Failure to Designate a Physician as Medical Director
Penalty
Summary
The facility failed to designate a physician to serve as the medical director, as required by regulations. The review of the facility's medical director contract, dated December 1, 2023, indicated that a medical group was to provide medical directorship and oversight services, assigning 'physicians' to provide such services. However, information submitted to the Department of Health on March 12, 2025, revealed that Employee E16 was listed as the designated Medical Director since January 1, 2020. Interviews with staff, including the Regional Clinical Specialist and the current Medical Director, Employee E15, indicated that she took over the role in August 2024 and that the medical group was considered the medical director. The Director of Nursing confirmed the facility's failure to designate a specific physician as the medical director.
Plan Of Correction
F-841 Responsibilities of Medical Director 1. A specific Medical Director will be assigned to the facility by the Administrator or designee. 2. There are no other like individuals in this position in this facility to review. 3. The Medical Director will be educated by the Administrator or designee on regulation F-841. 4. The Director of Nursing and/or the Administrator will review facility clinical and operational areas weekly for 3 weeks and monthly for 2 months. A summary of these meetings will be reviewed in the monthly QAPI meetings for 2 months.