Guidance for Medical Directors Series

Introduction

Since 1974, Medicare regulations have required that a physician serve as medical director in nursing facilities. In the last 50 years, the federal regulation [42 CFR 483.70(g), Federal Tag (F Tag) F841], has not substantively changed. It states that the medical director is responsible for the implementation of resident care policies and coordination of medical care in the facility. However, the CMS State Operations Manual (SOM) Guidance to Surveyors for Long Term Care Facilities, also known as Appendix PP, which provides guidance for interpreting nursing home regulations, has been updated several times. The Post-Acute and Long-Term Care Medical Association (PALTmed), previously known as the American Medical Directors Association (AMDA), has worked since 2002 to define the essential roles and tasks of the medical director, advise CMS and other federal agencies of these key elements, and train medical directors to become certified medical directors through its Core Curriculum.

This document outlines the key roles, responsibilities and tasks for nursing home medical directors as delineated by CMS and PALTmed. The revisions made to the SOM that took effect on April 28, 2025, are included in this paper.  

CMS defines “medical director” as a physician who oversees the medical care and other designated care and services in a healthcare organization or facility.¹ They define “physician/practitioner” as the individual who has responsibility for the medical care of a resident.¹ These definitions will be followed throughout this paper.

Criteria for Medical Directors  

The duties of the medical director, as laid out in 42 CFR 483.70(g), i.e., implementation of resident care policies and coordination of medical care in the facility, are quite broad.  But clearly, no single medical director can ensure all resident care policies are implemented for every resident, and no single medical director can coordinate all of the medical care provided to every resident. Medical directors must rely on facility personnel and the members of the Quality Assessment & Assurance (QA&A) Committee to bring potential areas of concern to their attention. Moreover, the medical director may not have the authority to take formal corrective action (e.g., firing an employee) or the fiscal ability to purchase desired equipment, etc., even when concerns are identified. So their duties, while expansive, are of necessity not all-encompassing, and the medical director cannot be held accountable for every alleged negligent act or omission, or every alleged regulatory violation that occurs in the facility.

The current federal regulation specifies that the role must be held by a physician and does not give a provision for other types of practitioners to hold this role. The medical director must:

• Hold a valid license to practice medicine in the state where the nursing home is located.  
• Be knowledgeable about current professional standards of practice in caring for nursing home residents.
• Possess leadership skills to allow them to coordinate and oversee the care provided by other practitioners.  

Some states have additional requirements, such as the medical director being a certified medical director (CMD) or completing specific continuing medical education (CME) content for medical directors.

Medical Director Contract/Agreement and Job Description

The facility should execute a contract or other type of formal agreement for medical director services. This contract should identify how the medical director will fulfill their responsibilities to implement resident care policies and coordinate medical care for residents in the facility. This contract should also clearly define the medical director’s roles, responsibilities and tasks, estimate the time required for these services, and set forth compensation at fair market value. The contract should also outline to whom the medical director reports and their collaboration in facility operations. In most instances, the medical director reports to the facility administrator or executive director. However, for facilities that are part of large corporations, alternative reporting structures may exist, such as reporting to a corporate chief medical officer or regional medical director. The medical director contract may serve as the medical director’s job description, or the facility may have a separate policy or document to outline this. PALTmed has developed a sample medical director contract.

Assistant/Associate Medical Director, Program Medical Director or Medical Director Designees 

Facilities and medical directors have flexibility on how the duties of the medical director are performed. It is the responsibility of the facility to ensure that all responsibilities of the medical director are effectively performed, regardless of how the tasks are accomplished or the technology used.¹  

Some facilities may contract an associate medical director or programmatic medical director for a specialty clinical program within the facility. These contracts should clearly define the roles, responsibilities, and tasks of these positions, the expected time required for these services, compensation at fair market value, and how these positions collaborate with the facility medical director. The facility medical director retains responsibility for oversight of these duties and programs, along with the coordination of resident care delivered within these programs.  

