Administration
Medical Director

Federal Requirements for Medical Director  [TOP]

State Requirements for Medical Director  [TOP]

Beyond requiring that each nursing home have a medical director and that the medical director have responsibility for policy development and coordination of medical care, the federal regulations leave further details to be specified by the State, other than requiring that the medical director hold required State licensure. Federal rules provide no detail on the scope of policy development or coordination, or the coordination between the attending physicians with, on the one hand, nursing home staff, and, on the other hand, specialists caring for the patient.   General federal requirements under Administration also call for the medical director to be legally qualified and licensed to practice in the State.  Some States amplify the credentials required.  For example, in New Jersey, the medical director is board-certified in a primary care specialty, such as family medicine, gerontology, or general internal medicine.  In Massachusetts, the medical director, who could be a staff or an advisory physician, shall spend at least four hours per month in the facility devoted to supervisory and advisory functions apart from any roles in patient care as attending physician.

Below are examples of the way the role of medical director has been elaborated in various States:

4 Ohio envisages an ambitious role for the medical director, summarized below (with omissions of some detail and statutory authorities, which are part of the full text) which includes leadership of a multidisciplinary care team, ongoing policy involvement, and substantial monitoring for quality. According to the rules, the Ohio medical director shall: (1) in collaboration with the administrator, the nursing director, and other health professionals, develop formal resident care policies for the nursing home that: (a)  Provide for the total medical and psycho-social needs of the resident, including admissions, transfer, discharge planning, range of services available to the resident, emergency procedures and frequency of physician visits in accordance with resident needs; b)  Promote resident rights; (2) Make available medical care for residents not under the care of their own physicians and to make available emergency medical care to all residents, provided their personal physicians are not readily available;

(3)  Meet periodically with nursing and other professional staff to discuss clinical and administrative issues, including the need for additional staff, specific resident care problems and professional staff needs for education or consultants to assist in meeting special needs such as dentistry, podiatry, dermatology, and orthopedics, offer solutions to problems, and identify areas where policy should be developed. In carrying out this function, the medical director shall: (a)  Observe residents and facilities at least quarterly or more frequently as needed; and (b)  Review pharmacy reports, at least quarterly, including summaries of drug regimen reviews, and take appropriate and timely action as needed to implement recommendations; (4)  Monitor the clinical practices of, and discuss identified problems with, attending physicians; act as a liaison between the attending physicians and other health professionals caring for residents and the residents’ families; and intervene as needed on behalf of residents or the home’s administration; (5)  Maintain surveillance of the health of the nursing home's staff.  (6)  Assist the administrator and professional staff in ensuring a safe and sanitary environment for residents and staff by reviewing incidents and accidents, identifying hazards to health and safety, and advising about possible correction or improvement of the environment.

Less elaborate statements in other States mandate similar activities:

4In Oregon the medical director shall: (a) Serve on the Quality Assessment and Assurance Committee; (b) Assist the facility to assure that adequate medical care is provided on a timely basis in accordance with facility policy;  and (c) Serve as attending physician for those residents who are not able to obtain services of another physician or ensure another physician is available to serve as attending physician.

4In Pennsylvania, the medical director responsible for the overall coordination of the medical care in the facility to ensure the adequacy and appropriateness of the medical services provided to the residents. He or she  may serve on a full- or part-time basis depending on the needs of the residents and the facility and may be designated for single or multiple facilities. A written agreement will exist between him/her and the facility. The medical director’s responsibilities shall include at least the following: (1) Review of incidents and accidents that occur on the premises and addressing the health and safety hazards of the facility and giving the administrator appropriate information from the medical director to help insure a safe and sanitary environment for residents and personnel; (2) Development of written policies which are approved by the governing body that delineate the responsibilities of attending physicians.

4In South Dakota, the medical director shall assure physician services are provided only by qualified caregivers.

Tennessee and Wisconsin illustrate more extensive lists of responsibilities (similar in scope to Ohio).  Both explicitly include monitoring the health status of employees to ensure that they pose no safety hazards to residents.

4 In Tennessee, the Medical Director shall: 1. Delineate the responsibilities of and communicate with attending physicians to ensure that each resident receives medical care; 2. Ensure the delivery of emergency and medical care when the resident’s attending physician or his/her designated alternate is unavailable; 3. Review reports of all accidents or unusual incidents occurring on the premises, identifying hazards to health and safety and recommending corrective action to the administrator; 4. Make periodic visits to the nursing home to evaluate the existing conditions and make recommendations for improvements; 5. Review and take appropriate action on reports from the Director of Nursing regarding significant clinical developments; 6. Monitor the health status of nursing home personnel to ensure  that  no health conditions exist which would adversely affect residents; and, 7. Advise and provide consultation on matters regarding medical care, standards of care, surveillance and infection control.

