Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Nursing Home Medical Directors 
Survey 
JANET REHNQUIST 
INSPECTOR GENERAL 
FEBRUARY 2003 
OEI-06-99-00300  O I G
FFICE OF  NSPECTOR  ENERAL

http://www.oig.hhs.gov/ 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, 
is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as 
the health and welfare of beneficiaries served by those programs.  This statutory mission is carried out 
through a nationwide network of audits, investigations, and inspections conducted by the following 
operating components: 
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The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
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order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the 
Department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and the 
public.  The findings and recommendations contained in the inspections reports generate rapid, accurate, 
and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil 
monetary penalties.  The OI also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support in OIGs internal 
operations.  The OCIG imposes program exclusions and civil monetary penalties on health care providers 
and litigates those actions within the Department.  The OCIG also represents OIG in the global settlement 
of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops model compliance plans, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  E X E C U T I V E   S U M M A R Y  
OBJECTIVE 
To identify the functions reported by medical directors that are expected of them by nursing 
homes, their expenditure of time meeting these functions, and their self-reported credential 
status. 
BACKGROUND 
Medical directors are required by the Code of Federal Regulations, Title 42 483.75(i)(2), to 
be responsible for the implementation of resident care policies and coordination of 
medical care services in the facility. Further, the Omnibus Budget Reconciliation Act of 
1987 (OBRA 1987) and subsequent policies suggest, but do not clearly state, that medical 
directors should be utilized in the direct management and identification of potential quality 
improvement problems and plans, and should ensure implementation of existing law and 
regulations.  The Centers for Medicare & Medicaid Services (CMS) has ultimate responsibility 
for ensuring implementation of OBRA 1987, but it is not always clear which individual(s) in the 
nursing home actually, and ultimately, must ensure that patients receive the necessary care  the 
medical director, the attending physician, the administrator, or the nursing staff. From the 191 
sampled nursing homes, 119 responding medical directors identified many specific functions as 
expected or should be expected of them by the nursing home, in the four key areas of quality 
improvement, patient services, residents rights, and administration. 
SURVEY RESPONSE 
Responding medical directors report many functions in four key areas they are 
frequently expected to perform 
Quality Improvement  Medical directors report that quality improvement activities are 
important.  These activities focus on the broader aspects of quality within the facility, including 
their review and revision of existing medical and clinical policies; encouragement of quality of 
care, regardless of patient case mix; and review and analysis of quality indicators for potential 
areas of concern.  By comparison, quality improvement functions that are more centered on the 
individual patient are reported less often by medical directors as expected by the nursing 
homes.  Committee involvement is one way that medical directors contribute to quality 
improvement in the nursing home.  Eighty-seven percent of responding medical directors report 
participation on nursing home committees for improving patient care. 
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Nursing Home Medical Directors  i  OEI-06-99-00300  Patient Services  At 92 percent, intervening with attending physicians about patient care 
concerns is the most frequently mentioned patient service expected of responding medical 
directors by the sampled nursing homes.  Other functions frequently reported by medical 
directors are their review of consultant pharmacists drug regimen reports (90 percent), 
provision of ongoing medical advice and guidance to nurses (86 percent), and routine meeting 
with nurses to discuss patient care issues (78 percent). About half of the responding medical 
directors are not expected by the nursing homes to provide direct care to patients. 
Residents Rights  Ninety-six percent of responding medical directors report that the 
promotion of residents' rights is an expected leadership role for them.  However, 60 to 69 
percent of responding medical directors report that ensuring residents rights is expected of 
them by the nursing homes. For example, they are expected to ensure: the appropriateness of 
a patients drug regimen (69 percent), a patients end-of-life decisions are honored (68 
percent), and both patients involvement in their own care planning and their right to refuse 
medication, when mentally competent to do so (60 percent). 
Administration  Generally, medical directors report that their administrative functions involve 
advising on survey regulatory matters (94 percent), providing liaison with facility staff (84 
percent), and keeping current on regulatory and medical treatment changes (83 percent). Few 
medical directors report participation in the training of nurses and nurse aides, as well as 
participation in the assurance of patients safety in the physical environment. Few also report 
their participation in verifying that their facilitys storage, preparation, and service of food are 
sanitary. 
Medical directors report some functions they are not frequently expected to 
perform, nor do they often believe they should; for others, they indicate a more 
diverse opinion 
Within patient services, residents rights, and administration, medical directors report some 
functions that are infrequently expected of them by the nursing homes. For some of these 
functions, medical directors also seldom report that they should perform them. For other 
functions in these broad categories, the frequency at which they report that they should perform 
them is higher and indicates a diversity of opinion about what their duties should include. 
Eighty-six percent of responding medical directors report spending 
8 hours or less per week at the sampled facilities 
Sixty-two percent of responding medical directors report visiting the facility one time per week 
or less often. Eighty-six percent of them spend 8 hours or less per week at the sampled facility. 
Seventy percent of medical directors report that 1 to 10 percent of their overall medical 
practice is devoted to their medical director role. 
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Nursing Home Medical Directors  ii  OEI-06-99-00300  Responding medical directors report they are professionally trained 
All responding medical directors report that they have professional medical training. Nearly all 
report specialization in either family practice (47 percent) or internal medicine (44 percent). 
Almost half of them report specialization in caring for elderly patients, either as geriatric 
physicians (21 percent) or by their obtaining a certificate of added qualifications in geriatrics 
(29 percent). Many medical directors also enhance their professional understanding of the 
elderly through additional training or participation in professional organizations. In fact, while 
regulations do not specify that medical directors should be licensed to practice, they are 
required to be physicians. 
SUMMARY 
This report identifies the functions for which 119 responding medical directors in 7 purposively-
sampled states report as being expected of them by the nursing homes. The responding 
medical directors also identified those functions for which they report that they should have 
responsibility. Identified functions fall within four categories: quality improvement, patient 
services, residents rights, and administration. These functions relate directly to their regulatory 
responsibility for implementation of resident-care policies and coordination of medical services 
in the facility.  The reported functions clearly indicate a physician-related role for them.  In fact, 
while regulations do not specify that medical directors should be licensed to practice, they are 
required to be physicians. 
Beyond the few functions within each of the four categories, for which 80 to 94 percent of the 
responding medical directors report are expected by the sampled nursing homes (Appendix C), 
there are many more functions less frequently reported by medical directors.  These are 
functions that medical directors report they are not expected to perform, nor do they report 
they should; for others, they indicate a diversity of opinion. Thus, much of what medical 
directors are expected to do by the nursing homes begins to vary markedly. Responding 
medical directors (86 percent) also report spending 8 hours or less per week performing the 
responsibilities expected of them. 
The CMS routinely works directly with representatives of the nursing home industry, patient 
advocacy organizations, and physician-related associations. We believe that CMS will find the 
presented information useful as it continues to work with them in establishing, clarifying, and 
enhancing the medical directors role. 
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Nursing Home Medical Directors  iii  OEI-06-99-00300  T A B L E   O F   C O N T E N T S  
PAGE 
EXECUTIVE SUMMARY  ..................................................... i

INTRODUCTION .............................................................1

SURVEY RESPONSE ........................................................6

Responding medical directors report many functions in four key areas 
they are frequently expected to perform  .......................................  6

Quality Improvement  ...............................................  7

Patient Services ....................................................8

Residents' Rights  ..................................................10

Administration ....................................................12

Medical directors report some functions they are not expected to perform, nor do they report

they should; for others, they indicate a diversity of opinion .......................... 13

Eighty-six percent of responding medical directors report spending 8 hours or less per week at

the sampled facilities ...................................................... 16

Responding medical directors report that they are professionally trained ................1 8

SUMMARY ................................................................. 19

ENDNOTES ................................................................ 20

APPENDICES .............................................................. 23

A:  Summary of Physician-Related Survey and Certification 
Nursing Home Regulations ..............................................23

B:  Seven Sample States - Selected Information .................................25

C: Medical Directors Self-reported Functions  .................................26

