the medical director f tag-501guidance* kurt hansen md, cmd douglas englebert rph september 29, 2005

The Medical Director The Medical Director F Tag-501Guidance*F Tag-501Guidance*

Kurt Hansen MD, CMDKurt Hansen MD, CMD

Douglas Englebert RPhDouglas Englebert RPhSeptember 29, 2005September 29, 2005

ObjectivesObjectives

Participant will be able to:Participant will be able to: Identify the role and responsibilities of the Identify the role and responsibilities of the

Medical Director.Medical Director. Demonstrate knowledge of the surveyor Demonstrate knowledge of the surveyor

guidance that is used to ensure a nursing guidance that is used to ensure a nursing home meets the Medical Director home meets the Medical Director requirements.requirements.

Utilize the investigative protocol to Utilize the investigative protocol to determine if the nursing home ensures the determine if the nursing home ensures the Medical Director coordinates medical care Medical Director coordinates medical care and implements resident care policies. and implements resident care policies.

Medical Director and Medical Director and Federal RegulationsFederal Regulations

No Change in Regulations. No Change in Regulations.

Federal Regulations 42 CFR 483.75(i) Federal Regulations 42 CFR 483.75(i) still require the facility designate a still require the facility designate a physician to serve as medical physician to serve as medical director who is responsible for director who is responsible for Implementation of resident care policiesImplementation of resident care policies Coordination of medical careCoordination of medical care

Medical Director and Medical Director and Federal RegulationsFederal Regulations

Change in Surveyor Change in Surveyor Guidance/Interpretive Guidance/Interpretive Guidelines/Investigative Protocol Guidelines/Investigative Protocol OnlyOnly Clarifies meaningClarifies meaning More detailsMore details Various examplesVarious examples Consistent with core roles/functions Consistent with core roles/functions

identified by medical directorsidentified by medical directors

Medical Director ORIGINAL Medical Director ORIGINAL Interpretive GuidelinesInterpretive Guidelines

Assure that facility is providing Assure that facility is providing appropriate care as requiredappropriate care as required

Monitor and ensure implementation Monitor and ensure implementation of resident care policiesof resident care policies

Provide oversight and supervision of Provide oversight and supervision of physician services and the medical physician services and the medical care of residentscare of residents

Medical Director ORIGINAL Medical Director ORIGINAL Interpretive GuidelinesInterpretive Guidelines

If inadequate medical care-including If inadequate medical care-including drug irregularities-identified or drug irregularities-identified or reported, evaluate and try to correct reported, evaluate and try to correct situationsituation

Assure support of essential medical Assure support of essential medical consultants as neededconsultants as needed

Medical Director ORGINAL Medical Director ORGINAL Interpretive GuidelinesInterpretive Guidelines

When necessary, consult resident When necessary, consult resident and his/her physician concerning and his/her physician concerning medical consultants as needed.medical consultants as needed.

Play significant role in overseeing Play significant role in overseeing overall clinical care of residents to overall clinical care of residents to ensure to extent possible that care is ensure to extent possible that care is adequateadequate

Medical Director ORGINAL Medical Director ORGINAL Interpretive GuidelinesInterpretive Guidelines

Only TWO Surveyor ProbesOnly TWO Surveyor Probes What does medical director do to What does medical director do to

coordinate medical services?coordinate medical services? How does medical director identify and How does medical director identify and

confirm problems of inadequate care?confirm problems of inadequate care?

Medical Director F501 UpdateMedical Director F501 Update

Why have an update?Why have an update?

OIG Feb 2003 OIG Feb 2003 report indicated inadequate regulatory report indicated inadequate regulatory

definition lead to underutilization of the definition lead to underutilization of the medical director by nursing homesmedical director by nursing homes



IOM report 2001 IOM report 2001 Indicated medical directors have very Indicated medical directors have very

little authority little authority To improve care medical director needs To improve care medical director needs

to have greater authority and to have greater authority and responsibility for medical servicesresponsibility for medical services



AMDA Position StatementAMDA Position Statement Guidelines are consistent with position Guidelines are consistent with position

statements related Medical Director statements related Medical Director ResponsibilitiesResponsibilities


Purpose and GoalsPurpose and Goals Better define medical director’s role and Better define medical director’s role and

importanceimportance Standardize expectations for providersStandardize expectations for providers Meet the changing needs of the long Meet the changing needs of the long

term care populationterm care population

Medical Director RoleMedical Director Role

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


Ensure adequate, appropriate Ensure adequate, appropriate physician services.physician services.

Review Credentials; oversee Review Credentials; oversee physicians and those who perform physicians and those who perform physician delegated tasks.physician delegated tasks.


Review physician performance and Review physician performance and provide feedback.provide feedback.

Oversee and help develop care Oversee and help develop care related policies and practices.related policies and practices.


Participate in efforts to improve Participate in efforts to improve quality of care and services.quality of care and services.