4In Wisconsin, the Medical Director, pursuant to a written agreement with the facility, serves on a part-time or full-time basis.  He/she is responsible to coordinate medical care by developing written rules and regulations for attending physicians, and liaison with attending physicians to provide that physicians’ orders are written promptly upon admission of a resident, that periodic evaluations of the adequacy and appropriateness of health professional and supportive staff and services are conducted, and that the medical needs of the residents are met. Responsibilities to the facility include monitoring the health status of the facility’s employees, and reviewing incidents and accidents that occur on the premises to identify hazards to health and safety.

Responsibilities of Attending Physician  [TOP]

Responsibilities for attending physicians need to be considered in tandem with those of the Medical Director, who often has explicit responsibility for ensuring that the attending physicians meet the responsibility.  NHRegs Comment: In actuality, the Medical Director often serves as attending physician for large proportions of the residents and must, in that capacity, meet attending physician standards.

4In Massachusetts, the medical director must spend at least four hours per month in the facility devoted to supervisory and advisory functions apart from any roles in patient care as attending physician. The specific requirements for timing of the initial physical examination and recording of progress notes described above can be embedded in a more general.   As seen in the previous section, some States require the Medical Director to serve as a backup attending physician when necessary; however, the attending physician is often also assigned responsibility for having backup coverage.  The facility may also have specific duties to notify the attending physician of various events or changes affecting their patients.  Some examples of duties related to attending physician follow;

4 In California, physician services shall include but are not limited to: (1) Patient evaluation including a written report of a physical examination within 5 days prior to admission or within 72 hours following admission; 2) An evaluation of the patient and review of orders for care and treatment on change of attending physicians; 3) Patient diagnoses; (4) Advice, treatment and determination of appropriate level of care needed for each patient; (5) Written and signed orders for diet, care, diagnostic tests and treatment of patients by others. Orders for restraints shall meet additional requirements cross-referenced to another section; (6) record progress notes and other appropriate entries in the patient's health records; (7) Provision for alternate physician coverage in the event the attending physician is not available.

4In Illinois, the facility shall notify the resident's physician of any accident, injury, or significant change in a resident's condition that threatens the health, safety or welfare of a resident, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days.  The facility shall obtain and record the physician's plan of care for the care or treatment of such accident, injury or change in condition at the time of notification. At the time of an accident or injury, immediate treatment shall be provided by personnel trained in first aid procedures.

4In Iowa, the person in charge of the facility shall immediately notify the physician of any accident, injury, or adverse change in the resident’s condition. 

4In Maryland, in care to a newly admitted resident, the attending physician shall: (1) Assess a new admission in a timely manner, based on a facility-developed protocol, depending on: (a) The individual's medical stability; (b) Recent and previous medical history; (c) Presence of significant or previously unidentified medical conditions; or  (d) Problems that cannot be handled readily by phone; (2) Seek, provide, and analyze needed information regarding a resident's current status, recent history, and medications and treatments, to enable safe, effective continuing care and appropriate regulatory compliance; (3) Provide appropriate information and documentation to support a facility-determined level of care for a new admission; (4) Provide for the authorization of admission orders in a timely manner, based on a facility-developed protocol, to enable the nursing facility to provide safe, appropriate, and timely care; and (5) For a resident who is to be transferred to the care of another health care practitioner, continue to provide all necessary medical care and services pending transfer until another physician has accepted responsibility for the resident. Additionally, to support Resident Discharges and Transfers, the attending physician shall: (1) Follow-up as needed with a physician or another health care practitioner at a receiving hospital within 24 hours of the transfer of an acutely ill or unstable resident; (2) Provide whatever summary or documentation may be needed at the time of transfer to enable care continuity at a receiving facility and to allow the nursing facility to meet its legal, regulatory, and clinical responsibilities for a discharged individual; and (3) Provide a pertinent medical discharge summary within 30 days of discharge or transfer of the resident. In terms of periodic, on-site visits to residents, the attending physician or licensed or certified professional health care practitioner shall (1) Visit a resident as frequently as the resident's condition requires, consistent with reasonable facility policies; (2) Determine the progress of each resident's condition at the time of a visit by evaluating the resident, talking with staff as needed, and reviewing relevant information, as needed; (3) Review and respond to issues requiring a physician's expertise, including: (a) The resident's current condition; (b) The status of any acute episodes of illness since the last visit; (c) Test results; (d) Other actual or high-risk potential medical problems that may affect the individual's functional, physical, or cognitive status; and (e) Staff, resident, or family questions regarding the individual's care and treatments; and (4) At each visit, provide a legible progress note in a timely manner for placement on the chart, which includes relevant information about significant ongoing, active, or potential problems, including: (a) Reasons for changing or maintaining current treatments or medications; and (b) A plan to address relevant medical issues.  NHRegsPlus Comment: Provision  (2) (e) could be interpreted as requiring the physician to respond directly to resident or family questions, which in turn is a mechanism to promote autonomous decision-making.  It is not clear how such a provision could be enforced.  Taken together, the various elements in the Maryland provisions, if followed, would result in proactive management of diseases and health problems.

