Monthly Archives: May 2015

Meet Dr. Deepak Shrivastava, Medical Director for the Stockton, Calif. Region

ShrivastavaDr. Deepak Shrivastava serves as the Medical Director for three Golden LivingCenters in California – Portside, Hypana and Chateau. He was nominated for Medical Director of the Year by all three LivingCenter Executive Directors for his tireless dedication to serving our patients and residents.

At any given time, Dr “Shriv” provides medical director coverage for over 290 long term patients, as well as approximately 40 short term patients operating within three very unique cultures and service offerings. One LivingCenter focuses on short term rehabilitation, another on dementia care, and the third on behavior management. Even with this amount of diversity among his portfolio, Dr. Shriv still visits LivingCenters on a regular as a regular attendant to all three QAPI meetings, as well as making by-weekly walking rounds with EDs and DONs.

Dr. Shriv also serves as the head of the ICU for the largest teaching hospital in San Joaquin County, as well as maintaining his status as a credentialed lecturer at the highly acclaimed UC Davis Medical School. Even with so many responsibilities, Dr. Shriv is just a phone call away from responding to his Golden LivingCenters.

Dr. Shriv is first and foremost a gentleman, a physician, a teacher and – most importantly – a friend. His support, leadership and ongoing mentoring allows our LivingCenters to remain competitive, consistent and innovative

Confirmation of Initial Orders


Please remember that when a patient arrives in the LivingCenter, you need to review the orders with the nurse at the facility. It is understandable that you may wish to defer some decisions until you’ve had a chance to review the chart and see the patient in person. Nevertheless, the admitting SNF attending physician is responsible for the orders from the moment the patient comes  through  the door, so it is advisable to know exactly what is happening. You’ll be asked specifically to approve orders until you see the patient.  This gives you the opportunity to catch errors from a discharging hospital, provide guidance when a particular medicine or treatment is not available, or be apprised of a clinical situation requiring particular surveillance.

Unless they are part of your rounding practice in the LivingCenter, hospitalists who discharge patients are not responsible for the orders which show up with the patient.  They will be entered in your name, and you’re responsible for the patient outcomes. I would contend that even if discharging doctors are part of your practice, it’s beneficial to know what the medications, labs and treatments are going to be. Certainly you may have some preferences regarding the nature of these reviews of initial orders.

This is a real opportunity to protect your patients.  The continued development of new medications and newer uses for older medications (for example, use of chemotherapeutic agents as antirheumatics)  increase the possibility of medication error between the hospital and LivingCenter.  Reviewing the medications and dosages at the time of admission provides another safeguard.

Feel free to talk with your DNS about them to agree on preferred practices and mutual expectations. They will be happy to assist you.

Communication During Changes of Condition


Linda has a problem.  Mr. Merrakesh, the 83-year-old gentleman in 125A has been coughing on and off for much of her shift.  He’s got a low grade temperature, and while he’s not short of breath, she’d really like to speak with the attending physician.  She picked up the phone, but bit her lip as she poised her hand ready to punch the office phone number. The last time she phoned Dr. Abner, she got an earful about how she shouldn’t have called. He then berated her during her presentation of the case.

Afterward it took all the fortitude she could muster just to finish out the night. Dr. Abner’s office prefers to be notified about changes in condition by fax and has made that abundantly clear. Still, Linda is worried about Mr. Merrakesh, and knows that the responses to faxes about changes in condition have sometimes been delayed for days. Maybe she should just send the patient to the local emergency department and not have to deal with Dr. Abner at all.

Could this be happening at your LivingCenter?  Are nurses afraid to phone you or one of your colleagues?  Changes of condition are key moments which we all know must be addressed in a timely and appropriately thoughtful manner. While we trust the nurse’s judgment as far as deciding when to call us, we cannot ask them to make medical treatment decisions or assessments without our input.

The standard of care in skilled nursing facilities continues to evolve.  Several years ago a patient in the office teased me for having a beeper. Now on-call doctors take calls directly on their cell phones. While some of our communication traffic, especially signature requests are transmitted by fax, faxes are not an appropriate way to communicate when a patient is getting sicker and needs a medical decision. Nor is it a good way to communicate where abnormal labs exist that need to be addressed within a few hours.  Not everyone knows your schedule … certainly you don’t want to come in on a Monday to find a critical lab has been sitting on the fax machine printout stack since Friday afternoon.

Timely communication between LivingCenter and physician can mean the difference between hospital admission and a successful intervention in the LivingCenter. It can mean the difference between a patient in pain all night and one who gets an intervention in time to make a difference. Occasionally, it means the difference between life and death.

How easy is it to reach your office?  Do you or your partners answer calls with patience and understanding, or are nurses filled with trepidation from the last conversation you had?  Would it influence them to not call you in a time of need?

I know that we all want to provide quality care for our patients.  I also know from experience that being on call all night for days, weeks or months can be grueling, and that late night calls where the situation is presented  in a  confused or disjointed  manner can be a challenge. Nevertheless, we have to find an appropriate balance.

Without a culture of understanding and patience, the nursing job becomes so much harder to do, and our patients ultimately suffer. When we make it easier for nurses to call, respond to calls in a timely fashion, and empower them to be free with their opinion of the situation, we enhance patient care, patient satisfaction and staff morale. Also, it helps protect us from regulatory and liability risk. Many doctors I’ve spoken with in long-term care feel overburdened and stressed. Patients are sicker, EHR systems more cumbersome, and regulatory forces more challenging.

If you’re experiencing this to the point where it is affecting your practice, talk with your ED and DNS. They may be able to help figure out how to streamline modes of communication, find ancillary services that can help you, and incorporate some processes that might make your rounds more efficient. Let them help you.