ACKNOWLEDGMENTS ..................................................... 30
 I N T R O D U C T I O N  
OBJECTIVE 
To identify the functions reported by medical directors that are expected of them by nursing 
homes, their expenditure of time meeting these functions, and their self-reported credential 
status. 
BACKGROUND 
The Omnibus Budget Reconciliation Act of 1987 (OBRA 1987)1 requires all nursing homes, 
called facilities, while participating in the Medicare and Medicaid programs to meet a 
common set of certification standards, to assess the needs of patients, and to help those patients 
maintain and achieve their highest practical level of physical, mental, and psychosocial well-
being. The OBRA 1987 and subsequent policies require that all Medicare and Medicaid 
certified nursing homes retain a physician as medical director.  These medical directors are 
required by the Code of Federal Regulations, Title 42 483.75(i)(2), to be responsible for the 
implementation of resident-care policies and coordination of  medical care services in the 
facility. This and other regulations (see Appendix A) suggest, but do not actually specify, that 
medical directors should be utilized in the direct management and identification of potential 
quality improvement problems and plans, and to ensure implementation of existing law and 
regulations. 
The Centers for Medicare & Medicaid Services (CMS) has ultimate responsibility for ensuring 
that OBRA 1987 requirements are implemented by states and nursing homes. The nursing 
home (facility) has the principal responsibility, assigned by most regulations, to implement or 
ensure implementation of those same reforms for the patients in their care. Yet, regulations 
provide no clear indication of which specific individual(s) in the nursing home will perform or 
ensure that patients receive the necessary care. Possible individuals include: 
C	 The medical director, whose role is largely undefined by CMS, except in the broadest 
sense of resident care and clinical policies and coordination of medical care (see details on 
page 2). 2 Additionally, while the medical director is required to be a physician,3 there is no 
regulation specifying that the physician should be licensed to practice; 
C	 The attending physician, who certifies a patients need for nursing home care and 
routinely provides the clinical response to a patients needs and addresses patient concerns 
identified by nursing staff 4; 
C	 The nursing staff, including the director of nursing, who have no direct regulatory 
requirements, except as their performance relates to their involvement in clinical care; and 
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Nursing Home Medical Directors  1  OEI-06-99-00300  C	 The administrator, hired by or is the owner of the facility, generally has little, if any medical 
background; expected to oversee all administrative and management activities associated 
with patient care and safety within the nursing home. 
While the survey process requirements have many sections relating to functions, which appear 
to be specific to physicians performance (see Appendix A), the CMS State Operations 
Manual (SOM), and the CMS Interpretive Guidelines (SOM, Appendix PP) explicitly 
address three areas for the role of the medical director: 
1)	 Drug regimen review5 encourages facilities to share pharmacists drug reviews with the 
medical director; 
2)  Medical director6 states that medical directors, who are retained by the facility, must 
C	 implement resident care policies regarding admissions, transfers and discharges; 
attending physician privileges and practices; responsibilities of non-physician healthcare 
workers; accidents and incidents; ancillary services such as laboratory, radiology, and 
pharmacy; use of medications; use and release of clinical information; and overall 
quality of care7; 
C	 ensure establishment and implementation of all resident clinical care policies and 
assurance that the nursing home is providing required appropriate care by 
monitoring and implementing policies for care, oversight, and supervision related to 
overseeing the overall adequacy of clinical care of patients; and 
C  coordinate medical care in the facility. 
3)	 Quality assessment and assurance8 notes that the medical director may be designated by the 
nursing facility to serve as the required physician on the quality assurance committee. 
No regulatory guidance exists on how medical directors are to accomplish these charges, nor is 
there any specific requirement for a medical directors direct, ongoing clinical interaction, or any 
related quality-specific activities, with patients or nursing home staff.  The CMS and the 
General Accounting Office have each raised serious concerns for patients' care and well-being, 
principally resulting from their studies of nursing home responsibilities, processes, and patient 
care.9 
METHODOLOGY 
Scope 
Given the lack of specificity in the law, regulations, and policy governing functions to be 
performed by medical directors, this study seeks to describe nursing homes expectations.  The 
range of possible functions and responsibilities of medical directors was based on the 
identification of potential roles that medical directors may have in a nursing home, according to 
the medical directors themselves, nursing home administrators, directors of 
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Nursing Home Medical Directors  2  OEI-06-99-00300  nursing, and attending physicians. Functions fell into the following categories:  patient services, 
quality assurance and improvement, residents rights, administration and management, training 
and education, and ensuring a safe physical environment. 
Finally, because we used a purposive sample, we have not projected our findings to the nation. 
Study and Survey Development 
We consulted at length with several public and private organizations associated with nursing 
home care.10 Each provided their professional perspectives on the inspection issues and 
methodologies, as well as advice on obtaining sample information about specific types of 
nursing home staff.  In addition, the American Medical Directors Association (AMDA), during 
their annual training conference for medical director certification, provided our staff with basic 
training concerning the medical directors role.  We also met with medical directors in nursing 
homes and research experts to gain their perspectives of both the many facets of the medical 
director's job and our planned methodology for this study. 
Sample Selection 
States  Based on recommendations from knowledgeable parties11 and research conducted 
during the study-development phase, we purposively selected California, Maine, New York, 
Ohio, South Dakota, Tennessee, and Texas as the sample states. Together, these states 
account for approximately 29 percent of certified nursing homes, 37 percent of Medicaid 
expenditures for institutional long-term care, and 30 percent of all certified beds (see Appendix 
B). Further, these seven states illustrate a variety of factors that may impact the role of a 
nursing homes medical director: 
C  High numbers of nursing home chains (California, Texas), 
C  Large nursing home patient populations (California, Ohio, New York, Texas), 
C	 Less populous and more rural states with approximately 13 percent (+/-) Medicare and 
Medicaid enrollment as a percent of population (Maine, Tennessee), 
C  Low percentages of Medicare physicians in rural states (South Dakota), and 
C  States in which less than 75 percent of physicians and other practitioners participate in 
Medicare Part B (South Dakota). 
Nursing Homes  For each sample state, the number of nursing homes selected was based on 
the states relative proportion of certified nursing home beds to the national number of certified 
nursing home beds. We believe that this is a more accurate indicator of each states relative 
nursing home size than the use of overall state population (see Appendix B).  We also limited 
the number of nursing homes in each sampled state to a maximum of 50 and a minimum of 5. 
We randomly selected the predetermined number of nursing 
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Nursing Home Medical Directors  3  OEI-06-99-00300  homes per state for a total of 205 certified nursing homes -- California (50), Maine (7), New 
York (45), Ohio (37), South Dakota (5), Tennessee (15), and Texas (46). 
Of the 205 sampled nursing homes, we dropped 14 because their survey responses indicated 
that they had been incorrectly sampled, i.e., the CMS database identified the nursing home as 
free-standing, but the administrator or medical director reported the nursing home was hospital-
based12 or the facility had closed.  As a result, our sample decreased to 191 nursing homes. 
Individual Respondents  We surveyed each of the sampled 191 nursing homes medical 
directors.  For about one-fourth of the 191 nursing homes (45 total across 7 States), we also 
surveyed nursing homes administrators, directors of nursing, and attending physicians. These 
three individuals, in each of the sampled nursing homes, were chosen as those most likely to 
interact directly with the medical director at various points in the process of caring for patients. 
Data Collection 
Mail Survey and Response Rates  Between the summer and winter of 2000, we collected 
data from respondents through a structured mail survey. Of the possible 326 respondents (191 
medical directors and 45 each from administrators, directors of nursing, and attending 
physicians), a total of 205 respondents (63 percent) returned usable surveys.13 By respondent 
type, this included 119 medical directors (62 percent), 31 administrators (69 percent), 33 
directors of nursing (73 percent), and 22 attending physicians (49 percent). 
We divided the functions performed by responding medical directors into four broad categories: 
quality improvement, residents' rights, patient services, and administration (which included 
training and education, as well as physical environment and employee health). Within each 
category were questions on specific functions that may be part of the medical directors role. 
For example, under the category residents rights is the specific function verify patients have 
a drug regimen free from unnecessary drugs. 
For specific functions, we asked respondents for their perceptions about the medical directors 
role from three perspectives: 
1)	 Expectation of the nursing home (e.g., required by the nursing home) that the function is the 
medical directors responsibility in that nursing home,14 
2)  Should the function be the responsibility of the medical director, and 
3)  Authority to the medical director from the nursing home to perform the function. 
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Nursing Home Medical Directors  4  OEI-06-99-00300  We also asked respondents about the importance of a medical directors leadership in several 
key areas and other questions intended to provide supplemental information about the medical 
directors role and activities. 
Data Analysis 
Using data from the completed surveys, we performed frequencies, cross-tabulations, and 
content analysis. Findings presented focus primarily on the responses from the medical 
directors. Data from the other respondent types, i.e., administrator, attending physician, and 
director of nursing, were used largely to discern marked differences between them and the 
responding medical directors and to provide supplemental information from another 
perspective. Occasionally, we reference possible functions that could be included in the 
medical directors job, but were chosen less frequently by respondents. 
Non-Respondent Analysis 
To detect non-respondent bias, we used our data to test for differences between responding 
and non-responding medical directors.  We were limited to comparing characteristics that were 
available from our file of sampled nursing homes. Since the responses by medical directors 
were anonymous, we could not test for differences between responding and non-responding 
medical directors.15 Factors for which we did test include state characteristics, the type of 
nursing facility (profit, non-profit, ownership), and the size of the facility (large, medium, small). 
No significant differences were found for any of these factors. In addition, we followed up with 
non-respondents by telephone, and the majority of them stated that the primary reason for not 
responding to the survey was lack of time. 
This study was conducted in accordance with the Quality Standards for Inspections issued by 
the Presidents Council on Integrity and Efficiency. 
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Nursing Home Medical Directors  5  OEI-06-99-00300  S U R V E Y  R E S P O N S E  
Survey responses from 119 nursing home medical directors found that they are expected by 
their nursing homes, and report they should be expected, to perform many specific functions in 
four key areas  quality improvement, patient services, residents rights, and administration. 
Functions of quality improvement and patient services are most frequently reported by medical 
directors as expected of them and most strongly seen as important by the medical directors. 
Examples of quality improvement include reviewing and revising existing medical and clinical 
policies, and encouraging quality care. Examples of patient services are intervening with 
attending physicians, when necessary, reviewing consultant pharmacists reports, and interacting 
with nurses. Functions associated with residents rights and administration are reported less 
often as expected by nursing homes and less often perceived as important. Medical directors 
report that some functions pertaining to staffing, appropriate patient care, training, and 
residents rights are infrequently expected of them by their nursing homes and may or may not 
be reported as functions which they should perform. Eighty-six percent of medical directors 
report spending 8 hours or less per week in the facility; 70 percent report spending less than 10 
percent of their overall professional practice on their medical director responsibilities. Finally, 
regulations require medical directors to be physicians; 92 percent report they are currently 
licensed, and all say they are professionally trained. 
Responding Medical Directors Report Many Functions In Four Key Areas They 
