| California Requires Medical Director Certification | <p>On Oct. 6, 2021, Governor Gavin Newsom signed into law California’s Assembly Bill 749, which will require that all skilled nursing centers engage only medical directors who are certified by the American Board of Post-Acute and Long-Term Care Medicine (ABPLM, www.abplm.org) or will be so certified within five years.<br>This bill, which was sponsored by the <a href="http://www.caltcm.org/" target="_blank">California Association of Long Term Care Medicine</a> and supported by the <a href="http://www.cahf.org/" target="_blank">California Association of Health Facilities</a>, did not receive one single “Nay” vote in any of the committee votes or in the state’s Assembly and Senate and faced virtually no opposition from any stakeholder.</p><h2>Need is Established</h2><p>The COVID-19 pandemic has demonstrated unequivocally that engaged, knowledgeable medical directors can make a huge difference in the outcomes in skilled nursing centers, which helps explain the overwhelming popularity of this bill.<br></p><p>Many lawmakers and others were surprised to learn that in California, and in most states, the only requirement to be a nursing center’s medical director was an active medical license—allowing nursing centers to hire retired surgeons or pediatricians or engaging medical directors whose sole purpose appeared to be referring admissions without any discernible interest in ensuring competent geriatric medicine or adherence to the regulations was practiced in the building. <br></p><p>Still more shocking to some legislators and public health officials was the fact that unlike in hospitals, which have robust and rigorous credentialing and proctoring requirements for physicians to obtain admitting privileges, nursing centers are not required to do any more than the most rudimentary verification of a clinician’s licensure and, if they are wise, proof of liability insurance.<br></p><p>While some nursing centers and management organizations do have formal credentialing requirements, a great majority do not—so it falls to the medical director to perform quality assurance functions in ensuring that the other physicians and advanced practice practitioners are providing appropriate care and treatment within the standard of care. <br></p><p>Theoretically, the most incompetent physicians can practice in nursing centers, caring for medically complex, frail, vulnerable patients, with a similarly disengaged medical director not really monitoring the care that’s being provided. Not surprisingly, this was an alarming realization.</p><h2>Require Credentials</h2><p>The Certified Medical Director (CMD) certification from ABPLM involves physician candidates completing the Core Curriculum, which comprises 46 hours of content spanning 22 critical areas of long term care management. Each topic builds on information shared and interactive exercises of the topics that precede to create a comprehensive and cohesive picture of medical direction in long term care. <br></p><p>These include clinical topics that ensure basic knowledge of geriatric medicine and palliative care, leadership and bioethics content, and a detailed coverage of the federal regulations and requirements of participation for skilled nursing centers. The cost for the certification is about $3,000 in total.<br></p><p>There have been more than 4,000 physicians certified as CMDs since the inception of this program in 1991, and <a href="http://www.jamda.com/article/S1525-8610%2809%2900198-4/fulltext" target="_blank">a study by Frederick Rowland <em>et al.</em></a> published in the July 2009 issue of the<em> Journal of the American Medical Directors Association</em> found that quality metrics are better in facilities that have a CMD for their medical director.</p><h2>Personal History</h2><p>As a physician who was hired as a medical director back in the mid-1990s, I was admittedly clueless about many of the complex regulatory, clinical, and risk management issues associated with being a nursing center medical director. I looked for a professional medical society that could help educate me and quickly found AMDA (then called the American Medical Directors Association, but now called the Society for Post-Acute and Long-Term Care Medicine, <a href="http://www.paltc.org/" target="_blank">www.paltc.org</a>).