CMD Regulatory Compliance & Quality Improvement 2 — Questions and Answers
Question 1: Under CMS Conditions of Participation, which of the following best describes the Medical Director's primary responsibility regarding quality assessment and performance improvement (QAPI)?
- Delegating all QAPI activities to the Director of Nursing
- Ensuring the facility maintains an ongoing, comprehensive QAPI program (Correct answer)
- Submitting monthly QAPI reports directly to CMS
- Limiting QAPI scope to medication error tracking only
Correct answer: Ensuring the facility maintains an ongoing, comprehensive QAPI program
CMS CoPs require the Medical Director to ensure the facility maintains a comprehensive, data-driven QAPI program addressing all care domains.
Question 2: A long-term care facility receives a deficiency citation for F-tag F758 (unnecessary antipsychotic medications). As Medical Director, what is the most appropriate first step?
- File an appeal with the state survey agency immediately
- Conduct a root cause analysis and develop a corrective action plan (Correct answer)
- Terminate the prescribing physicians' privileges
- Notify all families of the citation within 24 hours
Correct answer: Conduct a root cause analysis and develop a corrective action plan
A root cause analysis followed by a corrective action plan is the evidence-based first step in responding to a regulatory deficiency citation.
Question 3: Which federal regulation specifically governs the frequency of Medical Director visits to skilled nursing facilities?
- 42 CFR Part 483.75 requires weekly visits
- 42 CFR Part 483.70 requires monthly visits
- There is no federally mandated minimum visit frequency (Correct answer)
- OBRA 87 mandates biweekly visits
Correct answer: There is no federally mandated minimum visit frequency
Federal regulations do not specify a minimum visit frequency; the Medical Director must visit as often as necessary to fulfill their responsibilities.
Question 4: The PDSA (Plan-Do-Study-Act) cycle is used in quality improvement primarily to:
- Document regulatory compliance for state surveyors
- Test changes on a small scale before broad implementation (Correct answer)
- Replace root cause analysis in adverse event investigations
- Establish baseline performance metrics for CMS reporting
Correct answer: Test changes on a small scale before broad implementation
PDSA cycles allow facilities to test small-scale interventions, study results, and refine approaches before facility-wide rollout.
Question 5: Under HIPAA, a Medical Director reviewing aggregate quality data to identify trends in falls rates:
- Must obtain individual patient consent before accessing the data
- Is performing a permitted use under the healthcare operations provision (Correct answer)
- Must de-identify data before any analysis can occur
- Requires a Business Associate Agreement with each patient
Correct answer: Is performing a permitted use under the healthcare operations provision
HIPAA permits use of protected health information for healthcare operations, including quality assessment and improvement activities.
Question 6: A state surveyor cites a facility for not having physician orders reviewed within the required timeframe. The Medical Director should:
- Argue that individual attending physicians are solely responsible
- Accept joint accountability and work with medical staff to improve order review processes (Correct answer)
- Request that the citation be transferred to the attending physicians of record
- Immediately suspend all admissions pending physician compliance
Correct answer: Accept joint accountability and work with medical staff to improve order review processes
The Medical Director is accountable for the overall medical care program, including physician practice patterns, and must take leadership to correct systemic deficiencies.
Question 7: Which quality indicator would be most appropriate for a Medical Director to track when monitoring the effectiveness of a new pressure ulcer prevention protocol?
- Staff turnover rate
- Prevalence and incidence rates of facility-acquired pressure injuries (Correct answer)
- Total number of physician visits per month
- Percentage of residents with DNR orders
Correct answer: Prevalence and incidence rates of facility-acquired pressure injuries
Pressure injury prevalence and incidence rates are the direct outcome measures that reflect the effectiveness of a prevention protocol.
CMD Regulatory Compliance & Quality Improvement 2
Under CMS Conditions of Participation, which of the following best describes the Medical Director's primary responsibility regarding quality assessment and performance improvement (QAPI)?