Serve as liaison between physicians Serve as liaison between physicians and facility staff and management.and facility staff and management.


Liaison with community.Liaison with community.

Source of education, training and Source of education, training and information.information.

Medical Director Role-Medical Director Role-Bottom lineBottom line

Medical Director is a critical Medical Director is a critical component of quality nursing home component of quality nursing home services.services.

Challenges for facilities are difficult Challenges for facilities are difficult yet proven to be attainable.yet proven to be attainable.

Survey ImpactSurvey Impact

What will surveyor’s actually do?What will surveyor’s actually do?

Surveyors now have Investigative Surveyors now have Investigative Protocol Medical Director.Protocol Medical Director.

Survey InvestigativeSurvey InvestigativeProtocol ObjectiveProtocol Objective

Determine if the facility has Determine if the facility has designated a licensed physician to designated a licensed physician to serve as medical director.serve as medical director.

Determine if the medical director, in Determine if the medical director, in collaboration with the facility, collaboration with the facility, coordinates medical care and coordinates medical care and implementation of resident care implementation of resident care policies.policies.

Protocol UseProtocol Use

All initial surveysAll initial surveys All extended surveys; or All extended surveys; or As indicated during any other type of As indicated during any other type of

survey.survey.


When there is no licensed physician When there is no licensed physician serving as medical director; and/orserving as medical director; and/or


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


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

Procedure for Investigation: Procedure for Investigation: Provision of Medical DirectorProvision of Medical Director

InterviewInterview Medical Director, Administrator, DON, Medical Director, Administrator, DON,

OthersOthers

Overview of extent of roles and Overview of extent of roles and functions and the extent of facility functions and the extent of facility support to the Medical Director.support to the Medical Director.


Interview DONInterview DON How is medical director involved in How is medical director involved in

resident care policies?resident care policies? Interview Medical Director ExampleInterview Medical Director Example

What are some of the resident care What are some of the resident care policies the facility has involved you in policies the facility has involved you in e.g. immunization program? How does e.g. immunization program? How does the facility involve you?the facility involve you?


If you identify concern that there is If you identify concern that there is no functioning medical director:no functioning medical director: Determine the duration and reasons for Determine the duration and reasons for

the lack of a medical director.the lack of a medical director. Identify what facility has done to retain Identify what facility has done to retain

medical director.medical director.

Procedure for Investigation: Procedure for Investigation:

Responsibility for Resident Care Responsibility for Resident Care PoliciesPolicies

Procedure: Responsibility for Procedure: Responsibility for Resident Care PoliciesResident Care Policies

Interview facility leadership about Interview facility leadership about medical director involvement in medical director involvement in developing, reviewing and implementing developing, reviewing and implementing resident care policies consistent with resident care policies consistent with standards of practice.standards of practice.

Review policies.Review policies.

Procedure: Responsibility for Procedure: Responsibility for Resident Care PoliciesResident Care Policies

Interview medical director about Interview medical director about their input in:their input in: Scope of servicesScope of services Facility capacityFacility capacity Standards of practiceStandards of practice Care processesCare processes

Procedure for Investigation:Procedure for Investigation:

Medical Care Coordination Medical Care Coordination

Medical Care CoordinationMedical Care Coordination

Medical Director involvement with Medical Director involvement with physicians who perform physicians who perform inappropriately.inappropriately.

Assuring provisions are in place for Assuring provisions are in place for physician services 24 hours a day.physician services 24 hours a day.

Assures that physicians visit residents.Assures that physicians visit residents.

Medical Care CoordinationMedical Care Coordination

Assuring other professionals act Assuring other professionals act within scope of practice.within scope of practice.

Assures clear procedures are in place Assures clear procedures are in place to contact medical director.to contact medical director.

Clarifies expectations for medical Clarifies expectations for medical director responsedirector response

Medical Director ExpectationsMedical Director Expectations

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

Medical Director RolesMedical Director Roles

Intervene as appropriate in care of Intervene as appropriate in care of other physician’s patients.other physician’s patients. No response or lack of timely response No response or lack of timely response

to INR resultsto INR results Pain managementPain management Pressure ulcersPressure ulcers


Advise physicians to follow clinical Advise physicians to follow clinical practice procedures and protocols or practice procedures and protocols or provide medical rationale for failing provide medical rationale for failing to do so.to do so. Pain managementPain management Antipsychotics in dementiaAntipsychotics in dementia ImmunizationImmunization


Help develop and disseminate Help develop and disseminate policies and procedures related to policies and procedures related to effective patient care and regulatory effective patient care and regulatory compliancecompliance Pressure ulcer assessment, treatment, Pressure ulcer assessment, treatment,

physician notification etc. F314physician notification etc. F314 Immunization program/standing ordersImmunization program/standing orders Advance Directive policiesAdvance Directive policies Emergency response policiesEmergency response policies


Help the facility review and develop Help the facility review and develop approaches to managing various approaches to managing various clinical conditions and problems.clinical conditions and problems. Treating diabetes, heart failure, Treating diabetes, heart failure,

delirium, pressure ulcers, urinary delirium, pressure ulcers, urinary incontinence and falls.incontinence and falls.