<br></p><p>This organization, which is affiliated with the ABPLM, was a godsend to a young doctor just learning about nursing centers and how they operate. Though I may be biased, I strongly recommend that every nursing center exert any possible influence on its medical director to become a member of AMDA and its state or regional chapters, and to get CMD-certified. <br></p><p>Some physicians may balk at a request to take additional coursework or join a professional organization. It is clear that younger physicians are not “joiners” in the way that older doctors have traditionally been. So it may take a little persuasion, or even inserting language into medical director agreements that require a minimum number of CMD continuing education credits annually—or, better yet, an expectation that they become certified within a specified period of time.<br></p><p>It’s reasonable to consider time spent on obtaining a CMD, or attending courses that confer CMD credits, within the covered hours outlined in a medical director agreement or contract.</p><h2>What Residents Deserve</h2><p>Nursing centers today are like the hospitals, or at least the medical/surgical floors of hospitals, of a decade or two ago. Their residents deserve to have a competent, knowledgeable, and dedicated medical director as the medical leader and an integral part of the leadership and Quality Assurance and Performance Improvement team.<br></p><p>The CMD certificate through ABPLM is one way to guarantee at least a baseline level of knowledge that can move the needle on the quality of care provided.<br></p><p>It is likely that more states will follow California’s lead, and while a CMD requirement may pose a bit of a burden on the physicians serving in the medical director capacity, it may also help weed out those who really are not committed to the resident population—and is well worth it to give those residents and nursing centers the level of medical leadership they deserve. <br> <br><em>Karl Steinberg, MD, CMD, HMDC, is president of AMDA – The Society for Post-Acute and Long Term Care Medicine. He has been a nursing home and hospice medical director in the San Diego area since 1995 and is chief medical officer for Mariner Health Central and Beecan Health. </em></p> | 2021-12-01T05:00:00Z | <img alt="" src="/Issues/Special-Features/PublishingImages/2021/1221/1221_MedDirect.jpg" style="BORDER:0px solid;" /> | Survey and Certification | Karl Steinberg, MD, CMD | The recent pandemic has demonstrated the need for geriatric- and long term care-qualified physician leaders in skilled nursing centers. |
| How To: No-Fear Surveys | <br><p><img width="164" height="217" class="ms-rtePosition-2" alt="Kevin McElroy" src="/Monthly-Issue/2013/PublishingImages/1013/Kevin_mgmt.jpg" style="margin:10px;" />There are good surveys and not-so-good surveys. But one thing is true: Good surveys don’t happen by accident. They are the result of continuous planning, ongoing education, and keeping a razor-sharp focus on quality outcomes.<br><br>Especially with regard to the Centers for the Medicare & Medicaid Services Five-Star rating system, a good or bad survey can greatly impact a nursing center’s reputation in the community. And while it may not be rocket science, following some basic steps can help long term and post-acute care providers achieve their desired outcomes: good annual surveys. <br><br>Following are some tips for making this happen:<br><br><strong class="ms-rteForeColor-1">1. </strong>There is no such thing as “time to get ready for survey.” If a nursing home’s survey window is open and staff are just starting to review plans, they are already behind the eight-ball. Communities need to be ready for a survey 365 days a year. Think about it—the facility could be surveyed at any time (such as a complaint investigation). A good mantra for the team is, “Doing the right thing for our residents, every day!” Focusing on doing the right thing every day, 365 days a year, and not just because a “survey is coming,” puts the community one step ahead of the rest. <br><br><span class="ms-rteForeColor-1"><strong>2.</strong></span> First impressions matter. If the surveyors have a good first impression when they walk in the door, it can help set the tone for the entire survey. But if they walk in and the team is not prepared, there are odors, the community is not clean, and the team is not smiling and friendly, that will set the mood for a disappointing survey. <br><br><span class="ms-rteForeColor-1"><strong>3.</strong></span> Have the survey book updated and ready to go. This is a book that has everything in it the surveyors would want when they walk in the door, such as med pass times, activity calendars, and resident demographics. Unsure about what goes into a survey book? Check with the state nursing home association for a guide. Being prepared and organized will go a long way to starting off on the right foot. Grab a new three-ring binder; get an index together; and make sure the book is neat, organized, and easy to follow.