The Medical Director F Tag-501Guidance*

1. The Medical Director F Tag-501Guidance* Kurt Hansen MD, CMD Douglas Englebert RPh September 29, 2005

2. Objectives Participant will be able to: • Identify the role and responsibilities of the Medical Director. • Demonstrate knowledge of the surveyor guidance that is used to ensure a nursing home meets the Medical Director requirements. • Utilize the investigative protocol to determine if the nursing home ensures the Medical Director coordinates medical care and implements resident care policies.

3. Medical Director and Federal Regulations • No Change in Regulations. • Federal Regulations 42 CFR 483.75(i) still require the facility designate a physician to serve as medical director who is responsible for • Implementation of resident care policies • Coordination of medical care

4. Medical Director and Federal Regulations • Change in Surveyor Guidance/Interpretive Guidelines/Investigative Protocol Only • Clarifies meaning • More details • Various examples • Consistent with core roles/functions identified by medical directors

5. Medical Director ORIGINAL Interpretive Guidelines • Assure that facility is providing appropriate care as required • Monitor and ensure implementation of resident care policies • Provide oversight and supervision of physician services and the medical care of residents

6. Medical Director ORIGINAL Interpretive Guidelines • If inadequate medical care-including drug irregularities-identified or reported, evaluate and try to correct situation • Assure support of essential medical consultants as needed

7. Medical Director ORGINAL Interpretive Guidelines • When necessary, consult resident and his/her physician concerning medical consultants as needed. • Play significant role in overseeing overall clinical care of residents to ensure to extent possible that care is adequate

8. Medical Director ORGINAL Interpretive Guidelines • Only TWO Surveyor Probes • What does medical director do to coordinate medical services? • How does medical director identify and confirm problems of inadequate care?

9. Medical Director F501 Update • Why have an update? • OIG Feb 2003 • report indicated inadequate regulatory definition lead to underutilization of the medical director by nursing homes

10. Medical Director F501 Update • Why have an update? • IOM report 2001 • Indicated medical directors have very little authority • To improve care medical director needs to have greater authority and responsibility for medical services

11. Medical Director F501 Update • Why have an update? • AMDA Position Statement • Guidelines are consistent with position statements related Medical Director Responsibilities

12. Medical Director F501 Update • Purpose and Goals • Better define medical director’s role and importance • Standardize expectations for providers • Meet the changing needs of the long term care population

13. Medical Director Role • Medical Director requirement for nursing homes requires the need for an “active” medical director role vs. “passive” role.

14. Medical Director Role • Ensure adequate, appropriate physician services. • Review Credentials; oversee physicians and those who perform physician delegated tasks.

15. Medical Director Role • Review physician performance and provide feedback. • Oversee and help develop care related policies and practices.

16. Medical Director Role • Participate in efforts to improve quality of care and services. • Serve as liaison between physicians and facility staff and management.

17. Medical Director Role • Liaison with community. • Source of education, training and information.

18. Medical Director Role-Bottom line • Medical Director is a critical component of quality nursing home services. • Challenges for facilities are difficult yet proven to be attainable.

19. Survey Impact • What will surveyor’s actually do? • Surveyors now have Investigative Protocol Medical Director.

20. Survey InvestigativeProtocol Objective • Determine if the facility has designated a licensed physician to serve as medical director. • Determine if the medical director, in collaboration with the facility, coordinates medical care and implementation of resident care policies.

21. Protocol Use • All initial surveys • All extended surveys; or • As indicated during any other type of survey.

22. Protocol Use • When there is no licensed physician serving as medical director; and/or

23. Protocol Use • Facility failed to involve medical director in roles and functions related to medical care coordination and/or implementation of resident care policies.

24. Protocol Use • The medical director may not have performed the roles and functions related to coordination of medical care and/or implementation of resident care policies.

25. Procedure for Investigation: Provision of Medical Director Interview • Medical Director, Administrator, DON, Others • Overview of extent of roles and functions and the extent of facility support to the Medical Director.