Help the facility identify quality Help the facility identify quality indicators/measures to evaluate and indicators/measures to evaluate and improve the care.improve the care. FallsFalls Weight LossWeight Loss Pain ManagementPain Management Pressure ulcersPressure ulcers Immunization ratesImmunization rates


Be available during facility surveysBe available during facility surveys Provide guidance on standards of Provide guidance on standards of

practicepractice Acute change in conditionAcute change in condition BehaviorsBehaviors Medication errorsMedication errors FallsFalls

Citation LinksCitation 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?

When to consider F501When to consider F501

When surveyor has identified care When surveyor has identified care issuesissues

When surveyor has identified standard When surveyor has identified standard of practice issuesof practice issues

When surveyor has lack of policies for When surveyor has lack of policies for delivering care, no policies or delivering care, no policies or outdated policies for current concerns outdated policies for current concerns related to care.related to care.

When there is no medical director.When there is no medical director.

When to cite F501When to cite F501

The survey team usually identifies The survey team usually identifies noncompliance at other tags; ANDnoncompliance at other tags; AND

Relates that violation to the medical Relates that violation to the medical

director’s role and responsibilities.director’s role and responsibilities.

When is there a F501 violationWhen is there a F501 violation

Other care tag cited and:Other care tag cited and:

Facility fails to assure Medical director is Facility fails to assure Medical director is performing functions of position performing functions of position

Facility/Medical director fails to Facility/Medical director fails to coordinate medical care and servicescoordinate medical care and services



Facility fails to include Medical director Facility fails to include Medical director in providing input and helping develop, in providing input and helping develop, review and implement resident care review and implement resident care policiespolicies



Facility/medical director fail to resolve Facility/medical director fail to resolve issues related to continuity of care and issues related to continuity of care and transfer between care settings.transfer between care settings.

Facility/medical director fail to assure Facility/medical director fail to assure primary attending and back up primary attending and back up physician coverage.physician coverage.


Other tag cited and:Other tag cited and:

Facility/Medical Director Fail to assure Facility/Medical Director Fail to assure services reflect current standards of services reflect current standards of practice.practice.

Facility/Medical Director Fail to assure Facility/Medical Director Fail to assure facility is capable to provide specific facility is capable to provide specific complex care.complex care.


Facility has no medical directorFacility has no medical director

SeveritySeverity

Immediate JeopardyImmediate Jeopardy Must have another tag at IJ andMust have another tag at IJ and

Relate the issues to failures in medical Relate the issues to failures in medical care and systems to the roles and care and systems to the roles and responsibilities of the medical directorresponsibilities of the medical director

SeveritySeverity

Actual Harm Level 3Actual Harm Level 3 Must have actual harm at level 3 for Must have actual harm at level 3 for

another tag andanother tag and


SeveritySeverity

Actual Harm Level 2Actual Harm Level 2 Must have actual harm at level 2 for Must have actual harm at level 2 for

another tag andanother tag and


SeveritySeverity

Actual Harm Level 1Actual Harm Level 1 Must have cited potential for harm at Must have cited potential for harm at

level 1 for another tag, and level 1 for another tag, and Relate the issues to failures in medical Relate the issues to failures in medical

care and systems to the roles and care and systems to the roles and responsibilities of the medical director responsibilities of the medical director

OR…..OR…..

Severity Level 1Severity Level 1

Facility has no medical director andFacility has no medical director and There are no negative outcomes andThere are no negative outcomes and Medical care and systems are in place Medical care and systems are in place

andand The duration without medical director is The duration without medical director is

relatively short andrelatively short and Facility is actively seeking new medical Facility is actively seeking new medical

directordirector

Characteristics of SuccessCharacteristics of Success

Facilities that are in compliance with Facilities that are in compliance with the Medical Director requirementthe Medical Director requirement Choose a medical director who has Choose a medical director who has

interest, availability, and has skills as interest, availability, and has skills as identified in pertinent regulatory and identified in pertinent regulatory and professional standards.professional standards.

Clearly identify functions of medical Clearly identify functions of medical director via job description that was director via job description that was developed by assessing facility needs developed by assessing facility needs and required functions. and required functions.


Medical Director

Quality Assurance

Facility Care Delivery

Resident

ResourcesResources

www.amda.comwww.amda.com www.wamd.orgwww.wamd.org CMS: *SOM and training guide due CMS: *SOM and training guide due

out in October 2005.out in October 2005. www.Med-Pass.comwww.Med-Pass.com

the medical director f tag-501guidance* kurt hansen md, cmd douglas englebert rph september 29, 2005

Documents

medical care of residents

inadequate medical care

medical services

medical director requirements

medical directors slide

medical director f tag

appropriate care

clinical care of residents