Are Frequently Expected To Perform 
According to the responding medical directors, nursing homes expect them to perform  many 
functions falling within four broad categories: 1) quality improvement, 2) patient services, 3) 
residents rights, and 4) administration, which includes training. The CMS survey process 
requirements and their Interpretive Guidelines have many sections relating to functions which 
appear to be specific to physicians performing in these four areas (Appendix A). For this 
study, medical directors reported those activities that nursing homes most often expect of them 
and those which medical directors most often report should be their responsibility. In general, 
medical directors report that they have the authority from the nursing homes to perform many of 
the functions (see Appendix C). 
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Nursing Home Medical Directors  6  OEI-06-99-00300  Quality Improvement 
Medical directors see quality improvement activities as important and focus on the 
broader aspects of quality care 
Ninety-seven percent of responding medical directors report that their participation in the 
nursing home's quality improvement effort is important to their leadership role for establishing 
and maintaining quality patient care. Quality improvement in a nursing home can be as simple 
as ensuring conformance to state and federal requirements, or as complex as measuring the 
degree to which services meet professional standards.  In this category, Table 1 shows the 
activities that medical directors report as expected by nursing homes, most of which the medical 
directors clearly agree should be their responsibility. 
Table 1: Quality Improvement Functions Most Frequently Identified by Medical Directors 
Nursing Homes Expect  Medical Directors 
Specific and Related Functions  of Medical Directors  Should Perform 
Review and revise existing medical and clinical  90%  97% 
policies 
Encourage quality of care, regardless of patient case  88%  92% 
mix 
Review and analyze quality indicators for potential  86%  91% 
areas of concern 
Quality improvement planning, implementing, and/or  84%  93% 
follow-up 
Development of medical care policies and  81%  92% 
procedures 
Confirm patients problems identified by unit nurses  73%  83% 
are adequately addressed 
Serve as patients medical advocate  64%  81% 
Source: OIG survey responses from nursing home medical directors 
Most specific to medical directors, as specified by both regulation and the CMS Interpretive 
Guidelines, is a charge to implement resident care policies and coordinate medical care in the 
facility. One of the functions specifically required of medical directors is reviewing and 
revising existing medical and clinical policies. At 90 percent, it is also the function in this 
category that most responding medical directors reported as expected by the nursing homes. 
Examples of such medical and clinical policies are procedures for how staff should handle 
patient accidents or when the use of restraints is appropriate. While not all medical directors 
report that their nursing homes expect them to review and revise existing medical and clinical 
policies, 97 percent report that it should be their responsibility. Additionally, 70 percent report 
that reviewing and revising existing care policies or developing them is important to their 
leadership role. 
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Nursing Home Medical Directors  7  OEI-06-99-00300  Encouraging quality of care, regardless of the patient case mix, is reported by 88 percent 
of medical directors as expected by the nursing home and by 92 percent as important to their 
role.  This means that overall decisions related to patients' health-care needs should be 
determined fairly and equally, regardless of the severity of illness and the resultant services. 
This function is closely followed by others specifically related to general quality improvements. 
Examples of these other functions include medical directors conducting chart reviews on an 
ongoing basis, reviewing status reports from staff, conducting patient rounds, and attending 
quality assurance and improvement meetings monthly. 
After the general quality improvement functions, responding medical directors report less often 
being expected by the nursing homes to perform quality functions that are more centered on the 
individual patient  patients problems identified by unit nurses are adequately addressed 
(73 percent) and serving as the patients medical advocate (64 percent). The latter refers to 
ensuring that the patients medical care needs are adequately addressed, even if the facility has 
concerns about the potential cost of such care. However, a mean of 82 percent of medical 
directors report that these are functions which should be their responsibility. 
Eighty-seven percent of medical directors report that they participate on nursing 
home committees for improving patient care 
In addition to the specific quality improvement functions assigned to them, 87 percent of 
responding medical directors report that they fulfil the facilitys expectation to have a physician 
on the facilitys Quality Improvement Committee.  These medical directors meet at least 
quarterly with the committee; 3 percent report never attending. Eighty-five percent of medical 
directors report their nursing homes have Quality Improvement Committees which generally 
meet quarterly or more often.  Established for ongoing quality improvement, these committees 
are comprised of different disciplines, which may include the medical director. The committees 
identify patient care issues which should be addressed and those requiring preventive measures, 
and they identify possible medical- care policies needing development. 
Patient Services 
Professional interactions with attending physicians, nursing staff and consultant 
pharmacists on concerns with patient care are often expected of medical directors 
by the nursing homes and are viewed as important to patient services 
For responding medical directors, patient services present many opportunities for leadership by 
directly influencing the provision of quality patient care. Given that they are charged by 42 
CFR 483.75(i)(2)(ii) to coordinate medical care in the facility, responding medical directors 
report that application of geriatric principles (96 percent) 
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Nursing Home Medical Directors  8  OEI-06-99-00300  and patient care and consultation (92 percent) are important aspects of a medical director's 
leadership responsibility. In addition, 91 percent of responding medical directors indicate that 
they have a leadership responsibility to monitor attending physician performance. 
In that vein, intervening with attending physicians about patient care concerns, at 92 
percent, is the most frequently mentioned patient service expected of responding medical 
directors by the nursing homes; 97 percent of responding medical directors echo its importance 
by reporting that it should be their responsibility. Further, 68 percent report having nursing 
home responsibility to monitor for appropriate patient care by attending physicians, and 85 
percent report that they should have this responsibility from their nursing homes.  Although 
medical directors and nursing homes do not have direct regulatory responsibility for the 
performance of attending physicians, medical directors may influence an attending physicians 
delivery of medical care.  Reflecting this potential opportunity, 69 percent of medical directors 
report they have at least moderate influence upon the quality of medical care provided by 
attending physicians in their nursing homes; 54 percent of responding attending physicians 
report that medical directors have at least minor influence on their performance. 
Table 2: Patient Services Functions Most Frequently Identified by Medical Directors 
Nursing Homes Expect of  Medical Directors 
Specific and Related Functions  Medical Directors  Should Perform 
Intervene with attending physician when concerns are  92%  97% 
raised about his/her patient's care 
Review consultant pharmacists drug regimen reports  90%  93% 
Interact with Nurses: 
Provide ongoing medical advice and guidance to  86%  94% 
nurses  78%  88% 
Meet routinely with nurses to discuss patient care 
issues 
Perform attending physician duties  72%  83% 
Participate in the planning of patient care by ensuring the  69%  83% 
appropriateness of services and treatments 
Monitor for appropriate patient care by attending  68%  85% 
physicians 
Source: OIG survey responses from nursing home medical directors 
Ninety percent of responding medical directors are expected by their nursing homes to review 
drug regimen reports, in their role as medical director.  This expectation is in keeping with the 
Interpretative Guidelines, Tag F429, which encourages facilities to share consultant 
pharmacists drug reviews with their medical directors. These reviews identify concerns about 
medications ordered for a patients' diagnoses and possible problems, such as drug interactions 
or the need for dosage adjustments.  Regulations require that drug reviews occur monthly for all 
patients, and for consultant pharmacists to report any irregularities to the attending physician 
and the director of nursing. 
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Nursing Home Medical Directors  9  OEI-06-99-00300  Regulations do not require any direct involvement between medical directors and consultant 
pharmacists. However, 65 percent of medical directors report meeting with consultant 
pharmacists quarterly. 
Interacting with nurses on patient care and providing on-going medical advice are also 
reported by responding medical directors as functions expected of them by the nursing homes. 
Ninety-seven percent of responding directors of nursing indicate that they routinely have 
conversations with their medical directors, typically about patient care issues (94 percent) and 
problem patients (91 percent).  Such interactions may provide opportunities for medical 
directors to influence the quality of patient care throughout the nursing home, such as the need 
for a change in a patient's medications, or concern that a patient's symptoms are not typical of 
an identified diagnosis. 
Residents Rights 
Sixty to sixty-nine percent of responding medical directors report that ensuring 
residents rights, such as appropriate drug regimens, honoring end-of-life 
decisions, and ensuring treatment choices, is expected of them by the nursing 
homes 
The OBRA 1987 created a bill of rights for nursing home residents,16 which expands the 
individual rights they have outside nursing homes, e.g., privacy, religion, and speech, to include 
activities which may occur in the nursing home. These include such rights as having privacy, 
receiving appropriate medications, refusing treatment, and being consulted about their own 
care. Regulations for OBRA 1987 are intended to ensure that nursing home staff and 
physicians actively recognize the cognitive patient's autonomy and all patients' right to continued 
dignity.17 
Ninety-six percent of responding medical directors report that the promotion of residents' rights 
is an expected leadership role for them. Yet, of the four broad categories of functions that 
medical directors cited, ensuring residents rights are reported less often as expected by the 
nursing homes. Also, the percentage of medical directors concurring that ensuring residents 
rights should be their responsibility is slightly higher compared to what is expected of them by 
the nursing homes (Table 3). 
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Nursing Home Medical Directors  10  OEI-06-99-00300  Table 3: Residents Rights Functions Most Frequently Identified by Medical Directors 
Nursing Homes Expect of  Medical Directors 
Specific and Related Functions  Medical Directors  Should Perform 
Verify appropriateness of a patients drug regimen, 
ensure that drugs are: 
-- appropriately prescribed  69%  80% 
-- necessary 
69%  75% 
Ensure patients' end of life decisions are honored  69%  80% 
Verify appropriate medical response to drug regimen  68%  80% 
review concerns 
Confirm appropriate restraint usage  65%  77% 
Ensure cognitive patients' rights to refuse medications  60%  76% 
Support patients' direct involvement in care planning, if  60%  70% 
mentally able 
Source: OIG survey responses from nursing home medical directors 
The right to an appropriate drug regimen has become more important over the past several 
years. Significant research continues to note concern for the numbers of nursing home patients 
having drug regimens, which included unnecessary and/or inappropriate drugs.18 One major 
result has been the requirement that nursing home patients receive a drug regimen review at 
least once a month by a licensed pharmacist.19 Through record reviews and interactions with 
staff, medical directors can confirm and correct inappropriate restraint of patients for 
discipline or convenience,20 through the use of prescribed medications or physical restraints. 
Consultant pharmacists are required by regulation to report concerns to the attending physician 
and the director of nursing.21 However, there is no regulation or guidance indicating that the 
medical director or attending physician should be the one to respond to a consultant 
pharmacist's concerns or to verify that actions are taken to ensure recommended changes in a 
patient's drug regimen.22 Yet, 68 percent of medical directors report that, in their role as 
medical directors, they are expected by their nursing homes to verify appropriate medical 
response to drug regimen review concerns, and 80 percent agree that they should have this 
responsibility. Additionally, 74 percent of responding medical directors report that they should 
have responsibility to develop indicators for physician quality assurance in drug prescribing; 51 
percent of medical directors indicate that they currently have this responsibility. 
Honoring patients' end of life decisions is as frequently a reported nursing home responsibility 
of the medical director as is their ensuring a patients drug regimen. Few decisions are more 
personally important than when directing what treatments are or are not wanted.  Eighty-nine 
percent of responding medical directors indicate that they 
__________

