Long-Term Care Survey Alert

Here's how to cut off F501 tags at the get-go.

How involved is your medical director in managing the survey process in your facility? That's a question you can bet surveyors will be asking under the revised F501 tag if they find quality-of-care problems.

Any care issue that rises to a systemic level--or one that involves a nonstandard practice--can trigger surveyors to home in on medical director deficiencies, cautions Chris Puri, an attorney with Boult Cummings Conners & Berry PLC in Nashville, TN.

Head off problems at the pass: The facility should contact the medical director whenever a serious care issue arises, emphasizes Charles Crecelius, CMD, a medical director in St. Louis, MO. But simply picking up the phone to notify the person isn't enough. You also have to "obtain meaningful input from the person and keep records of the medical director's involvement," he emphasizes.

Target Poorly Performing Attending Physicians

The revised guidance expects medical directors to "ride herd" over attendings who don't meet performance expectations, cautions Puri.

Solution: Define what kinds of physician shortfalls warrant a review by the medical director--"for example, if the physician's clinical choices run contrary to facility protocols," suggests Puri. "Failing to change orders when warranted or follow-up on a resident's change in condition are red flags."

The nursing home would be "well served" by a medical director who at least periodically reviews whether the attendings respond to the staff's concerns and resident's changes in condition in real time, advises John Lessner, attorney with Ober/Kaler in Baltimore.

Real-world tip: To help gauge the quality of attending physician care, Sunshine Terrace Foundation looks at outcomes, "such as readmissions for the same medical problem and how appropriate the facility's admissions are to the acute-care setting," says Sara Sinclair, RN, CNHA, CEO of the Logan, UT-based corporation.

Define the Medical Director's Role During the Survey

Facilities that don't have their medical director ready to roll at the first sign of surveyors' concerns about nursing or medical care are asking for both quality-of-care and related F501 tags.

Spell it out: Define your expectations for what the medical director will do during the survey and exit conference. For example, the medical director can review portions of charts in person or by fax as needed, says Jacqueline Vance, RN, director of clinical affairs for the American Medical Directors Association.
SavaSenior Care Administrative Services LLC teleconferences the medical director in as needed during the survey, reports Annaliese Impink, associate general counsel for the Atlanta-based nursing home company. Medical directors should be ready to serve as a liaison with an attending physician whose care comes under surveyor scrutiny.

The medical directors can help clarify issues directly with surveyors before consulting with the attending physician, says Vance. They can also help explain, as appropriate, the judgment of other facility professionals, she adds.

Jettison Deficiencies During the Exit Conference

Medical directors can make a difference in the outcome of exit conferences and the survey by explaining clinical issues that have some ambiguity, observes Gene Larrabee, a nursing home administrator and consultant in St. Augustine, FL.

Examples: In one instance, a surveyor was going to cite a facility for a dignity issue, claiming the physical therapist hadn't provided enough privacy for a resident during a treatment. But "the medical director pointed out that it was clinically inappropriate for anyone to interrupt a therapy treatment," says Larrabee.  "The surveyor backed off and didn't cite," he adds.

Larrabee also witnessed an instance where surveyors were going to write up a facility for unnecessary drugs because a resident's prescribed medication didn't fit the person's medical diagnosis. "The medical director showed the surveyors that the medication's secondary use applied to the resident's diagnosis. And the surveyors accepted that explanation."

Or consider the case where a medical director "blew away a deficiency" at the exit conference by lecturing a surveyor about the difference between dehydration and hypovolemia, as relayed by Joseph Bianculli, an attorney in private practice in Arlington, VA. "The medical director came armed with all the latest studies and clinical data," he tells Eli.

To IDR or nor IDR? Medical directors can provide invaluable input in deciding whether to use the state-run informal dispute resolution process to challenge a survey issue, according to Harold Bob, MD, CMD, in comments at the recent American Medical Directors Association annual meeting in Dallas. For details, including a case study on an actual IDR situation analyzed by a Maryland surveyor and Bob, see the May 2006 Long-Term Care Survey Alert.

Editor's note: For more information on how to identify problems with physician care, read "Use The MDS To Red Flag Physician Care Shortfalls" in the January 2006 MDS Alert. For subscription information, call 1-800-874-9180.