N.J. Admin. Code § 8:85-2.3

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:85-2.3 - Physician services

(a) General requirements for physician services shall be as follows:

1. Each Medicaid beneficiary's care shall be under the supervision of a New Jersey licensed attending physician chosen by, or agreed to by, the Medicaid beneficiary, or if the beneficiary is incompetent, by the family or legal guardian.

2. In a NF providing care to children, the attending physician shall be board certified/eligible by the American Board of Pediatrics or the American Board of Family Practice.

3. The NF shall maintain arrangements that assure that the services of a New Jersey licensed physician who can act in case of emergency, are continuously available.

(b) Requirements for a medical director shall be as follows:

1. The NF shall retain, pursuant to a written agreement, a physician licensed under New Jersey law to serve as Medical Director on a part-time or full-time basis as is appropriate for the needs of the residents and the size of the facility. The Medical Director shall be responsible for the overall development of medical policies and coordination of the medical care in the facility to ensure the adequacy and appropriateness of medical services provided to beneficiaries and to monitor the health status of employees.

i. In a NF providing care exclusively to children, the medical director shall be certified/eligible by the American Board of Pediatrics or the American Board of Family Practice.

2. The duties of the medical director shall include, but not be limited to, the following:

i. Participation in the development of written policies, rules and regulations which are approved by the governing body of the facility;

ii. Delineation of the responsibilities of the attending physician(s) and ensuring that visits by medical consultants occur as needed;

iii. Acting as liaison between administration and medical staff for improving services and ensuring the carrying out of responsibilities of the medical staff;

iv. Surveying the execution of resident care policies, which includes a periodic evaluation of the adequacy and appropriateness of the services of health professional and supporting staff and monitoring the health status of the facility's employees;

v. Participation in the review of incidents and accidents that occur on the premises to identify hazards to health and safety of employees and residents. The Medical Director is given appropriate information to help ensure a safe and sanitary environment for residents and personnel;

vi. Ensuring that the medical regimen is incorporated in the resident care plan;

vii. Participation in the facility's quality assurance program through meetings, interviews and/or preparation or review of reports regarding infection control, pharmaceutical services, credentials, resident care, etc.;

viii. Collaboration with administration in the planning of educational programs for facility staff;

ix. Reviewing written reports of surveys and inspection and making recommendations to the administrator;

x. Participation in special projects, such as medical evaluation studies;

xi. Negotiating and resolving problems with the medical community;

xii. Responding quickly and appropriately to medical emergencies that are not handled by another attending physician; and

xiii. Ensuring that, for each Medicaid beneficiary, there is a designated primary and alternate physician who can be contacted when necessary.

(c) Requirements for an attending physician shall be as follows:

1. Initial medical findings and physician's orders;

i. There shall be available to the NF, prior to, or at the time of admission, resident information that includes medical history, diagnosis, current medical findings, medical plan of care and rehabilitation potential.

ii. If the resident is transferred from another health care facility, a transfer summary of the course of treatment including findings of diagnostic services shall accompany the resident. If the transfer summary information is not available in writing in the facility upon admission of the resident, it shall be obtained by the facility after admission.

iii. There shall be orders from a physician for the immediate care of the resident, to include, at a minimum, medications, dietary needs, hygiene, level of activity, and special therapies, if applicable. A current health facility discharge summary containing the information is acceptable.

(1) If medical orders for the immediate care of the resident are unobtainable at the time of admission, the physician with responsibility for emergency care shall give temporary orders.

(2) Each resident shall be examined by a physician within five days before, or 48 hours after admission.

2. The attending physician shall also be responsible for initial and ongoing medical evaluation, as follows:

i. The medical assessment of the Medicaid beneficiary shall begin at the time of admission to a NF and shall be the foundation for the planning, implementation, and evaluation of medical services directed toward the care needs of the resident.

ii. The medical assessment shall consist of the complete, documented, and identifiable appraisal (from the time of admission to discharge) of the Medicaid beneficiary's current physical and psychosocial health status. The medical assessment shall be utilized to determine the existing and potential requirements of care. The evaluation of the data obtained from the medical assessment shall lead to the development of the medical services portion of the interdisciplinary care plan. The assessment data shall be available to all staff involved in the care of the resident.

