One of the most important duties of a skilled nursing care center’s medical director is to provide oversight for other clinicians (that is, doctors, nurse practitioners, dentists, podiatrists, mental health professionals) who provide care in the facility. While it is unusual to have significant problems with wayward or overtly disruptive professional staff, it is not unheard of. And it is much more common in nursing centers to encounter clinicians who are slow to respond to calls, or delinquent in making routine regulatory visits.

Monitoring Outside Personnel

Most skilled nursing facilities have at least a rudimentary process for granting and monitoring admitting privileges for community attending physicians, including verification of an active medical license and some minimal level of malpractice insurance coverage. Flu shots and negative tuberculosis status are also advisable to verify and monitor.

Some facilities have a much more robust process, involving background checks and peer reference letters. It is advisable for the facility medical director to provide input on this process, including initially approving attending professionals’ privileges (usually along with the administrator and director of nursing), and periodically assess their performance.

Most nursing center medical directors are contractually bound to devote between five and 20 hours monthly to their duties, not including patient care. This should afford ample time for a medical director to perform chart audits to assess a clinician’s performance and speak with nursing and other facility personnel to get their impressions of an individual clinician’s work in the building.

Physician Visits Regulated

Under 42 CFR §483.30(b), a facility is to ensure that each resident receives a physician visit at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. At the time of these routine regulatory visits, the physician must “review the resident’s total program of care, including medications and treatments.”

Although the regulations do not explicitly specify that this visit must be from the attending physician, it appears clear from the guidance to surveyors (Appendix PP, State Operations Manual): “The intent of this regulation is to have the physician take an active role in supervising the care of residents. This should not be a superficial visit, but should include an evaluation of the resident’s condition and a review of and decision about the continued appropriateness of the resident’s current medical regime.”

It’s prudent for the nursing center to have a procedure to track attending physician visits, since if a surveyor identifies delinquent physician visits or signatures when reviewing charts, particularly in the context of other problems in the resident’s care, the facility will be cited at F-tag 711 or 712. Although some physicians or practices may have their own process for tracking a routine visit schedule, many busy nursing center physicians rely on the center’s staff to let them know, especially when they become delinquent. It’s rare for a physician to receive any professional sanction for being delinquent in performing nursing facility visits, but not as rare for facilities to get regulatory deficiencies.

Track Compliance Efforts

One simple example of a procedure for tracking timely physician visits is to assign this task to the medical records (or health information management) department, since they are already doing frequent chart audits. A tickler for due dates for 30-day visits for each resident can be implemented by reviewing physician progress notes.

When it is getting close to 30 days, a staff member—be it from someone in medical records, a nurse, or other clerical personnel—should contact the physician and document the reminder about the due visit in the medical record.

After a few days, if the visit has still not occurred, another request should be made, perhaps from someone with more authority such as the director of nursing or medical records supervisor, and again documented in the chart. Then in another few days if the visit has not occurred, this concern should be escalated to the medical director, who can contact the physician and inform them that if the visit is not made in the next two business days, the medical director will have to make a visit and place a note in the chart to keep the facility in compliance.

Medical Director Steps In

If the attending physician (or designee) has not made the required regulatory visit by a week or so after the visit is due, then the medical director should proceed to review the chart, see the resident, and document the visit in the chart. Since there is a 10-day grace period written into the regulations, (that is, 40 days from the preceding visit) that should be the time by which a nursing center should ensure a regulatory visit has been made.

When there are repeated delinquent visits or a pattern of nonresponsiveness on the part of a particular practitioner, the medical director should counsel the practitioner and discuss options for corrective action with the administrator and director of nursing. A nursing center should strive to maintain excellent professional relationships, but cannot tolerate placing their residents at risk under the care of poorly performing practitioners.

At the same time, residents are guaranteed a right to choose their own physician (within reason), and nursing centers rely in part on local physicians, especially hospitalists, to refer potential admissions to them.

So, these can be difficult and delicate situations, and they should be dealt with diplomatically but firmly. Often, a collegial request to improve behavior from a peer can make a significant and lasting difference in physician performance. One doctor asking another doctor to help out by being more responsive may be more favorably swallowed than an admonition from a nursing center administrator.

Formal Corrective Action

However, this does not always work. In situations where repeated unacceptable behavior occurs, there has to be a formal, stepwise procedure for corrective action. It’s vital to document each attempt to elicit change, including oral conversations, then written admonitions, then final warnings. 
Depending on how their medical staffing is structured, some nursing centers may ultimately choose to suspend or revoke a wayward physician’s admitting privileges, impose probationary conditions, or otherwise limit the scope of their practice in the facility. If it looks like that is going to happen, it’s advisable to seek counsel from an attorney or other outside risk management expert beyond the usual facility leadership.
Such actions may have repercussions that should be considered carefully in advance—but again, of paramount importance is the duty to the residents to ensure timely and appropriate access to physician services. The facility medical director is a key partner in this duty and should be available 24/7 if nursing center personnel can’t get hold of an attending physician—but this availability should not be taken advantage of indiscriminately.
Karl Steinberg, MD, CMD, HMDC, is a long term care geriatrician in Oceanside, Calif. He is chief medical officer for Mariner Health Central and medical director of Life Care Center of Vista and Carlsbad by the Sea Care Center. He is chair of AMDA’s Public Policy Committee and editor-in-chief of their monthly periodical, Caring for the Ages. A hospice and nursing home medical director since 1995, Steinberg is probably best known for taking his dogs on rounds in nursing homes and assisted living centers.