How Medical Directors Can Help During a State Survey


Survey time can be a tense time for everyone, but it doesn’t have to be.  During JCAHO Surveys at hospitals, I’ve seen doctors duck away in order to avoid being asked any questions. At Golden Living, we encourage our Medical Directors to meet and communicate with our State Survey teams.

We are proud of the dedication of our staff, the involvement of our leaders and the collaboration with our doctors. When inspectors come in to our LivingCenters, it is an opportunity for our Medical Directors to demonstrate their level of knowledge and involvement in our care processes. There also may be opportunities to clarify questions that the survey team has.  If they see a concerned, involved medical director, this will help their overall impression of the LivingCenter.

Here are some helpful hints. Feel free to save this somewhere convenient for reference during survey time.

Before the Survey:

  1. Pay attention to the Living Center Performance Assessments (LCPAs). These mock surveys are run by a team from another building in your area and are often tougher than the actual survey. Your understanding of what tags you get and which corrections are necessary will help prepare you for the State Survey.
  2. Know your Living Center. If you attend QAPI regularly, you’ll be able to answer questions about the operations of the building and address those questions from the surveyor about antipsychotics, weight loss, infection control, med errors and other issues that may arise.
  3. Get the signatures. Signature compliance can be a common area of vulnerability, so help maintain medical records with doctors on your staff who are not as good at signature compliance. If you help get these providers to maintain compliance, you may avert a citation, while simultaneously improving care.
  4. Fill out your timesheets. If possible submit brief reports at the QAPI meeting. This documents your involvement and will help to avert the F501 tag which cites a lack of adequate Medical Director involvement.
  5. Get to know your survey manual. Your executive director can give you a copy of the Survey Manual and help you with the specifically important aspects of your State regulations. Skimming the manual can help you understand what the surveyors want to see from your involvement in a LivingCenter.  The time spent reading the manual at home also counts toward documentable facility hours on your timesheet.
  6. Get involved with AMDA and your state medical directors association. They can alert you to recent survey areas of focus and help you stay up on how to approach problems.  Golden Living will cover your AMDA membership, and has a stipend available to help defray the costs of attending the National AMDA meeting.

Eight Steps to Success During a Survey:

  1. Have the ED or DNS contact you as soon as the survey team enters the building.  This allows you to find a time to schedule to meet the survey team.
  2. Arrange to meet the survey team by making an appointment. The best day for this is day two of the survey as on the first day, all you can do is make a good impression, and on exit day it’s too late to change their mind about anything and too late to make an impression.  On day two of the survey there’s often opportunity to talk them out of an unjustified tag, or provide insight. If you can’t get out of the office, at least speak to the survey leader over the phone on day two.
  3. Insist on meeting the survey team.  Surveyors should never refuse to meet with you.  Notify your regional medical director if this happens.
  4. Get to know the survey team.  Over the years you may run into some or all of them again. It pays to establish positive relationships and impressions.
  5. Don’t backdate anything.  Facility staff may provide you with documentation overdue for signature, often in the midst of a survey.  It is tempting to try to “help out” by backdating. This is unethical, illegal and a sure way to get a survey tag if you get caught.
  6. When conversing with the survey team, be respectful.  It may be necessary to disagree with them at times and to provide evidence to support your point. They will respect your opinion as a physician. Nevertheless, it is counterproductive to speak to them with a harsh, disrespectful or condescending tone.
  7. Listen to the Surveyors.  They are an objective team who may be able to teach you something about what needs to be improved in the Living Center, something which your facility leadership may have missed.  Understand that surveyors have been instructed to be sparing in positive feedback.
  8. Don’t make anything up! If you’re not sure about something, such as staffing ratios, a particular nursing protocol, or a company policy, it generally is wiser to check with your ED or DNS instead of guessing at what you wished you had known in a little more detail. Surveyors will accept that you don’t remember everything. Whatever you say may be taken at face value.

After the Survey

  1. Support the notion that our survey response is not just paper response and that you value the surveyor input. Some are quick to write off surveyors as biased, incompetent or unrealistic. In almost every criticism, there is a kernel of truth.  As Medical Director, it is important to foster a culture of excellence instead of a culture of compliance.
  2. Help the leadership develop their plans of correction. You can make a huge difference by  offering practical and sustainable suggestions for improvements.
  3. Be available if there is an appeal. Occasionally, a LivingCenter may appeal a particular citation. Your assistance could be the difference in a successful appeal.

As you’ve seen, our Golden Living staff works tirelessly to enhance the care of our patients.  Please help them get a fair evaluation for the hard work that they do. Survey time actually is time for us to shine.

Until Next Month,

Michael Yao Signature




Meet Dr. Aysha Habib, a GLC Medical Director of the Year from Virginia

Serving two Golden Living facilities in the Richmond, Virginia area, Dr. Aysha Habib works diligently to improve the quality of care for the patients in both Golden LivingCenter –  Elizabeth Adam Crump and Golden Living Community – Elizabeth House.

Dr. Habib was the recipient of the GLC Medical Director of the Year Award for the Southeast Region. There were numerous worthy nominees, but Dr. Habib’s record of clinical excellence, leadership involvement, and dedication stood out.

Bon Secours | Glen Allen Internal MedicineDuring her three years as Medical Director, there have been a few changes in leadership in the LivingCenters, and Dr. Habib has served as a source of stability and continuity for continued patient and resident care.

Always forward thinking, Dr. Habib worked to help the LivingCenter become part of the ACO with Bon Secours Hospital System. She was instrumental in setting up meetings and championing the LivingCenter in any and all partnership opportunities.

Recently Dr. Habib identified an opportunity to develop a program specifically to help patients with respiratory issues and recruited the Pulmonologist to provide such care to our patients in that area.