Nursing Home Medical Directors  11  OEI-06-99-00300  attempt to ensure that facilities have provided patients or their families with specific information 
about end-of-life issues, including the possibility of hospice care. 
Another resident's right discussed directly in nursing home regulations23 is having direct 
involvement in care planning for themselves and to make independent choices, while able.24 
This right is indirectly suggested by other federal laws established to ensure that patients are 
informed about this right.25 Yet again, no regulation clearly indicates which individual is 
responsible. Sixty percent of responding medical directors report that it is expected of them by 
the nursing home, and 70 percent say that it should be their responsibility. 
Administration 
The responding medical directors report that their administrative functions 
include advising on regulatory matters, providing liaison with facility staffs, and 
promoting employee health 
While the regulations are not explicit on the medical director's responsibilities in this category, 
many responding medical directors indicate three administrative functions as important to their 
leadership role: expanding knowledge of regulatory, legal, economic, and social factors 
affecting care (89 percent), participating in education or training for nurses (83 percent), and 
representing the facility in the community (78 percent). 
Responding medical directors also report that they have a role in operational administration 
beyond their involvement in delivery of care and services to patients (Table 4). 
Table 4: Administrative Functions Most Frequently Identified by Medical Directors 
Nursing Homes Expect of  Medical Directors 
Specific and Related Functions  Medical Directors  Should Perform 
Provide medical expertise for facility when necessary to  94%  96% 
respond to regulatory agency survey concerns 
Serve as liaison between medical staff, nursing staff,  84%  88% 
and administration 
Keep current with regulatory and medical treatment  83%  92% 
changes 
Promote employee health  72%  78% 
Source: OIG survey responses from nursing home medical directors 
By providing medical expertise to survey concerns, medical directors may have a role in 
helping the facility anticipate and resolve problems that later may be detected by 
__________ 
Nursing Home Medical Directors  12  OEI-06-99-00300  regulatory agency surveys.26 Typically, about one-half to two-thirds of responding medical 
directors participate in specific aspects of the survey process. For example, 