4In New York, the  facility shall ensure that the responsible physician: (i) participates as a member of the interdisciplinary care team in the development and review of the resident's comprehensive care plan with the understanding that the minimum level of physician participation in interdisciplinary development and review of the care plan shall be a person-to-person conference with the registered professional nurse who has principal responsibility for development and implementation of the resident's care plan; (ii) visits the resident whenever the resident's medical condition warrants medical attention and establishes and maintains a schedule of visits appropriate to the resident's medical condition; (iii) reviews the resident's total program of care, including medications and treatments, at each regularly scheduled visit; (iv) prepares, authenticates and dates progress notes at each visit; (v) authenticates and dates all orders; (vi) provides residents and designated representatives with his or her name, office address and telephone number and responds to calls from residents to discuss the resident's medical care; (vii) participates in facility training programs to familiarize him or herself with State regulations and facility policies; and (viii) is informed of the results of all Department of Health surveys related to medical service deficiencies and is involved in resolving such problems.  NHRegsComment: As with Maryland, provision (vi) envisages that the attending physician will respond directly to calls from resident’s.  If followed, this would address a common complaint of residents that once in a nursing home their medical information tends to be mediated through facility personnel rather than conveyed directly by their doctors.  The provision for a person-to-person conference with the charge nurse regarding the care plan is an unusually strong endorsement for interdisciplinary collaboration; in other states, it is the medical director only who is required formally to collaborate on the care plan.  Another unusual component is the provision that attending physicians be informed of regulatory survey deficiencies related to medical care; presumably the medical director would provide the vehicle for such communication.

4 In Oregon, the facility has the duty to see that all physician orders shall be promptly carried out unless inconsistent with the resident's expressed wishes. NHRegsPlus Comment: This intriguing caveat recognizes a resident’s right not to comply with physician orders.  It might be of interest to explore the extent to which facility personnel, residents, and families are aware of this caveat, and how it might be interpreted in specific cases because ethical dilemmas could arise over the judgments made regarding the tension between medical orders and resident wishes.

4In Texas, elaborate rules have been developed for routine and emergency prescription of and discontinuing of psychoactive medications, including informed consent for such medications. A psychoactive medication is any medication prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorders and used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state when treating the symptoms of mental illness, and specifically includes: (A) anti-psychotics or neuroleptics; (B) antidepressants; (C) agents for control of mania or depression; (D) anti-anxiety agents; (E) sedatives, hypnotics, or other sleep-promoting drugs; and (F) psychomotor stimulants.

A person may not administer a psychoactive medication to a resident who does not consent to the prescription unless: (1) the resident is having a medication-related emergency (defined clearly in the provision); or (2) the person authorized by law to consent on behalf of the resident has consented to the prescription. (c) Consent to the prescription of psychoactive medication given by a resident, or by a person authorized by law to consent on behalf of the resident, is valid only if: (1) the consent is given voluntarily and without coercive or undue influence; b) (2) the person who prescribes the medication, or that person's designee, provides the resident and, if applicable, the person authorized by law to consent on behalf of the resident, with the following information in a single document identified as being for the purpose of consent to treatment with psychoactive medication: (A) the specific condition to be treated; (B) the beneficial effects on that condition expected from the medication; (C) the probable clinically significant side effects and risks associated with the medication, as reported in widely available pharmacy databases or the manufacturer's package insert; and (D) the proposed course of the medication; (3) the resident and, if appropriate, the person authorized by law to consent on behalf of the resident, are informed in writing that consent may be revoked; and (4) the consent is evidenced in the resident's clinical record by a signed form prescribed by the facility, or by a statement of the person who prescribes the medication or that person's designee, that documents consent was given by the appropriate person and the circumstances under which the consent was obtained. (A) Consent is valid until: (i) consent is withdrawn; or (ii) the practitioner has discontinued the medication. NHRegsPlus Comments.  These provisions are the most extensive safeguards we have noted regarding informed consent for psychoactive medication use in nursing homes.  They have the added benefit that, if followed, they would create conditions for clinically appropriate use of psychoactive drugs and avoidance of side-effects.  This example is one where State regulations are clearly supportive of resident autonomy.

