The medical director's role in the state survey and dispute resolution.

An American Medical Directors Association (AMDA) policy on the role of the medical director, based on a position statement approved by the association in 2003, indicates that the medical director should review, respond to, and participate in federal, state, local, and other external surveys and inspections.1 Anecdotal discussions at annual AMDA symposia and state chapter meetings suggest that a number of medical directors take an active role when inspectors from the state survey agency are on site in the nursing facility by making themselves available to the survey team in person, by telephone, or both. By being available, the medical director may be able to address a surveyor’s concern about an avoidable versus unavoidable condition, a potentially inappropriate medication order, or the etiology of a wound. Allaying a surveyor’s concern may decrease the risk of the nursing facility receiving a citation or limit its scope and severity. Becoming involved in the survey process can be time consuming and frustrating formedical directors, however. Another AMDAposition paper suggests that the citation of deficiencies is often arbitrary and that the adversarial atmosphere created by this punitive approachdoes little to enhance resident safety or quality of care.2,3 Statistical validity also comes into question with some citations. In a case report describing a state survey’s citation of a nursing facility for med-pass errors, Woolley4 points out that in situations where error rates are low, largenumbers of observations of an activitymust bemade to reach acceptable validity of estimates for the true error rate. Whether involved in the survey process or not, most medical directors have experienced the angst of having their facilities receive deficiencies on a state survey. What can a facility’s administrative and clinical staff members do if they receive a citation with which they disagree? How should the medical director be involved? One option to challenging deficiencies is the Informal Dispute Resolution (IDR) process. IDR has been available to nursing facilities since 1995 and is a less expensive, less time-consuming alternative to the more formal appeals process adjudicated before an administrative law judge. The purpose of this informal process is to give providers one opportunity to refute cited deficiencies after any survey. Facilities may not use IDR to delay the formal imposition of remedies or to challenge any other aspect of the survey process. The procedures and time lines for IDR are described on the Centers for Medicare and Medicaid Services (CMS) Web site.5 Filing an IDR does