CMS allows the medical director to appoint a designee to act on their behalf, but does not specify the professional credentials required for this role. However, the regulations do note that having a designee does not remove the medical director’s responsibility to serve on the facility’s QAA/QAPI committee or their responsibility for overall care in the facility—medical and otherwise.¹
 

Medical Director Roles 
 

The medical director should be involved at all levels of individualized patient care and supervision, and for all persons served by the facility. The medical director serves as the clinician who oversees and guides the care that is provided, a leader who helps define a vision of quality improvement, an operations consultant who addresses day-to-day aspects of organizational function, and a direct supervisor of medical practitioners who provide direct patient care.

PALTmed has identified four key roles of the skilled nursing facility medical director, as follows:

• Physician Leadership: The medical director serves as the physician responsible for the overall care and clinical practice carried out at the facility. They organize and coordinate physician services and the services provided by other professionals as they relate to patient care. They participate in the surveillance and promotion of employee health and safety and strive to ensure that the rights of individuals (patients, staff and practitioners) are maintained and respected. They articulate the facility’s mission to the community.
• Patient Care/Clinical Leadership: The medical director applies clinical and administrative skills to guide the facility in providing care. They participate in administrative decision-making and recommend and approve relevant policies and procedures in accordance with current standards of clinical practice.  
• Quality of Care: The medical director helps the facility develop and manage quality and safety initiatives, including risk management. They participate in the QAA/QAPI process to ensure that medical care provided to residents meets professional standards, is patient-centered and person-directed, timely and equitable. They remain knowledgeable about social, regulatory, political and economic factors that relate to patient care and services, and work with the facility to meet these expectations.  
• Education, Information, and Communication: The medical director provides information that helps others (including facility staff and practitioners) to provide effective care. They participate in developing and disseminating key information and education to residents, resident representatives, staff, providers, healthcare trainees, healthcare organizations, and the community.  

Tasks

Specific tasks of the medical director may vary somewhat depending on the facility’s corporate structure, location, size, resident population, and clinical specialty. These tasks are generally listed as they relate to the four key roles of the medical director, starting with the more critical roles. This list should not be construed as authoritative or definitive for all situations. Medical directors are encouraged to review these tasks with facility and corporate leadership to further define and prioritize their responsibilities in the facility, emphasizing those with more importance in the specific facility ecosystem, and reducing or eliminating those with less relevance.

Physician Leadership

The medical director:

• Communicates regularly with the administrator, the director of nursing, and other facility leaders; and provides guidance needed to achieve the facility’s operational and clinical goals.
• Participates in the development, periodic reevaluation, and revision of resident care policies at least annually.
• Ensures, to the extent possible, that the facilities’ policies and practices respect resident rights, comfort, and dignity, and support person-centered and person-directed care.
• Actively participates in the creation, revision, and implementation of the facility emergency preparedness plan.
• Ensures, to the extent possible, that the ethical and legal rights and best interests of residents, including those who lack decision-making capacity, are respected.
• Participates in the activities of the facility’s Ethics Committee, if established, and assists as appropriate in resolving ethical and legal issues, including conflicts about treatment preferences, goals of care, and end-of-life care.
• Promotes and protects residents’ rights by ensuring systems are in place to identify and report abuse and participating in relevant resident and family meetings, interdisciplinary team (IDT) meetings, and similar activities.
• Ensures, to the extent possible, that the facility accommodates residents’ choice of an attending physician.
• Actively participates in the process of conducting and revising the facility assessment.
• Assists the facility with the interpretation and compliance with state and federal laws and regulations.
• Participates in licensure and regulatory surveys and interacts with surveyors and regulatory agencies as necessary and is available to assist in the creation of Plans of Correction (POC) and pursuit of regulatory appeals.
• Helps the facility make decisions about resource allocation, including budgetary and financial considerations that affect medical care (e.g., contracts, formularies, appropriate use of lab tests, allocation of resources).
• Aids the facility in establishing affiliation agreements and effective relationships with other healthcare organizations such as hospital systems, value-based purchasing (accountable care organizations, institutional special needs programs), insurance companies, utilization review organizations, and emergency medical systems.
• Assists the facility in addressing and communicating regarding situations that have brought the facility to the attention of the public and/or the media, if asked by corporate or administrative leaders.
• Helps the facility ensure that its medical records system, communications, and documentation support resident care and are HIPAA compliant.
• Helps guide the facility in the surveillance and promotion of employee health, including the assessment of infectious disease risk and situations that increase the risk for employee injury or illness.
• Assists the facility with identifying employee job requirements, assessing employee capabilities, and preventing employee illness and injuries.
• Advises the facility on establishing and implementing employee wellness programs.
• Makes recommendations to the facility on policies related to the health and safety of staff, visitors, and volunteers.