Organized Medical Staff  [TOP]

Some States require an organized medical staff, whereas others (notably Massachusetts and Wisconsin) enunciate provisions for such an organized staff if the facility has an organized staff. The most elaborate of the mandatory requirements for organized medical staff is in Connecticut, which established criteria for the frequency of staff meetings, quorum definitions, and attendance requirements, and due process for revoking staff privileges.  The Connecticut rules provided with little editorial reduction below to illustrate he degree of formality built into the expectations.

4 In Connecticut, (1)   Each facility shall have an active organized medical staff with no less than three (3) physicians, (2)  The medical director shall approve or deny applications for membership on the active organized medical staff after consultation with the existing active organized medical staff, if any, and subject to the ratification of the governing body. In reviewing an applicant's qualifications for membership, the medical director shall consider whether the applicant: (A) satisfies specific standards and criteria set in the medical by-laws of the facility; and (b) is available by phone twenty-four (24) hours per day; is available to respond promptly in an emergency; and is able to provide an alternate physician or coverage whenever necessary; (3)  All appointments shall be made in writing and shall delineate the physician's duties and responsibilities. The letter of appointment shall be signed by the medical director and the applicant. 4) Requirements for active organized medical staff members. (A)  Members shall meet at least once every ninety (90) days.  Minutes shall be maintained for all such meetings. The regular business of the medical staff meetings shall include, but not be limited to, the hearing and consideration of reports and other communications from physicians, the director of nurses and other health professionals on: (i) patient care topics, including all deaths, accidents, complications, infections; (ii) medical quality of care evaluations; and  (iii) interdisciplinary care issues, including nursing, physical therapy, therapeutic recreation, social work, pharmacy, podiatry, or dentistry. (B)  Members shall attend at least fifty (50) percent of medical staff meetings per year. If two (2) or more members of the active medical staff are members of the same partnership or incorporated group practice, one (1) member of such an association may fulfill the attendance requirements for the other members of that association provided quorum requirements are met. In such case, the member in attendance shall be entitled to only one (1) vote. (C)  The active organized medical staff shall adopt written by-laws governing the medical care of the facility's patients. Such by-laws shall be approved by the medical director and the governing body. The by-laws shall include, but not necessarily be limited to: (i) acceptable standards of practice for the medical staff; (ii) criteria for evaluating the quality of medical care provided in the facility; (iii) criteria by which the medical director shall decide the admission or denial of admission of a patient based on the facility's ability to provide care; (iv) standards for the medical director to grant or deny privileges and to discipline or suspend the privileges of members of the medical staff, including assurance of a due process of appeal in the event of such actions; (v) quorum requirements for staff meetings, provided a quorum may not be less than fifty (50) percent of the physicians on the active medical staff; (vi) specific definition of services, if any, which may be provided by nonphysician health professionals such as physician's assistants or nurse practitioners; (vii) standards to assure that members of the medical staff request medical consultants where the diagnosis is obscure, or where there is doubt as to the serious nature of the illness or as to treatment. Such standards shall minimally mandate that the consultant be qualified to render an opinion in the field in which the opinion is sought, and that the consultation include examination of the patient and medical record; (viii) standards to assure that, in the event of the medical director's absence, inability to act, or vacancy of the medical director's office, another physician on the facility's active organized medical staff is temporarily appointed to serve in that capacity; and (ix) conditions for privileges for the medical staff other than the active organized medical staff. (5) Each member of the facility's medical staff shall sign a statement attesting to the fact that such member has read and understood the facility's medical and facility policies and procedures, and applicable statutes and regulations, and that such member will abide by such requirements to the best of his/her ability.

Other examples are provided more briefly:

4In Georgia, there shall be an organized professional staff, with one physician designated as chief of staff.  The professional staff shall consist of at least one physician, one dentist and one registered nurse.  Other professional personnel such as the dietitian, social worker, physical therapist, pharmacist, etc. may be included on the professional staff.  This organization shall function under appropriate bylaws and shall meet at regularly scheduled intervals not less than semiannually.  It shall be the responsibility of this staff to develop and review patient care policies and to advise administration on matters pertaining to patient care.  The minutes of the meetings of this staff shall be available for inspection by the Department.