<br><br><strong class="ms-rteForeColor-1">4.</strong> Review the center’s quality indicator/quality measure data. Surveyors are using these data to see where the center is and which residents will be picked for their survey sample, before they even walk through the door. But all nursing homes have access to the exact same information anytime they want it (usually, the minimum data set coordinator can print out copies). Consider pulling and reviewing, on a monthly basis, and as a team, the facility-level and resident-level quality measure reports. They clearly indicate where the weak areas are and which residents may trigger more quality measures that could cause them to be chosen by the survey team for review.<br><br><span class="ms-rteForeColor-1"><strong>5.</strong></span> Set and communicate goals. Ask 10 people what their idea of a good survey is and there would likely be 10 different answers. In order for a team to move in the same direction, they all have to have a clear picture of what they need to accomplish—be it reducing tags by 50 percent, compared with the previous year; having no quality-of-care or G-level tags; or a deficiency-free survey—set goals that are clear, measureable, and can be understood by everyone on the team. And once the goals are set, beat that drum every moment possible, such as in staff meetings, newsletters, or on banners in the break room. It can’t just be the flavor of the month. If the team sees it is important and not going away, they will notice.<br><br><strong class="ms-rteForeColor-1">6.</strong> Provide year-round education and not just the “minimum requirements” that mandate what must be done. Consider offering continuous-return demonstrations on medication passes or incontinence care. Ensure that the team knows what quality measures are. Consider educating nurse assistants about how to communicate with surveyors. It may sound like a cliché, but it’s true: Knowledge is power. Arm the team with the knowledge they need to reach their survey goals.<br><br><strong class="ms-rteForeColor-1">7. </strong>Audit, Audit, Audit. The entire team should be continuously looking at systems and outcomes. The only way to know how things are going is to look. Give each department head an audit to complete monthly for review during QI meetings. Also, consider holding QI meetings monthly instead of quarterly. Have a “mini mock survey day” where each member of the team focuses on a particular area and reports back at the end of the day. Ask other members of the team (such as the consultant pharmacist) to assist with checks and audits. The idea is to constantly be digging and looking to make sure the systems and procedures are working properly. And remember, using the excuse that there is no time to do this works until there is a deficiency, after which the excuse will no longer work.<br><br>These may not be earth-shattering suggestions, but if these basic steps are followed, the entire team will be well on its way to achieving good—and maybe even excellent—survey outcomes. And don’t forget to lean on each other. <br><br>While these are just some tried and true tips, other administrators may have their own best practices as well. <br><br>If the team is focused on good quality outcomes, it will not only have good surveys, it will also feel good knowing the residents are receiving great care at their community. <br><br><em>Kevin McElroy, CNHA, CASP, is the administrator at Evergreen Living Center in St. Ignace, Mich. He can be reached at </em><a title="Email Kevin!" href="mailto:kmcelroy@mshosp.org" target="_blank">kmcelroy@mshosp.org.</a><br></p> | 2013-10-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2013/PublishingImages/1013/mgmt_thumb.jpg" style="BORDER:0px solid;" /> | Management;Survey and Certification | Kevin McElroy | There is no such thing as “time to get ready for survey.” If a nursing home’s survey window is open and staff are just starting to review plans, they are already behind the eight-ball. Communities need to be ready for a survey 365 days a year. |
| Quality Assessment, Assurance Made Easier | <div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div>
<div>Didn’t we just have a quality assessment and assurance (QAA) meeting? Where did the month go? Do we have all of our data? Did you follow up on your action items? Will you be ready to give an update? Is it time to invite the outside consultants to give their report? Sound familiar?</div>
