Regulatory Compliance  and a Long-Term Care Medical Director’s Role 

By Peter Mellette

Many physicians work in long-term care settings such as nursing facilities and retirement communities, attending to residents directly and instructing nursing staff on protocols to follow. Knowledge of federal guidance is helpful for attending physicians and for hired or contracted medical directors.

Nursing facilities pay medical directors (or their employer/contractor) to supervise and approve organizational policies for attending physicians, dentists, podiatrists, therapists, nutritionists and midlevels working in long-term care settings. Centers for Medicare & Medicaid Services (“CMS”) survey standards require facilities and their physicians to provide care that promotes residents to achieve the highest practicable well-being. To that end, CMS expects a medical director to participate in developing and approving policies related to resident care, follow up on issues identified by the facility’s quality assessment and assurance (“QAA”) committee and supervise outside practitioner services. The medical director must participate, directly or by proxy, in the facility’s QAA committee.

Medical directors also ensure residents have attending and backup physician coverage, review practitioner credentials, and facilitate continuity of care and transferring residents and their medical information between the facility and other care settings. A medical director may intervene when Medicare skilled recertification is not completed timely or when resident care is inconsistent with applicable standards of care, providing necessary feedback to physicians and other healthcare practitioners about their performance. A medical director’s failure to act when required gives CMS survey agencies a reason to cite deficiencies, often based on other professional standards.

Take standing orders. Professional organizations, including the American Medical Directors Association and the American Health Information Management Association (“AHIMA”), publish position statements, practice guidelines and documentation standards for attending physicians and their midlevel nurse practitioners or physician assistants. AHIMA practice guidelines specify that facilities use standing order policies sparingly. In Virginia, standing orders are disfavored outside of orders for the administration of influenza and pneumococcal vaccinations. The Department of Medical Assistance Services Physician Manual also notes that “orders must be specific for individual needs.”

Documentation that a physician receives and responds to orders, such as changes in resident condition and laboratory findings, allows the nursing facility and the physician to avoid lawsuits and sanctions due to poor outcomes and the failure to follow federal guidelines. The existence of appropriate and timely care orders (and the nursing facility’s timely documentation of compliance) can make the difference between ongoing surveyor attention (leading to facility noncompliance with large civil monetary penalties) versus a no deficiency finding or an unsanctioned correction of the problem under a plan of correction.

In lieu of standing orders, medical directors should establish decision matrices for resident care and physician contact. Even with such decision matrices, the facility staff should err on the side of caution by contacting both the attending physician and the resident’s family to avoid regulatory citations. “If in doubt, call” must remain the rule.

Long-term care services can present risks to patients without the guidance of an effective medical director and knowledgeable counsel. If Goodman Allen Donnelly can assist you in navigating legal compliance, please let us know.

This article originally published in: Hampton Roads Physician Spring 2024

This blog is made available by Goodman Allen Donnelly for general information, and does not constitute legal advice. By reading this blog, you understand that there is no attorney-client relationship between you and the firm. This blog should not be used as a substitute for competent legal advice from a licensed professional attorney in your state.