4In Illinois, (1) There shall be an advisory physician, or a medical advisory committee composed of physicians, who shall be responsible for advising the administrator on the overall medical management of the residents and the staff of the facility.  If the facility employs a house physician, he may be the advisory physician.  (2)  Additional for Skilled Nursing Facilities.  There shall be a medical advisory committee composed of two (2) or more physicians who shall be responsible for advising the administrator on the overall medical management of the residents and the staff in the facility. If the facility employs a house physician, the house physician may be one member of this committee. b)  The facility shall have and follow a written program of medical services which sets forth the following:  the philosophy of care and policies and procedures to implement it; the structure and function of the medical advisory committee if the facility has one; the health services provided; arrangements for transfer when medically indicated; and procedures for securing the cooperation of residents’ personal physicians.  The medical program shall be approved in writing by the advisory physician or the medical advisory committee. 

In Massachusetts, North Dakota, and Wisconsin, an organized medical staff is specified as one alternative way to deliver services.

4In Massachusetts, (A) Facilities shall establish written policies and procedures governing the delivery of physician and other medically related services; (B) Facilities shall provide medical supervision through a written agreement with (a) an organized medical staff of a hospital, (b) an organized medical staff within the facility, (c) a local medical society, or (d) two or more advisory physicians (at least one of whom does not have a proprietary interest in the facility). Supervisory and advisory functions shall include:  advice on the development of medical and patient care policies concerning patient admissions and discharge, medical records, responsibilities of attending physicians or physician-physician assistant team or physician-nurse practitioner team, supportive and preventive services, emergency medical care, and the review of the facility’s overall program of patient care.

4In North Dakota, the facility shall have a licensed physician who is specified as the medical director or a medical staff organized under bylaws and rules approved by and responsible to the governing body. The medical director or medical staff shall be responsible for the quality of all medical care provided to residents and for the ethical and professional practices of its members. 2. The duties and responsibilities of the medical director or medical staff must be delineated in a formal agreement with the governing body. 3. The medical director or medical staff shall be involved in the development of written medical staff policies which are approved by the governing body, which delineate the responsibilities of licensed health care practitioners. 4. The medical director or a member of the medical staff shall participate in the quality improvement and infection control program meetings.

4In Wisconsin, if facility has an organized medical staff, the medical director shall be designated by the medical staff with approval of the licensee.  Also if there is an organized medical staff, the staff will vote on approving the written rules and regulations required for attending physicians.

Although not linked to an organized medical staff, States may have specific rules affecting medical care, such as mental health provision (New Jersey, Texas), hospice assumption of care (Iowa), pediatric care for children in nursing homes (Texas), and revocations of attending physician privileges (Oregon).   For example:

4In New Jersey, the facility has a staff or consultant psychiatrist with admitting privileges to the inpatient psychiatric unit at a hospital.                       

4In Idaho, in the event that neither the patient’s/resident’s attending physician nor the emergency physician can be contacted, the patient/resident in an emergent situation may be transferred to the emergency department of a nearby hospital.

4In Iowa, professional management of a resident’s care shall be the responsibility of the hospice program when: the resident is terminally ill, and b. the resident has elected to receive hospice services under the federal Medicare program from a Medicare-certified hospice program, and c. the facility and the hospice program have entered into a written agreement under which the hospice program takes full responsibility for the professional management of hospice care.

 4In Texas, if children are admitted to the facility; (A) appropriate pediatric consultative services are utilized, in accordance with the comprehensive assessment and plan of care; and (B) a pediatrician or other physician with training or expertise in the clinical care of children with complex medical needs participates in all aspects of the medical care.

4In Wisconsin, physician visits are not ordinarily required for respite care residents.

Oregon has articulated a step-by-step procedure for policies to “assure physician services are provided in all cases when the attending physician or his/her alternate physician cannot or does not respond to the resident's needs.”

4In Oregon, if the physician or physician designee fails to visit the resident according to resident's need, fails to respond to requests for assistance in resident's care, or fails to return verbal or telephone orders reduced to writing and forwarded to the physician by the facility, then the facility administrator shall ensure: (A) Reasonable and repeated attempts are made and documented in the clinical record to get the physician or physician designee to visit resident or return signed orders; (B) The medical director is notified and the Quality Assessment and Assurance Committee reviews the situation; (C) The County Medical Society, State Medical Society, and the Board of Medical Examiners are notified in writing of the problem; (D) The Division is notified in writing of the physician's failure to visit resident(s) or complete his/her progress notes or signed orders; and (E) The resident and the resident's significant other(s) are notified.

[Summarized November 2006]
 

Table Comparing States  [TOP]

Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Administration by State (with a link to each State's specific language). Link to a downloadable PDF document containing all State regulation on Administration at the bottom of the Table.