Medical directors of nursing facilities in Maryland have a "good job," but now the Centers for Medicare and Medicaid Services (CMS) is trying to ensure that these medical directors actually "do a good job." In this regard, on November 28, 2005, CMS issued Transmittal 15 which directs skilled nursing facilities and intermediate nursing facilities, among other things, to involve their medical directors in the coordination of medical care, and the implementation of resident care policies and procedures.
A. Areas of Involvement
Transmittal 15 does not require medical directors to carry out policies or supervise staff directly, but rather Transmittal 15 requires medical directors to guide, to approve and to help oversee the coordination of medical care and the implementation of resident care policies and procedures. More specifically, areas that require medical director involvement include, but are not limited to, admission policies, clinical assessments, care planning, infection control, discharge planning, the use of ancillary services, availability of physician services, documentation of progress notes and all aspects of quality assurance.
B. Medical Director Investigations
CMS is also directing Medicare fiscal intermediaries and carriers to investigate nursing facilities with respect to their utilization of medical directors. In that regard, Transmittal 15 lists a three-step protocol for investigators.
First, the investigators are to verify that the facility has a medical director, and, if not, determine why not, and determine what steps are being undertaken to retain a medical director.
Second, the investigators are to ascertain whether the facility is involving the medical director sufficiently in the coordination of medical care and the implementation of resident care policies.
Third, the investigators are to determine if the medical director has actually performed the roles and functions related to coordination of medical care and implementation of resident care policies.
C. Facility Responses
Accordingly, facilities will have to demonstrate compliance with Transmittal 15. Often, the minutes of a meeting or documentation referencing the medical directors input into a process, policy, or problem will be a time-effective way of doing so.
Also, implementing a weekly or monthly time sheet or time card for medical directors would help document time spent on activities that coordinate medical care among physicians and residents or implement resident care policies. (Timesheets would also help a facility prove fair market value should an allegation of an anti-kickback statute violation arise).
The lesson of Transmittal 15 is that CMS has become serious about medical directors, and medical directors and their nursing facilities need to react accordingly.