45 percent report attending exit interviews between the administrator and surveyors. Further,

47 percent assist in writing correction plans for identified survey deficiencies, while 64 percent

report implementing those correction plans.  Fifty-two percent of responding medical directors

report conducting followup activities to ensure implementation of correction activities. 

Acting as a liaison between medical staff, nursing staff, and administration allows medical

directors to ensure assimilation of his/her quality care expectations and to ensure that other

important quality care issues are addressed timely. Staying current with regulatory and

treatment changes aids in the identification of new techniques and medications, techniques

determined to be potentially detrimental, or improved treatments for certain diagnoses. For

example, recent literature indicates that while side rails on patients beds were once acceptable

practices, they are now considered potentially dangerous for strangulation27 and that thyroid

testing may identify a reason for a patients lack of mental clarity.28

Medical Directors Report Some Functions They Are Not Frequently Expected 
To Perform, Nor Do They Often Report They Should; For Others, They Indicate 
A More Diverse Opinion 
Responses from medical directors showed specific functions within three of the four broad 
functional categories, i.e., patient services, residents rights, and administration (includes training 
and physical environment), that are infrequently expected of them by the nursing homes.  For 
some of these specific functions, medical directors also seldom reported they should perform 
them.  For other functions in the broad categories, the frequency at which they report they 
should perform them is higher and indicates a diversity of opinion about what their duties should 
include. 
In general, however, as mentioned earlier, the majority of medical directors have indicated they 
do have an important leadership role related to the general categories of patient services, 
residents rights, and administration.  Examples are : 
C  Patient Services  monitoring attending physician performance (91%) and staffing (79%), 
C  Residents Rights  the promotion of residents' rights (96%), and 
C  Administration  participation in education or training for nurses (83%) and expanding 
knowledge of regulatory, legal, economic, and social factors affecting care (80%) 
__________ 
13 
Nursing Home Medical Directors  OEI-06-99-00300  Infrequently Reported Functions 
Table 5 shows some functions reported by medical directors that are both infrequently 
expected of them by the nursing homes, and infrequently mentioned as those that medical 
directors should perform. These functions fall predominantly into the broad category of patient 
services, with specific functions related to staffing and assuring appropriate care. Ensuring 
adequate lighting, which can protect patients from falls, and food safety under physical 
environment are also infrequently reported, as is the availability of appropriate admission 
records under residents rights. 
Table 5: Functions Infrequently Identified by Medical Directors 
Nursing Homes  Medical Directors 
Specific Functions  Expect of Medical  Should Perform 
Directors 
Patient Services - Staffing 
Ensure sufficient staffing required to meet all patients  9%  27% 
needs 
Ensure sufficient nursing coverage for all shifts  3%  13% 
Ensure sufficient nurse aide coverage for all shifts  3%  11% 
Patient Services - Appropriate Care 
Ensure sufficient, appropriate supplies for each patients  17%  25% 
needs 
Administration - Physical Environment  12%  22% 
Verify facilitys sanitary storage, preparation, and service 
of food 
Confirm facilitys adequate and comfortable lighting 
levels for patients  11%  22% 
Residents Rights 
Ensure at admission availability of patients prior  28%  39% 
medical records and advance directives 
Source: OIG survey responses from nursing home medical directors 
Reported Functions Showing Diversity of Opinion 
Table 6 presents some functions reported by medical directors that may be infrequently 
expected of them by the nursing homes, but are viewed by 40 to 60 percent of them as 
functions that they should perform in their role as medical directors.  Thus, these functions 
indicate some diversity among medical directors responses as to which functions they should 
have responsibility. The functions fall predominantly into the broad categories of patient 
services, with specific functions related to direct patient care and appropriate care, and 
administration, with specific functions related to training and the environment. 
__________ 
14 
Nursing Home Medical Directors  OEI-06-99-00300  Patient Services  Direct Patient Care  Many responding medical directors are not required 
either by regulation or their nursing home to provide direct patient care. In fact, 51 percent or 
less of medical directors reported that nursing homes expected them to be responsible for 
patient services involving direct patient contact, such as conducting patient rounds (51 
percent), managing patients' acute illnesses (50 percent), and participating in patient 
assessments to identify patients' needs (40 percent). However, for each of these functions, a 
higher percent of medical directors responded that they should perform these direct care 
functions. 
Table 6: Medical Directors Responses Indicating Diversity of Opinion 
Nursing Homes  Medical Directors 
Specific Functions  Expect of Medical  Should Perform 
Directors 
Patient Services  Direct Care 
Perform patient rounds, which include direct contact  51%  62% 
with patients 
Actively treat or supervise the treatment of patients  50%  54% 
acute illnesses 
Perform comprehensive patient assessments  40%  48% 
Patient Services  Appropriate Care 
Monitor care performed by nurse aides  33%  46% 
Develop performance indicators for attending  31%  60% 
physicians 
Lead or chair the development of patient healthcare  27%  47% 
plans for all patients 
Meet routinely with nurse aides to discuss patient care  24%  40% 
Administration (Training) 
Teach attending physicians about state and federal  38%  57% 
regulations 
Educate healthcare staff on new policies and  37%  51% 
procedures 
Promote training related to all staffs functional  36%  45% 
requirements 
Administration (Environment) 
Promote a hazard-free environment  32%  46% 
Source: OIG survey responses from nursing home medical directors 
Even if medical directors are expected by the nursing home to be responsible for certain patient 
services, existing nursing home policies and procedures typically do not call for their direct 
involvement.  For example, 98 percent of medical directors report the standard procedure for 
managing patients acute illnesses is to directly notify the patients attending physician first. It 
appears that typically the primary attending physician is notified and the medical director may 
be informed. However, if unable to reach the primary physician, the medical director is called 
for consultation.  Also, if an emergency should occur, at the discretion of the nursing staff, the 
patient is transferred immediately to the emergency room for evaluation. Ninety-three percent 
of responding administrators report that it is not a facility policy for the nursing staff or 
__________ 
15 
Nursing Home Medical Directors  OEI-06-99-00300  administration staff to consult with the medical director prior to patient transfers.  According to 
68 percent of the medical directors, the primary deciding factor is whether there are physicians 
orders for the transfer. 
Patient Care - Appropriate Services Forty to 60 percent of responding medical directors 
report that they should perform functions to ensure appropriate patient care.  At the same time, 
medical directors infrequently report a nursing homes expectation for ensuring appropriate care 
through monitoring or oversight of staff interacting directly with patients. Examples are 
developing performance indicators for attending physicians (31 percent), monitoring for 
appropriate care by nurse aides (33 percent) and meeting routinely with nurse aides to discuss 
patient care (24%).29 Leading the development of patient health-care plans for all patients 
(27%) is also a function infrequently expected of medical directors by the nursing homes. 
Administration - Training  While 45 to 57 percent of medical directors indicate that they 
should provide training on various topics to attending physicians or nursing home staff, at 36 
percent to 38 percent, they less often report that their nursing homes expect them to provide 
this training.  However, 50 percent of them believe that their administrators encourage them to 
provide in-service training or education to nursing staff.  At the time of our survey, 46 percent 
of the medical directors report that nurses receive little training beyond that related to negative 
medication reactions to observe and report. Fewer medical directors report training nurses in 
important care areas, such as abuse definitions and reporting requirements (20 percent), 
residents' rights (26 percent), rehabilitation principles and therapies (31 percent), restraints (38 
percent), and providing care for patients at the end-of-life (40 percent). 
Eighty-Six Percent Of Responding Medical Directors Report Spending 
8 Hours Or Less Per Week At The Sampled Facilities 
Facility Visits and Hours  For each sampled facility, most responding medical directors 
report that, in their medical director capacity, they devote a portion of their professional time to 
the facility. Table 7 indicates how often medical directors report visiting the facility and the 
number of hours they report spending there weekly.  For example, 62 percent of responding 
medical directors visit the facility 1 time per week or less often. Eighty-six percent spend 8 