26. Procedure for Investigation: Provision of Medical Director • Interview DON • How is medical director involved in resident care policies? • Interview Medical Director Example • What are some of the resident care policies the facility has involved you in e.g. immunization program? How does the facility involve you?

27. Procedure for Investigation: Provision of Medical Director • If you identify concern that there is no functioning medical director: • Determine the duration and reasons for the lack of a medical director. • Identify what facility has done to retain medical director.

28. Procedure for Investigation: Responsibility for Resident Care Policies

29. Procedure: Responsibility for Resident Care Policies • Interview facility leadership about medical director involvement in developing, reviewing and implementing resident care policies consistent with standards of practice. • Review policies.

30. Procedure: Responsibility for Resident Care Policies • Interview medical director about their input in: • Scope of services • Facility capacity • Standards of practice • Care processes

31. Procedure for Investigation: • Medical Care Coordination

32. Medical Care Coordination • Medical Director involvement with physicians who perform inappropriately. • Assuring provisions are in place for physician services 24 hours a day. • Assures that physicians visit residents.

33. Medical Care Coordination • Assuring other professionals act within scope of practice. • Assures clear procedures are in place to contact medical director. • Clarifies expectations for medical director response

34. Medical Director Expectations • As a surveyor when you interview the medical director, director of nursing and nursing home administrator….what types of things do you expect to hear and see happening?

35. Medical Director Roles • Intervene as appropriate in care of other physician’s patients. • No response or lack of timely response to INR results • Pain management • Pressure ulcers

36. Medical Director Roles • Advise physicians to follow clinical practice procedures and protocols or provide medical rationale for failing to do so. • Pain management • Antipsychotics in dementia • Immunization

37. Medical Director Roles • Help develop and disseminate policies and procedures related to effective patient care and regulatory compliance • Pressure ulcer assessment, treatment, physician notification etc. F314 • Immunization program/standing orders • Advance Directive policies • Emergency response policies

38. Medical Director Roles • Help the facility review and develop approaches to managing various clinical conditions and problems. • Treating diabetes, heart failure, delirium, pressure ulcers, urinary incontinence and falls.

39. Medical Director Roles • Help the facility identify quality indicators/measures to evaluate and improve the care. • Falls • Weight Loss • Pain Management • Pressure ulcers • Immunization rates

40. Medical Director Roles • Be available during facility surveys • Provide guidance on standards of practice • Acute change in condition • Behaviors • Medication errors • Falls

41. Citation Links • Pressure Ulcer (F314) • Urinary Incontinence (F315) • Unnecessary Drug (F329) • Physician Consultation (F157) • Did you consider F501?

42. When to consider F501 • When surveyor has identified care issues • When surveyor has identified standard of practice issues • When surveyor has lack of policies for delivering care, no policies or outdated policies for current concerns related to care. • When there is no medical director.

43. When to cite F501 • The survey team usually identifies noncompliance at other tags; AND • Relates that violation to the medical director’s role and responsibilities.

44. When is there a F501 violation • Other care tag cited and: • Facility fails to assure Medical director is performing functions of position • Facility/Medical director fails to coordinate medical care and services

45. When is there a F501 violation • Other care tag cited and: • Facility fails to include Medical director in providing input and helping develop, review and implement resident care policies

46. When is there a F501 violation • Other care tag cited and: • Facility/medical director fail to resolve issues related to continuity of care and transfer between care settings. • Facility/medical director fail to assure primary attending and back up physician coverage.

47. When is there a F501 violation • Other tag cited and: • Facility/Medical Director Fail to assure services reflect current standards of practice. • Facility/Medical Director Fail to assure facility is capable to provide specific complex care.

48. When is there a F501 violation • Facility has no medical director

49. Severity • Immediate Jeopardy • Must have another tag at IJ and • Relate the issues to failures in medical care and systems to the roles and responsibilities of the medical director

50. Severity • Actual Harm Level 3 • Must have actual harm at level 3 for another tag and • Relate the issues to failures in medical care and systems to the roles and responsibilities of the medical director