Patient Care-Clinical Leadership

The medical director:

• Organizes, coordinates, and monitors the activities of the medical staff and is engaged in a system to ensure that the quality and appropriateness of services meet professional standards.
• Helps the facility arrange for the availability of qualified consultative healthcare providers and oversees the performance of the providers.
• Guides the administrator in approving and documenting the credentials of practitioners who provide care in the facility.
• Develops and periodically reviews policies governing medical staff services, such as bylaws, policies and procedures, and/or rules and regulations.
• Collaborates with the facility to intervene as appropriate with practitioners regarding healthcare that is inconsistent with current standards of practice.
• Assures coverage for medical emergencies and participates in decisions about the facility’s emergency equipment, medications, and supplies.
• Advises the facility about the appropriateness of each resident’s level of care, admissions, transfers, and rehospitalizations.
• Offers recommendations and supports practitioners and the facility regarding family and resident concerns.

Quality of Care

The medical director:

• Participates in monitoring and improving the facility’s care and operation through Quality Assessment and Assurance (QAA) and Quality Assessment/Process Improvement (QAPI) programs, using data from external (e.g., Centers for Medicare & Medicaid Services [CMS]) and internal metrics
• Guides and advises the facility’s committees related to QAA/QAPI activities.
• Helps ensure that the facility’s QAA/QAPI program addresses patient care quality issues to make sure that facility services are equitable.
• Includes provider and staff input in identifying and applying QAA/QAPI standards.
• Assists the facility in using the results of its QAA/QAPI program to revise policies, procedures, and practices.
• Participates in the review of care, including but not limited to areas mandated by regulation such as medication monitoring, laboratory monitoring, infection prevention, antibiotic stewardship, ordering of psychoactive medications, and assignment of diagnoses, especially psychiatric diagnoses.
• Offers recommendations for the facility to consider the feasibility and appropriateness of any proposed research projects and ensure that they meet pertinent standards and contain appropriate safeguards.
• Aids the facility in identifying private and public funding sources for research activities.
• Contributes to facility publications, online presence, and other community and stakeholder outreach efforts as appropriate.

Education, Information, and Communication

The medical director:

• Sustains their professional development and helps ensure that credentialed providers meet ongoing licensure, certification, continuing education requirements, and current standards.
• Holds membership and participates in relevant professional organizations and associations.
• Provides direct staff education in the form of in-service presentations on clinical, regulatory, ethical, and other relevant topics.
• Informs medical staff about relevant policies, procedures, and regulatory updates.
• Helps the facility disseminate information gained from the QAA/QAPI program to patients, resident representatives, staff, administrative and corporate personnel, practitioners, and outside entities as appropriate.
• Serves as a resource on geriatric and post-acute and long-term care medicine and helps staff and practitioners identify and access relevant educational resources.
• Reviews programs and policies supporting healthcare trainees within the facility (nursing and medical students, residents and fellows).
• Participates in the development, organization, and delivery of educational programs for patients, responsible parties, staff, and the community.
• Acts as an advocate for the facility, encourages and facilitates community involvement, and helps the facility educate other healthcare organizations, lawmakers, and the community about its capabilities and services.

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References

¹ REVISED: Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process