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<div>In 2009, Skilled Healthcare, LLC, created a task force to tackle these issues and to further its goal to enhance the value of the facility QAA committee. Task force participants included a wide range of stakeholders—administrators, clinical, and operational consultants. Along the way, further input came from facility medical directors and interdisciplinary team members. </div>
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<div>Skilled Healthcare, LLC, is an administrative service provider to long term care facilities and does not own or operate long term care facilities.</div>
<h3 class="ms-rteElement-H3">Getting Feedback From Centers</h3>
<div>The first step the task force took to ensure that the voice of the customer was heard was the creation and distribution of a simple five-question survey for facilities (see box, below).<br><img class="ms-rtePosition-2 ms-rteImage-2" src="/Issues/2011/PublishingImages/1211/Mgmt1.gif" alt="" style="margin:25px 15px;width:455px;height:363px;" /><br>Using survey feedback along with information from the centers’ 2567s statement of deficiencies when F-Tag 520 (QAA) was cited, the task force focused on revamping the current forms, as well as data collection tracking and trending tools, standardizing the format for the facility QAA committee meeting, while continuing to preserve patient confidentiality and statutory QAA privileges. </div>
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<div>And to further enhance process efficiency, the QAA tools were automated.</div>
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<div>Considerable time was spent developing the specifications for the programmer. While some programmers have a clinical background, most do not. Sketches were developed not only regarding the layout of the screens in which the data would be entered, but also the resulting look of the reports. </div>
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<div>To have screens that were “clean” and free of visual distractions, tools were incorporated. By placing the user’s mouse over a predefined prompt, the QAA committee members are cued as to what areas should be considered for discussion topics during the meeting.</div>
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<div>In developing this QAA program, it was important that the end product be streamlined and user friendly. Real-time analysis allows for intuitive navigation as, while user guides are always handy in a pinch, the task force wanted to avoid unnecessary and time-consuming tutorials on how to use the software. <br><br>Taking cues from issues inherent with new software, helpful features were added, such as prompts for the user to save the document before closing to minimize the need for rework. And the reports self-populate other QAA reports, which completely eliminates the need to input information into the QAA minutes more than once. </div>
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<div>As a result, the QAA Version 1.0 was thoroughly tested and piloted in a number of centers prior to being rolled out in 2010. </div>
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<div>In the spirit of continuous quality improvement, six months into its use, the task force again sought feedback: What do you like about QAA Version 1.0? What can be improved? With this additional feedback, QAA Version 2.0 was developed and rolled out in 2011. </div>
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<div>The current program consists of:<br><ul><li><strong>Monthly Quality Indicator Trend Report</strong></li></ul></div>
<div>This report reflects quality measures and quality indicators. The entire year’s data are reflected on the same page for ease of tracking and trending. In addition, national, state, and other facilities’ benchmark data are included for comparison.<br></div>
<div><ul><li><strong>QAA Agenda And Minutes Report</strong></li></ul></div>
<div>There are four main sections in this report: Care, Operations, Customer Satisfaction, and Other. These four sections are comprised of 94 prompts used for identifying issues. Ideally, after a prompt is discussed by the QAA committee, it is marked as either “reviewed” or “concern,” at which point a narrative note may be recorded in a drop box. In addition, when an area is marked as “concern,” a QAA Action Item drop box appears.<br><br></div>
<div>The QAA Action Item box is where commitments to develop and implement appropriate plans of action can be recorded.<span></span><br><br></div>
<div>Each area of concern has its own process owner, and each action item has its own completion date field. Until all action items are completed, this box will continue to come up from one QAA meeting to the next.</div>
