August 4, 2026
Do You Know a DINO—A Medical Director in Name Only?
By Karl Steinberg, MD, HMDC, HEC-C, CMD, FPALTC
As most of our readers know, federal regulations devote remarkably few words to one of the most consequential clinical leadership positions in a nursing home. Under 42 CFR §483.70(g), a skilled nursing facility (SNF) must designate a physician to serve as medical director. That physician is assigned just two broadly stated responsibilities: implementing resident-care policies and coordinating medical care in the facility.
The regulation establishes no required training or certification, minimum number of hours, frequency of on-site visits, or limit to the number of facilities one physician can oversee. Many of us know of SNF medical directors whose prior professional experience bears little relationship to post-acute and long-term care (PALTC)—perhaps a retired pediatrician or an interventional radiologist. Some may enter the building only once a month, or even once a quarter, to attend a quality meeting.
The Centers for Medicare & Medicaid Services (CMS) interpretive guidance to surveyors in Appendix PP provides considerably more substance. F-tag 841 describes additional medical director responsibilities, including participation in the Quality Assessment and Assurance committee; addressing problems identified through quality activities, including Quality Assurance and Performance Improvement; active involvement in the facility assessment; and intervening when practitioners provide care inconsistent with professional standards. Other expected functions in the guidance include helping to develop clinical policies, supporting staff education and infection-prevention activities, promoting person-directed and end-of-life care, evaluating practitioner performance, and helping establish systems to monitor the quality of medical care.
Importantly, CMS cautions that policies developed for multifacility organizations cannot simply be imposed uniformly across an entire chain. Each facility’s policies must reflect its particular environment, resident population, and facility assessment. That requirement becomes especially meaningful when a single physician serves as medical director for multiple buildings. Nevertheless, it is not unusual for medical directors to approve corporate policies handed down from above with little evidence of meaningful facility-specific review.
Several states have imposed more specific qualifications or responsibilities, and some also require medical director involvement in employee health.
California has taken a credentialing approach. Under legislation effective in 2022, most freestanding SNFs may contract only with a medical director who is—or will become within five years of initial appointment—a Certified Medical Director through the certification program associated with the Post-Acute and Long-Term Care Medical Association (PALTmed), or through an equivalent organization approved by the state.
Physicians already serving as medical directors on January 1, 2022, have until January 1, 2027, to obtain certification. Facilities must report the medical director’s identity and certification status to the California Department of Public Health, and report changes within 10 days.
In California, we had a relatively smooth path to passage of this legislation during the pandemic. Legislators were surprised to learn that the principal qualification for serving as a SNF medical director was essentially an unrestricted medical license—despite the extraordinarily complex regulatory environment and the frail, clinically complicated, and vulnerable population for whom the medical director is primarily responsible for safeguarding the quality of care.
Maryland requires a medical director to have at least two years of experience or specialized training in caring for geriatric or chronically ill and impaired residents. The physician must also complete an approved curriculum in physician management or administration, beginning the educational process during the first year of employment. Maryland further requires facilities to provide the medical director with adequate authority and support, hold practitioners accountable, and evaluate the medical director’s performance. As with all such requirements, their value ultimately depends on meaningful implementation and enforcement.
Pennsylvania requires a state-licensed physician, a written contract, and at least four hours annually of continuing medical education related to medical direction or post-acute and long-term care. Its regulations expressly require the medical director to oversee the appropriateness and quality of care, assist with staff education, support infection prevention, promote resident choice, and intervene when practitioner care is inconsistent with prevailing standards. Pennsylvania permits a physician to serve one or multiple facilities but establishes no numerical maximum.
Most recently, Florida began requiring nursing-home medical directors, effective January 1, 2026, to be certified, hold a comparable state-recognized credential, or be actively pursuing certification. Florida also imposes unusually concrete operational requirements. A medical director must visit each facility at least monthly; review new policies, incident and accident reports, and clinically related grievances; meet at least quarterly with the facility’s quality and risk-management committee; maintain a principal office within 60 miles of each facility, subject to limited exceptions; and serve as medical director for no more than 10 nursing homes.
Florida’s new limit raises a longstanding and somewhat uncomfortable national question: How many facilities are too many?
In one unconfirmed Oregon example, a single physician reportedly serves as medical director for more than 30 nursing homes. The California Department of Public Health has confirmed that one California physician holds the title at 21 facilities. Although such arrangements may technically comply with federal law, compliance on paper is not synonymous with effective clinical leadership.
The appropriate number will vary according to facility size, resident acuity, geographic proximity, administrative support, and the physician’s other clinical and professional responsibilities. Still, a medical director overseeing dozens of facilities is unlikely to understand each building’s resident population, clinical systems, practitioners, infection risks, prescribing patterns, quality data, and recurring adverse events meaningfully. At some point, the arithmetic becomes implausible.
Other states, along with PALTmed state and regional affiliates, are pursuing legislative and regulatory initiatives to raise the minimum standards for medical director competency. PALTmed’s board is also considering whether there is a number of facilities that is categorically too many for one physician to oversee effectively.
At a time when the need for high-quality skilled nursing care is increasing while the direct-care and professional workforce is shrinking, the value of a knowledgeable, available, and engaged medical director has never been greater. Facilities and residents need genuine clinical leadership—not merely a “DINO,” or medical director in name only.
Karl Steinberg is a past president of PALTmed, the California Association of Long Term Care Medicine (CALTCM), and the National POLST Collaborative. He has been an active skilled nursing facility and hospice medical director in the San Diego area since 1995 and is still best known for taking his poodles on patient care rounds with him.