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. 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. 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. 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. 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 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 Implementation of resident care policies Coordination of medical care 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 Assure that facility is providing appropriate care as required Monitor and ensure implementation of resident care policies Monitor and ensure implementation of resident care policies Provide oversight and supervision of physician services and the medical care of residents 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 If inadequate medical care-including drug irregularities-identified or reported, evaluate and try to correct situation Assure support of essential medical consultants as needed 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. 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 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 Only TWO Surveyor Probes What does medical director do to coordinate medical services? What does medical director do to coordinate medical services? How does medical director identify and confirm problems of inadequate care? How does medical director identify and confirm problems of inadequate care?

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

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

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

12. Medical Director F501 Update Purpose and Goals Purpose and Goals Better define medical director’s role and importance Better define medical director’s role and importance Standardize expectations for providers Standardize expectations for providers Meet the changing needs of the long term care population 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. 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. Ensure adequate, appropriate physician services. Review Credentials; oversee physicians and those who perform physician delegated tasks. Review Credentials; oversee physicians and those who perform physician delegated tasks.

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

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

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

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

19. Survey Impact What will surveyor’s actually do? What will surveyor’s actually do? Surveyors now have Investigative Protocol Medical Director. 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 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. 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 initial surveys All extended surveys; or All extended surveys; or As indicated during any other type of survey. As indicated during any other type of survey.

22. Protocol Use When there is no licensed physician serving as medical director; and/or 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. 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. 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. 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. Interview facility leadership about medical director involvement in developing, reviewing and implementing resident care policies consistent with standards of practice. Review policies. Review policies.

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

31. Procedure for Investigation: Medical Care Coordination Medical Care Coordination

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

33. Medical Care Coordination Assuring other professionals act within scope of practice. Assuring other professionals act within scope of practice. Assures clear procedures are in place to contact medical director. Assures clear procedures are in place to contact medical director. Clarifies expectations for medical director response 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? 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. Intervene as appropriate in care of other physician’s patients. No response or lack of timely response to INR results No response or lack of timely response to INR results Pain management Pain management Pressure ulcers Pressure ulcers

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

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

38. Medical Director Roles Help the facility review and develop approaches to managing various clinical conditions and problems. 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. 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. Help the facility identify quality indicators/measures to evaluate and improve the care. Falls Falls Weight Loss Weight Loss Pain Management Pain Management Pressure ulcers Pressure ulcers Immunization rates Immunization rates

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

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

42. When to consider F501 When surveyor has identified care issues When surveyor has identified care issues When surveyor has identified standard of practice 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 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. When there is no medical director.

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

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

45. When is there a F501 violation Other care tag cited and: Other care tag cited and: Facility fails to include Medical director in providing input and helping develop, review and implement resident care policies 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: 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 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. Facility/medical director fail to assure primary attending and back up physician coverage.

47. When is there a F501 violation Other tag cited and: Other tag cited and: Facility/Medical Director Fail to assure services reflect current standards of practice. 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. 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 Facility has no medical director

49. Severity Immediate Jeopardy Immediate Jeopardy Must have another tag at IJ and 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 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 Actual Harm Level 3 Must have actual harm at level 3 for another tag and 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 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 Actual Harm Level 2 Must have actual harm at level 2 for another tag and 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 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 Actual Harm Level 1 Must have cited potential for harm at level 1 for another tag, and 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 Relate the issues to failures in medical care and systems to the roles and responsibilities of the medical director OR….. OR…..

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

54. Characteristics of Success Facilities that are in compliance with the Medical Director requirement 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. 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. Clearly identify functions of medical director via job description that was developed by assessing facility needs and required functions.

55. Medical Director Role Medical Director Quality Assurance Facility Care Delivery Resident

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