hours or less per week at the sampled facility. The amount of time spent on their nursing home 
role may allow them to complete work already scheduled and for which they are held directly 
accountable, such as certain paperwork related to patient care or participation in committees. 
Other Professional Obligations  Seventy percent of responding medical directors report that 
less than 10 percent of their overall medical practice is devoted to their medical director role. 
Many medical directors balance their professional time at the facility with their other medical 
practice obligations inside or outside the nursing home. For example, 
__________ 
16 
Nursing Home Medical Directors  OEI-06-99-00300  54 percent of medical directors report serving as an attending physician in the same facility 
where they serve as medical director. As attending physicians, these 
Table 7: Time Medical Directors Devote to their Nursing Home Functions 
Activity as Medical Director  Percent Responding 
How often they visit the facility: 
daily  7% 
2 to 3 times weekly  23% 
1 time weekly  34% 
1 time every 2 weeks  10% 
1 time monthly  11% 
1 time every 2 months  7% 
variable schedule  9% 
Number of hours per week they spend in the facility: 
less than 1 to 4 hours  72% 
5 to 8 hours  14% 
9 to more than 15 hours  14% 
Part of their overall medical practice devoted to their 
medical director role: 
1 to 10 percent  70% 
11 to 33 percent 
23% 
more than 33 percent 
7% 
Source: OIG survey responses from nursing home medical directors 
medical directors report having an average of 47 patients in the nursing homes where they also 
serve as medical directors. Eighty-one percent of responding medical directors also report that 
they maintain a private practice outside the nursing facility, 54 percent report serving as a 
medical director for another facility, and 53 percent report serving as attending physician at 
another nursing home. They may also serve as a medical director at facilities other than nursing 
homes (21 percent) or teach in a college or university (20 percent). 
Although not frequently present in the nursing home, medical directors may 
communicate with nursing staff by telephone 
Telephone calls may serve as a primary method of communication between medical directors 
and nursing staff. Sixty-two percent of responding medical directors, 57 percent of attending 
physicians, and 82 percent of directors of nursing report not working evenings or weekends. 
For those times they are not in the facility, policies exist requiring their notification or attempted 
notification prior to certain medical decisions concerning patients.  As a result, the nursing staff 
and nurse aides must monitor the care of patients during such times, and the nurses are 
expected to telephone the medical directors, attending physicians, and directors of nursing to 
notify them regarding necessary medical care. Research supports that much of the medical care 
delivered in nursing homes occurs as a result of telephone calls, except for the regulatory need 
for 60-day certification of 
__________ 
17 
Nursing Home Medical Directors  OEI-06-99-00300  medical necessity. These calls serve as a method for managing communication between the 
staff, the physicians, and the directors of nursing.30 
Responding Medical Directors Report That They Are Professionally Trained 
License To Practice  While not required to be licensed, 92 percent of responding medical 
directors self-report that they are licensed as medical practitioners in their states.  Regulations 
require medical directors to be physicians who will implement care policies and coordinate 
medical care in the facility. 
Medical Training and Experience  All medical directors report that they have professional 
medical training. Consistent with other studies, medical directors report they typically come 
from a professional background of family practice (44 percent) or internal medicine (47 
percent), both considered helpful for their role.31 Of those who do not primarily specialize in 
either family practice or internal medicine, the majority of medical directors report receiving 
medical school residency training in internal medicine (30 percent) or family practice (24 
percent). Few responding medical directors report specialization in caring for elderly patients, 
as such is not provided in most medical schools. However, 22 percent report that they 
specialized in geriatrics in medical school, 30 percent report having a certificate of added 
qualifications in geriatrics, and 4 percent report completing a geriatric fellowship. 
Continuing Education Forty-eight percent of medical directors report that they complete 
continuing medical education credits yearly relating to geriatrics, gerontology, or long term care, 
but few indicate hours of clinical training in a long-term care setting or in geriatrics.  However, 
39 percent of medical directors report having membership in their state-affiliated American 
Medical Director Association (AMDA), and 25 percent indicate that they are currently certified 
or have been recertified through AMDA's medical director training program. Two percent of 
respondents indicate that they are currently working towards certification through AMDA, and 
3 percent were formerly certified by AMDA, but report that their certification has lapsed. 
__________ 
18 
Nursing Home Medical Directors  OEI-06-99-00300  S U M M A R Y  
This report identifies the functions for which 119 responding medical directors in 7 purposively-sampled 
states report as being expected of them by the nursing homes.  The responding medical directors also 
identified those functions for which they report they should have responsibility.  Identified functions fall 
within four categories: quality improvement, patient services, residents rights, and administration. 
These functions relate directly to their regulatory responsibility for implementation of resident care 
policies and coordination of medical services in the facility. The reported functions clearly indicate a 
physician-related role for them.  In fact, while regulations do not specify that medical directors should 
be licensed to practice, they are required to be physicians. 
Beyond the few functions within each of the four categories, for which 80 to 94 percent of the 
responding medical directors report are expected by the sampled nursing homes (Appendix C), there 
are many more functions less frequently reported by medical directors.  These are functions medical 
directors report that they are not expected to perform, nor do they report that they should; for others, 
they indicate a diversity of opinion. Thus, much of what medical directors are expected to do by the 
nursing homes begins to vary markedly. Responding medical directors (86 percent) also report 
spending 8 hours or less per week performing the responsibilities expected of them. 
The CMS routinely works directly with representatives of the nursing home industry, patient advocacy 
organizations, and physician-related associations. We believe that CMS will find the presented 
information useful as it continues to work with them in establishing, clarifying, and enhancing the medical 
directors role. 
__________ 
19 
Nursing Home Medical Directors  OEI-06-99-00300 E N D N O T E S  
1.  Public Law 100-203 passed by Congress on December 22, 1987. 
2.  Interpretative Guidelines, deficiency Tag F501, 42 CFR 483.75(i)-(ii). 
3.  42 CFR 483.75(i)(1). 
4.	 Attending physicians have no routine visit requirement, except as needed for continued 
certification for Medicare or Medicaid payment.  The medical directors themselves appear to 
agree to some extent on the functions that they indicate are expected of them by the nursing 
homes and for which they also report believing that they should have responsibility.  What 
constitutes a visit is largely undefined by any policy. 
5.	 Interpretative Guidelines, deficiency Tag F429, 42 CFR 483.60, Pharmacy services, and by 
42 CFR 483.75(i)(2)(ii) stating that the medical director has responsibility for coordination of 
medical care. 
6.  Interpretative Guidelines, deficiency Tag F501, 42 CFR 483.75(i)-(ii). 
7.  Interpretative Guidelines, deficiency Tag F501, 42 CFR 483.75(i) guidelines, PP-192. 
8.  Interpretative Guidelines, deficiency Tag F520, 42 CFR 483.75(o). 
9.  Reports on nursing home issues by GAO include: 
C  Nursing Homes - Many Shortcomings Exist in Efforts to Protect Residents from 
Abuse (GAO-02-448T); 
C  Health and Human Services - Status of Achieving Key Outcomes and Addressing 
Major Management Challenges (GAO-01-7489); 
C  Long Term Care - Implications of Supreme Courts Olmstead Decision are Still 
Unfolding (GAO-01-1167T); 
C  Nursing Workforce - Recruitment and Retention of Nurses and Nurse Aides is a 
Growing Concern(GAO-01-750T); 
C  Major Management Challenges and Program Risks (GAO-01-247); 
C  Nursing Homes - Success of Quality Initiatives Requires Sustained Federal and 
State Commitment (GAO/T/HEHS-00-209); 
C  Nursing Homes - Sustained Efforts are Essential to Realize Potential of the Quality 
Incentives (GAO/HEHS-00-197); 
C  Nursing Homes - Enhanced HCFA Oversight of State Programs Would Better 
Ensure Quality Care (GAO/T/HEHS-00-27); 
C  Nursing Home Care - Enhanced HCFA Oversight of State Programs Would Better 
Ensure Quality (GAO/HEHS-00-06); and 
C  Nursing Homes - Proposal to Enhance Oversight of Poorly Performing Homes has 
Merit (GAO/HEHS-99-157). 
__________ 
20 
Nursing Home Medical Directors  OEI-06-99-00300 10.  These organizations included: 
C  the American Medical Directors Association (AMDA), the principal professional 
organization for medical directors, 
C	 the American Association of Homes and Services for the Aging (AAHSA) and the 
American Health Care Association (AHCA), the primary nursing home industry 
associations, 
C  the American Society of Consultant Pharmacists, 

