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 (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
Dr. Hansen Please provide examples of how does or how should a medical director ensure appropriate care is provided. How does he/she monitor implementation? How does medical director provide oversight and supervision.

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
Give examples of When necessary…

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?
Give examples of When necessary…

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 Investigative Protocol 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.
How does the survey team determine if no licensed physician for medical director.
How should a facility be checking if physician is licensed. (DRL web site)

22. Protocol Use
When there is no licensed physician serving as medical director; and/or
How does the survey team determine if no licensed physician for medical director.
How should a facility be checking if physician is licensed. (DRL web site)

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.
Bullet one: Survey can get this by interviewing medical director. Ask Dr. Hansen how we can do this. Check agreement due to F500

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.
Bullet one: Survey can get this by interviewing medical director. Ask Dr. Hansen how we can do this. Check agreement due to F500

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
Scope of services: what things do we have the resources to be able to provide.
Facility capacity: what resources do we as a facility have ie can we do IV care, dialysis, end of life, respiratory care etc.
Standards of Practice: What policies do we have in place for addressing pressure sores…do the policies reflect the current standard of care. Many standards for pressure ulcers are listed at F314.
Care Processes: Assessment, care planning, treatment implementation and monitoring or evaluation. How do you contact physicians, access consultants, implement physician orders, etc.

31. Procedure for Investigation:
Medical Care Coordination
Scope of services: what things do we have the resources to be able to provide.
Facility capacity: what resources do we as a facility have ie can we do IV care, dialysis, end of life, respiratory care etc.
Standards of Practice: What policies do we have in place for addressing pressure sores…do the policies reflect the current standard of care. Many standards for pressure ulcers are listed at F314.
Care Processes: Assessment, care planning, treatment implementation and monitoring or evaluation. How do you contact physicians, access consultants, implement physician orders, etc.

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

51. Severity Actual Harm Level 2
Must have actual harm at level 2 for another tag and
Relate the issues to failures in medical care and systems to the roles and responsibilities of the medical director

52. Severity Actual Harm Level 1
Must have cited potential for harm at level 1 for another tag, and
Relate the issues to failures in medical care and systems to the roles and responsibilities of the medical director
OR…..

53. Severity Level 1 Facility has no medical director and
There are no negative outcomes and
Medical care and systems are in place and
The duration without medical director is relatively short and
Facility is actively seeking new medical director

54. Characteristics of Success
Facilities that are in compliance with the Medical Director requirement
Choose a medical director who has interest, availability, and has skills as identified in pertinent regulatory and professional standards.
Clearly identify functions of medical director via job description that was developed by assessing facility needs and required functions.

55. Medical Director Role
Resident

56. Resources www.amda.com www.wamd.org
CMS: *SOM and training guide due out in October 2005.