sudden or marked adverse change in the resident's signs, symptoms, or behavior;

(c) any significant weight change in a 30-day period unless the resident's physician stipulates another parameter in writing;

(d) any adverse response or reaction by a resident to a medication or treatment;

(e) any error in medication administration or treatment;

(f) the discovery of a decubitus ulcer, the beginning of treatment, and if treatment is not effective; and

(g) any inability of the licensee to obtain or administer drugs, equipment, supplies, or services promptly as prescribed.

(8) If the attending physician or designee is not readily available, the emergency care physician shall provide any emergency medical care. The licensee shall post the telephone numbers of the emergency care physician at the control station.

(9) Any attempt by a staff member to notify a physician shall be noted by the staff member in the resident's record, to include the time and method of communication and the name of any person acknowledging contact.

Utah Admin. Code R432-200-15

Amended by Utah State Bulletin Number 2024-03, effective 1/22/2024