C  the National Association of Directors of Nursing Administration in Long Term Care,

C  the National Citizens Coalition for Nursing Home Reform (NCCNHR),

C  the Gerontological Society of America, and 

C  the American Geriatrics Society. 

11.	 Centers for Medicare & Medicaid Studies, AAHSA, AHCA, and NCCNHR each provided input 
for sample state selection. 
12.	 Medical directors are positioned in many environments, nursing homes being but one.  The 
environment is a specific determinant of how that individual may perform his or her 
responsibilities.  For example, a hospitals medical director may be a physician working full-time 
for the hospital, allowing more ease of access to his/her services.  The hospital-based nursing 
home may also have more ready access to physicians providing care to their patients in the 
hospital than the nursing homes may have in the availability of physicians willing to provide care to 
patients in nursing homes. 
13.	 Initially, received surveys were reviewed to ensure that each was either completely answered or 
that specific questions were minimally completed (tables beginning each section and questions 
related to possible barriers).  If neither was the case, the survey was considered a non-response. 
14.	 In the survey instruments themselves, the phrase required by the nursing home is used to clarify 
expectations of medical directors.  However, in reporting these findings, we will use the phrase 
expected by the nursing home.  This will more easily allow differentiation between those 
functions expected by the nursing home versus functions required by federal regulation. 
15.	 We attempted to match non-responding medical directors with the unique physician identifier 
number (UPIN) database, which maintains selected information on registered physicians, 
including their specialties and graduate date from medical school.  Our match rate based on the 
non-responding medical directors was too low for making any valid determinations. 
16.  42 CFR 483.25. 
17.	 Residents' rights queried in this inspection included appropriate restraint usage; honoring 
end-of-life decisions; patients' rights to refuse medications; patients' utilization of kitchen; patients' 
self-selection of attending physicians; patients' involvement in care planning; patients having drug 
regimens free from unnecessary and inappropriately prescribed drugs; and existing policy meeting 
drug withdrawal guidelines. 
18.  American Society of Consultant Pharmacists. 
19.	 42 CFR 483.60(c)(1) requires a licensed pharmacist to review each patient's drug regimen at 
least monthly with more frequent reviews, as necessitated by the patient's condition and drug 
regimen. 
__________ 
21 
Nursing Home Medical Directors  OEI-06-99-00300  20.  42 CFR 483.25(1)(1), 42 CFR 483.13(a). 
21.  42 CFR 483.60(c)(2). 
22.  Interpretative Guidelines, deficiency Tag F430. 
23.  42 CFR 483.10(b)(4). 
24.  42 CFR 483.10(d)(2)-(3). 
25.	 The Patient Self Determination Act of 1990 requires all institutions receiving either Medicare or 
Medicaid funding to inform patients of their right to accept or refuse medical treatment through an 
advance directive.  Further, the Balanced Budget Act of 1997 requires that such advance 
directives be placed in a prominent place within the individual's medical record. 
26.	 Nursing facility performance is monitored through regulatory state and federal surveys, as well as 
ad hoc investigations addressing specific patient concerns, which may occur over time. 
27.	 Food and Drug Administration, Center for Devices and Radiological Health, FDA Safety Alert: 
Entrapment Hazards with Hospital Bed Side Rails, August 1995.  Available on internet at 
http://www.fda.gov/cdrh/bedrails.html.  Parker, K, Miles SO, Deaths Caused by Bed rails, 
Journal of the American Geriatric Society, 1997; 45:797-802. 
28.	 Myers, Wayne A., M.D., New Techniques in the Psychotherapy of Older Patients, 1991, and 
American Psychiatric Association, Mental Health of the Elderly, Public Information Internet 
site, Revision June 1992. 
29.	 Nine percent of directors of nursing report that medical directors meet with nurse aides and that 
such meetings occur quarterly.  Fully 70 percent of medical directors and 91 percent of directors 
of nursing report no meetings between medical directors and nurse aides, except as necessary. 
30.	 W. Fowkes, D. Christenson, D. McKay, An analysis of the use of the telephone in the 
management of patients in skilled nursing facilities,  Journal of American Geriatric Society 
1997; 45 (1):67-70.  The result of this research is a recommendation that voice mail is a primary 
tool for managing the communication between nursing staff and physicians. 
31.	 Levinson, Monte J., MD, CMD and Jonathan Musher, MD, CMD, Current role of the medical 
director in community-based nursing facilities, Clinics in Geriatric Medicine 1995 Aug; 11 
(3):343-358. 
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22 
Nursing Home Medical Directors  OEI-06-99-00300  APPENDIX  A 
SUMMARY OF PHYSICIAN-RELATED SURVEY 
AND CERTIFICATION NURSING HOME REGULATIONS (1) 
General Purpose of  Code of  Centers 
Regulation(2)  Federal  for  Intent of Regulation for Physicians 
Physicians should Ensure  Regulations  Medicare &  (Attending or Medical Director) 
Medicaid 
for Patients and Facility  (42 CFR 
Services 
Citation) 
Deficiency 
Tags 
Resident Rights  Lays the foundation for residents rights 
Right to a Dignified Existence  483.10  150  requirements and ensures promotion of the 
exercise of these rights by patients. 
Right to be Informed  154 
(understandability related to the 
patients needs) 
Right to Refuse Treatment 
155 
Right to be Informed concerning 
156 
costs, legal rights, and name, 
speciality, and way of contacting the 
physician responsible for his/her care 
Right to Choose attending physician  163 
Participate in Planning Care and 
Treatment (and changes)  483.13  280 
Right to Self-Administer Drugs  176 
Right to be Free from Restraints  221, 222 
Right to be Free from Abuse  223 
Staff Treatment of Residents  224 
Monitor physician participation in assessment 
and care planning, particularly as related to the 
Resident Assessment and  483.20(b)(1)- state-specified Resident Assessment Instrument, 
Comprehensive Care Plans,  483.20(b)(2)(i 272-280,  including both the Minimum Data Set and the 
including Review and Frequency  xiii),  285  utilization guidelines with Resident Assessment 
Protocols. This includes ensuring that the 
483.20(b)(4) 
assessment is accurate and reflects the patients 
current status, to ensure each assessment is 
prepared by those qualified to assess care based on 
knowledge about the patients status and needs. 
Monitor and ensure that patients receive, from 
the facility, the necessary care and services to 
attain or maintain their highest practical physical, 
mental, and psychosocial well-being, in 
accordance with the comprehensive assessment 
and plan of care. This includes ensuring each 
Quality of Care 
483.25  309-331  patients activities for daily living do not 
deteriorate, unless such deterioration was 
unavoidable. These treatments and services are 
any provided by employees, contractors, or 
volunteers, particularly those services related to 
pain control, use of special communication 
systems, vision and hearing, pressure sores, 
urinary incontinence, range of motion, mental 
and psychosocial functioning, special eating 
requirements, accidents, nutrition, hydration, any 
special needs, and unnecessary drugs. 
__________ 
23 
Nursing Home Medical Directors  OEI-06-99-00300  General Purpose of  Code of  Centers 
Regulation(2)  Federal  for  Intent of Regulation for Physicians 
Physicians should Ensure  Regulations  Medicare &  (Attending or Medical Director) 
Medicaid 
for Patients and Facility  (42 CFR 
Services 
Citation) 
Deficiency 
Tags 
Ensure that each patient has a review at least 
Drug Regimen Review  483.6  428  monthly by a licenced pharmacist with the 
understanding that the review may have to occur 
more frequently, depending on the patients 
condition and drugs prescribed. 
Ensure that a facility infection-control program 
Infection Control  483.65  441  effectively investigates, controls, and prevents 
infections. 
Relates to 483.60  4.29502e+11  Encourages the facility to share pharmacists drug 
regimen review reports with the medical director. 
Implement resident care policies regarding 
admissions, transfers and discharges, physician 
483.75 
privileges and practices, and responsibilities of 
483.75(i) 
non-physician health-care workers. Implement 
resident care policies regarding accidents and 
Medical Director 
incidents; ancillary services, such as laboratory, 
radiology, and pharmacy; use of medications; use 
and release of clinical information; and overall 
quality of care. Ensure establishment and 
implementation of all resident care policies, and 
ensure that the nursing home is providing 
appropriate care as required by monitoring and 
implementing policies for care, and 
oversight, supervision as related to overseeing the 
483.75(i)(2)(i)  overall clinical care of patients to ensure adequacy 
of patient care services. 
The medical director may be the designated 
483.75(o) 
physician serving on this committee. 
Ensure accurate, complete, and organized clinical 
Clinical Records  483.75(l)  514  information concerning each patient and ready 
access to such information. To ensure safety and 
confidentiality of patient records. 
Ensure the establishment of quality assurance 
Quality Assessment  483.75(o)  520  committees to identify and address quality issues 
and Assurance  and to implement quality improvement/corrective 
action plans as necessary. 
(1)  These regulations, interpretive deficiency tags, and intent of the regulations are excerpted and interpreted for this study 
as being services for medical directors and attending physicians. Source: CMS State Operations Manual . 
(2)  Federally certified nursing homes, including skilled, are required to be in compliance with the requirements set at Title 
42, Code of Federal Regulations (CFR) Part 483, Subpart B, to receive payment under the Medicare and Medicaid 
programs. This certification requires a minimum of a life safety code survey and a standard survey conducted onsite at 
the facilities by federal or state survey teams. 
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24 
Nursing Home Medical Directors  OEI-06-99-00300  APPENDIX B 
SEVEN SAMPLE STATES - SELECTED INFORMATION(1), (2) 
1999  1999 Nursing 
Certified  Home Beds as  Certified 
NFs(3) as %  % of Total  Beds as  Av Beds  Medicare/  Medicaid  Medicaid 
States  of Total  State  % of  per  Medicaid  Expenditures  Medical Vendor 
Certified  Medicare/  Total  Nursing  Recipients  Institutional  Expenditures in 
NFs  Medicaid  Certified  Home  in NFs  LTC(1)  NFs(1) 
Recipients(4)  Beds 
CA  1,390  132,962  7.4  96  79,099  $2,530,105,425  $2,097,872,885 
(8.1)  (59.5) 
ME  125  8,393  0.5  67  6,182  $263,089,445  $181,220,851 
(0.7)  (73.7) 
NY  659  118,656(5)  6.6  180  96,114  $7,377,851,374  $4,906,873,789 
(3.9)  (81.0) 
OH  1,007  104,817  5.8  104  62,048  $2,065,785,756  $1,569,723,823 
(5.9)  (59.2) 
SD  114  7,938  0.4  70  4,767  $126,339,319  $97,951,839 
(0.7)  (60.1) 
TN  352  39,275  2.2  112  29,418  $829,152,516  $619,886,256 
(2.1)  (74.9) 
TX  1,254  125,904  7.0  100  71,064  $1,852,938,381  $1,270,530,921 
(7.3)  (56.4) 
State 
Total  4,901  537,945  29.9  104  348,692  $15,045,262,21  $10,744,060,364 
6 
U.S. 
Total  17,083  1,807,285  106  1,140,996  $40,799,455,37  $29,629,741,643 
4 
% U.S. 
Total  28.70%  29.77%  98%  30.56%  36.88%  36.26% 
(1)  Health Care Financing Review, Medicare and Medicaid Statistical Supplement, 1998, Pub. No. 03409, December 
1998. 
(2)  Across the States 2000, Profiles of Long Term Care Systems, Policy Institute, American Association of Retired Persons, 
Fourth Edition. 
(3)  Starting in fiscal year 1991, the distinction between intermediate and skilled nursing homes was eliminated; conditions 
of participation for both were unified with the services being renamed nursing facility (NF) services (e.g., nursing facilities now 
include both intermediate and skilled nursing homes). 
(4)  Percentage indicated followed in parentheses by state population in thousands. 
(5)  New York has no Medicare-only certified nursing homes. 
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25 
Nursing Home Medical Directors  OEI-06-99-00300  APPENDIX C 
Medical Directors Self-reported Functions 
Nursing Home  Medical  Medical Director 
EXPECTS OR  Director  has 
FUNCTIONS 
REQUIRES  SHOULD  AUTHORITY TO 
of Medical Director  PERFORM  PERFORM 
Percent of medical directors indicating Yes 
QUALITY ASSURANCE AND QUALITY IMPROVEMENT 
Review and revise existing medical and clinical policies  90  97  95 
Encourage quality of care irrespective of the case mix  88  92  90 
Review and analyze quality indicators for potential areas of  86  91  90 
concern 
Quality improvement planning, implementing, and/or follow-up  84  93  88 
Development of medical care policies and procedures  81  92  89 
Confirm that patient problems identified by unit nurses are  73  83  83 
adequately addressed 
Serve as patients medical advocate  64  81  78 
Monitor for adequate documentation of health care by any  60  77  75 
provider 
Develop indicators for physician quality assurance in drug  51  74  66 
prescribing 
Write and implement patient health maintenance policies  51  70  67 
Monitor for appropriate patient care by nurses (RNs, LVNs,  50  68  65 
LPNs, PNs) 
Monitor for appropriate patient care by nurse aides  33  46  47 
Balance a patients needs with financial and administrative  33  41  42 
constraints of the facility 
Develop performance indicators for attending physicians  31  60  57 
INDIVIDUAL RESIDENTS RIGHTS 
Ensure that patients end-of-life decisions are honored  69  80  79 
Verify patients have a drug regimen free from inappropriately  69  80  75 
prescribed drugs 
Verify patients have a drug regimen free from unnecessary  69  75  74 
drugs 
Verify appropriate medical response to drug regimen review  68  80  75 
concerns 
Confirm appropriate restraint usage  65  77  79 
Verify existing policy meeting COBRA drug withdrawal  65  76  74 
guidelines 
Ensure cognitive patients rights to refuse medications  60  76  74 
Support patients direct involvement in care planning, if  60  70  70 
mentally able 
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26 
Nursing Home Medical Directors  OEI-06-99-00300  Nursing Home  Medical  Medical Director 
EXPECTS OR  Director  has 
FUNCTIONS 
REQUIRES  SHOULD  AUTHORITY TO 
of Medical Director  PERFORM  PERFORM 
Percent of medical directors indicating Yes 
60  64  65 
Secure opportunity for patients self-selection of attending 
physicians 
Provide opportunity for patients to utilize the kitchen during  10  9  12 
evening hours, if able 
PATIENT SERVICES 
Intervene with an attending physician when concerns are  92  97  93 
raised about that physicians patient care 
Review reports of consultant pharmacists drug regimen  90  93  94 
reviews 
Provide ongoing medical advice and guidance to nurses  86  94  89 
(RNs, LVNs, LPNs, PNs) 
Meet routinely with nurses to discuss patient care issues  78  88  84 
Perform attending physician duties  72  83  91 
Mediate differences or inappropriate conduct between  72  86  80 
providers 
Monitor the availability of attending physician services  72  85  84 
Participate in the planning of patient care by ensuring the  69  83  78 
appropriateness of services and treatments 
Monitor for appropriate patient care by attending physicians  68  85  79 
Monitor for appropriate consultant pharmacist performance  66  84  74 
Monitor the availability of any consultant services  64  74  72 
Serve as member of interdisciplinary team and participate in  61  66  78 
most or all meetings 
Interact directly with attending physicians concerning patient
 61  78  76 
care provided by nurse practitioners and physician

