Failure to Designate a Medical Director
Penalty
Summary
The facility failed to designate a physician to serve as the medical director, as required by regulations. The review of facility documents and staff interviews revealed inconsistencies in the designation of the medical director. The facility's medical director contract indicated that a Doctor of Osteopathic Medicine, Employee E40, was responsible for medical directorship services. However, information submitted to the Department of Health listed Employee E38 as the designated medical director since 2016, despite the Nursing Home Administrator (NHA) stating that Employee E38 had not been the medical director since their tenure began. Instead, Employee E39 was noted to have taken over the role at the beginning of 2024. Further interviews revealed confusion and lack of clarity regarding the medical director's role. The NHA mentioned that multiple individuals were considered the medical director, and the facility utilized a group for these services. The Director of Nursing confirmed that Employee E40 was not frequently present in the facility and had delegated the role to Employee E39, who attended Quality Assurance and Performance Improvement (QAPI) meetings. Employee E39, during an interview, stated that he worked under Employee E40 and functioned as the facility's medical director, having started his visits in October 2023. This lack of a clear, designated medical director led to the deficiency noted in the report.
Plan Of Correction
1. A letter was submitted to the Department informing them of a change in medical director. 2. The NHA will review at least quarterly any administrative changes that might require notification to the Department and notify the Department timely.