iii. The tools utilized in the assessment process shall include a complete history and physical examination, eliciting medically defined conditions and prior medical history, admission form(s), transfer form(s), HSDP, and data from other members of the interdisciplinary team.

iv. Other Medicaid recipient data utilized should include:

(1) Clinical physical and psychological symptoms and signs;

(2) Capabilities to perform functional activities of daily living;

(3) Sensory (hearing, speech, and vision) and physical impairments;

(4) Medical necessity of additional nursing services, in accordance with 8:85-2.2;

(5) Nutritional status and requirements;

(6) Special treatments or procedures (including laboratory and other diagnostic services);

(7) Psychosocial status;

(8) Dental condition;

(9) Activities potential;

(10) Rehabilitation potential;

(11) Cognitive status;

(12) Drug therapy;

(13) Safety requirements;

(14) Attention to comfort and dignity; and

(15) Plans of alternative care, when applicable.

v. In addition to the requirements in (c)2iv above, medical evaluations of children in a NF shall include the following:

(1) Assessment of developmental status;

(2) Measurement and recording of head circumference until the age of 24 months;

(3) Measurement and recording of blood pressure, from age three;

(4) Assessment of immunization status and administration of appropriate immunizations according to the recommendations of the Academy of Pediatrics;

(5) Hemoglobin determination once during each of the following times: six to eight months, two to six years, and 10 to 12 years of age;

(6) Urinalysis--a minimum of once between age 18 and 24 months and once between 13 and 15 years of age;

(7) Tuberculin testing once during each of the following times: nine to 12 months, four to six years, and 10 to 15 years of age; and

(8) Lead screening (EP Test) upon admission.

vi. As an active member of the interdisciplinary team, the attending physician shall:

(1) Identify and document the medical needs of the Medicaid beneficiary;

(2) Be attentive to and develop individualized preventive, maintenance, restorative and/or rehabilitative medical interventions in relation to the physical and psychosocial needs identified in order to prevent deterioration, maintain wellness and promote maximum development or restoration;

(3) Be observant of clinical signs and symptoms of the Medicaid beneficiary;

(4) Perform, annually, a complete physical examination, as the medical component of the comprehensive resident assessment;

(5) Periodically evaluate and be cognizant of the Medicaid beneficiary's total clinical record including the interdisciplinary care plan and facilitate necessary changes as medically indicated;

(6) Identify and document the effectiveness of, and the Medicaid beneficiary's response to, therapeutic intervention such as medications, treatment and special therapies, and, where possible, the reason for any ineffectiveness in the Medicaid beneficiary's responses.

3. Physician progress notes shall:

i. Be maintained in accordance with accepted professional standards and practices as necessitated by the Medicaid beneficiary's medical condition;

ii. Be a legible, individualized summary of the Medicaid beneficiary's medical status and reflect current medical condition, including clinical signs and symptoms; significant change in physical or mental conditions; response to medications, treatments, and special therapies; indications of injury including the date, time and action taken; medical necessity for extent of change in the medical treatment plan; and

iii. Be written, signed, and dated at each visit.

4. Physician orders shall be completed as follows:

i. Orders concerning medications and treatment shall be in effect for the specified number of days indicated by the physician, but in no case shall exceed a period of 60 days. Vague and blanket orders shall not be acceptable. The physician shall review all orders and re-confirm in writing with signature and date, when any orders are continued.

ii. Stop orders shall conform with the standards of the Formulary Committee of the facility.

5. Physician visits shall be conducted as follows:

i. All required physician visits shall be made by the physician personally, or a physician assistant or nurse practitioner, as permitted by State law.

(1) For the first 90 days, the Medicaid beneficiary shall be visited and examined every 30 days. Thereafter, with written justification, the interval between visits may be extended for up to 60 days.

(2) Additional visits shall be made when significant clinical changes in the Medicaid beneficiary's condition require medical intervention.

N.J. Admin. Code § 8:85-2.3

Recodified from N.J.A.C. 10:63-2.3 and amended by R.2005 d.389, effective 1/17/2006.
See: 36 N.J.R. 4700(a), 37 N.J.R. 1185(a), 38 N.J.R. 674(a).
Rewrote the section.