assistants

Verify qualifications of attending physicians  54  74  62 
Ensure appropriate care of patients by nurse practitioners  54  73  65 
and physician assistants 
Perform patient rounds, which include direct contact with  51  62  73 
patients 
Actively treat or supervise treatment of patients acute  50  54  74 
illnesses 
Monitor patient charts for appropriate attending physician  49  70  63 
documentation 
Interact directly with patients families concerning patients  48  55  69 
care needs 
Monitor patient care provided by nurse practitioners and  50  67  65 
physician assistants 
Verify qualifications of any consultants  43  68  54 
Perform comprehensive patient assessments  40  48  63 
Refer patients for nursing home admission  31  42  57 
Ensure that, upon admission, patients prior medical records  28  39  46 
and advance directives are available 
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27 
Nursing Home Medical Directors  OEI-06-99-00300  Nursing Home  Medical  Medical Director 
EXPECTS OR  Director  has 
FUNCTIONS 
REQUIRES  SHOULD  AUTHORITY TO 
of Medical Director  PERFORM  PERFORM 
Percent of medical directors indicating Yes 
Lead or chair the development of medical interdisciplinary  27  47  47 
health-care plans for all patients 
Meet routinely with nurse aides to discuss patient care  24  40  48 
issues 
Ensure sufficient and appropriate supplies per patient needs  17  25  21 
Ensure sufficient staffing as required to meet patients needs  9  27  10 
Ensure sufficient nurse coverage (RNs, LVNs, LPNs, and  3  13  3 
PNs) per shift 
Ensure sufficient nurse aide coverage per shift  3  11  4 
ADMINISTRATION AND MANAGEMENT 
Provide medical expertise for facility when necessary to  94  96  96 
respond to regulatory agency survey concerns 
Liaison between medical staff, nursing staff, and  84  88  89 
administration 
Keep current with regulatory and medical treatment changes  83  92  86 
Promote employee health  72  78  75 
Liaison between patients/their families and the medical staff,  49  62  68 
nursing staff, and administration 
Develop and strengthen community relations  46  52  54 
Recruit attending physicians  27  40  42 
Participation in facility budget process  7  18  12 
TRAINING AND EDUCATION 
Train or coordinate training for nursing staff to provide  54  68  70 
physicians appropriate and necessary patient medical 
information 
Teach nursing staff, including aides, that certain drugs are  53  71  70 
inappropriate for elderly patients 
Teach attending physicians about state and federal  38  57  56 
regulations 
Educate health-care staff on new policies and procedures  37  51  55 
Promote on-going training of medical and non-medical staff  36  45  46 
related to their functional requirements 
Provide training on health-care ethics  34  50  59 
Teach nursing staff, including aides, about state and federal  28  38  42 
regulations 
Teach the aging process to direct care staff, other than  25  42  51 
nursing staff (e.g., social worker, dietitian, etc.) 
Provide training to community regarding nursing home  22  35  44 
services, possible care choices, and patients rights 
ENSURING A SAFE PHYSICAL ENVIRONMENT 
Promote a hazard-free resident environment  32  46  40 
Ensure occurrence of emergency evacuation and safety  21  26  29 
drills 
Promote noise control  18  33  28 
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28 
Nursing Home Medical Directors  OEI-06-99-00300  Nursing Home  Medical  Medical Director 
EXPECTS OR  Director  has 
FUNCTIONS 
REQUIRES  SHOULD  AUTHORITY TO 
of Medical Director  PERFORM  PERFORM 
Percent of medical directors indicating Yes 
12  22  26 
Verify facilitys sanitary storage, preparation, and service of 
food 
Confirm facilitys adequate and comfortable lighting levels for  11  22  25 
patients 
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29 
Nursing Home Medical Directors  OEI-06-99-00300  A C K N O W L E D G M E N T S
The OEI Region VI office prepared this report under the direction of Judith V. Tyler,
Regional Inspector General.  Principal OEI staff included:
Dallas Headquarters
Leah K. Bostick, Project Leader Sandy Khoury, Program Analyst
Marnette Dhooghe, Program Analyst
Clark Thomas, Program Analyst
Scott Whitaker, Program Analyst
Nancy Watts, Administrative Officer
Lisa White, Administrative Officer
For information or copies of this report, please contact
the Office of Inspector Generals
Public Affairs office at (202)619-1343
Reports are also available on the World Wide Web at our home page address:
http://oig.hhs.gov/
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Nursing Home Medical Directors 30 OEI-06-99-00300