Long-Term Care Survey Alert

Nail down what the new survey guidance really requires.

Expect surveyors to have F501 tags on their minds when they write you up for a quality-of-care deficiency.

The finalized survey guidance for F501 now in effect directs surveyors to take a hard look at the medical director's involvement in the facility if they cite noncompliance with a host of F tags. And while the revised guidance doesn't change the underlying regs, it definitely ups the ante for getting your medical director up to speed to meet a list of "clarified" performance expectations.

"Surveyors will likely go hog wild once they get up to speed" on the revised survey guidance, predicts Kathy Hurst, JD, director of healthcare operations for Anaheim Hills-based TSW Management Group, which manages several nursing facilities in California.
To head off F tags, make sure your facility and medical director are ready for survey prime time.

The first rule of survival: Figure out what you really need--and don't need--to do. That way, you can invest your time and resources wisely.

Start by making sure you have a contingency plan for having a medical director in place at all times, advises Christopher Puri, an attorney with Boult Cummings Conners & Berry PLC in Nashville, TN.  Facilities caught in between medical directors will automatically trigger surveyors to use the investigative protocol for F501, which you want to prevent, if at all possible. 

Develop a Collaborative Model

To ensure compliance with CMS' clarified F501 requirements, strive for a collaborative model with shared authority between the facility and medical director, suggests Puri. "A good working relationship between the medical director and facility is going to be critical" under the revised F501 survey guidance," he notes. "You don't want a situation where the facility or the medical director is doing everything," he says, "because so many aspects of the guidance require interactions between the two."

For example, the revised guidance says the medical director must "collaborate with facility leadership, staff and other practitioners to help develop, implement and evaluate resident care policies and procedures reflecting current standards of practice."

Don't read too much into it: "Implementation" doesn't mean the medical director physically has to do the work, says Hurst. "It just means the medical director has to ensure patient care is being delivered in an appropriate manner," she adds. "The medical director isn't responsible for implementing any specific policy or drafting the policies."

The regulatory guidance also states that the medical director should be part of the ongoing educational program. Again, that doesn't mean the person has to actually provide the education, Hurst points out. "The medical director can simply suggest topics he/she thinks are needed, such as more training for nurses on congestive heart failure. The facility then would provide that education."

Target Care Policies/Procedures

The medical director should make sure the facility's policies are up to date and reflect current standards of care, says Charles Crecelius, MD, PhD, CMD, a medical director in St. Louis, MO. That's especially important for policies that pertain to recent quality of care problems in the facility and revised survey guidance in the State Operations Manual, he adds. (To date, the Centers for Medicare & Medicaid Services CMS has issuednew F314 (pressure ulcers) and F315 (urinary incontinence and urinary catheters) tags but the agency plans to roll out a steady stream of revisions.)

Tip: Nurse practitioners can help a medical director develop practical and useful policies and procedures, notes attorney Howard Sollins with Ober/Kaler in Baltimore.

The medical director is expected to play a key role in the following areas, Jacqueline Vance, RN, director of clinical affairs for the American Medical Directors Association, tells Eli:

1. Policies to avoid unnecessary resident transfers
2. Proactive involvement in survey
3. Risk management around key clinical areas such as:

• Pressure ulcers
• Falls
• Infection control
• Medication management P&Ps
• P&Ps for appropriate, consistent care
• Avoiding unnecessary treatment

Survival tip: The F501 survey investigative protocol directs surveyors to interview medical directors about their input into the facility's scope of services and ability to care for individuals with complex or special care needs. The list includes residents receiving dialysis, end-of-life care, IV meds/fluids and problematic behaviors or complex mood disorders.

Educate, Educate, Educate

Once you've nailed down the requirements spelled out by the revised survey guidance, make sure your medical director understands them, as well. "The facility may understand [what the medical director should do] but unless the administrators sit down with the person to explain it, the facility will find itself at risk for deficiencies," says Annaliese Impink, vice president and associate general counsel for SavaSeniorCare Administrative Services LLC based in Atlanta.

And an F501 tag is a big deal for the facility if it's a G-level or higher--any deficiency at that level is, says attorney John Lessner with Ober/Kaler. But medical directors should also understand that a citation can pose liability problems for them, as well, he adds. "In some states, a deficiency at F501 could trigger reporting obligations (either self-reporting or reporting by the facility administrator) of the physician to the state licensing board."