.16 Medical Director — Responsibilities.

A. General Responsibilities. The medical director is responsible for:

(1) Overall coordination, execution, and monitoring of physician services;

(2) Monitoring and evaluating the health care services and outcomes, including clinical and physician services provided to the nursing home’s residents; and

(3) Designating an alternate medical director with sufficient training and experience to perform the responsibilities of the medical director as described in the regulations of this chapter.

B. Practitioner Oversight. The medical director shall:

(1) Oversee all physicians and other licensed or certified professional health care practitioners who provide health care to the facility's residents;

(2) Ensure that there is a procedure for the review of the practitioners' credentials and the granting of privileges for licensed or certified professional health care practitioners who treat residents of the nursing facility; and

(3) Recommend rules governing the performance of physicians and other licensed or certified professional health care practitioners who admit residents to the facility.

C. Defining the Scope of Medical Services.

(1) The medical director, in collaboration with the facility, shall recommend written policies and procedures that are approved by the licensee, delineating the scope of physician services and medical care.

(2) The facility shall make these policies and procedures available to a resident or resident's representative upon admission and whenever a substantive change is made.

D. Ensuring Physician Accountability. The medical director, in collaboration with the facility, shall recommend policies and procedures that cover essential physician responsibilities to the residents and the facility, including:

(1) Accepting responsibility for the care of residents;

(2) Supporting resident discharges and transfers;

(3) Making periodic, pertinent resident visits in the facility;

(4) Providing adequate ongoing medical coverage;

(5) Providing appropriate resident care;

(6) Providing appropriate, timely medical orders;

(7) Providing appropriate, timely, and pertinent documentation;

(8) Advising residents and families about formulating advance directives; and

(9) Any other responsibilities as determined by the facility and the medical director.

E. Quality Assurance. The medical director shall actively participate in the nursing home’s quality improvement process. Participation shall include:

(1) Regular reports and attendance at the nursing home’s quality improvement committee meetings; and

(2) Routine participation in ongoing facility efforts to improve the overall quality of the clinical care, including facility efforts to evaluate and address the causes of various care-related problems and deficiencies cited by the Office of Health Care Quality.

F. Employee Health Oversight. The nursing home, in consultation with the medical director and other physicians, if necessary, shall establish and maintain surveillance of the health status of employees, including:

(1) Advising on the development and execution of an employee health program, which shall include provisions for determining that employees are free of communicable diseases according to current accepted standards of practice; and

(2) Ensuring that the facility plans and implements required immunization programs.

G. Other Related Duties. The medical director shall perform other essential duties related to clinical care and physician practices, including:

(1) Advising the administrator and the director of nursing on clinical issues, including the criteria for residents to be admitted, transferred, or discharged from the nursing facility;

(2) Working with the nursing facility to establish appropriate relationships with area hospitals and other pertinent institutions to improve care of the residents;

(3) Advising and consulting with the nursing facility staff regarding communicable diseases, infection control, and isolation procedures, and serving as a liaison with local health officials and public health agencies that have policies and programs that may affect the nursing facility's care and services to residents;

(4) Providing or arranging for temporary physician services as needed to ensure that each resident has continuous physician coverage;

(5) Participating as appropriate in facility committee projects and meetings concerning clinical care and quality improvement that require physician input; and

(6) Educating or overseeing the education of, and informing, all attending physicians about their roles, responsibilities, and applicable rules and regulations.

H. Medical Director Oversight Plan.

(1) Based upon physician and medical director responsibilities in nursing facilities, as described in this chapter, the medical director shall develop and implement a plan describing how the medical director will carry out the responsibilities for the:

(a) Overall monitoring, coordination, and execution of physician services and medical care to residents of the nursing facility; and

(b) Systematic review of the quality of health care, including medical and physician services, provided to the facility's residents.

(2) Minimum Requirements of the Plan. The medical director oversight plan shall include, at least, a plan to ensure that physicians:

(a) Accept appropriate responsibility for residents under the physicians' care in the nursing facility;

(b) Provide appropriate, timely medical care consistent with widely identified medical principles relevant to the facility's population; and

(c) Provide appropriate, timely, and pertinent medical documentation and orders.

(3) Documentation Regarding Medical Director Activities.

(a) The medical director shall keep documentation regarding the medical director's activities in relation to designated responsibilities.

(b) The documentation required in this subsection may include:

(i) Notes;

(ii) Minutes;

(iii) Copies of faxes, letters, and telephone communications with attending physicians, other facility staff and departments, the administration, the governing body, and others regarding concerns, inquiries, and interventions.

(c) The documentation required in this subsection shall show evidence of the medical director's interventions and follow-up of the effectiveness of those interventions.

I. Quality Assurance Committee Minutes. Committee minutes shall reflect monthly input from the medical director regarding physician issues and general facility clinical care issues.