<div style="text-align:left;"><ul><li><strong>QAA Minutes Action Plan</strong></li></ul></div>
<div><span><span><span><span><img class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1211/Mgmt1.jpg" alt="" style="margin:5px 10px;width:328px;height:219px;" /></span></span></span></span>This report self-populates from the QAA Agenda and Minutes Report. It reflects areas of concern and action items the center is currently addressing. Having this report at their fingertips enables administrators to bring the report to their stand-up or department head meeting and ask the process owner for an update on how their action items are progressing. The intention of this report is to help ensure that the action items are being worked and not forgotten.<br><span><span><span></span></span></span><br></div>
<div>The DSDs can also find this report helpf<span><span></span></span>ul. By reviewing this report when planning in-services, the goal is for the DSD to identify what issues the center is addressing and pull resources (that is, training materials) to further assist the center in achieving performance improvement.</div>
<div><ul><li><strong>Calendar Of QAA Items Discussed</strong></li></ul></div>
<div>Feedback the Task Force received in 2009 included centers finding it cumbersome to keep track of what QAA items were discussed from month to month. The QAA Task Force cannot dictate which areas and how often something should be discussed, as each center is unique. Some prompts may be reviewed monthly, others quarterly, and still others, such as contracts, may be reviewed annually.<br></div>
<div>The Calendar of QAA Items Discussed also self-populates from the QAA Agenda and Minutes Report. When utilized, the QAA committee can see at a glance when an area was last discussed and whether it was “reviewed” or a “concern.”</div>
<div><ul><li><strong>QAA Specific Query Item Look Up Report </strong></li></ul></div>
<div>The intention of this report is to allow the user to pull up a chronological report of specific QAA items discussed. Although QAA is privileged information, during a survey a center (after consulting with legal) may decide to pull up all notes from their QAA meetings for the last three months that focused on falls to show surveyors that a falls issue had been self-identified and action items were in the process of being implemented and monitored. <br><br></div>
<div>Automation of the QAA has improved the effectiveness of the QAA process: </div>
<div><ul><li>Kevin Bellinger, administrator at Baldwin Healthcare and Rehabilitation Center, LLC, Baldwin City, Kan., says, “QAA Version 2.0 is much more efficient than the paper version because it pulls clinical information from various sources, which allows the team to spend more time brainstorming ideas and solutions to concerns or issues.</li></ul></div>
<div>I really like how the system lets you click on each area you want to review during the QAA meeting and then directly input concerns and the plan of correction.” </div>
<div><ul><li>Rashonda Caldwell, RN, DON, at Clairmont Longview, LP, Longview, Texas: “I enjoy utilizing QAA Version 2.0 for several reasons. First, it allows the user the option to input notes regarding an area of interest or to enter a plan on what the facility is going to do to reach a goal in a certain area such as pressure ulcers or falls. Second, it is a much more organized system than the traditional paper version of QAA documentation. I can’t tell you how much I love the fact that a QAA member or I can input the necessary information for our departments and generate a report.”</li></ul></div>
<div><ul><li>Aisha Salaam, RN, MSN, MPH, senior vice president, professional services at Skilled Healthcare, says, “Developing and implementing a user-friendly online QAA program has provided a vehicle that offers an opportunity for heightened system monitoring and action plan follow-up accountability, all with an eye to continuing to improve clinical care, quality of life, safety, customer satisfaction, and care transitions.” </li></ul></div>
<div><em>Karen Schindler, PT, is vice president, quality initiatives, and Anthony Ramirez, RN, is director of clinical information technology, for Skilled Healthcare. Schindler can be reached at: <a href="mailto:kschindler@skilledhc.com">kschindler@skilledhc.com.</a></em></div> | 2011-12-01T05:00:00Z | <img alt="" src="/Issues/2011/PublishingImages/1211/Mgmt1_thumb.jpg" style="BORDER:0px solid;" /> | Management;Survey and Certification;Quality;Quality Improvement | Karen Schindler and Anthony Ramirez | In 2009, Skilled Healthcare, LLC, created a task force to tackle these issues and to further its goal to enhance the value of the facility QAA committee.
