Your Role as Medical Director in the Survey Process
Your Role as Medical Director in the Survey Process: Tips for Leading the Team
As medical director, you have an important role in helping to ensure your facility's continual survey readiness. Active participation in quality improvement activities such as routine audits, observations and leadership rounds has a positive impact on your team's readiness and confidence during surveys.
Appendix PP of the State Operations Manual (SOM) includes the regulations and guidance on how to interpret the regulations, as well as guidance on how to investigate compliance with the regulations. This is the “go to” resource for all things regulatory as you prepare for a survey.
In November 2024, the Centers for Medicare & Medicaid Services (CMS) revised Appendix PP to include new guidance and clarification regarding the medical director’s responsibilities. This guidance was added at F841 and now includes:
- 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 provider.
- Participation in the quality assessment and assurance committee (QAA) or assigning a designee to represent him/her. (refer to F868)
- Addressing issues related to the coordination of medical care and implementation of resident care policies identified through the facility’s quality assessment and assurance committee and other activities
- Active involvement in the process of conducting the facility assessment (refer to F838)
In addition, the medical director's responsibilities should include, but are not limited to:
- Administrative decisions, including recommending, developing, and approving facility policies related to residents' care. Resident care includes physical, mental, and psychosocial well-being.
- Discussing and intervening (as appropriate) with a health-care practitioner regarding medical care that is consistent with current standards of care, for example, physicians assigning new psychiatric diagnoses and/or prescribing psychotropic medications without following professional standards of practice.
The full F-Tag841 can be found on page 670 here.
The QAPI and QAA review also includes medical director questions (page 856) and new interview questions on the critical element pathway for unnecessary medications (page 872).
Key Tasks of the Medical Director:
- Actively participate as required by §483.71 in the facility-wide assessment which is the basis for determining what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Ask to be involved particularly in the components of the assessment that address the care required by the resident population, the use evidence-based, data driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity and other needs as well as the staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population. (Review F-Tag 838)
- Ask to see the matrix (CMS-802 form) in your facility to see how this might help you understand and oversee your facility. The matrix form identifies key components of care for all facility residents.
- Ask the Director of Nursing what constitutes “survey prep” at the facility, and how you can help. Note that responses to surveyor questions are often cited verbatim in the CMS Statement of Deficiencies, so adequate preparation is essential.
- Be actively involved in your facility’s QAPI (Quality Assurance and Performance Improvement) initiatives, as these are intended to achieve and maintain regulatory compliance. See new surveyor questions for the medical director around QAPI and QAA at the end of this document.
Things to audit on a routine basis for continual readiness for surveys:
Tip: Leverage your facility’s EMR for surveillance of practitioner performance to prepare for surveys. They have both dashboards for snapshots of outstanding/overdue items and report generation for more detailed review of items.
- Appropriate diagnoses for urinary catheters
- Appropriate justification and drug reduction trials for psychoactive medications (see PALTmed’s guidance document with more information on this)
- Pain control and use of opioids
- Appropriate consent for antipsychotics
- Timeliness of provider visits
Where do surveyors start?
Surveys start with a day of full observation, resident interviews and limited record reviews. Their record reviews include a review of advance directives; confirmation of insulin, anticoagulants, antipsychotics with a diagnosis of dementia and PASRR (Pre-Admission Screening and Resident Review) for residents with a mental health issue or developmental delay; new admissions, especially regarding high-risk medications; and extenuating circumstances (which may be based on staff interviews).
*All inspectors observe infection control practices throughout the survey.
Surveyors will talk to your facility’s QAPI chair on topics such as influenza and pneumococcal vaccination, infection prevention and control, and antibiotic stewardship programs, so be prepared to discuss these with your QAPI team in preparation for a surveyor visit. Surveyors will also ask the facility Administrator and Director of Nursing at a minimum, what QAPI projects the QAPI committee is currently working on.
They will also ask staff how they bring issues they identify to the QAPI committee so randomly asking staff that question as you interact with them can also help with continual survey readiness.
Critical Element Pathways are instructions on how surveyors should investigate a topic. Topics can include:
- Unnecessary medications
- Psychoactive medications
- Medication regimen review
- Abuse
- Neglect
- Physical restraints
- Quality of care
- Medication management
- Fall prevention
- Wound care
- Pain management
- Infection control practices
- Restraint usage
- Documentation
By familiarizing yourself with the critical element pathways, you will have a more solid understanding and expectation of what surveyors will be asking you and other staff. See the updated critical element pathway below related to the use of unnecessary medications/chemical restraints/psychotropic medications, and medication regimen review, and note the section with questions for the medical director:
Your presence as a medical director is IMPORTANT. It is a show of support and solidarity with staff, so be visible and approachable!
How can you help support staff during these stressful visits?
- Encourage Positivity: Project confidence and maintain a calm, supportive presence to foster a similar demeanor in others.
- Clean up: Ask the Administrator or Director of Nursing to advise you of any issues that arise, or any policies and procedures requested by surveyors. Review and identify areas that could be updated, clarified or improved upon. The team’s proactive response to fixing anything identified by a surveyor can impact either the scope and severity of a citation or even whether a citation is given in some circumstances.
- Actively observe: Identify and assess potential issues before surveyors do, then report findings to Nursing leadership to collaboratively address concerns. Document all observations and resolutions during the survey process for QAPI review. This documentation helps determine whether issues are isolated incidents or systemic problems requiring sustainable solutions.
Last updated January 27, 2025
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