Medical Director CME Requirement Not Met
Summary
The facility failed to ensure that the Medical Director completed the required annual continuing medical education (CME) hours. According to the regulation, the Medical Director must complete at least four hours annually of CME pertinent to the field of medical direction or post-acute and long-term care medicine. However, upon review of facility documentation and through staff interviews, it was determined that there was no available evidence to confirm the completion of these CME hours. During an interview, the Nursing Home Administrator was unable to provide documented evidence that the Medical Director had fulfilled this requirement.
Plan Of Correction
Medical Director was out of the country at the time of survey. Administrator to follow up with Medical Director upon return and obtain certificate of completion. Medical Director returned from vacation week of 4/14/2025. Facility did reach out and obtained documentation of completed continuing education, which was forwarded to the field office. Administrator/designee will review in quarterly quality assurance committee meeting to ensure we have up-to-date documentation on hand.
Penalty
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