Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 1
Subtitle 07 - HOSPITALS
Chapter 10.07.02 - Nursing Homes
Section 10.07.02.16 - Medical Director - Responsibilities
Universal Citation: MD Code Reg 10.07.02.16
Current through Register Vol. 51, No. 19, September 20, 2024
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.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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