Task force participants included a wide range of stakeholders—administrators, clinical, and operational consultants. Along the way, further input came from facility medical directors and interdisciplinary team members. |
| Corporate Compliance: SNFs Must Get On Board | <div>Today’s skilled nursing facilities (SNFs) see more acute patients than ever before, while government investigations of these facilities are increasing. Between 2005 and 2007, more than 91 percent of nursing facilities were cited for deficiencies during annual surveys, with quality-of-care deficiencies on the rise.</div>
<h3 class="ms-rteElement-H3"><strong>Investigations Broadened</strong></h3>
<div>Historically, Corporate Integrity Agreements (CIA), or agreements between the Office of Inspector General (OIG) and a health care provider as part of a settlement for alleged civil wrongdoing relating to federal health law, dealt almost exclusively with reimbursement and fraudulent practices related to billing. </div>
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<div>That all changed in 2000, when the first CIA that focused on quality of care went into effect. Since then, more than 35 nursing facility companies have entered into such agreements. Today, a typical quality-of-care CIA lasts between three and five years and can cost a provider anywhere from $250,000 to $5 million in settlement and litigation costs.</div>
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<div>According to David Zimmerman, professor of industrial and systems engineering at the University of Wisconsin-Madison, the emphasis on quality of care surfaced when OIG became concerned that providers under CIAs that were also facing bankruptcy might take shortcuts in quality of care.</div>
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<div>Also worth noting is the fact that the government has broadened its investigatory range to include nursing facility companies of all sizes. The federal government’s pursuit of more transparency within SNFs has gone beyond the annual survey. According to attorney Alan Schabes, of Benesch, Friedlander, Coplan & Aronoff, the government is now spending more and more time investigating possible claims against nursing facility providers based on violations of the federal False Claims Act (FCA). </div>
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<div>Such claims are frequently based on the assertion that the services that were provided were of such poor quality that they were “worthless services.” The government has also continued to leverage exclusion, or the revoking of a nursing facility provider’s right to participate in and receive payments, from Medicare and Medicaid programs.</div>
<h3 class="ms-rteElement-H3"><strong>Health Reform Law Implications</strong></h3>
<div>Citing clients who have spent upwards of $100,000 just on a single FCA investigation, Schabes says meeting today’s quality-of-care requirements means going above and beyond the annual survey. </div>
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<div>The health care reform law, also known as the Patient Protection and Affordable Care Act of 2010, mandated nursing facility compliance by 2013. This law also appears to require a mandatory compliance and ethics program for all physicians, small and large nursing facilities, pharmacies, medical equipment suppliers, and more. </div>
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<div>While the specifics of the new law have yet to be spelled out, the OIG compliance program guidelines for nursing facilities are likely to provide a model for compliance requirements. The law also requires a standardized training program for all compliant providers. Compliance training should reach the entire staff and have some ability to track its own effectiveness. Consistent and targeted training for care providers, managers, administrative staff, corporate officers, facility directors, and even family members at each level will further the culture of compliance throughout the organization and ensure training goals are met. </div>
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<div>Staff training should be provided in a practical way, such as through live in-person training, videos, and publications, depending on the employee’s needs. Training materials and methods should also take into account the skills, experience, and knowledge of each trainee. Simply put, the better trained the staff, the better the quality of care and the more compliant a facility will be. </div>
<h3 class="ms-rteElement-H3"><strong>Staff Training Essential</strong></h3>
<div>Zimmerman notes that training will play a key role in any compliance program “because compliance is necessary at all levels of the organization, right down to the caregivers that are the certified nurse assistants.” </div>
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<div>This is not something that is naturally taught in technical education programs or nursing schools, Zimmerman says, so organizations need to ensure that all employees are aware of what the rules are with respect to compliance with regulations.</div>
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<div>Effective training will not only instruct on care issues, but also on what needs to be reported, how it should be reported, and provide an overall review of an organization’s reporting process. </div>
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<div>Also important is the presence of an evaluation process to ensure that the training was effective, including the evaluation of clinical competencies associated with the training. Truly effective corporate compliance programs will include a thorough internal infrastructure of policies and procedures that include checks and balances at every level of the organization. </div>
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<div>As the penalties and liabilities for insufficient oversight rise and the 2013 compliance deadline approaches, SNFs will determine the best way to incorporate compliance into the day-to-day operations of their facilities. </div>
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<p><em>Tamar Abell is principal of Upstairs Solutions, Skokie, Ill., a provider-owned compnay that offers more than 130 online training courses specifically developed for senior care and an easy-to-use recordkeeping system to manage and track training, licenses, and competencies.</em></p> | 2011-05-01T04:00:00Z | <img alt="" height="150" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/clip%20art%20document%20fine%20print.jpg" width="150" style="BORDER:0px solid;" /> | Management;Survey and Certification;Quality Improvement | Tamar Abell | A meaningful compliance program that addresses quality of care and financial issues must be the cornerstone of every provider’s mission and culture. |