Revised Ftag of the Week – F841 Responsibilities of the Medical Director

This week’s “Ftag of the Week” on the CMSCG Blog is a review of F841 Responsibilities of the Medical Director. F841 is one of the tags with revised/ clarified guidance to surveyors that will be effective at the end of March 2025. It’s clear from the draft Interpretive Guidance (IG) that the Centers for Medicare and Medicaid Services (CMS) expects nursing facilities to have Medical Directors who are involved in driving resident care policies and practices.

Additional Responsibilities

It’s interesting that CMS felt the need to add the following list of responsibilities to the role of the Medical Director – we think they’re pretty common sense:

• Active involvement in the Facility Assessment process (hint – that means more than just adding his/her name as a participant)
• Administrative decisions, including recommending, developing and approving facility policies related to resident care
• Addressing issues which surface related to the coordination of medical care and implementation of resident care policies which are identified as part of the QA process or through the QAPI Committee
• Implementation of resident care policies

This last bullet, related to implementing resident care policies is actually one of the regulatory requirements, but it’s getting some extra attention in these revisions. The revised IG specifies that:

A Medical Director’s responsibilities . . . include implementation of resident care policies, such as ensuring physicians and other practitioners adhere to facility policies on diagnosing and prescribing medications and intervening with a health care practitioner regarding medical care that is inconsistent with current professional standards of care.

The areas needing intervention, per CMS, could include physicians who assign new psychiatric diagnoses and/or prescribe psychotropic meds without following professional standards of practice. In case that’s not clear enough, there’s a new example that’s been added to the guidance to surveyors which paints a crystal-clear picture of how F841 could be cited.

Typically, when we write an Ftag of the Week, we provide some examples of actual survey citations. However, the draft IG has a new example that should be a big hint to providers about what these revisions are all about – psychotropic meds and those associated diagnoses.

The example provided indicates that the facility’s Medical Director was made aware that residents were being newly diagnosed with schizophrenia by their physician. The medical records of the resident did not include supporting documentation for this diagnosis. Instead of reviewing the residents’ medical records or discussing the new diagnoses with the prescribing practitioner, the Medical Director did not intervene and allowed residents to be at risk for harm by receiving psychotropic medications which may not have been clinically indicated.

What’s Your Medical Director Going to Say?

The other important area to be aware of is that your Medical Director will now be part of the interview process for two of the newly revised Critical Element Pathways.

Unnecessary Medications, Chemical Restraints/ Psychotropic Medications, and Medication Regimen Review Critical Element Pathway

An entire section for the attending physician has been added for review under this Critical Element Pathway for investigating compliance with F756 Medication Regimen Review, F757 Free from Unnecessary Medications and F605 Free from Chemical Restraints. The answers to those questions have the potential to validate surveyor concerns if the physician doesn’t have good answers. How will the practitioners in your organization answer questions such as  . .. What is the clinical indication for an antipsychotic being used for a diagnosis of dementia . . . or what approaches were attempted prior to the use of psychotropic med?

Then there’s the Medical Director interview, which looks at potential noncompliance with F757 and F605. The questions reflect what’s been added in the revised surveyor guidance, specifically:

• How are you made aware when there is a concern identified related to a practitioner’s adherence to facility policies regarding establishing a diagnosis and prescribing medications?
• What’s your process for discussing and intervening, if appropriate, when medical care being provided is inconsistent with current professional standards?
• Were you aware that a medication was ordered for a resident and there was a lack of documentation by the prescribing practitioner to support the diagnosis? If yes, how did you address the lack of documentation? If no – why not?

Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) Review

As part of this review, if there is identified noncompliance at the system level, the surveyor must conduct an investigation. For each area where systems-level noncompliance related to resident care and/or the coordination of medical care has been identified, the Medical Director will be interviewed. The surveyor will ask if the Medical Director was aware of each area and if so, what actions were taken in response to the concern. The Medical Director will also be asked if he/she or a designee participate in QAA Committee meetings. So, as part of the QAPI/QAA review, the potential for F841 to be cited is there, and also F868 if the Medical Director/ designee does not participate in QAA activities.

The Bigger Picture

The revisions to the surveyor guidance at F841 are only the tip of the iceberg related to surveyor guidance for psychotropic medications and mental disorders – especially schizophrenia and schizoaffective disorder. These areas have been on the regulatory radar for quite some time and the scrutiny is only increasing.

Be sure to check back to the CMSCG Blog for important Ftag of the Week posts and other guidance to help you prepare for your next survey. Speaking of preparing for survey – contact CMSCG to learn more about our survey readiness consulting services for nursing homes, including mock surveys.  Our interdisciplinary team of compliance and quality improvement consultants will help ensure your next survey is a success.